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Are Routine Daily Chest X-Rays Justifiable in the ICU?
Abstract & Commentary
By David J. Pierson, MD, Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington. Dr. Pierson reports no financial relationships relevant to this field of study.
This article originally appeared in the April 2007 issue of Critical Care Alert. It was peer reviewed by William Thompson, MD. Dr. Thompson is Staff Pulmonologist, VA Medical Center; Associate Professor of Medicine, University of Washington. Dr. Thompson reports no financial relationships relevant to this field of study.
Synopsis: Elimination of daily routine CXRs reduced the number of CXRs in a mixed medical-surgical ICU, while not affecting readmission rate and ICU and hospital mortality rates.
Source: Graat ME, et al. Elimination of daily routine chest radiographs in a mixed medical-surgical intensive care unit. Intensive Care Med. 2007:33:639-644.
Graat and colleagues at the University of Amsterdam in The Netherlands, conducted this prospective study to determine the impact of discontinuing daily chest radiographs in the ICU. The ICU in question is a closed, 28-bed unit, admitting medical, cardiac, surgical, and trauma patients in a tertiary care hospital. For 5 months in 2004, while a policy of routine daily chest X-rays was in effect, the investigators tracked all chest X-rays obtained on patients in the unit, both routine and for specific indications. After a one-month interval, during which policy changed and obtaining routine daily chest X-rays was discontinued, Graat et al tracked all films obtained during a second 5-month period. During the latter interval, chest X-rays were obtained on ICU admission, following insertion of central lines or intravascular devices, following intubation, after insertion of chest tubes, with an increase in oxygen requirements, or with a change in pulmonary secretions suggestive of pneumonia.
A total of 5161 chest X-rays were obtained during the study — 3894 films on 754 patients while the policy of daily X-rays was in effect, and 1267 films on 622 patients after it was discontinued. The patients in the second phase were older (62 vs 60 years), and fewer of them underwent cardiac surgery (both, P < 0.05). Otherwise, the patients managed in the ICU during the 2 intervals were similar. Using predefined criteria for unexpected radiographic abnormalities, there were 147 such findings during the first interval — in 10.2% of on-demand chest X-rays — of which 57 (3.9%) led to a change in therapy. In the second interval, after daily chest X-rays were stopped, there were 156 unexpected abnormalities — in 1.6% of on-demand chest X-rays — of which 61 (4.8%) led to a change in therapy. The slight increase in unexpected abnormalities on non-routine films, and the frequency with which these were associated with a change in therapy, were both statistically significant (P < 0.05). ICU length of stay, readmission rate, and mortality in the ICU and in the hospital did not differ in the 2-study intervals.
Studies have shown that patients in ICUs, particularly intubated patients on mechanical ventilation, have a high incidence of radiographic abnormalities. Because other bedside tools, such as history and physical examination are imperfect in the high-stakes task of detecting changes in critically ill patients, the daily morning chest X-ray has long been assumed to be an important management component. However, this is only the most recent in a series of studies whose findings cast doubt on that assumption.
The present study is an extension of one published a year ago by the same group of investigators.1 In that earlier study, Graat et al sought to determine how frequently unexpected, predefined abnormalities were identified on routine daily chest X-rays in their unit, and how often such changes resulted in changes in management. They evaluated 2457 daily films obtained in 754 consecutive patients over a 5-month period. In 14.3% of these patients (5.8% of daily chest X-rays), an unexpected abnormality found. The latter included large atelectasis (24 instances), large infiltrates (23 instances), severe pulmonary congestion (29 instances), large pleural effusions (13 cases), barotraumas (pneumothorax or pneumomediastinum, 14 cases), and malposition of the endotracheal tube (32 instances). Graat et al judged that in only 2.2% of all daily routine chest X-rays was an abnormality found that resulted in a change in management. These findings did not differ in medical vs surgical patients.
There are several potential criticisms of the present study. For one thing, the first observation period was March through July, and the second was September through January, with significant differences in patient age and admitting diagnoses between those groups. How these differences might have affected the incidence of complications and their radiographic manifestations is unclear, but examining the same time period during 2 different years would have been a cleaner design. More importantly, perhaps, it is uncertain whether length of stay, readmissions, and ICU and hospital mortality are the only relevant outcomes to which the question of daily chest X-rays might pertain.
Still, it is probably appropriate to question whether simply being in an ICU warrants a daily chest X-ray. In the absence of clinical suspicion that something might have changed, this is probably something that can be safely omitted in most circumstances, particularly for patients who are not intubated or at increased risk for respiratory complications.
1. Graat ME, et al. The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low. Crit Care. 2006;10:R11.