Elimination of daily routine chest radiographs does not change on-demand radiography practice in post–cardiothoracic surgery patients

Lung Ultrasound Reduces Chest X-rays in Postoperative Care after Thoracic Surgery: Is There a Role for Artificial Intelligence?-Systematic Review

BACKGROUND

Chest X-ray (CXR) remains the standard imaging modality in postoperative care after non-cardiac thoracic surgery. Lung ultrasound (LUS) showed promising results in CXR reduction. The aim of this review was to identify areas where the evaluation of LUS videos by artificial intelligence could improve the implementation of LUS in thoracic surgery.

METHODS

A literature review of the replacement of the CXR by LUS after thoracic surgery and the evaluation of LUS videos by artificial intelligence after thoracic surgery was conducted in Medline.

RESULTS

Here, eight out of 10 reviewed studies evaluating LUS in CXR reduction showed that LUS can reduce CXR without a negative impact on patient outcome after thoracic surgery. No studies on the evaluation of LUS signs by artificial intelligence after thoracic surgery were found.

CONCLUSION

LUS can reduce CXR after thoracic surgery. We presume that artificial intelligence could help increase the LUS accuracy, objectify the LUS findings, shorten the learning curve, and decrease the number of inconclusive results. To confirm this assumption, clinical trials are necessary. This research is funded by the Slovak Research and Development Agency, grant number APVV 20-0232.

ACR Appropriateness Criteria® Intensive Care Unit Patients

Chest radiography is the most frequent and primary imaging modality in the intensive care unit (ICU), given its portability, rapid image acquisition, and availability of immediate information on the bedside preview. Due to the severity of underlying disease and frequent need of placement of monitoring devices, ICU patients are very likely to develop complications related to underlying disease process and interventions. Portable chest radiography in the ICU is an essential tool to monitor the disease process and the complications from interventions; however, it is subject to overuse especially in stable patients. Restricting the use of chest radiographs in the ICU to only when indicated has not been shown to cause harm. The emerging role of bedside point-of-care lung ultrasound performed by the clinicians is noted in the recent literature. The bedside lung ultrasound appears promising but needs cautious evaluation in the future to determine its role in ICU patients. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Most patient conditions do not a priori debilitate the sensitivity of thoracic ultrasound in thoracic surgery-a prospective comparative study

Background

The few existing studies on the accuracy of lung ultrasound in the detection of a postoperative pneumothorax after thoracic surgery differ in the sonographic technique and the inclusion criteria. Several conditions are considered unfavourable in the sonographic examination of the lung. We aim to test these conditions for their impact on the diagnostic accuracy of lung ultrasound.

Methods

We compared lung ultrasound and chest roentgenograms for the detection of a pneumothorax after lung-resecting surgery in two prospective trials (register ID DRKS00014557 and DRKS00020216). The ultrasound examiners and radiologists were blinded towards the corresponding findings. We performed posthoc subgroup analyses to determine the influence of various patient or surgery related conditions on the sensitivity and specificity of ultrasound in the detection of pneumothorax.

Results

We performed 340 examinations in 208 patients. The covariates were age, gender, body mass index, smoking status, severity of chronic obstructive pulmonary disease, previous ipsilateral operation or irradiation, thoracotomy, postoperative skin emphysema, indwelling chest tube and X-ray in supine position. In univariate analysis, an indwelling chest-tube was associated with a higher sensitivity (58%, p = 0.04), and a postoperative subcutaneous emphysema with a lower specificity (73% vs. 88%, p = 0.02). None of the other subgroups differed in sensitivity or specificity from the total population .

Conclusions

Most of the patient- or surgery related conditions usually considered unfavourable for lung ultrasound did not impair the sensitivity or specificity of lung ultrasound. Further studies should not excluce patients with these conditions, but test the accuracy under routine conditions.

Trial registration

DRKS, DRKS00014557, registered 06/09/2018, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00014557 and DRKS00020216, registered 03/12/2019, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00020216

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-021-01454-6.

Chest Ultrasound Can Reduce the Use of Roentgenograms in Postoperative Care After Thoracic Surgery

BACKGROUND

Roentgenography remains the standard imaging modality after thoracic surgery. Trials from intensive medicine proved a high accuracy of ultrasound examination in the diagnosis of various conditions. The assumption was that ultrasound examination could reduce the number of roentgenograms after thoracic surgery.

METHODS

This prospective study compared ultrasound examinations performed by thoracic surgeons with roentgenograms in the diagnosis of pneumothorax and pleural effusion after noncardiac thoracic surgery. Patients received 2 ultrasound scans, the first on the day of surgery and the second before chest tube removal.

RESULTS

A total of 297 patients underwent 545 examinations; 336 ultrasound scans (61.6%) showed neither pneumothorax nor pleural effusion. Pneumothorax was detected on 69 roentgenograms and 51 ultrasound scans. Both modalities showed positive results in 32 cases and negative results in 395 cases (Cohen's κ, 53.4%). Ultrasound missed 37 clinically irrelevant pneumothoraces. Roentgenograms missed 19 pneumothoraces; 15 of them were clinically irrelevant. Sensitivity and specificity were 59.4% and 95.9% in the first examination and 50.0% and 94.8% in the second examination, respectively. Pleural effusion was detected on 169 roentgenograms and 117 ultrasound scans. Both modalities showed positive results in 88 cases and negative results in 336 cases (Cohen's κ, 49.6%). Ultrasound scans missed 81 pleural effusions; except for 5 cases, the clinical decisions would not have changed. Roentgenograms missed 29 clinically irrelevant pleural effusions. Sensitivity and specificity were 44.4% and 92.6% in the first examination and 60.9% and 91.3% in the second examination, respectively.

CONCLUSIONS

Given high specificities, a large share of results without pneumothorax and pleural effusion, and mismatch analysis, we could reduce the number of roentgenograms by 61.6% by using ultrasound as a primary imaging modality.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Deimplementation of Routine Chest X-rays in Adult Intensive Care Units

BACKGROUND

Choosing Wisely® is a national initiative to deimplement or reduce low-value care. However, there is limited evidence on the effectiveness of strategies to influence ordering patterns.

OBJECTIVE

We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies.

DESIGN

We aimed to describe the effectiveness of an intervention to reduce daily chest X-ray (CXR) ordering in two intensive care units (ICUs) and evaluate deimplementation strategies.

SETTING

The study was performed in the medical intensive care unit (MICU) and cardiovascular intensive care unit (CVICU) of an academic medical center in the United States from October 2015 to June 2016.

PARTICIPANTS

The initiative included the staff of the MICU and CVICU (physicians, surgeons, nurse practitioners, fellows, residents, medical students, and X-ray technologists).

INTERVENTION COMPONENTS

We utilized provider education, peer champions, and weekly data feedback of CXR ordering rates.

MEASUREMENTS

We analyzed the CXR ordering rates and factors facilitating or inhibiting deimplementation.

RESULTS

Segmented linear time-series analysis suggested a small but statistically significant decrease in CXR ordering rates in the CVICU (P < .001) but not in the MICU. Facilitators of deimplementation, which were more prominent in the CVICU, included engagement of peer champions, stable staffing, and regular data feedback. Barriers included the need to establish goal CXR ordering rates, insufficient intervention visibility, and waning investment among medical residents in the MICU due to frequent rotation and competing priorities.

CONCLUSIONS

Intervention modestly reduced CXRs ordered in one of two ICUs evaluated. Understanding why adoption differed between the two units may inform future interventions to deimplement low-value diagnostic tests.

Trends in Use of Daily Chest Radiographs Among US Adults Receiving Mechanical Ventilation

IMPORTANCE

Guidelines from December 2011 recommended against obtaining daily chest radiographs (CXRs) for patients requiring mechanical ventilation (MV). Daily CXR use for patients receiving MV in US hospitals is unknown and, if high, may represent an opportunity to reduce low-value care and unnecessary radiation.

OBJECTIVES

To determine frequency of daily CXR use for US patients receiving MV, assess variability across hospitals, and evaluate whether use has decreased over time.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of hospitalized adults (aged ≥18 years) receiving MV for 3 days or longer. Mechanical ventilation was defined by having an International Classification of Diseases, Ninth Revision, Clinical Modification code of 96.7x and an MV charge on more than 1 hospital day. Hospital discharges in the Premier Perspectives database were examined from July 1, 2008, to December 31, 2014. Data analysis was conducted from July 28, 2017, to December 13, 2017.

EXPOSURES

Hospital discharge date (quarter of the year) and hospital in which patients received MV.

MAIN OUTCOMES AND MEASURES

The outcome was daily CXR use (up to 7 days) during MV. We used standard statistics to describe CXR use, multilevel multivariable regression modeling with adjusted median odds ratio (OR) to evaluate variability by hospital, and multivariable piecewise regression (breakpoint: fourth quarter of 2011) with adjusted OR to evaluate time trends and response to guideline recommendations.

RESULTS

The primary cohort included 512 518 patients receiving MV (mean [SD] age, 63.0 [16.1] years; 46% female) in 416 hospitals, of whom 321 093 (63%) received daily CXRs. Wide variability was seen across hospitals; hospitals performed daily CXRs on a median of 66% of patients (interquartile range, 50%-77%; full range, 12%-97%). The adjusted median OR was 2.43 (95% CI, 2.29-2.59), suggesting the same patient had 2.43-fold higher odds of receiving a daily CXR if admitted to a higher- vs lower-use hospital; the odds of receiving daily CXRs were unchanged through quarter 3 of 2011 (adjusted OR, 1.00; 95% CI, 0.99-1.01), after which there was a 3% relative reduction in the odds of daily CXR use per quarter (adjusted OR, 0.97; 95% CI, 0.96-0.98).

CONCLUSIONS AND RELEVANCE

Three-fifths of US patients receiving MV also received daily CXRs from 2008 to 2014, although use declined slowly after new guidelines were published. The hospital at which a patient received care was associated with the odds of daily CXR receipt.

Daily routine versus on-demand chest radiograph policy and practice in adult ICU patients- clinicians' perspective

Background

Chest radiographs are taken daily as a part of routine investigations in Intensive care unit (ICU) patients. They are less effective and unlikely to alter the management of the majority of these patients compared to the radiographs obtained when indicated. According to the American College of Radiology (ACR) Appropriateness criteria, only selective ordering of chest radiographs is recommended, including elderly or high risk patients. The aim of this study was to identify and assess the clinician’s perspective in abandoning the current practice of daily routine chest radiograph and replacing with the on-demand radiograph in Saudi hospitals.

Methods

This was a cross-sectional study. A valid self-administered questionnaire was distributed to all clinical staff members working in ICUs in the major tertiary hospitals in Saudi Arabia. The study population was primarily the ICU intensivists (physicians), nurses and respiratory therapists (RT). The data collected were statistically processed using SPSS version 20.0; descriptive and inferential analyses were done.

Results

Out of 730 questionnaires sent, we received only 495 completed questionnaires with a response rate of 67.8%. Majority of them (n = 351) are working at academic hospitals. About half of the respondents (n = 247) are working in an open-format ICUs. Findings showed that the daily routine chest X-ray was performed in almost 96.8% of ICUs patients, which the majority of the clinical staff members (73%) thought that this current daily routine CXR protocol in the ICUs should be replaced with the on-demand CXR policy. Interestingly, the differences in demographic and work-related characteristics had no significant impact on the clinician’s view and supported moving to on-demand CXR policy and practice.

Conclusions

The daily routine CXR is still a common practice in most of the Saudi hospitals ICUs although enough empirical evidence shows that it can be avoided. We observed that intensivists support the change of the current practice and recommend an on-demand CXR policy likely to be followed in intensive care management.

Electronic supplementary material

The online version of this article (10.1186/s12880-018-0248-6) contains supplementary material, which is available to authorized users.

Single intervention for a reduction in portable chest radiography (pCXR) in cardiovascular and surgical/trauma ICUs and associated outcomes

PURPOSE

Studies suggest that "on-demand" radiography is equivalent to daily routine with regard to adverse events. In these studies, provider behavior is controlled. Pragmatic implementation has not been studied.

MATERIALS AND METHODS

This was a quasi-experimental, pre-post intervention study. Medical directors of two intervention ICUs requested pCXRs be ordered on an on-demand basis at one time point, without controlling or monitoring behavior or providing follow-up.

RESULTS

A total of 11,994 patient days over 18months were included. Combined characteristics: Age: 56.7, 66% male, 96% survival, APACHE II 14 (IQR: 11-19), mechanical ventilation (MV) (occurrences)/patient admission: mean 0.7 (SD: 0.6; range: 0-5), duration (hours) of MV: 21.7 (IQR: 9.8-81.4) and ICU LOS (days): 2.8 (IQR: 1.8-5.6). Average pCXR rate/patient/day before was 0.93 (95% CI: 0.89-0.96), and 0.73 (95% CI: 0.69-0.77) after. Controlling for severity, daily pCXR rate decreased by 21.7% (p<0.001), then increased by about 3%/month (p=0.044). There was no change in APACHE II, mortality, and occurrences or duration of MV, unplanned re-intubations, ICU LOS.

CONCLUSIONS

In critically ill adults, pCXR reduction can be achieved in cardiothoracic and trauma/surgical patients with a pragmatic intervention, without adversely affecting patient care, outside a controlled study.

A Pilot Assessment of 3 Point-of-Care Strategies for Diagnosis of Perioperative Lung Pathology

BACKGROUND

Lung ultrasonography is superior to clinical examination and chest X-ray (CXR) in diagnosis of acute respiratory pathology in the emergency and critical care setting and after cardiothoracic surgery in intensive care. Lung ultrasound may be useful before cardiothoracic surgery and after discharge from intensive care, but the proportion of significant respiratory pathology in this setting is unknown and may be too low to justify its routine use. The aim of this study was to determine the proportion of clinically significant respiratory pathology detectable with CXR, clinical examination, and lung ultrasound in patients on the ward before and after cardiothoracic surgery.

METHODS

In this prospective observational study, patients undergoing elective cardiothoracic surgery who received a CXR as part of standard care preoperatively or after discharge from the intensive care unit received a standardized clinical assessment and then a lung ultrasound examination within 24 hours of the CXR by 2 clinicians. The incidence of collapse/atelectasis, consolidation, alveolar-interstitial syndrome, pleural effusion, and pneumothorax were compared between clinical examination, CXR, and lung ultrasound (reference method) based on predefined diagnostic criteria in 3 zones of each lung.

RESULTS

In 78 participants included, presence of any pathology was detected in 56% of the cohort by lung ultrasound; 24% preoperatively and 94% postoperatively. With lung ultrasound as a reference, the sensitivity of the 5 different pathologies ranged from 7% to 69% (CXR), 7% to 76% (clinical examination), and 14% to 94% (combined); the specificity of the 5 different pathologies ranged from 91% to 98% (CXR), from 90% to 99% (clinical examination), and from 82% to 97% (combined). For clinical examination and lung ultrasound, intraobserver agreements beyond chance ranged from 0.28 to 0.70 and from 0.84 to 0.97, respectively. The agreements beyond chance of pathologic diagnoses between modalities ranged from 0.11 to 0.64 (CXR and lung ultrasound), from 0.08 to 0.7 (CXR and lung ultrasound), and from 0 to 0.58 (clinical examination and CXR).

CONCLUSIONS

Clinically important respiratory pathology is detectable by lung ultrasound in a substantial number of noncritically ill, pre or postoperative cardiothoracic surgery participants with high estimate of interobserver agreement beyond that expected by chance, and we showed clinically significant diagnoses may be missed by the contemporary practice of clinical examination and CXR.

Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care

OBJECTIVES

Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient.

DATA SOURCE AND SYNTHESIS

Narrative review of relevant English-language peer-reviewed medical literature.

CONCLUSIONS

Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.

Defining indications for selective chest radiography in the first 24 hours after cardiac surgery

OBJECTIVE

In the intensive-care unit (ICU), chest radiographs (CXRs) are frequently obtained routinely for postoperative cardiac surgery patients, despite the fact that the efficacy of routine CXRs is known to be low. We investigated the efficacy and safety of CXRs performed after cardiac surgery for specified indications only.

METHODS

In this observational cohort study, we prospectively included all patients who underwent conventional major cardiac surgery by median sternotomy in the year 2012. On-demand CXRs could be obtained during the first postoperative period for specified indications only. A routine control CXR was performed on the morning of the first postoperative day for all patients who had not undergone a CXR before that time. The diagnostic and therapeutic efficacy values were calculated for all CXRs. Differences were tested using Fisher's exact test or χ(2) analysis.

RESULTS

A total of 1102 consecutive cardiac surgery patients were included in this study. The diagnostic efficacy of CXRs for major abnormalities was higher for the postoperative on-demand CXRs (n = 301; 27%) than for the routine CXRs taken the morning after surgery (n = 801; 73%) (6.6% vs 2.7%, P = .004). The therapeutic efficacy was higher for the on-demand CXRs, whereas the need for intervention after the next-morning, routine CXRs was limited to 5 patients (4.0% vs 0.6%, P < .001). None of these patients experienced a major adverse event.

CONCLUSIONS

Defining clear indications for selective CXRs after cardiac surgery is effective and seems to be safe. This approach may significantly reduce the total number of CXRs performed, and will increase their efficacy.

The value of routine chest radiographs after minimally invasive cardiac surgery: an observational cohort study

Background

Chest radiographs (CXRs) are obtained frequently in postoperative cardiac surgery patients. The diagnostic and therapeutic efficacy of routine CXRs is known to be low and the discussion regarding the safety of abandoning these CXRs after cardiac surgery is still ongoing. We investigated the value of routine CXRs directly after minimally invasive cardiac surgery.

Methods

We prospectively included all patients who underwent minimally invasive cardiac surgery by port access, ministernotomy or bilateral video-assisted thoracoscopy (VATS) in the year 2012. A direct postoperative CXR was performed on all patients at ICU arrival. All CXR findings were noted, including whether they led to an intervention or not. The results were compared to the postoperative CXR results in patients who underwent conventional cardiac surgery by full median sternotomy over the same period.

Main results

A total of 249 consecutive patients were included. Most of these patients underwent valve surgery, rhythm surgery or a combination of both. The diagnostic efficacy for minor findings was highest in the port access and bilateral VATS groups (56% and 63% versus 28% and 45%) (p < 0.005). The diagnostic efficacy for major findings was also higher in these groups (8.9% and 11% versus 4.3% and 3.8%) (p = 0.010). The need for an intervention was most common after minimally invasive surgery by port access, although this difference was not statistically significant (p = 0.056).

Conclusions

The diagnostic efficacy of routine CXRs performed after minimally invasive cardiac surgery by port access or bilateral VATS is higher than the efficacy of CXRs performed after conventional cardiac surgery. A routine CXR after these procedures should still be considered.

Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey

Background

ICU patients frequently undergo chest radiographs (CXRs). The diagnostic and therapeutic efficacy of routine CXRs are now known to be low, but the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a survey of Dutch intensivists on the current practice of chest radiography in their departments.

Methods

Web-based questionnaires, containing questions regarding ICU characteristics, ICU patients, daily CXR strategies, indications for routine CXRs and the practice of radiologic evaluation, were sent to the medical directors of all adult ICUs in the Netherlands. CXR strategies were compared between all academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results obtained in 2006 and 2013.

Results

Of the 83 ICUs that were contacted, 69 (83%) responded to the survey. Only 7% of responding ICUs were currently performing daily routine CXRs for all patients, and 61% of the responding ICUs were said never to perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine CXRs was assumed by intensivists to be lower than 10% or to be between 10 and 20%. The efficacy of ‘on-demand’ CXRs was assumed to be between 10 and 60%. There is a consensus between intensivists to perform a routine CXR after endotracheal intubation, chest tube placement or central venous catheterization.

Conclusion

The strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume the value of CXRs to be higher than the efficacy that is reported in the literature.

Cumulative total effective whole-body radiation dose in critically ill patients

BACKGROUND

Uncertainty exists about a safe dose limit to minimize radiation-induced cancer. Maximum occupational exposure is 20 mSv/y averaged over 5 years with no more than 50 mSv in any single year. Radiation exposure to the general population is less, but the average dose in the United States has doubled in the past 30 years, largely from medical radiation exposure. We hypothesized that patients in a mixed-use surgical ICU (SICU) approach or exceed this limit and that trauma patients were more likely to exceed 50 mSv because of frequent diagnostic imaging.

METHODS

Patients admitted into 15 predesignated SICU beds in a level I trauma center during a 30-day consecutive period were prospectively observed. Effective dose was determined using Huda's method for all radiography, CT imaging, and fluoroscopic examinations. Univariate and multivariable linear regressions were used to analyze the relationships between observed values and outcomes.

RESULTS

Five of 74 patients (6.8%) exceeded exposures of 50 mSv. Univariate analysis showed trauma designation, length of stay, number of CT scans, fluoroscopy minutes, and number of general radiographs were all associated with increased doses, leading to exceeding occupational exposure limits. In a multivariable analysis, only the number of CT scans and fluoroscopy minutes remained significantly associated with increased whole-body radiation dose.

CONCLUSIONS

Radiation levels frequently exceeded occupational exposure standards. CT imaging contributed the most exposure. Health-care providers must practice efficient stewardship of radiologic imaging in all critically ill and injured patients. Diagnostic benefit must always be weighed against the risk of cumulative radiation dose.

Are daily routine chest radiographs necessary after pulmonary surgery in adult patients?

A best evidence topic was constructed according to a structured protocol. The question addressed was whether daily routine (DR) chest radiographs (CXRs) are necessary after pulmonary surgery in adult patients. Of the 66 papers found using a report search, seven presented the best evidence to answer the clinical question. Four of these seven studies specifically addressed post-cardiothoracic adult patients. Three of these seven studies addressed intensive care unit (ICU) patients and included post-cardiothoracic adult patients in well-designed studies. Six of these seven studies compared the DR CXRs strategy to the clinically indicated, on-demand (OD) CXRs strategy. Another study analysed the clinical impact of ceasing to perform the DR, postoperative, post-chest tubes removal CXRs. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that, on the whole, the seven studies are unanimously in favour of forgoing DR CXRs after lung resection and advocate OD CXRs. One study suggested that hypoxic patients could benefit from a DR CXRs strategy, while other studies failed to identify any subgroup for whom performing DR CXRs was beneficial. Indeed, DR CXRs, commonly taken after thoracic surgery, have poor diagnostic and therapeutic value. Eliminating them for adult patients having undergone thoracic surgery significantly decreases the number of CXRs per patient without increasing mortality rates, length of hospital stays (LOSs), readmission rates and adverse events. Hence, current evidence shows that DR CXRs could be forgone after lung resection because OD CXRs, recommended by clinical monitoring, have a better impact on management and have not been proved to negatively affect patient outcomes. Moreover, an OD CXRs strategy lowers the cost of care. Nevertheless, an OD CXRs strategy requires close clinical monitoring by experienced surgeons and dedicated intensivists. However, given the published studies' low level of evidence, prospective and randomized trials, specifically after thoracic surgery, are necessary in order to confirm these results.

Impact of chest X-ray before discharge in asymptomatic children after cardiac surgery--prospective evaluation

In many paediatric cardiac units chest radiographs are performed routinely before discharge after cardiac surgery. These radiographs contribute to radiation exposure. To evaluate the diagnostic impact of routine chest X-rays before discharge in children undergoing open heart surgery and to analyze certain risk factors predicting pathologic findings. This was a prospective (6 months) single-centre observational clinical study. One hundred twenty-eight consecutive children undergoing heart surgery underwent biplane chest X-ray at a mean of 13 days after surgery. Pathologic findings on chest X-rays were defined as infiltrate, atelectasis, pleural effusion, pneumothorax, or signs of fluid overload. One hundred nine asymptomatic children were included in the final analysis. Risk factors, such as age, corrective versus palliative surgery, reoperation, sternotomy versus lateral thoracotomy, and relevant pulmonary events during postoperative paediatric intensive care unit (PICU) stay, were analysed. In only 5.5 % (6 of 109) of these asymptomatic patients were pathologic findings on routine chest X-ray before discharge found. In only three of these cases (50 %), subsequent noninvasive medical intervention (increasing diuretics) was needed. All six patients had relevant pulmonary events during their PICU stay. Risk factor analysis showed only pulmonary complications during PICU stay to be significantly associated (p = 0.005) with pathologic X-ray findings. Routine chest radiographs before discharge after cardiac surgery can be omitted in asymptomatic children with an uneventful and straightforward perioperative course. Chest radiographs before discharge are warrantable if pulmonary complications did occur during their PICU stay, as this is a risk factor for pathologic findings in chest X-rays before discharge.

Routine chest x-rays in intensive care units: a systematic review and meta-analysis

Introduction

Chest x-rays (CXRs) are the most frequent radiological tests performed in the intensive care unit (ICU). However, the utility of performing daily routine CXRs is unclear.

Methods

We searched Medline and Embase (1948 to March 2011) for randomized and quasi-randomized controlled trials (RCTs) and before-after observational studies comparing a strategy of routine CXRs to a more restrictive approach with CXRs performed to investigate clinical changes among critically ill adults or children. In duplicate, we extracted data on the CXR strategy, study quality and clinical outcomes (ICU and hospital mortality; duration of mechanical ventilation and ICU and hospital stay).

Results

Nine studies (39,358 CXRs; 9,611 patients) were included in the meta-analysis. Three trials (N = 870) of moderate to good quality provided information on the safety of a restrictive routine CXR strategy; only one trial systematically assessed for missed findings. Pooled data from trials showed no evidence of effect of a restrictive approach on ICU mortality (risk ratio [RR] 1.04, 95% confidence interval [CI] 0.84 to 1.28, P = 0.72; two trials, N = 776), hospital mortality (RR 0.98, 95% CI 0.68 to 1.41, P = 0.91; two trials, N = 259), ICU length of stay (weighted mean difference [WMD] -0.86 days, 95% CI -2.38 to 0.66 days, P = 0.27; three trials, N = 870), hospital length of stay (WMD -2.50 days, 95% CI -6.62 to 1.61 days, P = 0.23; two trials, N = 259), or duration of mechanical ventilation (WMD -0.30 days, 95% CI -1.48 to 0.89 days, P = 0.62; three trials, N = 705). Adding data from six observational studies, one of which systematically screened for missed findings, gave similar results.

Conclusions

This meta-analysis did not detect any harm associated with a restrictive chest radiograph strategy. However, confidence intervals were wide and harm was not rigorously assessed. Therefore, the safety of abandoning routine CXRs in patients admitted to the ICU remains uncertain.

Chest radiographs in 104 French ICUs: current prescription strategies and clinical value (the RadioDay study)

OBJECTIVE

To analyze the current practices of chest radiograph (CXR) prescription and their clinical impact.

DESIGN

Prospective snapshot observational study (on RadioDay) combined with a survey.

PATIENTS

Patients who were given a CXR on RadioDay.

SETTING

One hundred four French intensive care units (ICUs).

RESULTS

On RadioDay, 854 CXRs (in 804 patients) were ordered. For the "CXRs morning round," the prescription policy was declared to be "on-demand" (in 63 % of the ICUs), "daily routine only in mechanically ventilated patients (MV)" (30 %) or, less frequently, "daily routine in all patients" (7 %). When analyzing the two main local policies, as compared with "daily routine only in MV" ICUs, in "on-demand" ICUs: (1) fewer CXRs were ordered (0.6 ± 0.3 vs. 0.9 ± 0.2 CXRs/patient, p < 0.001) with no increase in the rate of unscheduled CXRs (i.e., CXRs performed outside the morning round), and (2) individual CXRs were more often followed by a therapeutic intervention (which would not have occurred without the CXR): 34 vs. 25 % of the CXRs (p < 0.05). Last, in case of severe respiratory disease (low PaO(2)/FiO(2) ratio), it is noteworthy that the clinical value of "on-demand" individual CXRs was still markedly higher than that of "daily routine" CXRs.

CONCLUSION

Nearly two-thirds of the participating ICUs adopted the "on-demand" strategy of prescription, which was associated with a lower rate of CXRs with no increase in unscheduled CXRs and was of higher clinical value than a "daily routine in MV" strategy. Importantly, the study design did not allow assessing if the "on-demand" strategy had missed or delayed some diagnoses.

Prospective trial evaluating sonography after thoracic surgery in postoperative care and decision making

OBJECTIVE

Following thoracic surgery, daily chest X-rays (CXRs) are performed to assess patient evolution and to make decisions regarding chest tube removal and patient discharge. Sonography after thoracic surgery (SATS) has the potential to be an effective, convenient, inexpensive and easy to learn tool in the post-operative management of thoracic surgery patients. We hypothesized that SATS could alleviate the need for repetitive CXRs, thus reducing the related risks, costs and inconvenience.

METHODS

This study consisted of a prospective cohort trial. All patients scheduled to undergo thoracic surgery at a single academic medical centre were eligible. Post-operative bedside pleural ultrasound was performed whenever a CXR was ordered by the treating team. Investigators specifically assessed patients with the goals of identifying pleural effusions and pneumothoraces. Study investigators were blinded to CXR results. SATS findings were compared with CXRs, which were considered the gold standard in routine post-operative pleural space evaluation.

RESULTS

One hundred and twenty patients were prospectively enrolled over a 5.5-month period. Three hundred and fifty-two ultrasound examinations were performed (mean = 3.0 ± 2.4 exams per patient). The time interval between the ultrasound and the comparative CXR was 166 ± 149 min. The mean time required to perform SATS was 11 ± 6 min per exam. In the detection of pleural effusion, SATS yielded a sensitivity of 83.1% and a specificity of 59.3%. In the detection of pneumothoraces, a sensitivity of 21.2% and a specificity of 94.7% were obtained.

CONCLUSIONS

Post-operative ultrasound may alleviate the need to perform routine CXR in patients with a previously ruled out pneumothorax. SATS used selectively may be able to reduce the number of routine CXRs performed; however, it does not have high enough accuracy to replace CXRs.

[Prediction of the clinical usefulness of routine chest X-rays in a traumatology ICU]

BACKGROUND

The clinical value of routine chest X-rays in critical care has been questioned, but has not been studied in the trauma environment to date. The objective of this study was to identify easy to use clinical predictors of utility in this setting.

MATERIAL AND METHODS

A prospective observational study was made in an 8-bed traumatology ICU. Severe trauma patients (ISS > 15), aged 15 or older and admitted for 48 h or longer were included. Pregnant women and radiographs obtained during initial care or for reasons other than routine indication were excluded. A staff physician, separated from clinical duties, independently reviewed the films in search of changes, as described in a closed checklist. Following closed criteria, the attending physicians reported previous day clinical events and changes in clinical management after chest X-ray obtainment. Demographic and epidemiological data were also recorded. The associations among variables were studied by univariate and multivariate analysis.

RESULTS

A total of 1440 routine chest X-rays were obtained from 138 consecutive patients during one year. Young males prevailed (82%; 39 ± 16 years). The most common process was severe blunt trauma (97%). Fifty-two percent suffered severe chest trauma. The mean length of stay was 12.9 ± 10.1 days. Mechanical ventilation was used in 86.8% of the cases. A median of 10.4 ± 9.3 films were obtained from each patient. A total of 14% of the X-rays showed changes, most commonly malpositioning of an indwelling device (6.8%) or infiltrates (4.9%). Those findings led to a change in care in 84.6% of the cases. Multivariate analysis identified the following significant (p < 0.05) risk factors for radiographic changes: first two days of evolution, mechanical ventilation, worsening of PaO₂/FiO₂, worsening of lung compliance and changes in respiratory secretions.

CONCLUSIONS

Based on the results obtained, the risk of not identifying dangerous conditions by restricting routine chest X-rays prescription to the described conditions is low. Observing this policy would probably mean substantial savings and a reduction in radiation exposure.

Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicentre, cluster-randomised, two-period crossover study

BACKGROUND

Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, some units use an on-demand strategy, in which chest radiographs are done only if warranted by the patient's clinical status. By comparison between routine and on-demand strategies, we aimed to establish which strategy was more efficient and effective for optimum patient care.

METHODS

In a cluster-randomised, open-label crossover study, we randomly assigned 21 intensive care units at 18 hospitals in France to use a routine or an on-demand strategy for prescription of chest radiographs during the first of two treatment periods. Units used the alternative strategy in the second period. Each treatment period lasted for the time taken for enrolment and study of 20 consecutive patients per intensive care unit; patients were monitored until discharge from the unit or for up to 30 days' mechanical ventilation, whichever was first. Units enrolled 967 patients, but 118 were excluded because they had been receiving mechanical ventilation for less than 2 days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00893672.

FINDINGS

11 intensive care units were randomly allocated to use a routine strategy to order chest radiographs in the first treatment period, and 10 units to use an on-demand strategy. Overall, 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1.09, 95% CI 1.05-1.14), and 425 had 3148 on-demand chest radiographs (mean 0.75, 0.67-0.83), which corresponded to a reduction of 32% (95% CI 25-38) with the on-demand strategy (p<0.0001).

INTERPRETATION

Our results strongly support adoption of an on-demand strategy in preference to a routine strategy to decrease use of chest radiographs in mechanically ventilated patients without a reduction in patients' quality of care or safety.

FUNDING

Assistance Publique-Hôpitaux de Paris (Direction Régionale de la Recherche Clinique Ile de France).

Is a routine chest X-ray indicated before discharge following paediatric cardiac surgery?

In many paediatric cardiosurgical units, a chest X-ray is routinely performed before discharge. We sought to evaluate the clinical impact of such routine radiographs in the management of children after cardiac surgery. Of 100 consecutive children, a chest X-ray was performed in 71 prior to discharge. Of these, 38 were clinically indicated, while 33 were performed as a routine. Therapeutic changes were instituted on the basis of the X-ray in 4 patients, in all of whom the imaging had been clinically indicated. No therapeutic changes followed those radiographs performed on a routine basis.

CONCLUSION

Routine chest radiographs can be omitted prior to discharging patients after paediatric heart surgery.