Can we abandon daily routine chest radiography in intensive care patients?

Radiation risk issues in recurrent imaging

Millions of patients benefit from medical imaging every single day. However, we have entered an unprecedented era in imaging practices wherein 1 out of 125 patients can be exposed to effective dose >50 mSv from a single CT exam and 3 out of 10,000 patients undergoing CT exams could potentially receive cumulative effective doses > 100 mSv in a single day. Recurrent imaging with CT, fluoroscopically guided interventions, and hybrid imaging modalities such as positron emission tomography/computed tomography (PET/CT) is more prevalent today than ever before. Presently, we do not know the cumulative doses that patients may be receiving across all imaging modalities combined. Furthermore, patients with diseases with longer life expectancies are being exposed to high doses of radiation enabling radiation effects to manifest over a longer time period. The emphasis in the past on improving justification of imaging and optimization of technique and practice has proved useful. While that must continue, the current situation requires imaging device manufacturers to urgently develop imaging technologies that are safer for patients as high doses have been observed in patients where imaging has been justified through clinical decision-support and optimized by keeping doses below the national benchmark doses. There is a need to have a critical look at the fundamental principles of radiation protection as cumulative doses are likely to increase in the coming years.

Accuracy of the Radiographic Assessment of Lung Edema Score for the Diagnosis of ARDS

Background: Bilateral opacities on chest radiographs are part of the Berlin Definition for Acute Respiratory Distress Syndrome (ARDS) but have poor interobserver reliability. The “Radiographic Assessment of Lung Edema” (RALE) score was recently proposed for evaluation of the extent and density of alveolar opacities on chest radiographs of ARDS patients. The current study determined the accuracy of the RALE score for the diagnosis and the prognosis of ARDS.

Methods:Post-hoc analysis of a cohort of invasively ventilated intensive care unit (ICU) patients expected to need invasive ventilation for >24 h. The Berlin Definition was used as the gold standard. The RALE score was calculated for the first available chest radiograph after start of ventilation in the ICU. The primary endpoint was the diagnostic accuracy for ARDS of the RALE score. Secondary endpoints included the prognostic value of the RALE score for ICU and hospital mortality, and the association with ARDS severity, and the PaO₂/FiO₂. Receiver operating characteristic (ROC) curves were constructed, and the optimal cutoff was used to determine sensitivity, specificity and the negative and positive predictive value of the RALE score for ARDS.

Results: The study included 131 patients, of whom 30 had ARDS (11 mild, 15 moderate, and 4 severe ARDS). The first available chest radiograph was obtained median 0 [0 to 1] days after start of invasive ventilation in ICU. Compared to patients without ARDS, a higher RALE score was found in patients with ARDS (24 [interquartile range (IQR) 16–30] vs. 6 [IQR 3–11]; P < 0.001), with RALE scores of 20 [IQR 14–24], 26 [IQR 16–32], and 32 [IQR 19–36] for mild, moderate and severe ARDS, respectively, (P = 0.166). The area under the ROC for ARDS was excellent (0.91 [0.86–0.96]). The best cutoff for ARDS diagnosis was 10 with 100% sensitivity, 71% specificity, 51% positive predictive value and 100% negative predictive value. The RALE score was not associated with ICU or hospital mortality, and weakly correlated with the PaO₂/FiO₂.

Conclusion: In this cohort of invasively ventilated ICU patients, the RALE score had excellent diagnostic accuracy for ARDS.

Unintentional exposure and incidental findings during conventional chest radiography in the pediatric intensive care unit

Radiation overexposure is common in chest X-ray (CXRs) of pediatric patients. However, overexposure may reveal incidental findings that can help to guide patient management or warrant quality improvement.To assess the prevalence of overexposure in CXRs in pediatric intensive care unit (PICU); and identify the incidental findings within overexposed areas, we conducted a retrospective cohort study of children who were admitted to PICU. Two independent evaluators reviewed patient's charts and digital CXRs according to the American College of Radiology standards; to evaluate overexposure of the anatomical parameters and incidental findings.A total of 400 CXRs of 85 patients were reviewed. The mean number of CXRs per patient was 4.7. Almost all (99.75%) CXRs met the criteria for overexposure, with the most common being upper abdomen (99.2%), upper limbs (97%) and neck (95.7%). In addition, 43% of these X-rays were cropped by the radiology technician to appear within the requested perimeter. There was a significant association between field cropping and overexposure (t-test: t = 9.8, P < .001). Incidental findings were seen in 41.5% of the radiographs; with the most common being gaseous abdominal distension (73.1%), low-positioned nasogastric tube (24.6%), and constipation (10.3%).Anatomical overexposure in routine CXRs remains high and raises a concern in PICU practice. Appropriate collimation of the X-ray beam, rather than electronically cropping the image, is highly recommended to minimize hiding incidental findings in the cropped-out areas. Redefining the anatomic boundaries of CXR in critically ill infants and children may need further studies and consideration. Quality improvement initiatives to minimize radiation overexposure in PICU are recommended, especially in younger children and those with more severe illness upon PICU admission.

Association of Variation in Consultant Use Among Hospitalist Physicians With Outcomes Among Medicare Beneficiaries

IMPORTANCE

Evidence is lacking on the consequences of high rates of inpatient consultation.

OBJECTIVE

To examine outcomes and resource use of patients cared for by hospitalists who use more inpatient consultation than their colleagues.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study of medical admissions to hospitalists among fee-for-service Medicare beneficiaries was conducted. Hospitalist consultation tendency was identified from January 1, 2013, to December 31, 2014; admissions were calculated in 2013; and outcomes were measured in 2014. Data were analyzed from January 31, 2017, to May 9, 2019. A total of 711 654 admissions with patients receiving care from 14 584 hospitalists at 737 hospitals were included.

EXPOSURE

Admission to high-consulting hospitalists, considered to be those who were in the top 25% of the distribution of consulting frequency at their own hospital (adjusted for patient case mix).

MAIN OUTCOMES AND MEASURES

Outcomes included length of stay, Medicare Part B inpatient charges, discharge destination, all-cause 7- and 30-day readmissions, 90-day outpatient specialist visits, and 30-day mortality.

RESULTS

The 711 654 hospital admissions included 408 489 women (57.4%); mean (SD) age of the population was 80 (8.5) years. Length of stay of patients cared for by high-consulting hospitalists was longer compared with other hospitalists (adjusted incidence rate ratio, 1.04; 95% CI, 1.03-1.05). The admissions resulted in a mean of $137.91 (95% CI, $118.89-$156.93) more in Medicare Part B charges and were less likely to end with the patient going home (adjusted odds ratio [aOR], 0.96; 95% CI, 0.94-0.98) compared with patients cared for by other hospitalists in the cohort. Patients cared for by high-consulting hospitalists also were 7% more likely than patients cared for by other hospitalists to see an outpatient specialist at 90 days (aOR 1.07; 95% CI, 1.05-1.09), with no significant differences in 30-day mortality (aOR 1.01, 95% CI, 0.98-1.03) or readmissions (7-day readmissions: aOR 1.01; 95% CI, 0.98-1.03; 30-day readmissions: aOR, 1.01; 95% CI, 0.99-1.03).

CONCLUSIONS AND RELEVANCE

Hospitalists who obtain consultations more than their colleagues at the same institution were associated with greater use of health care resources without apparent mortality benefit. Further investigation should identify whether reducing high rates of consultation can reduce resource use without harming patients.

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.

Cardiothoracic MRI in the ICU: A 10-Year Experience

RATIONALE AND OBJECTIVE

The objective of this study was to identify the feasibility and pitfalls of cardiothoracic magnetic resonance imaging (MRI) in intensive care unit (ICU) patients.

MATERIALS AND METHODS

This retrospective study identified adult ICU patients scheduled for cardiothoracic MRIs during a 10-year study period. ICU patients scheduled for brain MRIs served as a comparison group. A chart review was performed to identify factors impacting a patient's ability to undergo an MRI. Differences between completed and canceled examinations for both cardiothoracic and brain MRIs were evaluated. For the cardiothoracic group, clinical indications and the diagnostic value of the study performed were also identified.

RESULTS

A total of 143 cardiothoracic MRIs and 1011 brain MRIs were requested. Cardiothoracic MRI patients were less frequently completed (52% vs 62%), more frequently men (64% vs 43%), younger (55 vs 63 years), less likely mechanically ventilated (8% vs 29%), more likely to require intravenous contrast (83% vs 23%), and had longer examination times compared to brain MRI patients (64 vs 21 minutes). Successful completion of cardiothoracic MRI was associated with lower serum creatinine, higher glomerular filtration rate, and the absence of mechanical ventilation; significant differences were not seen with regard to gender and use of vasoactive agents. Cardiothoracic MRI results were diagnostic in 69% of examinations, most frequently when performed for myocardial disease (84%) and aortic disease (33%), and less frequently for viability (33%).

CONCLUSIONS

In an ICU population, successful completion of cardiothoracic MRI is challenging but feasible in patients with intact renal function and the absence of mechanical ventilation. Examinations were most frequently diagnostic for myocardial and aortic disease indications.

Can portable tomosynthesis improve the diagnostic value of bedside chest X-ray in the intensive care unit? A proof of concept study

Portable bedside chest X-ray (CXR) is an important and frequently used tool in the intensive care unit (ICU). Unfortunately, the diagnostic value of portable CXR is often low due to technical limitations and suboptimal patient positioning. Additionally, abnormalities in the chest may be hidden on the projection image by overlapping anatomy and devices such as endotracheal tubes, lines and catheters. Digital tomosynthesis (DTS) can solve the problem of anatomical overlap. In DTS, several low-dose X-ray images from different angles are acquired and subsequently used by a reconstruction algorithm to compute section images along planes parallel to the detector. However, a portable device to be used for portable bedside chest DTS is not on the market yet. In this work, we discuss modifications to a portable X-ray device to enable portable DTS and illustrate the potential of portable DTS to improve the diagnostic value of bedside CXR in the ICU. A simulation, based on computed tomography scans, is presented. Our experiments comparing portable DTS with conventional bedside CXR showed a substantially improved detection of pneumothorax and other abnormalities.

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.

[Imaging in intensive care]

The application of imaging methods in patients that are highly dependent on medical support is limited. Ultrasound has a prominent impact due to its flexibility, bedside availability, rapid results, and cost-effectiveness - especially in the assessment of cardiovascular and abdominal diseases. Ultrasound artifacts at the pleura-air interface play an emerging role in the diagnosis of thoracic disease. X-ray imaging is increasingly limited to the assessment of medical artifacts and the follow-up of pulmonary disorders. Daily routine chest X-rays should be abandoned. Multidetector computed tomography has evolved as the gold standard in the definitive diagnosis of many acute critical disorders despite the need for patient transportation. The application of magnetic resonance tomography is in contrast restricted to specific central nervous system diseases.

[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.

An integrated approach for prescribing fewer chest x-rays in the ICU

Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU.

Chest radiograph evaluation and interpretation

Chest imaging is an important tool in managing critically ill patients. Basic chest radiology is still used to quickly detect abnormalities in the chest. Critical care nurses are often the ones who first read the radiologist's report of chest radiograph results and provide their interpretation to a physician. Oftentimes, chest radiographs are obtained routinely on a daily basis for every critical care patient, with the goal of effective clinical management. Critical care nurses can confirm cardiopulmonary assessment findings by also evaluating their patient's chest radiographs and reviewing the radiologist's report. By learning some basic skills in interpreting and evaluating chest radiographs, nurses can recognize and localize gross pathologic changes visible on a chest radiograph. This article provides basic chest radiograph interpretation information that allows readers to review relevant anatomy and physiology, summarize normal and abnormal findings on chest radiographs, and describe radiographic findings in common pulmonary and cardiac disorders.

[Decrease of unnecessary chest x-rays in Intensive Care Unit: application of a combined cycle of quality improvement]

PURPOSE

To demonstrate that interdisciplinary consensus improves the quality of work in the daily Intensive Care Unit (ICU), thus avoiding unnecessary routine x-ray examinations. We propose to monitor the results to maintain this low percentage of requests for x-rays.

DESIGN

Cycle of improvement in care quality.

SETTING

An 18-bed polyvalent ICU.

PATIENTS

A random sample of patients admitted in ICU during one month.

INTERVENTIONS

Establishment of basic agreed on protocol for routine chest portable x-ray (CPR) indications. After assessing the excessive amount of CPR according to those criteria, all intensivists accepted their application. Five years later, a second assessment of the degree of non-compliance was carried out and a monitoring schedule was established in order to avoid making unnecessary CPR again. Furthermore, a consensus between two intensivists was considered obligatory before a CPR request. Accordingly, all non-urgent CPR forms were signed by two intensivists, following the mentioned clinical criteria. VARIABLE: Unsuitable portable chest x-ray indications.

RESULTS

In 1997, the overall non-compliance rate (ONCR) was 16.9%. After reducing it to 6.1%, lack of follow-up led to a non-compliance rate of 27.6% in 2003. Stable patients with uncomplicated ischemic heart disease (44.4% in 1997 and 53.8% in 2003) accounted for most of the inadequate ONCR indications. By using the consensus system for requesting routine portable x-rays that required the agreement of two intensivists achieved a reduction of non-compliance to 2.5% in 2003. The monitoring schedule designed has made it possible to follow the time of compliance degree and detect relaxation in the prescriptions.

CONCLUSIONS

Unnecessary CPR can be easily reduced stressing our control in clinically stable patients. The requirement to justify a routine request (agreement between intensivists) makes it possible to decrease the number of CPRs. Periodic monitoring is the definitive tool for a successful improvement cycle.

Thoracic imaging in the ICU

Imaging in the ICU plays a crucial role in patient care. The portable chest radiograph (CXR) is the most commonly requested radiographic examination, and, despite its limitations, it often reveals abnormalities that may not be detected clinically. Recent advances in CT technology have made it possible to obtain diagnostic-quality images even in the most dyspneic patient. This article reviews the significant contribution thoracic imaging makes in diagnosing and managing critically ill patients.

Elimination of daily routine chest radiographs in a mixed medical-surgical intensive care unit

OBJECTIVE

To determine the impact of elimination of daily routine chest radiographs (CXRs) in a mixed medical-surgical intensive care unit (ICU) on utility of on demand CXRs, length of stay (LOS) in ICU, readmission rate, and mortality rate.

DESIGN AND SETTING

Prospective, nonrandomized, controlled study in a 28-bed ICU. Analysis included data of all admitted ICU patients during 5 months before and after elimination of daily routine CXRs.

RESULTS

Before elimination, 2457 daily routine CXRs and 1437 on demand CXRs were obtained from 754 patients. After elimination, 1267 CXRs were obtained from 622 patients. The ratio of CXRs/patient day decreased from 1.1+/-0.3 to 0.6+/-0.4 (p<0.05). Elimination did not result in a change in utility and timing of on demand CXRs. The absolute diagnostic and therapeutic value of on demand CXRs increased with elimination of daily routine CXRs: before intervention, 147 unexpected predefined abnormalities were found (10.2% of all on demand CXRs in 15.9% of all patients), of which 57 (3.9%) in 6.4% of all patients led to a change in therapy. After intervention, 156 unexpected predefined abnormalities were found (11.6%; p<0.05), of which 61 (4.8%) in 9.5% of all patients (p<0.05) led to a change in therapy. The LOS in ICU, readmission rate and ICU, and hospital mortality rate were not influenced by the change in strategy.

CONCLUSIONS

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.

Year in review 2006: Critical Care--Resource management

As health care resources become increasingly constrained, it is imperative that intensive care unit resources be optimized. In the years to come, a number of challenges to intensive care medicine will need to be addressed as society changes. Last year's Critical Care papers provided us with a number of interesting and highly accessed original papers dealing with health care resources. The information yielded by these studies can help us to deal with issues such as prognostication, early detection and treatment of delirium, prevention of medical errors and use of radiology resources in critically ill patients. Finally, several aspects of scientific research in critically ill patients were investigated, focusing on the possibility of obtaining informed consent and recall of having given informed consent.

Chest radiography practice in critically ill patients: a postal survey in the Netherlands

Background

To ascertain current chest radiography practice in intensive care units (ICUs) in the Netherlands.

Methods

Postal survey: a questionnaire was sent to all ICUs with > 5 beds suitable for mechanical ventilation; pediatric ICUs were excluded. When an ICU performed daily-routine chest radiographs in any group of patients it was considered to be a "daily-routine chest radiography" ICU.

Results

From the number of ICUs responding, 63% practice a daily-routine strategy, in which chest radiographs are obtained on a daily basis without any specific reason. A daily-routine chest radiography strategy is practiced less frequently in university-affiliated ICUs (50%) as compared to other ICUs (68%), as well as in larger ICUs (> 20 beds, 50%) as compared to smaller ICUs (< 20 beds, 65%) (P > 0.05). Remarkably, physicians that practice a daily-routine strategy consider daily-routine radiographs helpful in guiding daily practice in less than 30% of all performed radiographs. Chest radiographs are considered essential for verification of the position of invasive devices (81%) and for diagnosing pneumothorax, pneumonia or acute respiratory distress syndrome (82%, 74% and 69%, respectively). On demand chest radiographs are obtained after introduction of thoracic drains, central venous lines and endotracheal tubes in 98%, 84% and 75% of responding ICUs, respectively. Chest films are also obtained in case of ventilatory deterioration (49% of responding ICUs), and after cardiopulmonary resuscitation (59%), tracheotomy (58%) and mini-tracheotomy (23%).

Conclusion

There is notable lack of consensus on chest radiography practice in the Netherlands. This survey suggests that a large number of intensivists may doubt the value of daily-routine chest radiography, but still practice a daily-routine strategy.

Radiographic measures of intravascular volume status: the role of vascular pedicle width

PURPOSE OF REVIEW

A valid, low-cost, high-yield instrument to assess intravascular volume status in critically ill patients does not exist. The portable chest X-ray is a common part of any intensivist's or chest clinician's daily rounds.

RECENT FINDINGS

A simple, objective, valid measure of intravascular volume status, the vascular pedicle width, remains underappreciated in the medical literature. While more invasive, more expensive, and less common technologies are looked upon to assist in the clinical evaluation of volume status among critically ill patients, the vascular pedicle width stands alone in its low-cost, nearly risk-free potential to impact clinical practice. Even as the daily chest X-ray has become less common in practice, the role of measuring vascular pedicle width is potentially significant, particularly among mechanically ventilated patients. A standardized approach to reading the portable chest X-ray (supine or erect) is needed to facilitate interpretation of complex medical problems among the critically ill. Prospective evaluation of its appropriate use, particularly as compared with other, typically more invasive measures of intravascular volume, is warranted.

SUMMARY

Vascular pedicle width measurement using a standardized approach to daily chest X-ray interpretation represents untapped potential for improving the non-invasive assessment of volume status in critically ill patients.

The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low

INTRODUCTION

The clinical value of daily routine chest radiographs (CXRs) in critically ill patients is unknown. We conducted this study to evaluate how frequently unexpected predefined major abnormalities are identified with daily routine CXRs, and how often these findings lead to a change in care for intensive care unit (ICU) patients.

METHOD

This was a prospective observational study conducted in a 28-bed, mixed medical-surgical ICU of a university hospital.

RESULTS

Over a 5-month period, 2,457 daily routine CXRs were done in 754 consecutive ICU patients. The majority of these CXRs did not reveal any new predefined major finding. In only 5.8% of daily routine CXRs (14.3% of patients) was one or more new and unexpected abnormality encountered, including large atelectases (24 times in 20 patients), large infiltrates (23 in 22), severe pulmonary congestion (29 in 25), severe pleural effusion (13 in 13), pneumothorax/pneumomediastinum (14 in 13), and malposition of the orotracheal tube (32 in 26). Fewer than half of the CXRs with a new and unexpected finding were ultimately clinically relevant; in only 2.2% of all daily routine CXRs (6.4% of patients) did these radiologic abnormalities result in a change to therapy. Subgroup analysis revealed no differences between medical and surgical patients with regard to the incidence of new and unexpected findings on daily routine CXRs and the effect of new and unexpected CXR findings on daily care.

CONCLUSION

In the ICU, daily routine CXRs seldom reveal unexpected, clinically relevant abnormalities, and they rarely prompt action. We propose that this diagnostic examination be abandoned in ICU patients.