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Communications to the Editor |

Daily Routine Chest Radiographs FREE TO VIEW

Marcus J. Schultz
Author and Funding Information

Affiliations: University of Amsterdam Amsterdam, The Netherlands,  St. Vincent Hospital Worcester, MA,  Beth Israel Deaconess HealthCare Boston, MA

Correspondence to: Marcus J. Schultz, MD, PhD, University of Amsterdam, Department of Intensive Care Medicine, Meibergdreef 9, Amsterdam, The Netherlands 1105 AZ; e-mail: m.j.schultz@amc.uva.nl



Chest. 2004;125(3):1167. doi:10.1378/chest.125.3.1167
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Published online

To the Editor:

I read with interest the report by Krivopal and coworkers (May 2003)1 on the utility of daily routine portable chest radiographs in mechanically ventilated patients in a medical ICU. Krivopal et al showed that a strategy using daily routine chest radiographs, compared with a restrictive strategy in which radiographs are obtained based only on clinical indications, was not associated with better outcome. Although the advantage of a restrictive strategy was not as large as I expected,2 this report significantly contributes to the discussion between the two different schools of thought regarding the utility of obtaining daily chest radiographs in critically ill patients.

Unfortunately, the investigators excluded patients who had been intubated for > 72 h (ie, patients who had been transferred from another hospital). This is part of my concern. In my institution, these patients, especially, are the ones with complex diseases and are probably those in whom it would be most interesting to see whether a restrictive strategy is as safe as a strategy in which daily routine chest radiographs are made.

I was very much surprised to see that the absolute number of radiographs prompting an intervention was larger in the restrictive-strategy group. This can only be the case when the number of “radiologic events” was higher in the last group of patients. In the discussion, it is claimed that this might be the result of a difference in the number of patients (approximately 15%, not 25%, as claimed by the authors) and in case mix, but I strongly disagree that these are the only explanations. Since this was an unblinded study, giving more attention to the radiographs by individual physicians may very well have caused this difference.

Although the investigators claim that a restrictive strategy is cheaper (226 vs 293 radiographs), this needs more exploration. Were all radiology tests taken into account? I can imagine that when more radiologic events are seen, as was the case in the restrictive-strategy group, more radiology tests, such as CT scanning can or will be used. One or two transports to the CT scan ward may cause the advantage of fewer chest radiographs to be unimportant.

Krivopal, M, Shlobin, OA, Schwartzstein, RM (2003) Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU.Chest123,1607-1614. [CrossRef] [PubMed]
 
Price, MB, Grant, MJ, Welkie, K Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit.Crit Care Med1999;27,1588-1593. [CrossRef] [PubMed]
 
To the Editor:

I read the article by Krivopal et al1 with interest but was disappointed that they omitted references to my two previous articles on this subject. In comparing the utility of daily “routine vs clinically indicated” portable radiographs of the chest in ventilated medical ICU patients, they found that studies ordered with a clinical indication had a higher score for both diagnostic and therapeutic efficacy, and that there was no difference in the health outcomes for the two groups. Our results shed a different light on the subject, and I would like to share them with you.

Our first study2 on diagnostic efficacy was performed in 1979 and 1982. In 1979, seven examinations in 32 patients (21.9%) with “no change in clinical status” showed new findings, while in 1982, 24 of 51 patients (47.1%) showed new findings. These changes would not have been known if the examinations had not been requested.

Like Krivopal et al, we realized that the radiographic changes had little meaning unless the clinician thought that they were important enough to take some action. It was not until 1997 that we documented the impact of routine daily chest radiographs on treatment decisions in an 11-bed medical ICU.3 Two hundred consecutive patients underwent 471 portable chest examinations. A change in therapy was made on the basis of 174 of the radiographs (37%). The most frequent therapeutic interventions were the use of diuretics to treat pulmonary edema (26%), repositioning of the endotracheal tube (24%), and diagnostic studies to determine the cause of new pulmonary infiltrates (16%). At least one change in therapy was made for 91 of the 133 intubated patients (66%), but for only 14 of the 62 nonintubated patients (23%). In our facility, the routine radiograph seemed to be an important indication for treatment decisions.

There are several other considerations that are worth noting. The numbers in the present study were small, with only 94 patients in 10 months. Were there actually only about two patients per week who had been intubated for > 48 h in their 20-bed ICU? How did these small numbers influence their results?

The authors also make reference to radiation dose and cost. The amount of radiation received by the ICU patient, even with multiple repeated examinations, presents no risk to the health of the patient, given their presence in the ICU. The cost of the chest radiograph makes up only a small fraction of the cost of an ICU stay. The cost for not making the proper patient management decisions completely eclipses the cost of radiography.

The ICUs in the authors institution are run by residents. Because of the multiplicity of problems with ICU patients, the next steps in management are frequently difficult to discern. How often did the negative chest radiograph finding influence the residents in their planning so that they did not undertake other types of unnecessary tests? How often did the normal finding or lack of change in the radiograph increase the confidence of the residents that they were following the proper course of action?

Because of our findings and the above considerations of the present study, I think that the issue of the indication for daily routine radiographs has not been settled. I do feel that the daily routine radiographs make an important contribution to the management of the ICU patient and that they are justified.

References
Krivopal, M, Shlobin, OA, Schwartzstein, RM Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU.Chest2003;123,1607-1614. [CrossRef] [PubMed]
 
Janower, ML, Nocera, ZJ, Mukai, JK Utility and efficacy of portable chest radiographs.AJR Am J Roentgenol1984;142,265-267. [PubMed]
 
Marik, PE, Janower, ML The impact of routine chest radiography on ICU management decisions: an observational study.Am J Crit Care1997;6,95-98. [PubMed]
 
To the Editor:

We appreciate the comments of Drs. Janower and Schultz regarding our study of the utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU. We welcome the opportunity to respond to their questions and comments.

Dr. Janower’s 1997 study appears to suffer from the same problems we noted in other earlier attempts to assess the utility of routine chest radiographs in this patient population. His study was observational rather than a randomized, controlled trial. One quarter of the “abnormalities” detected were repositioning of the endotracheal tube, an intervention that is unlikely to have prevented a significant adverse outcome. Furthermore, in his study, we cannot determine how many of the abnormalities that were detected would have been found if the radiograph had been obtained as the result of a clinical suspicion of a problem. Finally, there is no attempt to determine whether the real outcomes of interest (eg, length of time on the ventilator, length of stay in the ICU, or mortality) are affected by the use of routine radiographs. We acknowledged in our manuscript that the relatively small size of our sample may have led to a β error with respect to some of these outcomes. Nevertheless, we believe that as a result of our study design our data provide more information than those of the observational study he reports. Although it is possible that a negative routine radiograph may have averted unnecessary testing by residents, our anecdotal experience would suggest that there are a greater number of routine films with “false-positive” results in the ICU setting than truly negative radiograph findings. Thus, the performance of routine radiographs might be expected to lead to a greater expenditure of resources rather than to a reduction of costs.

Dr. Schultz raises a question about our decision to exclude patients who had been intubated for > 72 h at the time of randomization. We agree that these patients, typically transferred from another facility due to a failure to respond to therapy, are often more complex than the usual ICU patient. Consequently, we believed that a subgroup analysis would have been necessary with separate randomization for that group, and we were concerned that we would not have a sufficient number of patients in the time frame established for the study to arrive at meaningful results. Further study of this group of patients is warranted.

The absolute number of radiographs prompting an intervention was larger in the nonroutine arm of the study. Although the staff in the ICU was not blinded to the randomization, the radiologists interpreting the radiographs were blinded. We remind Dr. Schultz that the definition of a “new finding” was based on the radiologist’s interpretation. Thus, a bias by the residents and attending physicians in the ICU cannot explain this finding.

Finally, Dr. Shultz’s comments regarding the total cost of the patients’ radiologic evaluations are valid and were acknowledged in our discussion. In addition to expenses associated with personnel costs attributed to the inefficiency of nonroutine radiographs, it is possible that the total number of studies and related costs in the nonroutine group was greater than those in the routine group, especially since a higher number of new findings was detected. However, those studies would presumably be clinically indicated. It is the goal of all of us to reduce the cost of testing that does not further the clinical outcome of the patient.

Larger studies as well as investigations of different patient populations will be needed to answer all the questions surrounding the topic of routine chest radiographs in patients with respiratory failure who are treated with mechanical ventilation. Such studies should be performed in a randomized, controlled protocol, and meaningful clinical outcomes should be sought.


Figures

Tables

References

Krivopal, M, Shlobin, OA, Schwartzstein, RM (2003) Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU.Chest123,1607-1614. [CrossRef] [PubMed]
 
Price, MB, Grant, MJ, Welkie, K Financial impact of elimination of routine chest radiographs in a pediatric intensive care unit.Crit Care Med1999;27,1588-1593. [CrossRef] [PubMed]
 
Krivopal, M, Shlobin, OA, Schwartzstein, RM Utility of daily routine portable chest radiographs in mechanically ventilated patients in the medical ICU.Chest2003;123,1607-1614. [CrossRef] [PubMed]
 
Janower, ML, Nocera, ZJ, Mukai, JK Utility and efficacy of portable chest radiographs.AJR Am J Roentgenol1984;142,265-267. [PubMed]
 
Marik, PE, Janower, ML The impact of routine chest radiography on ICU management decisions: an observational study.Am J Crit Care1997;6,95-98. [PubMed]
 
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