Chest
Volume 123, Issue 5, May 2003, Pages 1607-1614
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Clinical Investigations in Critical Care
Utility of Daily Routine Portable Chest Radiographs in Mechanically Ventilated Patients in the Medical ICU

https://doi.org/10.1378/chest.123.5.1607Get rights and content

Study objectives:

To determine whether there is any difference in diagnostic, therapeutic, and outcome efficacy between protocols utilizing daily (ie, routine) chest radiographs (CXRs) and those utilizing clinically indicated (ie, nonroutine) CXRs in mechanically ventilated patients.

Design:

Prospective, randomized, observational study.

Setting:

A 20-bed medical ICU at a university hospital.

Patients:

Adult patients who had been receiving mechanical ventilation for > 48 h.

Interventions:

None.

Measurements and results:

Ninety-four patients who had been intubated for at least 48 h were randomized to receive either routine or nonroutine CXRs and were observed until extubation or death. The percentage of CXRs with new findings was significantly larger in the nonroutine CXR group (53.1%; 120 CXRs) compared to that in the routine CXR group (33.4%; 98 CXRs; odds ratio [OR], 1.59; 95% confidence interval [CI], 1.16 to 2.18; p = 0.004). The number of CXRs with new findings that resulted in interventions was significantly larger in the nonroutine CXR group (26.5%; 60 CXRs) compared to that in the routine CXR group (13.3%; 39 CXRs; OR, 2.0; 95% CI, 1.29 to 3.08; p = 0.002). There was no difference in the mean duration of mechanical ventilation (routine CXR arm, 7.93 days; nonroutine CXR arm, 6.76 days; p = 0.2606), length of ICU stay (routine CXR arm, 11.93 days; nonroutine CXR arm, 9.55 days; p = 0.1936), and total length of hospital stay (routine CXR arm, 19.34 days; nonroutine CXR arm, 16.45 days; p = 0.2199) between the two groups. Although patients in the nonroutine arm of the study received fewer CXRs, adverse outcomes (eg, length of mechanical ventilation, length of hospital stay, length of ICU stay, and mortality) did not increase (p = 0.818). Using the number of CXRs per patient as a surrogate, there was a statistically significant cost savings and decreased radiation exposure in the nonroutine CXR group.

Conclusions:

For mechanically ventilated patients, a strategy calling for daily routine CXRs compared to CXRs obtained based on clinical indications alone was not associated with reduced ICU or hospital length of stay or with reduced mortality.

Section snippets

Procedure and Data Collection

We prospectively evaluated patients who had been admitted to the 20-bed medical ICU of the Beth Israel Deaconess Medical Center in Boston, MA, over a 10-month period in 1999 to 2000, at which time there was no set policy regarding daily vs clinically indicated CXRs. Practice varied depending on the beliefs and biases of the individual faculty member who was serving as the ICU attending physician for a given month. Our closed medical ICU is staffed 24 h per day with medical house staff who are

Evaluation of Population Groups

We evaluated 94 patients over a 10-month period (Fig 1). A total of 293 CXRs were obtained from 43 patients in the routine arm of the study. These included 200 daily routine CXRs and 93 CXRs that were obtained as a result of a specific clinical indication. In the nonroutine arm of the study, there were 226 CXRs that were acquired from 51 patients. We enrolled a seemingly low number of patients in our study because the entry criteria did not allow all individuals with respiratory failure to be

Discussion

We have shown that a strategy that called for only nonroutine (ie, clinically indicated) CXRs did not differ from one that required routine (ie, daily) CXRs in terms of diagnostic and therapeutic efficacy when applied to patients receiving mechanical ventilation in a medical ICU. In evaluating outcome efficacy, we also showed that the patients from whom only nonroutine CXRs were obtained did as well from a clinical perspective as the patients from whom routine CXRs were obtained. Furthermore,

ACKNOWLEDGMENT

We are indebted to Sara Yankelev, MPH, of Abt Associates Clinical Trials, Cambridge, MA, for assistance in the statistical analyses. We express our appreciation to the nursing staff of the medical ICU for their assistance during the study. Finally, we extend our gratitude to the medical house staff of the Beth Israel Deaconess Medical Center, who were instrumental in data acquisition.

References (8)

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    Overall, we found no differences in outcomes, including mortality, complications, LOS or requirement for mechanical ventilation. These findings are in line with multiple other studies including the largest meta-analysis performed on this topic.1–3,9,10,13–16,19 This meta-analysis analyzed 9 studies with a combined total of 39,358 CXRs for 9611 patients and found no difference in ICU or hospital mortality, ICU or overall LOS or duration of mechanical ventilation.10

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