Significant changes in the practice of chest radiography in Dutch intensive care units: a web-based survey
© Tolsma et al.; licensee Springer. 2014
Received: 15 September 2013
Accepted: 24 March 2014
Published: 4 April 2014
ICU patients frequently undergo chest radiographs (CXRs). The diagnostic and therapeutic efficacy of routine CXRs are now known to be low, but the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a survey of Dutch intensivists on the current practice of chest radiography in their departments.
Web-based questionnaires, containing questions regarding ICU characteristics, ICU patients, daily CXR strategies, indications for routine CXRs and the practice of radiologic evaluation, were sent to the medical directors of all adult ICUs in the Netherlands. CXR strategies were compared between all academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results obtained in 2006 and 2013.
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.
The strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume the value of CXRs to be higher than the efficacy that is reported in the literature.
KeywordsChest radiography Imaging Intensive care
ICU patients frequently undergo chest radiographs (CXRs) on a routine basis, after a change in their clinical situation or directly after surgery. Several investigators have studied the clinical value of routine CXRs following central venous catheterization, endotracheal intubation, cardiac surgery, pulmonary surgery or chest tube placement and removal[1–18]. Other investigators have studied the value of daily routine CXRs in a mixed ICU population or in mechanically ventilated patients only[19–28]. The diagnostic and therapeutic efficacy of these routine radiographs is now known to be low[1–3, 6–10, 12–15, 17, 19, 20, 22–25, 28]. Studies that compared a routine CXR strategy with an ‘on-demand’ CXR strategy did not show any difference in outcome measures[29–34].
Despite these results, in 2006, Graat et al. showed that in a majority of ICUs in The Netherlands, a daily routine CXR strategy was still common practice. Intensivists at that time assumed a higher value of daily CXRs than had been reported in the literature. Although a more restrictive CXR strategy seems safe, Ganapathy et al. stated in a more recent meta-analysis that study populations were small and the number of missed findings had not been sufficiently evaluated. Meanwhile, the discussion regarding specific indications for CXRs in critically ill patients and the safety of abandoning routine CXRs is still ongoing. We performed a new survey among Dutch intensivists on their current chest radiography practice in order to study the influence of time and knowledge in relation to any changes in that practice.
For our study, we selected all Dutch academic hospitals (related to a university medical school) and non-academic hospitals with an independent adult ICU department. A web-based questionnaire (Additional file1), deployed using the website http://www.thesistools.com, was sent to the medical staff of these ICUs by the end of April 2013. A reminder was sent after two weeks, four weeks and six weeks after the questionnaire was originally sent. All hospitals received one questionnaire, as it is currently common in our country to have one adult ICU center with a combined medical staff and a mixed patient population. For data analysis, we included all questionnaires that were answered within eight weeks from the start of the study, with a response of more than 80%. The questionnaire we deployed was based on the questionnaire used previously in 2006. After confirming a specific hospital’s response, this response was made anonymously. To prevent duplicated data, additional responses from the same hospital were not included.
The survey contained questions regarding hospital and ICU characteristics, type of ICU patients, CXR strategies, indications for routine CXRs and the practice of radiologic evaluation. Regarding ICU size, only beds with the possibility of mechanical ventilation were taken into account. We asked the intensivists to judge the clinical value (therapeutic efficacy) of routine and ‘on-demand’ CXRs and to judge the value of an established radiologic evaluation with a radiologist. We finally asked them to state some indications for routine CXRs.
CXR strategies were compared between all hospitals, between academic and non-academic hospitals and between ICUs of different sizes. A comparison was made between the survey results from 2006 and 2013. Therapeutic efficacy was defined as the percent of CXR findings that resulted in a subsequent change in patient management.
Data analysis was performed using IBM SPSS Statistics 21.0 (IBM,Armonk, NY, USA). All variables were expressed as counts (%). Differences in CXR strategies between 2006 and 2013 were examined using Fisher’s exact test.
Hospital and ICU characteristics (All hospitals, n = 69)
Hospital type; n (%)
ICU level; n (%)
Number of ICU beds; n (%)
5 to 15
Number of fulltime intensivists; n (%)
1 to 5
5 to 10
11 to 20
Current CXR practice
All hospitals (n = 69); n (%)
Patients on ventilation only
Certain fixed days a week
First days of admission only
Cardiothoracic surgery patients only
Other, not specified
Academic hospitals (n = 7); n (%)
Non-academic hospitals (n = 62); n (%)
ICU < 5 beds (n = 9); n (%)
ICU 5 to 15 beds (n = 40); n (%)
ICU > 15 beds (n = 20); n (%)
Comparison of CXR strategies between 2006 and 2013
2006 (n = 41)
2013 (n = 69)
Daily routine CXR strategy; n (%)
Mechanically ventilated patients
Other daily routine strategy
‘On-demand only’ strategy; n (%)
Routine CXR after; n (%)
Chest tube placement
Practice of radiologic evaluation (All hospitals, n = 69)
Radiologic conference; n (%)
Daily except weekends
On request only
Judged value of radiologic conference; n (%)
Good for cooperation
Required for training purpose
Assumed efficacy value of CXRs (All hospitals, n = 69)
Assumed therapeutic efficacy; n (%)
10 to 20%
20 to 30%
30 to 60%
Suggested indications for which a CXR is deemed essential for diagnosis or assessment (All hospitals, n = 69)
Indication; n (%)
Presence of ARDS
Presence of a pneumonia
Presence of a pneumothorax
Patients volume status
Correct position of CVL
Correct position of chest tube
Correct position of IABP
Our results show that a strategy of daily routine CXRs is performed for all patients in only 7% of ICUs and for all mechanically ventilated patients in only 6% of ICUs, while 61% of the ICUs never perform CXRs on a routine basis. A daily meeting with a radiologist is an established practice in the majority of ICUs and is judged to be important or even essential. Our results are in line with the results of Lakhal et al. who did an observational day study in French ICUs in 2010. In their study population, a daily routine CXR strategy was also practiced in 7% of ICUs, while 63% of ICUs never performed routine CXRs. Compared to the results of Graat et al. in 2006, there has been an obvious change in chest radiography strategies in Dutch ICUs. Then, the majority of ICUs practiced a daily routine CXR strategy. An ‘on-demand only’ strategy and other more liberal routine strategies have become more common in recent years.
The indications for routine CXRs suggested by the responders in our survey are, in general, comparable to the indications suggested in the surveys performed by Graat et al. and Hejblum et al.[35, 36]. There is still consensus between intensivists regarding the importance of obtaining a CXR after endotracheal intubation, chest tube placement and central venous catheterization and for diagnostic workups for pneumonia, ARDS or pneumothorax. However, the indications for a routine CXR after intubation and central venous catheterization are not supported by the literature[1–3, 6]. There is no consensus that a routine CXR should be performed for all mechanically ventilated patients[35, 37].
Although our results, and the reduction in routine CXR strategies, suggest that intensivists seem to be aware of the limited clinical value of routine CXRs, they still assume this value to be higher than the efficacy that is reported in the literature. This is also true for the clinical value of ‘on-demand’ CXRs. In recent literature, the reported diagnostic efficacy for CXR small findings is between 30 and 65%, while the diagnostic efficacy for important findings and the therapeutic efficacy of CXRs are reported to be between 2 and 7%[22–24, 28]. Intensivists may assume a higher clinical value of CXRs due to the value of negative CXR findings, which has not been previously studied. The ability of CXR findings to exclude complications, certain clinical situations or the need for an intervention, probably has a clinical impact that is hard to study.
During the last decade, multiple studies have shown that an ‘on-demand’ CXR strategy increases the diagnostic and therapeutic efficacy of CXRs in critically ill patients while subsequently reducing the number of CXRs and subsequent costs significantly. No difference in mortality, length of mechanical ventilation or length of ICU or hospital stay was found[29–34]. Kroner et al. found no change in the number of computed tomography (CT) or ultrasound studies performed by the department of radiology for ICUs that use an ‘on-demand’ CXR strategy. To our knowledge there are no studies regarding the impact of an ‘on-demand’ CXR strategy on the number of ultrasound studies performed by intensivists or vice versa. A routine ultrasound examination of the pleura and pericardium performed by ICU physicians after cardiac surgery or before ICU discharge might further reduce the use routine CXR strategies.
However, completely abandoning routine CXRs for ICU patients is still under debate because the currently available studies did not evaluate the effect of missed findings, had low patient numbers and did not rigorously assess possible harm. More prospective studies need to be performed on the topic of missed findings, the clinical value of negative findings and the indications for CXRs in an ‘on-demand only’ strategy, before a definitive conclusion can be drawn.
The strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from being a common practice in 2006 to a rare current practice. Other routine strategies and an ‘on-demand only’ strategy have become more popular. Intensivists still assume that the value of CXRs is higher than the efficacy reported in the literature.
Adult Respiratory Distress Syndrome
Central venous line
Intra-aortic balloon pump
Iintensive care unit.
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