Routine Daily Chest X-ray

OVERVIEW

Chest radiography is a core ICU investigation, but its routine use is increasingly questioned.

• Modern evidence supports a restrictive, clinically‑triggered strategy, with no harm demonstrated from eliminating daily CXRs.
• The 2020 American College of Radiolgoy (ACR )Appropriateness Criteria recommend CXR when clinically indicated, not daily in stable patients.

INDICATIONS

• Acute deterioration (respiratory or cardiovascular)
• Admission or transfer to ICU
• Post‑procedure/device placement:
  • ETT
  • CVC / PAC
  • Intercostal catheter
  • Pacing wire
  • NG/OG tube
• Suspected complications: pneumothorax, malposition, oedema, new infiltrates
• Post chest tube removal (selective; ACR: May Be Appropriate)

METHOD

• erect preferred
• consistent distance and energy level
• in full inspiration (hold during exposure ideal but no always practical)
• Portable AP films standard in ICU

PRECAUTIONS

• pregnancy
• over reproductive organs in young patients
• staff to stay > 3m away from x-ray machine

INFORMATION

• position of hardware
• heart
• mediastinum
• soft tissue
• bone
• lung

ADVANTAGES

• hardware placement confirmation (lines, tubes, pipes, wires)
• detection of expected/unexpected disease progression and complications
• assessment of hypervolaemia, new infiltrates, pleural complications
• baseline documentation for future comparison

DISADVANTAGES

• radiation exposure (staff and patients)
• cost and time
• requires patient movement (risk of dislodging lines/ tubes, pateint discomfort, occupational health risk to staff from turnig/lifting patients, etc)
• false positive/ negative findings
• evidence does not suggest that daily routine CXR leads to changes in therapeutic decision making
• length of stay and duration of MV not adversely affected by elimination of routine daily CXR
• increasing use of ultrasound at the bedside shows superior performance to CXR for some purposes (e.g. diagnosis of pneumothorax, effusion, and consolidation)
• CT chest is required for definitive diagnosis in many conditions

EVIDENCE

Evidence to support or refute practice is sparse

• no harm found from a restrictive strategy in a meta-analysis of 9,611 patients from 9 studies (Ganapathy et al, 2012)
• difficult to study due to: investigator bias, blinding problems and outcome assessment
• generalisability is an issue (North America and Europe – single specialty ICU vs Australasian ICU – MDT based, closed units)

American College of Radiology recommendations (2020 update):

• Admission/transfer → Usually Appropriate
• Stable, no change → May Be Appropriate (Disagreement)
• Deterioration → Usually Appropriate
• Post device placement → Usually Appropriate
• Post chest tube removal → May Be Appropriate

CXR versus ultrasound

• Lung ultrasound superior to CXR for pneumothorax, effusion, consolidation
• CXR remains preferred for line/tube confirmation and NG tube placement

PRACTICAL TIPS AND PITFALLS

CXR is not required for:

• Stable ventilated patient with no clinical change
• Daily routine imaging without a specific question
• Line/tube review when previously confirmed and no concern

CXR is required for:

• cardiorespiratory deterioration
• after thoracic device insertion
• on admission/ transfer to ICU

Common pitfalls with CXR interpretation in ICU:

• ETT depth misinterpreted due to neck position
• Cardiomegaly overcalled on AP films
• Rotation mimicking mediastinal widening
• Supine pneumothorax easily missed

References and Links

Journal articles

• Ganapathy A, Adhikari NK, Spiegelman J, Scales DC. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. Crit Care. 2012 Dec 12;16(2):R68. PMC3681397.

FOAM and web resources

• American College of Radiology ACR Appropriateness Criteria (revised 2020)