Routine Daily Chest X-ray
OVERVIEW
- controversial issue
- viewed as an essential tool but is subject to overuse and misinterpretation
- no evidence of harm from a more restrictive strategy
INDICATIONS
- any ventilated patient with a sudden respiratory or cardiovascular deterioration
- post line/tube insertion (NG, ETT, CVL, PAC, ICD, pacing wire)
METHOD
- erect preferred
- consistent distance and energy level
- in full inspiration (hold during exposure ideal but no always practical)
PRECAUTIONS
- pregnancy
- over reproductive organs in young patients
- staff to stay > 3m away from x-rays
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
DISADVANTAGES
- radiation exposure (staff and patients)
- potential for lines/tube displacement
- cost and time
- requires patient movement (risk of dislodging lines, etc)
- false positives/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 thoracic ultrasound at the bedside supplants many uses of CXR
- CT chest is required for many diagnoses
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
- hard 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 recommends that mechanically ventilated patient should have a daily routine CXR
References and Links
Introduction to ICU Series
Introduction to ICU Series Landing Page
DAY TO DAY ICU: FASTHUG, ICU Ward Round, Clinical Examination, Communication in a Crisis, Documenting the ward round in ICU, Human Factors
AIRWAY: Bag Valve Mask Ventilation, Oropharyngeal Airway, Nasopharyngeal Airway, Endotracheal Tube (ETT), Tracheostomy Tubes
BREATHING: Positive End Expiratory Pressure (PEEP), High Flow Nasal Prongs (HFNP), Intubation and Mechanical Ventilation, Mechanical Ventilation Overview, Non-invasive Ventilation (NIV)
CIRCULATION: Arrhythmias, Atrial Fibrillation, ICU after Cardiac Surgery, Pacing Modes, ECMO, Shock
CNS: Brain Death, Delirium in the ICU, Examination of the Unconscious Patient, External-ventricular Drain (EVD), Sedation in the ICU
GASTROINTESTINAL: Enteral Nutrition vs Parenteral Nutrition, Intolerance to EN, Prokinetics, Stress Ulcer Prophylaxis (SUP), Ileus
GENITOURINARY: Acute Kidney Injury (AKI), CRRT Indications
HAEMATOLOGICAL: Anaemia, Blood Products, Massive Transfusion Protocol (MTP)
INFECTIOUS DISEASE: Antimicrobial Stewardship, Antimicrobial Quick Reference, Central Line Associated Bacterial Infection (CLABSI), Handwashing in ICU, Neutropenic Sepsis, Nosocomial Infections, Sepsis Overview
SPECIAL GROUPS IN ICU: Early Management of the Critically Ill Child, Paediatric Formulas, Paediatric Vital Signs, Pregnancy and ICU, Obesity, Elderly
FLUIDS AND ELECTROLYTES: Albumin vs 0.9% Saline, Assessing Fluid Status, Electrolyte Abnormalities, Hypertonic Saline
PHARMACOLOGY: Drug Infusion Doses, Summary of Vasopressors, Prokinetics, Steroid Conversion, GI Drug Absorption in Critical Illness
PROCEDURES: Arterial line, CVC, Intercostal Catheter (ICC), Intraosseous Needle, Underwater seal drain, Naso- and Orogastric Tubes (NGT/OGT), Rapid Infusion Catheter (RIC)
INVESTIGATIONS: ABG Interpretation, Echo in ICU, CXR in ICU, Routine daily CXR, FBC, TEG/ROTEM, US in Critical Care
ICU MONITORING: NIBP vs Arterial line, Arterial Line Pressure Transduction, Cardiac Output, Central Venous Pressure (CVP), CO2 / Capnography, Pulmonary Artery Catheter (PAC / Swan-Ganz), Pulse Oximeter
- 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.
- American College of Radiology ACR Appropriateness Criteria (revised 2014)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
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Hi LITFL, just wondering if that should say American College of Radiology recommends that mechanically ventilated patient should NOT have a daily routine CXR – https://acsearch.acr.org/docs/69452/Narrative/ ?