Critical Care: Imaging in Critical Illness |

Routine Daily Chest Radiograph in the Medical ICU: Stop It! The Evidence Is Not There FREE TO VIEW

Adebayo Fasanya, MD; Rihab Sharara, MD; Jennifer Leap, DO; Anca Pelinescu, MD; Timothy Mickus, MD; Raghukumar Thirumala, MD
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Allegheny General Hospital, Pittsburgh, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):295A. doi:10.1016/j.chest.2016.08.308
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SESSION TITLE: Imaging in Critical Illness

SESSION TYPE: Original Investigation Slide

PRESENTED ON: Tuesday, October 25, 2016 at 11:00 AM - 12:15 PM

PURPOSE: Chest x-rays (CXR) are the most frequent radiological tests performed in the intensive care unit (ICU). Proposed advantages of daily routine CXR are early detection & thus earlier treatment of clinically unsuspected abnormalities, documentation of disease progression and response to therapy, and detection of complications associated with indwelling devices. Proposed disadvantages include, variable interpretation of CXR depending on clinician and patient factors, low incidence of clinically unsuspected abnormalities, potential harm arising from unnecessary treatment of minor or false positive findings, cost, radiation exposure and adverse events arising from repositioning of the patient to obtain the CXR. Anecdotal reports suggest that more routine daily CXR are performed in the Allegheny General Hospital (AGH) medical intensive care unit (MICU) than what is necessary. A review of the literature suggests (and a consensus statement by the American College of Radiology concurs) that routine daily chest radiographs in the ICU are not indicated. The American Thoracic Society also agrees that routine chestradiography is rarely indicated and may be harmful. Unexpected findings on chest radiographs were noted in <6% of the 2457 daily routine radiographs ordered in 754 consecutive ICU patients in a mixed medical-surgical ICU. The unexpected CXR findings prompted a change in management in less than half of these cases. Stable patients are particularly unlikely to benefit from routine chest radiography. Our mission was to determine if routine daily CXR is beneficial in the MICU and to determine how often the CXR prompted a major intervention.

METHODS: We reviewed 242 consecutive CXRs obtained at AGH MICU and the consequent management changes in 60 ICU patients. The indications for the CXRs, significant changes observed on the x-ray, and x-rays performed after procedures were also computed.

RESULTS: Twenty-four out of 242 (9.9%) CXRs had significant changes as determined by a radiologist. Thirty-three out of 242 (13.6%) management changes occurred. Out of the management changes, only 18 of 242 (7.4%) involved major procedures like bronchoscopy, repositioning of tubes, or chest tube placement/thoracentesis. Twenty-seven of 242 (11.2%) x-rays were for tube adjustment/insertion, and 24 of 242 (9.9%) were for line placement.

CONCLUSIONS: More CXRs than necessary are still ordered in the MICU. 9 out of 10 times, there were no significant changes and results from only about 1 in 13 CXRs required major procedures.

CLINICAL IMPLICATIONS: We should use clinical assessment to determine whether to order CXR. Routine daily CXR in the MICU is rarely beneficial, and physicians should carefully reconsider the clinical need for routine daily chest x-rays.

DISCLOSURE: The following authors have nothing to disclose: Adebayo Fasanya, Rihab Sharara, Jennifer Leap, Anca Pelinescu, Timothy Mickus, Raghukumar Thirumala

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