Question 4

College Answer

Daily “routine” CXR in (usually) intubated patients: controversial-evidence to support or refute practice, hard to study due to investigator bias, blinding problems and outcome assessment.

Generalisability may be an issue from often single specialty North American or European units to the usual multidisciplinary Australasian ICU. The consensus opinion of the Am. College of radiology is that daily routine CXR are indicated in patients who are mechanically ventilated . The evidence to date does not suggest that daily routine CXRs lead to changes in therapeutic decision making. Data suggest that length of stay and duration of mechanical ventilation are not adversely affected by elimination of daily routine CXR.

Benefits:

a) Confirmation of placement of major lines / tubes / pipes / wires

detects expected/unexpected disease progression/complications requiring treatment

b) Reasonable assessment of hypervolaemia/LVF, new infiltrates accompanying fever, pleural complications, endotracheal tube displacement

Problems:

radiation exposure-staff/patients potential for line/tube displacement Cost

False positive/false negative findings

Discussion

Rationale for routine CXRs:

• Critically ill patients may have rapidly evolving thoracic pathology
• This pathology may not be easily evaluated by clinical means
• Mechanically ventilated patients are especially prone to rapid changes
• Routine radiography may yield a management-influencing surveillance benefit

Advantages:

• Regular review of line and tube position
• Regular review of fluid balance as observed by pulmonary interstitial water
• Surveillance for VAP
• Assessment of the reasiness for extubation
• Observation of changes in lung parenchyma in response to treatment (eg. resolution of pneumonia)

Disadvantages:

• Radiation exposure
• Risk of tube/line dislodgement with positioning
• Lack of association between radiological apparance and physiological performance

Evidence and recommendations:

• Only about 7% of CXRs result in a change in management
• In another study, only 2.3% of CXRs revealed new pathology
• 2012 meta-analysis: no harm associated with "restrictive" use of CXRs
• Americal College of Radiology recommends they are performed for clinical indications only

Ganapathy, Anusoumya, et al. "Routine chest x-rays in intensive care units: a systematic review and meta-analysis." Crit Care 16.2 (2012): R68.

 

Amorosa, Judith K., et al. "ACR appropriateness criteria routine chest radiographs in intensive care unit patients." Journal of the American College of Radiology 10.3 (2013): 170-174.

 

Veličković, Jelena, et al. "Routine chest radiographs in the surgical intensive care unit: Can we change clinical habits with no proven benefit?." Acta chirurgica iugoslavica 60.3 (2013): 39-44.

 

Cruz, Jeffrey, et al. "Evaluation of the Clinical Utility of Routine Daily Chest Radiography in Intensive Care Unit Patients With Tracheostomy Tubes A Retrospective Review." Journal of intensive care medicine (2014): 0885066614538393.