Daily-routine chest radiography in the intensive care

Done by: Marleen E. Graat and Marcus J. Schultz, Amsterdam, the Netherlands

Reviewed by: Adebola O Adesanya, Dallas, Texas, USA

PubMed Search
Limited to human and English language; search strategy: (radiography, thoracic[MeSH] OR “chest x-ray” OR “chest radiograph”) AND (intensive care[MeSH] OR intensive care units[MeSH] OR critical care[MeSH]) AND ("routine" OR "daily").

Search results
The search listed 20 studies on the efficacy of daily-routine chest radiography: 15 were performed at adult intensive care units [1-15], 5 at pediatric intensive care units [16-20]; 2 studies compared a restrictive strategy (no daily-routine chest radiographs, only chest films on demand) with a strategy in which both daily-routine chest radiographs and clinically indicated films were obtained, one in pediatric patients [18] and one in adult patients [15].

Studies on the value of daily routine chest radiographs - adults
Investigators used (different) soft outcomes (“minor” and/or “major”) to determine the efficacy of chest radiographs in intensive care patients [1-10,12-14,16,17,19,20]; in most publications the number of radiographic abnormalities was reported; it was not mentioned whether findings were “new” and/or “unexpected”, nor whether they induced a change in therapy. In 4 studies the authors tried to differentiate meticulously between “minor” and “major” findings on daily-routine chest radiographs, whether those findings were “old” or “new”, and whether they were “expected” or “unexpected” [5,6,8,12]. Five studies evaluated thoroughly whether the findings on daily-routine chest radiographs had any clinical impact [4,5,12-14].  

Although incidence rates of radiographic abnormalities on daily-routine chest radiographs were high, most of the reported abnormalities were in fact clinically not important, i.e., not mandating any change in therapy. Indeed, incidence rates of findings dropped significantly when only clinically important findings were considered. Nevertheless, some studies still suggest that daily-routine chest radiographs have major impact on therapy [4,13]. 

We recently studied the true impact of findings on daily-routine chest radiographs and showed that less than half of CXR with a new and unexpected finding turned out to be clinically relevant: only 2.2% of all daily routine chest radiographs (6.4% of patients) had these radiologic abnormalities result in a change in therapy [21]. Subgroup analysis revealed no differences between medical and surgical patients with regard to the incidence of new and unexpected findings on daily-routine chest radiographs and the effect of new and unexpected chest radiographs-findings on daily care.

Studies on the value of daily routine chest radiographs - children

Study results in pediatric intensive care units regarding the value of daily routine chest radiography merely showed the same as those listed for adult intensive care units [16,17,19,20]: while reported incidence rates of radiographic findings were high, the incidence rate dropped when only clinically important findings were taken into consideration.

Clinical trials comparing a restrictive strategy with a daily routine strategy
Until now, only 2 studies compared a daily-routine strategy directly with a restrictive strategy (in which chest radiographs were taken only if clinically indicated) [15,18].

In a prospective, randomized, observational study, Krivopal et al determined whether there was any difference in diagnostic, therapeutic, and outcome efficacy between a routine and a non-routine chest radiography strategy in mechanically ventilated medical patients [15]. Patients were randomly assigned to have their chest radiographs done routinely every morning and on clinical indication, or only on clinical indication and after insertion of invasive devices. There was no difference in the mean duration of mechanical ventilation, length of stay in intensive care and total length of hospital stay between the two groups. Unfortunately, this was only a small study. In addition, the study investigators excluded patients who were intubated for > 72 hours (i.e., patients who were transferred from another hospital). This is unfortunate: especially since these patients are the ones with complex diseases, and probably those in which it would be most interesting to see whether a restrictive strategy is as safe as a daily-routine chest radiography strategy.

In a prospective, non-randomized, controlled study in a pediatric intensive care unit, Price et aldetermined the impact of change in chest radiograph ordering. Ordering changed from a daily-routine chest radiography policy to no standing orders for routine daily morning chest radiographs (i.e., each radiograph required a written order and a clinical indication) [18]. There were no significant changes in average length of stay in intensive care unit or hospital, nor in average duration of mechanical ventilation.

Conclusions           

At least two studies suggest that a restrictive strategy is safe. Additional studies are needed to help resolve the issue of daily-routine versus a restricted regime regarding chest radiography. 

References

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