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Abstract & Commentary
Do We Need Daily Chest X-Rays in the ICU?
By Andrew M. Luks, MD, Pulmonary and Critical Care Medicine, University of Washington, Seattle, is Associate Editor for Critical Care Alert.
Dr. Luks reports no financial relationship to this field of study.
Synopsis: This meta-analysis of clinical trials examining the effect of stopping routine chest radiographs in the intensive care unit found that unselective daily routine chest radiographs can be eliminated without increasing the incidence of adverse events.
Source: Oba Y, Zaza T. Abandoning daily routine chest radiography in the intensive care unit: Meta-analysis. Radiology 2010;255:386-395.
Daily chest radiographs have long been a staple of practice for intubated patients in the intensive care unit (ICU) and their use persists despite several studies questioning whether they are of any benefit to patients.1,2 Oba and Zaza conducted a systematic review of the literature on this issue to determine whether abandoning daily routine chest radiography would adversely affect patient outcomes and to identify subgroups that might benefit from continuing daily films.
Using a Medline search, the authors identified all clinical trials that compared the impact of daily routine chest radiography with clinically indicated chest radiography. Studies were included in the analysis if they used randomized controlled or observational designs, investigated particular primary outcomes including hospital or ICU mortality, duration of mechanical ventilation or hospital stay, and adverse event rates (unplanned extubation, readmission to the ICU, or in-hospital complications such as malpositioned tubes or pneumothoraces requiring intervention) and at least 30% of the patients in the study were receiving mechanical ventilation.
The authors identified 128 citations upon their initial search but eventually narrowed this list down to a total of 8 studies that met their entry criteria and were included in their data analysis. Two of the studies were randomized, controlled studies while the rest were observational studies. Four of these studies reported major adverse events. The 8 studies included in the analysis comprised a total of 7078 ICU medical and surgical ICU patients, 3429 of whom underwent routine daily radiographs and 3649 of whom only received chest radiographs when clinically indicated. In the included studies the mean number of daily films in the routine radiograph group varied between 2.4 and 10.5 films per ICU stay while the mean value in the on-demand groups ranged from 0.4 to 4.4.
In the pooled analysis, the authors found that routine daily chest radiographs did not affect ICU or in-hospital mortality (odds ratio [OR], 1.02; 95% confidence interval [CI], 0.89-1.17). There were also no significant differences in ICU or hospital length of stay and days of mechanical ventilation. None of these results changed when they examined the randomized and observational studies separately. The incidence of adverse events was also similar between the two groups (OR, 0.93; 95% CI, 0.57-1.53). Using univariate and multivariate regression meta-analyses, the authors were unable to identify any subgroup (e.g., medical or surgical patients, mechanically ventilated patients) that benefited from routine daily chest radiographs.
The results of the study by Oba and Zaza are not new. These authors have simply shown using a different study design what previous randomized and observational studies have already shown that routine daily chest radiographs do not improve patient outcomes. In the face of such data, many of the typical rationales for continuing to obtain daily radiographs no longer hold much water. For example, clinicians often cite the fact that they can check the position of the endotracheal tube and minimize the risk of unplanned extubation. Oba and Zaza's results, as well as those of the other studies, show that daily radiographs make no difference in this regard. Similarly, some physicians might argue that a new opacity might alert them to the possibility of pneumonia and prompt an earlier work-up or earlier antibiotics. Again, the fact that length of stay, duration of mechanical ventilation, and mortality are unchanged suggests this rationale does not hold up either.
With relatively consistent data across studies questioning the utility of the practice, the question remains as to why it persists. I must admit that my head is often sore after completing patient care stints in the ICU as a result of banging it against a wall out of frustration; I write many orders to discontinue daily chest radiographs, only to see the patient's films continually show up on the team's morning review of its imaging studies. I have even resorted to keeping running tabs on the white boards in the patients' rooms titled "Consecutive Days With Unnecessary Chest X-rays" to little or no effect. The problem is likely multifactorial in origin. Radiology departments likely have little incentive to abandon the practice as each radiograph taken generates revenue for the department and the radiologist interpreting it. More importantly, like the culture change required for the recent shift in sedation practices, abandoning daily chest radiographs involves amending a culture and practice that has been in place for many years. As a result, it will require a considerable amount of education of nurses, respiratory therapists, and physicians. The data are there to support this change and, in an age of increasing cost-consciousness and emphasis on quality improvement initiatives, it is time to push this change forward.