| 1. Palazzetti V, Gasparri E, Gambini C, et al. Chest radiography in intensive care: an irreplaceable survey?. Radiologia Medica. 118(5):744-51, 2013 Aug. |
Observational-Dx |
258 patients |
To evaluate the impact and value of bedside chest X-ray in intensive care units. |
DE for chest X-rays was 84.5%, with 15.5% of tests remaining unchanged over time. Patient stratification by disease indicated that the DE was 85.27% in transplant, 90.79% in postoperative care after general surgery, 83.89% in respiratory failure, 82.42% in polytrauma, 90.54% in postoperative care after neurosurgery, 86.6% in postoperative care after vascular surgery, 83.3% in neurological conditions and 93.4% in other diseases. |
2 |
| 2. Mortani Barbosa EJ Jr, Lynch MC, Langlotz CP, Gefter WB. Optimization of Radiology Reports for Intensive Care Unit Portable Chest Radiographs: Perceptions and Preferences of Radiologists and ICU Practitioners. Journal of Thoracic Imaging. 31(1):43-8, 2016 Jan. |
Review/Other-Dx |
1343 patients (1265 referring practitioners and 76 radiologists) |
To evaluate opinions and perceptions of radiologists and referring practitioners regarding reports of portable chest radiography (pCXR) obtained in the intensive care unit (ICU). |
One hundred ninety-two referring practitioners and 63 radiologists answered the surveys, resulting in response rates of 15% and 83%. The majority of radiologists and referring practitioners are satisfied with the quality of the reports; however, radiologists and referring practitioners disagree about the reports' clinical value and impact, the referring practitioners having a more positive view. Both groups overwhelmingly agree that pertinent clinical information is crucial for optimal image interpretation. The 2 groups differ in their preferences regarding report style and information content, with radiologists strongly supporting concise reports emphasizing temporal changes and major findings, whereas referring practitioners prefer more complete, itemized structured reports describing support devices in detail. |
4 |
| 3. Xirouchaki N, Kondili E, Prinianakis G, Malliotakis P, Georgopoulos D. Impact of lung ultrasound on clinical decision making in critically ill patients. Intensive Care Med. 40(1):57-65, 2014 Jan. |
Observational-Dx |
253 patients |
To assess the impact of lung ultrasound (LU) on clinical decision making in mechanically ventilated critically ill patients. |
Two hundred and fifty-three LU examinations were performed; 108 studies (42.7%) were performed for unexplained deterioration of arterial blood gases, and 145 (57.3%) for a suspected pathologic entity (60 for pneumothorax, 34 for significant pleural effusion, 22 for diffuse interstitial syndrome, 15 for unilateral lobar or total lung atelectasis, and 14 for pneumonia). The net reclassification index was 85.6%, indicating that LU significantly influenced the decision-making process. The management was changed directly as a result of information provided by the LU in 119 out of 253 cases (47%). In 81 cases, the change in patient management involved invasive interventions (chest tube, bronchoscopy, diagnostic thoracentesis/fluid drainage, continuous venous-venous hemofiltration, abdominal decompression, tracheotomy), and in 38 cases, non-invasive (PEEP change/titration, recruitment maneuver, diuretics, physiotherapy, change in bed position, antibiotics initiation/change). In 53 out of 253 cases (21%), LU revealed findings which supported diagnoses not suspected by the primary physician (7 cases of pneumothorax, 9 of significant pleural effusion, 9 of pneumonia, 16 of unilateral atelectasis, and 12 of diffuse interstitial syndrome). |
4 |
| 4. Phillips CT, Manning WJ. Advantages and pitfalls of pocket ultrasound vs daily chest radiography in the coronary care unit: A single-user experience. Echocardiography. 34(5):656-661, 2017 May. |
Observational-Dx |
66 patients |
To assess pocket ultrasound in detecting common conditions in the coronary care unit (CCU) compared to portable daily chest radiography (CXR) and conventional transthoracic echocardiography (TTE). |
A total of 102 CXR and pocket ultrasound examinations were performed in 66 patients. The most common CXR indication was "interval change" (37%) and finding central line (65%). Pocket ultrasound demonstrated overall good concordance with CXR ranging from 77% for pleural effusion to 92% for pneumonia. Additionally, the pocket ultrasound examination appeared to anticipate resolution of pulmonary edema prior to the CXR. Compared to TTE, pocket ultrasound had excellent sensitivity for cardiac findings with values ranging from 85% for left atrial enlargement to 100% for cardiomegaly, but limited specificity of cardiomegaly at just 51%. |
2 |
| 5. Winkler MH, Touw HR, van de Ven PM, Twisk J, Tuinman PR. Diagnostic Accuracy of Chest Radiograph, and When Concomitantly Studied Lung Ultrasound, in Critically Ill Patients With Respiratory Symptoms: A Systematic Review and Meta-Analysis. Critical Care Medicine. 2018 Mar 29. |
Review/Other-Dx |
10 full-text studies, including 543 patients |
To evaluate the diagnostic accuracy of chest radiograph, and when concomitantly studied lung ultrasound, in comparison with the gold-standard CT for adult critically ill patients with respiratory symptoms. |
In the meta-analysis, we included 10 full-text studies, including 543 patients, and found that chest radiograph has an overall sensitivity of 49% (95% CI, 40-58%) and specificity of 92% (86-95%). In seven studies, where also lung ultrasound was studied, lung ultrasound had an overall sensitivity of 95% (92-96%) and specificity of 94% (90-97%). Substantial heterogeneity was found. A planned subgroup analysis for individual pathologies was performed. The results of four abstract-only studies, included in the systematic review, were considered unlikely to significantly influence results of our meta-analysis. Study limitations were that most studies were of low power combined with methodological limitations. |
4 |
| 6. Tolsma M, Rijpstra TA, Schultz MJ, Mulder PG, van der Meer NJ. Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey. Annals of Intensive Care. 4(1):10, 2014 Apr 04. |
Review/Other-Dx |
N/A |
To perform a survey of Dutch intensivists on the current practice of chest radiography in their departments. |
Of the 83 ICUs that were contacted, 69 (83%) responded to the survey. Only 7% of responding ICUs were currently performing daily routine CXRs for all patients, and 61% of the responding ICUs were said never to perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in 72% of the responding ICUs and is judged to be important or even essential by those ICUs. The therapeutic efficacy of routine CXRs was assumed by intensivists to be lower than 10% or to be between 10 and 20%. The efficacy of 'on-demand' CXRs was assumed to be between 10 and 60%. There is a consensus between intensivists to perform a routine CXR after endotracheal intubation, chest tube placement or central venous catheterization. |
4 |
| 7. Mets O, Spronk PE, Binnekade J, Stoker J, de Mol BA, Schultz MJ. Elimination of daily routine chest radiographs does not change on-demand radiography practice in post-cardiothoracic surgery patients. J Thorac Cardiovasc Surg. 134(1):139-44, 2007 Jul. |
Observational-Dx |
175 patients |
To determine the effect of elimination of daily routine chest radiographs on chest radiographic practice in cardiothoracic surgery patients in the intensive care unit and the post-intensive care unit ward. |
Before intervention, in the intensive care unit 353 daily routine chest radiographs and 261 on-demand chest radiographs were obtained in 175 patients; after intervention, 275 on-demand chest radiographs were obtained in 163 patients. Before intervention, in the post-intensive care unit ward 413 on-demand chest radiographs were obtained in 167 patients; after intervention, 445 on-demand chest radiographs were obtained in 161 patients. In the intensive care unit the number of chest radiographs per patient day decreased from 1.8 +/- 0.6 to 1.1 +/- 0.6. In the post-intensive care unit ward the number of chest radiographs per patient per day was 0.4 +/- 0.2, both before and after the intervention. Slightly more unexpected abnormalities were found in the on-demand chest radiographs after the intervention. No negative influence on chest radiography timing, length of stay in the intensive care unit and hospital, and readmission rate was seen. |
4 |
| 8. Ganapathy A, Adhikari NK, Spiegelman J, Scales DC. Routine chest x-rays in intensive care units: a systematic review and meta-analysis. [Review]. Critical Care (London, England). 16(2):R68, 2012 Dec 12. |
Meta-analysis |
Nine studies(39,358 CXRs; 9,611 patients) |
To investigate clinical changes among critically ill adults or children. In duplicate, we extracted data on the Chest x-rays (CXR) strategy, study quality and clinical outcomes (ICU and hospital mortality; duration of mechanical ventilation and ICU and hospital stay). |
Nine studies (39,358 CXRs; 9,611 patients) were included in the meta-analysis. Three trials (N = 870) of moderate to good quality provided information on the safety of a restrictive routine CXR strategy; only one trial systematically assessed for missed findings. Pooled data from trials showed no evidence of effect of a restrictive approach on ICU mortality (risk ratio [RR] 1.04, 95% confidence interval [CI] 0.84 to 1.28, P = 0.72; two trials, N = 776), hospital mortality (RR 0.98, 95% CI 0.68 to 1.41, P = 0.91; two trials, N = 259), ICU length of stay (weighted mean difference [WMD] -0.86 days, 95% CI -2.38 to 0.66 days, P = 0.27; three trials, N = 870), hospital length of stay (WMD -2.50 days, 95% CI -6.62 to 1.61 days, P = 0.23; two trials, N = 259), or duration of mechanical ventilation (WMD -0.30 days, 95% CI -1.48 to 0.89 days, P = 0.62; three trials, N = 705). Adding data from six observational studies, one of which systematically screened for missed findings, gave similar results. |
Good |
| 9. Sy E, Luong M, Quon M, et al. Implementation of a quality improvement initiative to reduce daily chest radiographs in the intensive care unit. [Review]. BMJ Qual Saf. 25(5):379-85, 2016 May. |
Review/Other-Dx |
1492 patients |
To reduce the number of routine chest radiographs (CXRs) done in a tertiary care intensive care unit (ICU) |
There were 0.73 CXRs per patient-day done during the preintervention period and 0.54 CXRs per patient-day done during the postintervention period, a 26% reduction. There were no differences between the periods in age, sex or severity of illness (Acute Physiology and Chronic Health Evaluation (APACHE) II score) of the patients, number of chest CTs, mechanical ventilator days, length of ICU stay and ICU or hospital mortality. |
4 |
| 10. Tolsma M, Rijpstra TA, Rosseel PM, et al. Defining indications for selective chest radiography in the first 24 hours after cardiac surgery. J Thorac Cardiovasc Surg. 150(1):225-9, 2015 Jul. |
Observational-Dx |
102 patients |
To investigate the efficacy and safety of chest radiographs (CXRs) performed after cardiac surgery for specified indications only. |
A total of 1102 consecutive cardiac surgery patients were included in this study. The diagnostic efficacy of CXRs for major abnormalities was higher for the postoperative on-demand CXRs (n = 301; 27%) than for the routine CXRs taken the morning after surgery (n = 801; 73%) (6.6% vs 2.7%, P = .004). The therapeutic efficacy was higher for the on-demand CXRs, whereas the need for intervention after the next-morning, routine CXRs was limited to 5 patients (4.0% vs 0.6%, P < .001). None of these patients experienced a major adverse event. |
2 |
| 11. Reeb J, Falcoz PE, Olland A, Massard G. Are daily routine chest radiographs necessary after pulmonary surgery in adult patients?. [Review]. Interactive Cardiovascular & Thoracic Surgery. 17(6):995-8, 2013 Dec. |
Review/Other-Dx |
66 papers |
To determine whether daily routine (DR) chest radiographs (CXRs) are necessary after pulmonary surgery in adult patients |
No results stated in the abstract. |
4 |
| 12. Ebrahimi A, Yousefifard M, Mohammad Kazemi H, et al. Diagnostic Accuracy of Chest Ultrasonography versus Chest Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffus. 13(4):29-40, 2014. |
Meta-analysis |
28 articles |
To evaluate the diagnostic accuracy of Chest Ultrasonography(CUS) and chest radiography (CXR) for detection of pneumothorax. |
The analysis showed the pooled sensitivity and specificity of CUS were 0.87 (95% CI: 0.81-0.92; I2= 88.89, P<0.001) and 0.99 (95% CI: 0.98-0.99; I2= 86.46, P<0.001), respectively. The pooled sensitivity and specificity of CXR were 0.46 (95% CI: 0.36-0.56; I2= 85.34, P<0.001) and 1.0 (95% CI: 0.99-1.0; I2= 79.67, P<0.001), respectively. The Meta regression showed that the sensitivity (0.88; 95% CI: 0.82 - 0.94) and specificity (0.99; 95% CI: 0.98 - 1.00) of ultrasound performed by the emergency physician was higher than by non-emergency physician. Non-trauma setting was associated with higher pooled sensitivity (0.90; 95% CI: 0.83 - 0.98) and lower specificity (0.97; 95% CI: 0.95 - 0.99). |
Good |
| 13. Graat ME, Choi G, Wolthuis EK, et al. The clinical value of daily routine chest radiographs in a mixed medical-surgical intensive care unit is low. Critical Care (London, England). 10(1):R11, 2006 Feb. |
Observational-Dx |
754 patients, 2,457 CXRs |
Prospective observational study to determine if daily routine CXRs reveal unexpected, clinically relevant abnormalities and whether it helps ICU patients. |
Daily routine CXRs rarely reveal abnormalities and should not be used in ICU patients. Study proposes this examination be abandoned in ICU patients. |
3 |
| 14. Al Shahrani A, Al-Surimi K. Daily routine versus on-demand chest radiograph policy and practice in adult ICU patients- clinicians' perspective. BMC med. imaging. 18(1):4, 2018 04 03. |
Review/Other-Dx |
N/A |
To identify and assess the clinician's perspective in abandoning the current practice of daily routine chest radiograph and replacing with the on-demand radiograph in Saudi hospitals. |
Out of 730 questionnaires sent, we received only 495 completed questionnaires with a response rate of 67.8%. Majority of them (n?=?351) are working at academic hospitals. About half of the respondents (n?=?247) are working in an open-format ICUs. Findings showed that the daily routine chest X-ray was performed in almost 96.8% of ICUs patients, which the majority of the clinical staff members (73%) thought that this current daily routine CXR protocol in the ICUs should be replaced with the on-demand CXR policy. Interestingly, the differences in demographic and work-related characteristics had no significant impact on the clinician's view and supported moving to on-demand CXR policy and practice. |
4 |
| 15. Cerfolio RJ, Bryant AS. Daily chest roentgenograms are unnecessary in nonhypoxic patients who have undergone pulmonary resection by thoracotomy. Annals of Thoracic Surgery. 92(2):440-3, 2011 Aug. |
Observational-Tx |
1,037 patients |
To assess the clinical benefit of performing a daily chest roentgenogram (CXR) on patients who have had a pulmonary resection. |
Between January 2006 and December 2009, 1,037 patients met the eligibility criteria for this study. Types of resection were wedge in 282 patients, segmentectomy in 146, and lobectomy in 609. Only 20 of the 834 patients (2%) who did not have a pneumothorax on the recovery room CXR had hypoxia, compared with 42 patients (21%) who had a recovery room pneumothorax (odds ratio 10.6, 95% confidence interval: 6.1 to 18.5, p<0.001). Daily CXR changed the care of only 268 of 975 patients (27%) who never had hypoxia compared with 49 of the 62 patients (79%) who were hypoxic (odds ratio 9.2, 95% confidence interval: 4.3 to 13.7, p<0.001). Moreover, the changes in care made by the CXR in the 268 nonhypoxic patients were for small pneumothoraces, and the impact of these changes is dubious |
3 |
| 16. Abdalla W, Elgendy M, Abdelaziz AA, Ammar MA. Lung ultrasound versus chest radiography for the diagnosis of pneumothorax in critically ill patients: A prospective, single-blind study. Saudi journal of anaesthesia. 10(3):265-9, 2016 Jul-Sep. |
Observational-Dx |
192 patients |
To compare the diagnostic accuracy of lung US against bedside chest radiography (CR) for the detection of PTX using thoracic computed tomography (CT) as the gold standard. |
Of the studied patients, CT of the chest confirmed the diagnosis of PTX in 36 (18.75%) patients of which 31 were diagnosed by thoracic US while CR detected only 19 cases. Overall lung US showed a considerable higher sensitivity than bedside CR (86.1% vs. 52.7%), lung US also showed higher, negative predictive values, and diagnostic accuracy against CR (96.8% vs. 90.1%), and (95.3% vs. 90.6%), respectively. CR had a slightly higher specificity than lung US (99.4% vs. 97.4%), and higher positive predictive values (95.0% vs. 88.6%). |
2 |
| 17. Ashton-Cleary DT. Is thoracic ultrasound a viable alternative to conventional imaging in the critical care setting?. [Review]. Br J Anaesth. 111(2):152-60, 2013 Aug. |
Review/Other-Dx |
N/A |
To explore the diagnostic performance of thoracic ultrasound in the imaging of pleural effusion, consolidation, extra-vascular lung water (EVLW), and pneumothorax. |
No results stated in the abstract. |
4 |
| 18. Bensted K, McKenzie J, Havryk A, Plit M, Ben-Menachem E. Lung Ultrasound After Transbronchial Biopsy for Pneumothorax Screening in Post-Lung Transplant Patients. Journal of Bronchology & Interventional Pulmonology. 25(1):42-47, 2018 Jan. |
Observational-Dx |
165 patients |
To investigate the validity of lung ultrasoundscreen for pneumothorax after transbronchial lung biopsy. |
In total, 165 patients were enrolled in the study. Eight pneumothoraces were diagnosed by image intensifier or CXR before lung ultrasound. There were 8 pneumothoraces diagnosed on CXR 2-hour postbiopsy. Lung ultrasound had a sensitivity of 75% and specificity of 93%. Positive predictive value was 35% and negative predictive value was 99%. The mean number of biopsies taken in patients with and without a pneuomothorax on CXR was 10.6 (±3.1) and 10.9 (±2.1), respectively (P=0.79). The overall pneumothorax rate was 9.7%. |
2 |
| 19. Mongodi S, Via G, Girard M, et al. Lung Ultrasound for Early Diagnosis of Ventilator-Associated Pneumonia. Chest. 149(4):969-80, 2016 Apr. |
Observational-Dx |
99 patients |
To diagnose and monitor community-acquired pneumonia. However, no scientific evidence is yet available on whether LUS reliably improves the diagnosis of VAP. |
For the diagnosis of VAP, subpleural consolidation and dynamic arborescent/linear air bronchogram had a positive predictive value of 86% with a positive likelihood ratio of 2.8. Two dynamic linear/arborescent air bronchograms produced a positive predictive value of 94% with a positive likelihood ratio of 7.1. The area under the curve for VPLUS-EAgram and VPLUS were 0.832 and 0.743, respectively. VPLUS-EAgram = 3 had 77% (58-90) specificity and 78% (65-88) sensitivity; VPLUS = 2 had 69% (50-84) specificity and 71% (58-81) sensitivity. |
2 |
| 20. Wang G, Ji X, Xu Y, Xiang X. Lung ultrasound: a promising tool to monitor ventilator-associated pneumonia in critically ill patients. [Review]. Critical Care (London, England). 20(1):320, 2016 10 27. |
Review/Other-Dx |
N/A |
To review the evidence for ultrasound to monitor ventilator-associated pneumonia in critically ill patients. |
No results stated in the abstract. |
4 |
| 21. Brogi E, Gargani L, Bignami E, et al. Thoracic ultrasound for pleural effusion in the intensive care unit: a narrative review from diagnosis to treatment. [Review]. Crit Care. 21(1):325, 2017 Dec 28. |
Review/Other-Dx |
5 articles |
To review the data regarding the diagnosis and management of pleural effusion, paying particular attention to the impact of ultrasound. Technical data concerning thoracentesis and chest tube drainage are also provided |
No results stated in the abstract. |
4 |
| 22. Ohman J, Harjola VP, Karjalainen P, Lassus J. Rapid cardiothoracic ultrasound protocol for diagnosis of acute heart failure in the emergency department. Eur J Emerg Med. 26(2):112-117, 2019 Apr. |
Observational-Dx |
100 patients |
To evaluate the performance of a rapid cardiothoracic ultrasound protocol (CaTUS), combining echocardiographically derived E/e' and lung ultrasound (LUS), for diagnosing acute heart failure (AHF) in patients with undifferentiated dyspnea in an emergency department (ED). |
We enrolled 100 patients with undifferentiated dyspnea from a tertiary care ED, who all had CaTUS done immediately upon arrival in the ED. CaTUS was positive for AHF with an E/e' > 15 and congestion, that is bilateral B-lines or bilateral pleural fluid, on LUS. In addition, an inferior vena cava index was also recorded to analyze whether including a central venous pressure estimate would add diagnostic benefit to the CaTUS protocol. All 100 patients had a brain natriuretic peptide (BNP) sample withdrawn, and 96 patients underwent chest radiography in the ED, which was analyzed later by a blinded radiologist. The reference diagnosis of AHF consisted of either a BNP of more than 400?ng/l or a BNP of less than 100?ng/l in combination with congestion on chest radiography and structural heart disease on conventional echocardiography.CaTUS had a sensitivity of 100% (95% confidence interval: 91.4-100%), a specificity of 95.8% (95% confidence interval: 84.6-99.3%), and an area under the curve of 0.979 for diagnosing AHF (P<0.001). The diagnostic accuracy of CaTUS was higher than of either E/e' or LUS alone. Adding the inferior vena cava index to CaTUS did not improve diagnostic accuracy. CaTUS seemed helpful also for differential diagnostics of dyspnea, mainly regarding pneumonias and pulmonary embolisms. |
1 |
| 23. Bass CM, Sajed DR, Adedipe AA, West TE. Pulmonary ultrasound and pulse oximetry versus chest radiography and arterial blood gas analysis for the diagnosis of acute respiratory distress syndrome: a pilot study. Critical Care (London, England). 19:282, 2015 Jul 21. |
Observational-Dx |
77 patients |
To test whether pulmonary ultrasound and pulse oximetry could be used in place of traditional radiographic and oxygenation evaluation for ARDS. |
One hundred and twenty three ultrasound assessments were performed on 77 consecutively enrolled patients with respiratory failure. Oxygenation and radiographic criteria for ARDS were met in 35 assessments. Where SpO2?=?97%, the Spearman rank correlation coefficient between SpO2/FiO2 and PaO2/FiO2 was 0.83, p < 0.0001. The sensitivity and specificity of the previously reported threshold of SpO2/FiO2 = 315 for PaO2/FiO2 = 300 was 83% (95% confidence interval (CI) 68-93), and 50% (95% CI 1-99), respectively. Sensitivity and specificity of SpO2/FiO2 = 235 for PaO2/FiO2 = 200 was 70% (95% CI 47-87), and 90% (95% CI 68-99), respectively. For pulmonary ultrasound assessments interpreted by the study physician, the sensitivity and specificity of ultrasound interstitial syndrome bilaterally and involving at least three lung fields were 80% (95% CI 63-92) and 62% (95% CI 49-74) for radiographic criteria for ARDS. Combining SpO2/FiO2 with ultrasound to determine oxygenation and radiographic criteria for ARDS, the sensitivity was 83% (95% CI 52-98) and specificity was 62% (95% CI 38-82). For moderate-severe ARDS criteria (PaO2/FiO2 = 200), sensitivity was 64% (95% CI 31-89) and specificity was 86% (95% CI 65-97). Excluding repeat assessments and independent interpretation of ultrasound images did not significantly alter the sensitivity measures. |
2 |
| 24. Gray P, Sullivan G, Ostryzniuk P, McEwen TA, Rigby M, Roberts DE. Value of postprocedural chest radiographs in the adult intensive care unit. Crit Care Med. 1992;20(11):1513-1518. |
Observational-Dx |
316 patients |
Prospective controlled study to evaluate the necessity for post-procedural CXR after catheterization of central veins, insertion of PAC, and placement of ETT. |
Ability to predict the absence of complications after cordis catheter insertions via the subclavian vein or internal jugular vein (151/152; P<.001) and ability to predict uncomplicated pulmonary artery catheterization (110/111; P<.001) were high. Unsuspected complications were more frequent with central vein multilumen catheter insertions (3/24; P<.001). Physicians were unable to predict the majority of complications associated with endotracheal intubations (28/32; P>.50). |
2 |
| 25. Strain DS, Kinasewitz GT, Vereen LE, George RB. Value of routine daily chest x-rays in the medical intensive care unit. Crit Care Med. 1985;13(7):534-536. |
Observational-Dx |
94 patients, 507 CXRs |
Prospective study to determine the value of the daily routine CXR in the medical ICU. |
76 (15%) of 507 CXRs revealed an unsuspected abnormality, 71 (93%) of which led to a management change. There was significantly (P<.02) more unsuspected abnormalities and management changes in the pulmonary and unstable cardiac patients, independent of ventilator status. Patients with two or more catheters and/or tubes visible on the CXR also had significantly more management changes (51/312 vs 11/150, P<.05). Concludes that while CXR affect the management of pulmonary and unstable cardiac patients in the ICU, routine films rarely influence management of uncomplicated cardiac patients and those without heart or lung disease, and are not needed in this group. |
3 |
| 26. Silverstein DS, Livingston DH, Elcavage J, Kovar L, Kelly KM. The utility of routine daily chest radiography in the surgical intensive care unit. J Trauma. 1993;35(4):643-646. |
Review/Other-Dx |
University center: 256 patients; Suburban hospital: 269 patients, 525 CXRs |
Prospective study to assess the impact of routine daily CXR in the surgical ICU. |
1,028 medical devices were evaluated. 55 (5.4%) were considered to be in a minor incorrect position and 13 (1.3%) required repositioning. 78 CXRs were normal. There were 775 cardiopulmonary findings on the remaining 477 CXRs. When compared with previous CXRs, only 12% (89/775) of the findings were considered new, 65% were unchanged, 14% were improved, and 15% demonstrated worsening of a known finding. Of the 89 new cardiopulmonary findings, only 3 had any potential clinical impact (pneumothorax in 2, effusion in 1). Study concludes that routine daily CXR should be abandoned and need for a morning CXR be based on clinical necessity. |
4 |
| 27. O'Brien W, Karski JM, Cheng D, Carroll-Munro J, Peniston C, Sandler A. Routine chest roentgenography on admission to intensive care unit after heart operations: is it of any value? J Thorac Cardiovasc Surg. 1997;113(1):130-133. |
Review/Other-Dx |
404 patients |
To determine the value of routine CXR on admission to ICU after heart operations. |
18 (4.5%) of 404 required intervention because of abnormalities detected by CXR but not predicted by the initial physical and laboratory assessment. Concludes that CXR is recommended if clinical and laboratory assessment indicates the possibility of underlying pathologic conditions that can only be confirmed or diagnosed by CXR. |
4 |
| 28. Henschke CI, Pasternack GS, Schroeder S, Hart KK, Herman PG. Bedside chest radiography: diagnostic efficacy. Radiology. 1983;149(1):23-26. |
Review/Other-Dx |
140 patients, 1,132 CXRs |
Prospective study to evaluate the efficacy of a bedside CXR in patients admitted to the surgical and medical ICU. |
Endotracheal or tracheostomy tubes were present in 54% of exams; 12% were malpositioned. Central venous catheters were present in 47%; 9% were malpositioned. Interval changes (cardiopulmonary findings) were present in 44% of the radiographs. 65% of the radiographs had findings or changes affecting the patient's management. Recommends use of bedside radiography. |
4 |
| 29. Horst HM, Fagan B, Beute GH. Chest radiographs in surgical intensive care patients: a valuable "routine". Henry Ford Hosp Med J. 1986;34(2):84-86. |
Observational-Dx |
262 patients, 411 CXRs |
Evaluation of CXR to determine their clinical value for surgical ICU patients. Radiographic findings, previous CXR and clinical expectations were compared. |
138 unexpected findings on 112 CXR. The unexpected findings were equally divided between pulmonary problems (72) and device malposition (66). 30% of unexpected findings were considered potentially life threatening. Study recommends routine CXR for monitoring surgical ICU patients. |
3 |
| 30. Brunel W, Coleman DL, Schwartz DE, Peper E, Cohen NH. Assessment of routine chest roentgenograms and the physical examination to confirm endotracheal tube position. Chest. 1989;96(5):1043-1045. |
Review/Other-Dx |
219 patients |
Prospective study to evaluate the accuracy of the physical examination in assessing ETT position and the appropriateness of taking routine CXR after intubation in the ICU. |
Techniques to minimize risk of tube malposition were not completely reliable. Study confirms unreliability of the physical examination to assess ETT position. CXRs after intubation are recommended to verify tube position, particularly after emergency intubations. |
4 |
| 31. Marik PE, Janower ML. The impact of routine chest radiography on ICU management decisions: an observational study. Am J Crit Care. 1997;6(2):95-98. |
Review/Other-Dx |
200 patients, 47 CXRs |
Observational study to determine the impact of routine CXR on ICU treatment decisions. |
At least one change in therapy was made for 91 (66%) of the 138 intubated patients but for only 14 (23%) of the 62 non-intubated patients; this difference was significant. Study concludes that routine CXR may be justified in critically ill patients in a medical ICU because most of these patients have management decisions based on information obtained from CXR. |
4 |
| 32. Bekemeyer WB, Crapo RO, Calhoon S, Cannon CY, Clayton PD. Efficacy of chest radiography in a respiratory intensive care unit. A prospective study. Chest. 1985;88(5):691-696. |
Observational-Dx |
167 patients, 1,354 CXRs |
Prospective study to determine diagnostic and therapeutic efficacy of CXR in a respiratory ICU. |
In a respiratory ICU, routine morning radiographic examination frequently demonstrates unexpected or changing abnormalities. Post-procedure radiographic examination uncommonly demonstrates complications related to the procedure, but frequently demonstrates abnormalities of tube or catheter placement. |
3 |
| 33. Bhagwanjee S, Muckart DJ. Routine daily chest radiography is not indicated for ventilated patients in a surgical ICU. Intensive Care Med. 1996;22(12):1335-1338. |
Observational-Dx |
34 patients, 164 CXRs |
To determine whether clinical examination can accurately predict radiological change and if routine CXR is effective in ventilated patients in a surgical ICU. |
Two significant radiographically changes were missed on clinical examination: catheter malposition and pneumothorax, representing a yield from radiography of 1%. Study concludes that clinical examination can effectively predict the need for radiography and therefore CXR is not recommended for ventilated patients. |
2 |
| 34. Kollef MH, Legare EJ, Damiano M. Endotracheal tube misplacement: incidence, risk factors, and impact of a quality improvement program. South Med J. 1994;87(2):248-254. |
Review/Other-Dx |
Retrospective review: 278 patients, Prospective: 246 patients |
Comparative study in an adult ICU to assess the impact of a quality improvement program on the occurrence of serious complications related to ETT misplacement and to identify risk factors. |
113 (46%) of 246 patients were identified as having at least one ETT misplacement requiring immediate repositioning. The incidence of serious complications related to ETT misplacement was significantly less during the implementation of the quality improvement program (0 of 246 patients) than during the retrospective period (5 of 278 patients). Multivariate analysis showed that a longer duration of endotracheal intubation, the lack of chemical paralysis, and the occurrence of cardiac arrest were independently predictive of ETT misplacement. Results suggest a specific ICU quality improvement program can have a favorable impact on patient outcome. |
4 |
| 35. Wang ML, Schuster KM, Bhattacharya B, Maung AA, Kaplan LJ, Davis KA. Repositioning endotracheal tubes in the intensive care unit: depth changes poorly correlate with postrepositioning radiographic location. The Journal of Trauma and Acute Care Surgery. 75(1):146-9, 2013 Jul. |
Observational-Dx |
55 patients |
To determine the accuracy of repositioning endotracheal tubes in the intensive care unit. |
Fifty-five patients met inclusion criteria and had a complete set of data (80% male). ET advancement was the most commonly required intervention (80%). For advancement, the median starting position was 7.10 cm (IQR, 2.20 cm) from the carina, with a median planned advancement of 2.00 cm. The actual advancement was a median of 1.15 cm, achieving 57.5% of the goal. Patients requiring ET withdrawal were more likely female (8 of 11, p < 0.001). For the withdrawal group, the median starting position was 0.70 cm (IQR, 1.05 cm) from the carina with a planned median withdrawal of 2.00 cm (IQR, 0.75 cm). The actual withdrawal was a median of 1.00 cm, achieving 50.0% of the goal. Overall, the mean difference between the planned and actual intervention was 1.55 cm (95% confidence interval, 1.16-1.95 cm) differing by a mean of 40% from the planned intervention (95% confidence interval, 29.0-51.0%). There was no correlation between the original location or the planned intervention and the accuracy of the intervention. In three cases, the ET moved opposite of the planned intervention. |
2 |
| 36. Cruz J, Ferra M, Kasarabada A, Gasperino J, Zigmund B. Evaluation of the Clinical Utility of Routine Daily Chest Radiography in Intensive Care Unit Patients With Tracheostomy Tubes: A Retrospective Review. [Review]. Journal of Intensive Care Medicine. 31(5):333-7, 2016 Jun. |
Review/Other-Dx |
79 patients |
To review the clinical utility of Routine daily chest radiography in intensive care unit patients with tracheostomy tubes. |
Of the 761 CRs, only 18 (2.3%) radiographs revealed new complications. All complications were clinically suspected prior to imaging. Only 5 (0.7%) complications resulted in a management change. The most common management changes were a change in antibiotic regimen (0.3%) and ordering of diuretics (0.3%). |
4 |
| 37. Lakhani P.. Deep Convolutional Neural Networks for Endotracheal Tube Position and X-ray Image Classification: Challenges and Opportunities. Journal of Digital Imaging. 30(4):460-468, 2017 Aug. |
Observational-Dx |
300 presence/absence of an endotracheal tube |
To evaluate the efficacy of deep convolutional neural networks (DCNNs) in differentiating subtle, intermediate, and more obvious image differences in radiography. |
The datasets were split into training, validation, and test. Both untrained and pre-trained deep neural networks were employed, including AlexNet and GoogLeNet classifiers, using the Caffe framework. Data augmentation was performed for the presence/absence and low/normal ET tube datasets. Receiver operating characteristic (ROC), area under the curves (AUC), and 95% confidence intervals were calculated. Statistical differences of the AUCs were determined using a non-parametric approach. The pre-trained AlexNet and GoogLeNet classifiers had perfect accuracy (AUC 1.00) in differentiating chest vs. abdominal radiographs, using only 45 training cases. For more difficult datasets, including the presence/absence and low/normal position endotracheal tubes, more training cases, pre-trained networks, and data-augmentation approaches were helpful to increase accuracy. The best-performing network for classifying presence vs. absence of an ET tube was still very accurate with an AUC of 0.99. However, for the most difficult dataset, such as low vs. normal position of the endotracheal tube, DCNNs did not perform as well, but achieved a reasonable AUC of 0.81. |
2 |
| 38. Hourmozdi JJ, Markin A, Johnson B, Fleming PR, Miller JB. Routine Chest Radiography Is Not Necessary After Ultrasound-Guided Right Internal Jugular Vein Catheterization. Crit Care Med. 44(9):e804-8, 2016 09. |
Review/Other-Dx |
N/A |
To hypothesize that the rate of clinically relevant complications detected on chest radiographs following ultrasound-guided right internal jugular vein catheterization is exceedingly low. |
Data from standardized procedure notes and postprocedure chest radiographs were extracted and individually reviewed to verify the presence of pneumothorax or misplacement, and any intervention performed for either complication. The overall success rate of ultrasound-guided right internal jugular vein central venous catheter placement was 96.9% with an average of 1.3 attempts. There was only one pneumothorax (0.1% [95% CI, 0-0.4%]), and the rate of catheter misplacement requiring repositioning or replacement was 1.0% (95% CI, 0.6-1.7%). There were no arterial placements found on chest radiographs. Multivariate regression analysis showed no correlation between high-risk patient characteristics and composite complication rate. |
4 |
| 39. Woodland DC, Randall Cooper C, Farzan Rashid M, et al. Routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room. J Crit Care. 46:13-16, 2018 08. |
Review/Other-Dx |
200 patients |
To determine if routine chest X-ray is unnecessary after ultrasound-guided central venous line placement in the operating room. |
In 200 central line placements for Whipple procedures, 198 lines were placed in the right internal jugular and 2 were placed in the subclavian. No cases of pneumothorax or hemothorax were identified and 30 (15.3%) of CVCs were improperly positioned. Only 1 (0.5%) of these was deemed clinically significant and repositioned after the CXR was performed. |
4 |
| 40. Sise MJ, Hollingsworth P, Brimm JE, Peters RM, Virgilio RW, Shackford SR. Complications of the flow-directed pulmonary artery catheter: A prospective analysis in 219 patients. Crit Care Med. 1981;9(4):315-318. |
Review/Other-Dx |
219 patients, 320 catheters |
Prospective study to determine and analyze the complications of the flow-directed PAC. |
Major complications occurred in 3% of catheterizations. Findings suggest that, when indicated in the care of critically ill patients, the properly placed and maintained PAC has an acceptably low morbidity and mortality rate, particularly when used for 72 hours or less. |
4 |
| 41. Fan EMP, Tan SB, Ang SY. Nasogastric tube placement confirmation: where we are and where we should be heading. Proceedings of Singapore Healthcare 2017;26:189-95. |
Review/Other-Dx |
26 articles |
To assess the position of the nasogastric tube (NGT) |
A method to confirm NGT placement that is accurate, affordable, does not require gastric aspirates, and is able to be used not only upon insertion but also at regular intervals is lacking. |
4 |
| 42. Das SK, Choupoo NS, Haldar R, Lahkar A. Transtracheal ultrasound for verification of endotracheal tube placement: a systematic review and meta-analysis. [Review]. Canadian Journal of Anaesthesia. 62(4):413-23, 2015 Apr. |
Meta-analysis |
11 studies |
To evaluate the diagnostic accuracy of transtracheal ultrasound in detecting endotracheal intubation. |
Eleven studies and 969 intubations were included in the final analysis. Eight studies and 713 intubations were performed in emergency situations and the others were carried out in elective situations. Transtracheal ultrasonography's pooled sensitivity and specificity with 95% confidence intervals (CIs) were 0.98 (95% CI 0.97 to 0.99) and 0.98 (95% CI 0.95 to 0.99), respectively. In emergency scenarios, transtracheal ultrasonography showed an aggregate sensitivity and specificity of 0.98 (95% CI 0.97 to 0.99) and 0.94 (95% CI 0.86 to 0.98), respectively. |
Good |
| 43. Hosseini JS, Talebian MT, Ghafari MH, Eslami V. Secondary confirmation of endotracheal tube position by diaphragm motion in right subcostal ultrasound view. International Journal of Critical Illness and Injury Science. 3(2):113-7, 2013 Apr. |
Observational-Dx |
57 patients |
To assess the sensitivity and specificity of right subcostal ultrasound view to confirm correct endotracheal tube intubation (ETT). |
A total of 57 patients aged 59 ± 5 who underwent ETT insertion were studied. Thirty-four of them were male (60%). Ultrasound correctly identified 11 out of 12 esophageal intubations for a sensitivity of 92% (95% CI = 62-100), but misidentified one esophageal intubation as tracheal. Sonographers correctly identified 43 out of 45 (96%) tracheal intubations for a specificity of 96% (95% CI = 85-99), but misdiagnosed two tracheal intubations as esophageal. |
2 |
| 44. Jenkins JA, Gharahbaghian L, Doniger SJ, et al. Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement. The Western Journal of Emergency Medicine. 13(4):305-11, 2012 Sep. |
Review/Other-Dx |
17 patients |
To demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement. |
Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10-5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode. |
4 |
| 45. Zanobetti M, Coppa A, Bulletti F, et al. Verification of correct central venous catheter placement in the emergency department: comparison between ultrasonography and chest radiography. Internal & Emergency Medicine. 8(2):173-80, 2013 Mar. |
Observational-Dx |
210 patients |
To verify the correct central venous catheter placement (ultrasonography vs chest radiography) in the emergency department: |
A prospective, blinded, observational study was performed, from January 2009 to December 2011, in the emergency department of a university-affiliated teaching hospital. Ultrasonography interpretation was completed during image acquisition; ultrasound scan was performed in 5 ± 3 min, whereas the time interval between chest radiograph request and its final interpretation was 65 ± 74 min p < 0.0001. We found a high concordance between the two diagnostic modalities in the identification of catheter position (Kappa = 82 %, p < 0.0001), and their ability to identify a possible wrong position showed a high correlation (Pearson's r = 0.76 %, p < 0.0001) with a sensitivity of 94 %, a specificity of 89 % for ultrasonography. Regarding the mechanical complications, three iatrogenic pneumothoraces occurred, all were correctly identified by ultrasonography and confirmed by chest radiography (sensitivity 100 %). Our study showed a high correlation between these two modalities to identify possible malpositioning of a catheter resulting from cannulation of central veins, and its complications. The less time required to perform ultrasonography allows earlier use of the catheter for the administration of acute therapies that can be life-saving for the critically ill patients. |
2 |
| 46. Amir R, Knio ZO, Mahmood F, et al. Ultrasound as a Screening Tool for Central Venous Catheter Positioning and Exclusion of Pneumothorax. Critical Care Medicine. 45(7):1192-1198, 2017 Jul. |
Observational-Dx |
137 patients |
To review the combination of transthoracic echocardiography and lung ultrasound is noninferior to chest radiograph when used to accurately assess central venous catheter positioning and screen for pneumothorax. |
Data analysis was done for 137 patients. Chest radiograph ruled out pneumothorax in 137 of 137 patients (100%). Lung ultrasound was performed in 123 of 137 patients and successfully screened for pneumothorax in 123 of 123 (100%). Chest radiograph approximated accurate catheter tip position in 136 of 137 patients (99.3%). Adequate subcostal four-chamber views could not be obtained in 13 patients. Accurate positioning of central venous catheter with ultrasound was then confirmed in 121 of 124 patients (97.6%) as described previously. |
2 |
| 47. Galante O, Slutsky T, Fuchs L, et al. Single-Operator Ultrasound-Guided Central Venous Catheter Insertion Verifies Proper Tip Placement. Critical Care Medicine. 45(10):e994-e1000, 2017 Oct. |
Observational-Dx |
64 patients |
To evaluate whether a single-operator ultrasound-guided, right-sided, central venous catheter insertion verifies proper placement and shortens time to catheter utilization. |
The primary outcome was the correct placement of the catheter tip determined by postprocedural chest radiography. The subclavian site was used in 41 patients (64%) (inserted without ultrasound guidance) in the ultrasound-assisted group and 62 (67%) in the control group, whereas the jugular vein was used in the remaining patients. The tip was accurately positioned in 59 of 68 patients (86.7%) in the ultrasound-assisted group compared with 51 of 94 (54.8%) in the control group (p < 0.001). The median time from end of the procedure to catheter utilization after chest radiography approval was 2.4 hours. |
2 |
| 48. Raman D, Sharma M, Moghekar A, Wang X, Hatipoglu U. Utilization of Thoracic Ultrasound for Confirmation of Central Venous Catheter Placement and Exclusion of Pneumothorax: A Novel Technique in Real-Time Application. Journal of Intensive Care Medicine. 885066617705839, 2017 Jan 01. |
Experimental-Dx |
60 patients |
To evaluate the safety and utility of ultrasonography as a tool to confirm central venous catheter (CVC) position and to exclude insertion-related pneumothorax in place of chest radiography (CXR) in a tertiary medical intensive care unit (ICU). |
Thirty patients were randomized to the conventional group and 30 were randomized to the ultrasound group. One patient was excluded in the control group since the procedure needed to be aborted. Patient characteristics were well matched for age, body mass index, and acute physiologic assessment and chronic health evaluation (APACHE III) scores. There was a 56.7% ( P < .0001) reduction in CXR use in the ultrasound arm. Mean time to use was 53.6 minutes in the control group and 25 minutes in the ultrasound arm ( P = .0015). Mean time required to complete the procedure was 27.7 minutes in the control group and 24.1 minutes in the ultrasound group ( P = .2053). No pneumothorax was detected in either arm. |
2 |
| 49. Wilson SP, Assaf S, Lahham S, et al. Simplified point-of-care ultrasound protocol to confirm central venous catheter placement: A prospective study. World journal of emergency medicine. 8(1):25-28, 2017. |
Observational-Dx |
78 patients |
To hypothesize that a simple point-of-care ultrasound (POCUS) protocol could effectively confirm placement and reduce time to confirmation. |
Seventy-eight patients were enrolled. POCUS had a sensitivity of 86.8% (95%CI 77.1%-93.5%) and specificity of 100% (95%CI15.8%-100.0%) for identifying correct central venous catheter placement. Median POCUS and CXR completion were 16 minutes (IQR 10-29) and 32 minutes (IQR 19-45), respectively. |
2 |
| 50. Kamalipour H, Ahmadi S, Kamali K, Moaref A, Shafa M, Kamalipour P. Ultrasound for Localization of Central Venous Catheter: A Good Alternative to Chest X-Ray?. Anesthesiology & Pain Medicine. 6(5):e38834, 2016 Oct. |
Observational-Dx |
116 patients |
To compare contrast-enhanced ultrasonography (CEUS) and chest radiography for detecting the correct location of CVCs. |
Chest radiography revealed 16 CVC misplacements: two cases of intravascular and 14 cases of right atrium (RA) misplacement. CEUS detected 11 true catheter malpositionings in the RA, while it could not recognize seven catheter placements correctly. CEUS showed two false RA misplacements and five falsely correct CVC positions. A sensitivity of 98% and specificity of 69% were achieved for CEUS in detecting CVC misplacements. Positive and negative predictive values were 95% and 85%, respectively. The interrater agreement (kappa) between CEUS and radiography was 0.72 (P < 0.001). |
2 |
| 51. Ablordeppey EA, Drewry AM, Beyer AB, et al. Diagnostic Accuracy of Central Venous Catheter Confirmation by Bedside Ultrasound Versus Chest Radiography in Critically Ill Patients: A Systematic Review and Meta-Analysis. [Review]. Critical Care Medicine. 45(4):715-724, 2017 Apr. |
Meta-analysis |
15 Studies |
To perform a systematic review and meta-analysis to examine the accuracy of bedside ultrasound for confirmation of central venous catheter position and exclusion of pneumothorax compared with chest radiography. |
Fifteen studies with 1,553 central venous catheter placements were identified with a pooled sensitivity and specificity of catheter malposition by ultrasound of 0.82 (0.77-0.86) and 0.98 (0.97-0.99), respectively. The pooled positive and negative likelihood ratios of catheter malposition by ultrasound were 31.12 (14.72-65.78) and 0.25 (0.13-0.47). The sensitivity and specificity of ultrasound for pneumothorax detection was nearly 100% in the participating studies. Bedside ultrasound reduced mean central venous catheter confirmation time by 58.3 minutes. Risk of bias and clinical heterogeneity in the studies were high. |
Good |
| 52. Zatelli M, Vezzali N. 4-Point ultrasonography to confirm the correct position of the nasogastric tube in 114 critically ill patients. Journal of Ultrasound. 20(1):53-58, 2017 Mar. |
Observational-Dx |
114 patients |
To estimate the diagnostic accuracy of this new technique, 4-point ultrasonography to confirm nasogastric tube placement in intensive care. |
One hundred fourteen of the gastric tubes were visualized by sonography in the digestive tract and all were confirmed by radiography (sensitivity 100%). The entire sonographic procedure, including the longitudinal and transversal scan of the esophagus, the esophagogastric junction, the antrum and the fundus, took 10 min. |
2 |
| 53. Kim HM, So BH, Jeong WJ, Choi SM, Park KN. The effectiveness of ultrasonography in verifying the placement of a nasogastric tube in patients with low consciousness at an emergency center. Scandinavian Journal of Trauma, Resuscitation & Emergency Medicine. 20:38, 2012 Jun 12. |
Observational-Dx |
47 patients |
To compare the effectiveness of using auscultation, pH measurements of gastric aspirates, and ultrasonography as physical examination methods to verify nasogastric tube(NGT) placement in emergency room patients with low consciousness who require NGT insertion. |
The sensitivity and specificity were 100% and 33.3%, respectively, for auscultation and 86.4% and 66.7%, respectively, for ultrasonography. Kappa values were the highest for auscultation at 0.484 compared to chest x-rays, followed by 0.299 for ultrasonography and 0.444 for pH analysis of the gastric aspirate. The ultrasonography has a positive predictive value of 97.4% and a negative predictive value of 25%. |
2 |
| 54. Sepehripour AH, Farid S, Shah R. Is routine chest radiography indicated following chest drain removal after cardiothoracic surgery? Interact Cardiovasc Thorac Surg. 2012;14(6):834-838. |
Review/Other-Dx |
6 articles |
To determine whether routine CXR is indicated following chest drain removal in patients undergoing cardiothoracic surgery. |
The authors conclude that there is evidence that routine post drain removal CXR provides no diagnostic or therapeutic advantage over clinically indicated CXR or simple clinical assessment. The best evidence studies reported the detection of pathology on routine CXR ranging from 2% to 40% compared with 79% in clinically indicated CXRs (P=0.005). Whilst the rate of intervention following routine CXR was as high as 4% in the smallest study, clinical signs and symptoms suggestive of pathology were a significant predictor of major re-intervention (P<0.01). |
4 |
| 55. Clec'h C, Simon P, Hamdi A, et al. Are daily routine chest radiographs useful in critically ill, mechanically ventilated patients? A randomized study. Intensive Care Medicine. 34(2):264-70, 2008 Feb. |
Experimental-Dx |
165 patients randomized |
To compare the diagnostic, therapeutic and outcome efficacy of a restrictive prescription of CXRs with that of a routine prescription, focusing on delayed diagnoses and treatments potentially related to the restrictive prescription. |
For each CXR, a questionnaire was completed addressing the reason for the CXR, the new findings, and any subsequent therapeutic intervention. The endpoints were the rates of new findings, the rates of new findings that prompted therapeutic intervention, the rate of delayed diagnoses, and mortality. 84 patients were included in the routine prescription group and 81 in the restrictive prescription group. The rates of new findings and the rates of new findings that prompted therapeutic intervention in the restrictive prescription group and in the routine prescription group were 66% vs 7.2% (P<0.0001), and 56.4% vs 5.5% (P<0.0001) respectively. The rate of delayed diagnoses in the restrictive prescription group was 0.7%. Mortality was similar. |
1 |
| 56. Eisenberg RL, Khabbaz KR. Are chest radiographs routinely indicated after chest tube removal following cardiac surgery? AJR Am J Roentgenol. 2011;197(1):122-124. |
Review/Other-Dx |
400 patients |
To determine the incidence and clinical significance of pneumothoraces detected on routine radiography after chest tube removal following cardiac surgery and correlate those findings with an immediate postprocedure assessment of the likelihood of new pneumothorax. |
Of 9.3% of cases (37/400) of new pneumothoraces after chest tube removal, 70.3% were tiny (barely perceptible), 27.0% were small (<1 cm from the pleural line to the apex of the hemithorax), and 2.7% were medium (6–10 cm from the pleural line to the apex of the hemithorax). The incidences of small and medium pneumothoraces were substantially greater in patients with higher levels of clinical suspicion. All tiny pneumothoraces had no clinical importance. Not obtaining routine CXRs after chest tube removal in the 345 patients (86.3%) with the lowest level of clinical suspicion would have resulted in missing six small pneumothoraces (1.7%), none of which led to medical or surgical intervention or a delay in discharge. |
4 |
| 57. Khan T, Chawla G, Daniel R, Swamy M, Dimitri WR. Is routine chest X-ray following mediastinal drain removal after cardiac surgery useful? Eur J Cardiothorac Surg. 2008;34(3):542-544. |
Review/Other-Dx |
151 patients |
To determine if routine CXR following mediastinal drain removal after cardiac surgery is useful. |
There were 113 males and 38 females with a mean age of 67.5 years. 14 patients (9%) had obstructive airway disease. The left and right pleurae were opened in 62% and 11% of patients respectively and a chest drain was inserted in all of them intraoperatively. 3 patients (2%) developed pneumothorax following drain removal. 2 of these patients had clinical signs and symptoms, which would have warranted a CXR. 1 patient had a moderate pneumothorax but was not clinically compromised. 2 patients needed chest drain reinsertion that was subsequently removed after 3 and 4 days. The third patient was monitored clinically and the pneumothorax resolved spontaneously on subsequent CXR. In the remaining 148 patients, postdrain removal CXR did not provide any additional information to alter the management. The cost saving of omitting an additional CXR was calculated to be about £10,000 per year. |
4 |
| 58. McCormick JT, O'Mara MS, Papasavas PK, Caushaj PF. The use of routine chest X-ray films after chest tube removal in postoperative cardiac patients. Ann Thorac Surg. 2002;74(6):2161-2164. |
Observational-Dx |
703 patients |
To assess the yield and clinical impact of routine CXR after chest tube removal in postoperative cardiac patients and determine the safety of omitting them. |
Tubes were removed on postoperative days 1 to 7 (average, 1.45 days). The 2 groups of patients were comparable in age, gender, procedure, and co-morbidity (P>.01). 703 patients underwent routine postoperative tube removal CXRs. Abnormal findings were present in 282 patients. Resultant therapeutic intervention was undertaken in 13 patients and 9 were symptomatic. No imaging after routine postoperative CXRs was conducted in 283 patients. These patients remained asymptomatic and required no intervention. 14 patients had clinically indicated CXRs after chest tube removal. 2 of these patients had additional tubes placed, and 1 patient had follow-up films. In total, there was a 1.5% incidence of therapeutic intervention after chest tube removal. All patients were discharged without further sequelae of their tubes. |
3 |
| 59. Pacharn P, Heller DN, Kammen BF, et al. Are chest radiographs routinely necessary following thoracostomy tube removal? Pediatr Radiol. 2002;32(2):138-142. |
Observational-Dx |
374 patients |
To examine whether clinical signs and symptoms may be a sensitive predictor of pneumothorax in all pediatric patients following thoracostomy tube removal. |
51/374 children (13.6%) had a radiographically defined pneumothorax within 6 hours after thoracostomy tube removal. The pneumothorax was large (>40%) in 2 children, moderate (20%–40%) in 5 children, and small (<20%) in 44 children. Symptoms (dyspnea, tachypnea, respiratory distress) or signs (increased oxygen requirement, worsening arterial blood gas and/or hypotension) of respiratory distress were present at the time of the initial CXR in 6/7 patients, who later underwent a major clinical intervention, and in 1 patient who did not. Major clinical interventions were performed in all patients with a large pneumothorax, 4/5 patients with a moderate pneumothorax, and 1 patient with a small pneumothorax that later enlarged. |
4 |
| 60. Whitehouse MR, Patel A, Morgan JA. The necessity of routine post-thoracostomy tube chest radiographs in post-operative thoracic surgery patients. Surgeon. 2009;7(2):79-81. |
Observational-Dx |
74 patients |
To determine whether routine CXRs post-operatively and post-thoracostomy tube removal directly influenced patient management. |
In the cohort of 74 patients, 66 (89%) patients had postoperative CXRs. Only 3 (5%) patients who had a CXR had change in their management. 25 (34%) patients had a CXR post-thoracostomy tube removal. Only 1 (4%) patient in this group who had a CXR after thoracostomy tube removal had a change of management. Interestingly, the decision to change patient management was not made on the basis of the CXRs alone; the clinical situation was the main determinant. Patients that did not have a CXR postoperatively (8 patients, 11%) and post-thoracostomy tube removal (49 patients, 66%) did not suffer any adverse sequelae. |
3 |
| 61. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. |
Review/Other-Dx |
N/A |
To provide evidence-based guidelines on exposure of patients to ionizing radiation. |
No abstract available. |
4 |
