Routine Chest X-ray after Percutaneous Tracheostomy is Unnecessary

CLiP, catheter and line position dataset

Correct catheter position is crucial to ensuring appropriate function of the catheter and avoid complications. This paper describes a dataset consisting of 50,612 image level and 17,999 manually labelled annotations from 30,083 chest radiographs from the publicly available NIH ChestXRay14 dataset with manually annotated and segmented endotracheal tubes (ETT), nasoenteric tubes (NET) and central venous catheters (CVCs).

The Diagnostic Yield and Clinical Impact of a Chest X-Ray after Percutaneous Dilatational Tracheostomy: A Prospective Cohort Study

A chest X-ray (CXR) is routinely performed after percutaneous dilatational tracheostomy (PDT). The purpose of this study was to evaluate the diagnostic yield of routine CXR following PDT and its impact on patient management and to identify predictors of post-PDT CXR changes. Two-hundred-and-thirty-nine patients who underwent PDT in a 21-bed intensive care unit were included prospectively in the study. The following data were collected: patient demographics, APACHE III scores, pre-PDT FiO2 and PEEP, PDT technique, perioperative complications and the use of bronchoscopic guidance. We compared post-PDT CXR with the last pre-PDT CXR. We documented any post-PDT new radiographic findings including atelectasis, pneumothorax, pneumomediastinum, surgical emphysema, pulmonary infiltrates or tracheostomy tube malposition. We also recorded management modifications based on post-PDT radiographic changes, including increased PEEP, chest physiotherapy, therapeutic bronchoscopy or chest tube insertion. Atelectasis was the only new finding detected on post-PDT CXRs of 24 (10%) patients. The new radiographic findings resulted in a total of 14 modifications of management in 10 (4%) patients including increased PEEP in six, chest physiotherapy in six and bronchoscopy in two patients. Trauma and pre-PDT PEEP >5 cmH2O were independent predictors of post-PDT CXR changes. Routine CXR following PDT has a low diagnostic yield, detecting mainly atelectasis and leading to a change in the management in only a minority of patients. Routine CXR after apparently uncomplicated PDT performed by an experienced operator may not be necessary and selective use may improve its diagnostic yield. Further studies are required to validate the safety of selective versus routine post-PDT CXR.

Evaluation of the Clinical Utility of Routine Daily Chest Radiography in Intensive Care Unit Patients With Tracheostomy Tubes: A Retrospective Review

BACKGROUND

The utilization of imaging procedures is under scrutiny due to high costs and radiation exposure to patients and staff associated with some radiologic procedures. Within our institution's intensive care unit (ICU), it is common for patients to undergo chest radiography (CR) not only immediately following tracheostomy tube placement but also on a daily basis, irrespective of the patient's clinical status. We hypothesize that the clinical utility of performing routine daily CR on patients with tracheostomy tubes is low and leads to unnecessary financial cost.

METHODS

A retrospective medical chart review was done on 761 CRs performed on 79 ICU patients with tracheostomy from April 2010 to July 2011. We searched the radiology reports of the 761 CRs for the presence of new radiographically detected complications and reviewed medical records to determine which complications were clinically suspected and which radiology reports led to changes in patient management.

RESULTS

Of the 761 CRs, only 18 (2.3%) radiographs revealed new complications. All complications were clinically suspected prior to imaging. Only 5 (0.7%) complications resulted in a management change. The most common management changes were a change in antibiotic regimen (0.3%) and ordering of diuretics (0.3%).

CONCLUSIONS

Routine daily imaging of patients with tracheostomy in an ICU provides little clinical utility, and CR in this population should be performed selectively based on the patient's clinical status.

Is routine chest X-ray after surgical and percutaneous tracheostomy necessary in adults: a systemic review of the current literature

BACKGROUND

For many years, routine post-tracheostomy chest X-ray has been the standard of care for patients in many countries. However, recent evidence suggests that this is unnecessary and cost-ineffective.

OBJECTIVE

To review the current literature and examine the role of routine post-tracheostomy chest X-ray in adult patients.

TYPE OF REVIEW

Systemic review.

SEARCH STRATEGY

Electronic databases (PubMed, EMBASE, Cochrane) were searched using the keywords 'chest X-ray/radiography/radiograph' and 'tracheostomy/tracheotomy' in various permutations. Search period ranged from 1960 to 2012. Inclusion criteria included systematic reviews, meta-analyses, randomised control trials, prospective and retrospective case series. Paediatric and non-English articles were excluded. Abstracts and subsequently full text articles were screened by two of the authors independently. References from obtained articles were also examined.

EVALUATION METHOD

Specific outcome measures were collated to evaluate the usefulness of post-tracheostomy chest X-ray: Chest X-ray detected (tracheostomy-related) complication rates Proportion of cases requiring significant intervention Potential predictors of complications

RESULTS

Routine post-tracheostomy chest X-ray is of a low yield, and its findings had limited impact on patient management. Complication detection rates for surgical and percutaneous tracheostomy are 2.2% and 3.2%, respectively. Only 0.7% and 1.8% of chest X-rays performed in surgical and percutaneous tracheostomy cases, respectively, required intervention. Certain groups of patients, however, are at higher risks of complications, and may benefit from post-tracheostomy chest X-ray. For surgical tracheostomy, these groups include those with post-operative signs and symptoms of complications or had emergent or 'difficult' tracheostomies. For percutaneous tracheostomy, high-risk patients include trauma cases (unspecified), patients with post-procedural signs and symptoms of complications, patients who have high ventilatory requirements, difficult tracheostomy cases or tracheostomy cases performed without bronchoscopic guidance.

CONCLUSION

The practice of routine post-tracheostomy chest X-ray is debatable owing to its low yield and minimal impact on clinical management. However, certain groups of patients appear to be at higher risks of post-tracheostomy complications; currently, there is insufficient evidence to conclude the absolute need for routine chest X-ray in these groups of patients, although it may be prudent to do so based on available evidence in the literature and logical clinical reasoning.

[The role of routine chest radiography after percutaneous dilatational tracheostomy. A prospective randomized study]

BACKGROUND

Routine chest radiography (X-ray) after percutaneous dilatational tracheostomy has been considered standard procedure in the past. However, recent observations show this to be unnecessary and cost ineffective. Prospective randomised trials have been lacking.

PATIENT AND METHODS

Critically ill patients admitted to an ICU with an indication for a percutaneous tracheostomy were consecutively randomized into group 1 (routine postprocedural chest X-ray) and group 2 (chest X-ray only when considered clinically indicated). Tracheostomy was performed under bronchoscopic guidance.

RESULTS

A total of 100 patients (50 per group) were included. Three major complications were observed in group 1 and one presumed complication in group 2. There were 11 minor complications in group 1 and 16 in group 2. Routine chest X-ray in group 1 did not reveal any abnormality related to the tracheostomy. A control chest X-ray was considered necessary in only one patient in group 2, but with no pathological change observed.

CONCLUSION

Routine chest radiography after a percutaneous dilatational tracheostomy conducted under fibre optic bronchoscopic guidance is probably not useful.

Chest X-ray after tracheostomy is not necessary unless clinically indicated

BACKGROUND

Chest radiography is routinely used post-tracheostomy to evaluate for complications. Often, the chest X-ray findings do not change clinical management. The present study was conducted to evaluate the utility of post-tracheostomy X-rays.

METHOD

This retrospective review of 255 patients was performed at a single-center, university, level I trauma center. All patients underwent tracheostomy and were evaluated for postprocedure complications.

RESULTS

Of the 255 patients, 95.7% had no change in postprocedure chest X-ray findings. New significant chest X-ray findings were found in 4.3% of patients, including subcutaneous emphysema, pneumothorax, and new significant consolidation. Only three of these patients required change in clinical management, and all changes were based on clinical presentation alone.

CONCLUSIONS

Routine chest X-ray following tracheostomy fails to provide additional information beyond clinical examination. Therefore radiographic examination should be performed only after technically difficult procedures or if the patient experiences clinical deterioration. Significant cost savings and minimization of radiation exposure can be achieved when chest radiography after tracheostomy is performed exclusively for clinical indications.

Survey of Percutaneous Tracheostomy Practice in UK Intensive Care Units

In order to assess current practice of percutaneous tracheostomy (PT) in UK intensive care units (ICUs), we created a web-based survey by e-mail invitation to the clinical directors of 184 ICUs taking part in the ICNARC case-mix programme. The response rate was 46% (n=85). Most units performed 100 or fewer PTs each year. Just over half, 55.3%, had access to resident on-site surgical backup with ENT being the most common specialty providing this. Nearly one third, 30.6%, performed PTs out of routine hours; 30.6% used ultrasound to visualise potential problematic vessels. Bronchoscopy was used by 81.7% of units for all PTs performed, and conical dilation was the most popular technique. Fifteen units, 8.2%, did not routinely perform chest X-ray after PT insertion, but 49.4% of respondents did not feel that chest X-ray was mandatory after routine uncomplicated PT insertion. Despite certain trends in practice, there is still disparity in the practice of PT among ICUs in the UK. Ultrasound examination for problematic blood vessels prior to PT should be considered, bronchoscopy should be readily available and the use of routine chest X-ray after uncomplicated PT insertion should be questioned.

Tracheostomy: current practice on timing, correction of coagulation disorders and peri-operative management - a postal survey in the Netherlands

BACKGROUND

Several factors may delay tracheostomy. As many critically ill patients either suffer from coagulation abnormalities or are being treated with anticoagulants, fear of bleeding complications during the procedure may also delay tracheostomy. It is unknown whether such (usually mild) coagulation abnormalities are corrected first and to what extent. The purpose of this study was to ascertain current practice of tracheostomy in the Netherlands with regard to timing, pre-operative correction of coagulation disorders and peri-/intra-operative measures.

METHODS

In October 2005, a questionnaire was sent to the medical directors of all non-pediatric ICUs with >/=5 beds suitable for mechanical ventilation in the Netherlands.

RESULTS

A response was obtained from 44 (64%) out of 69 ICUs included in the survey. Seventy-five percent of patients receive tracheostomy within 2 days after the decision to proceed with a tracheostomy. Reasons indicated as frequent causes for delay were most often logistical factors. A heterogeneous attitude exists regarding values of coagulation parameters acceptable to perform tracheostomy. Fifty percent of the respondents have no guideline on correction of coagulation disorders or anticoagulant therapy before tracheostomy. Antimicrobial prophylaxis is almost never administered before tracheostomy. Forty-eight percent mentioned always using endoscopic guidance and 66% of ICUs only perform chest radiography on indication.

CONCLUSIONS

There is a high variation in peri- and intra-operative practice of tracheostomy in the Netherlands. Especially on the subject of coagulation and tracheostomy there are different opinions and protocols are often lacking.

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Routine chest x rays following bronchoscopy guided percutaneous dilational tracheostomy

A short cut review was carried out to establish whether routine chest x rays are required following bronchoscopy guided percutaneous dilational tracheostomy (PDT). A total of 393 citations were reviewed of which six answered the three part question. The clinical bottom line is that at present there is no clinical evidence to support routine postprocedure chest x ray following bronchoscopy guided percutaneous dilatianal tracheostomy.

Clinical review: percutaneous dilatational tracheostomy

As the number of critically ill patients requiring tracheotomy for prolonged ventilation has increased, the demand for a procedural alternative to the surgical tracheostomy (ST) has also emerged. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside. It is now considered a viable alternative to (ST) in the intensive care unit. Evaluation of PDT procedural modifications will require evaluation in randomized clinical trials. Regardless of the PDT technique, meticulous preoperative and postoperative management are necessary to maintain the excellent safety record of PDT.