Chest x-rays in the ICU

Article #

Literature Type




Citation: Oba, Y., Zaza, T. Abandoning daily routine chest radiograph in the intensive care unit: meta-analysis. Radiology. 2010 May;255(2):386-95

Purpose of study: “Our objectives were to systematically examine if abandoning daily routine [e.g. routine vs. on-demand] chest radiography would adversely affect outcomes such as mortality and LOS and identify a subgroup in which daily routine chest radiography might be beneficial.”

Design: Two authors independently identified 128 articles from NLM (1/1/1950 to 12/31/2008).  23 studies were deemed as relevant. 14 were excluded for lack of comparison group.  Eight studies were used in the final meta-analysis. 

Key Results: “A pooled analysis revealed that the elimination of daily routine chest radiography did not affect either hospital (OR, 1.02; 95% CI: 0.89, 1.17; P = .78) or ICU (OR, 0.92; 95% CI: 0.76, 1.11; P = .4) mortality. There was no evidence of statistical heterogeneity among the included trials (I2 = 0%). There was no significant difference in the hospital mortality between the on-demand and daily routine groups when the randomized controlled trials (OR, 0.97; 95% CI: 0.57, 1.64; P = 0.90) or observational studies (OR, 1.02; 95% CI: 0.89, 1.18; P = 0.75) were separately analyzed, which was also true for the ICU mortality (OR, 1.06; 95% CI: 0.55, 2.02; P = .87 for randomized controlled trials and OR, 0.91; 95% CI: 0.75, 1.11; P = .35 for observational studies).”  

Summary: “Our systematic analysis demonstrates that the elimination of daily routine chest radiography did not adversely affect hard outcomes, such as hospital or ICU mortality, hospital or ICU length of stay, and ventilator days. Therefore, we assert that daily routine chest radiography can potentially be safely eliminated in most ICU patients.”


Delphi study

Citation: Hejblum, G., Ioos, V, et al. A web-based Delphi study on the indications of chest radiographs for patients in ICUs. Chest. 2008 May;133(5):1107-12. Epub 2007 Nov 7.

Purpose of study: “Many of the indications for CXRs in the ICU are controversial, such as the ordering of daily routine CXRs for intubated patients. The opinions of intensivists about ordering CXRs have not been reported. Comparing these opinions to established guidelines and identifying situations where opinions diverge in the absence of guidelines are of considerable interest.”

Design: The researchers used a web-based Delphi survey of 190 fellows and boarded intensivists from 34 ICUs (20 teaching and 14 nonteaching hospitals) in France.

Key Results: 82 completed all three Delphi iterations.  A total of 29 items, or clinical scenarios were posed to the group.  Routine chest x-rays were deemed appropriate for eight items (table 1, below).

Summary: A major result of our study is that the intensivists did not consider that a routine daily CXR is required in intubated patients. This attitude is in disagreement with the ACR recommendation1 that was based on the fact that endotracheal tube malpositioning is diagnosed in 12 to 15% of patients, whereas physical examination findings have suggested that malpositioning occurs in only 3% of patients. Considering that routine daily CXRs ordered because of the presence of an endotracheal tube contribute a substantial proportion of the bedside CXRs obtained in ICUs, a reappraisal of the need for routine daily CXR in the situation may be timely.”


BayviewPro likes the following terminology used:

·         Routine (ie, without clinical evaluation)

o   Scheduled: e.g. monitoring of indwelling medical device, specific clinical situation

o   Unscheduled: e.g. after placement of a medical device, ICU admission

·         On demand (ie, after clinical evaluation)

o   Scheduled: based on clinical status

o   Unscheduled: after a change in clinical status

3 (see article 5)

Review article


Citation: Loos, V., Galbois, A., et al. An integrated approach for prescribing fewer chest x-rays in the ICU. Ann Intensive Care. 2011 Mar 21;1(1):4.

Purpose of study: “In recent years, several studies have focused on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes.”

Summary: The article reviewed various alternative techniques (e.g. bedside ultrasound to assess for pneumothorax after proceduralization, capnography for NG tube placement, etc).


Prospective RCT

Citation: Clec'h, C., Simon, P., et al. Are daily routine chest radiographs useful in critically ill, mechanically ventilated patients? A randomized study. Intensive Care Med. 2008 Feb;34(2):264-70.

Purpose of study: “we carried out a study to assess not only the efficacy, but also the safety of a restrictive prescription of CXRs.”

Design: Single center RCT (non-blinded); Inclusion: all consecutive patients, admitted to M/SICU, who required invasive mechanical ventilation (MV), over a six-month enrollment period were enrolled; Exclusion: MN <= 48 hours; patients requiring re-intubation; MV through tracheostomy tube; withdrawal of care.  Patients were followed up until hospital d/c or death. 372 patients, 191 eligible, 26 excluded, randomized (computer generated) to routine (84) and restrictive (81).  Endpoints: rates of new findings, rates of new findings that prompted therapeutic intervention, rate of delayed diagnoses (restrictive group) and ICU/hospital mortality.  Routine group: CXR were ordered and interpreted daily. Restrictive group: CXR was obtained daily, but only interpreted if an abnormality was anticipated (clinically indicated CXR); remaining CXRs were hidden and then interpreted after the study was completed (to assess for misses).

Key Results: baseline variables for both groups were not significantly different; Restrictive group: 94 clinically indicated CXRs were obtained, 62 (66%) had new findings vs. routine where 885 CXRs were obtained and only 64 (7.2%) revealed new findings.  There were no differences in ICU or hospital mortality or LOS, and mechanical ventilation free days. Table 2 (below).

Summary: “Restrictive use of CXR is effective and safe.” “Protocols advocating routine CXRs in MV patients could be safely abandoned…CXR should instead be performed when a significant abnormality is anticipated.”

5 (see article 3)

Prospective, Multicenter, cluster-randomized, two-period crossover study

Citation: Hejblum, G., Chalumeau-Lemoine, L, et al. Comparison of routine and on-demand prescription of chest radiographs in mechanically ventilated adults: a multicenter, cluster-randomized, two-period crossover study. Lancet. 2009 Nov 14;374(9702):1687-93.

Purpose of study: “Substantial variation was recorded [referencing article 3, above] between the physicians' opinions of whether routine chest radiographs were needed for mechanically ventilated patients with different clinical conditions. Therefore, we did a large prospective multicenter study to assess the efficiency and effectiveness of routine versus on-demand chest radiographs for optimum care of mechanically ventilated patients, using a two-period cluster-randomized design.”

Design: Randomization of 21 ICUs (Paris), first period the ICU used either a routine strategy (all MV patients were given a CXR, irrespective of clinical status) or an on-demand strategy (MV patients were given a CXR based on clinically findings after examination; second period opposite strategy was used; unscheduled CXR could be requested at any point in time; admission CXRs were not included in analysis;  (Figure 1, below)

Key Results: mean CXR per patient-day were less in on-demand group, unscheduled were no different.  No difference in the number of days of MV, LOS, and/or mortality (see table 3, below)

Summary: “Results from our study show a substantial reduction in use of chest radiographs with the on-demand strategy in all 21 participating intensive care units, corresponding to a 32% decrease overall compared with the routine strategy. Between the strategies, we recorded similar numbers of chest radiographs that led or contributed to therapeutic or diagnostic interventions, duration of mechanical ventilation and stay in the intensive care unit, and mortality.” “Results from our study strongly support the adoption of an on-demand strategy in preference to a routine strategy to decrease the number of chest radiographs done in mechanically ventilated adult patients without a reduction in patient safety. In view of the large number of patients who undergo mechanical ventilation, these results could substantially benefit clinical practice.”


Prospective comparative design with an intervention

Citation: Mets, O., Spronk, P.E., et al. Elimination of daily routine chest radiographs does not change on-demand radiography practice in post-cardiothoracic surgery patients. J Thorac Cardiovasc Surg. 2007 Jul;134(1):139-44.

Purpose of study: “Recently, we showed that daily routine chest radiographs seldom reveal unexpected clinically relevant abnormalities, and they rarely cause further action. In view of these findings, we abandoned daily routine chest radiographs for all patients in our ICU, including those after cardiopulmonary surgery. It was feared that the abandoning of daily routine chest radiographs would result in a sharp increase of on-demand chest radiographs; in addition, it was speculated that many abnormalities would be missed, resulting in an increase of diagnostic value of the latter radiology studies. In the present study we determined the effect of the above mentioned change on chest radiography practice in the ICU and the post-ICU ward. In addition, we compared the diagnostic efficacy of chest radiographs, ICU and hospital LOS, and readmission rates to the ICU before and after the intervention.”

Design: Prospective comparative study of a 28-bed closed ICU unit (Netherlands) and 4-bed post-ICU ward.  Phase 1 was three months prior to intervention and phase 2 was three months after the intervention. “The intervention consisted of a change in the ordering practice of chest radiographs: only on-demand chest radiographs were to be obtained. The attending physicians were not blinded for this change in strategy; in fact, they were the ones who had to abandon the daily routine strategy. In addition, there were no standing orders for chest radiographs starting the new strategy. Each chest radiograph required a clinical indication, such as admittance to the ICU; insertion of central venous lines, intra-aortic balloon pump, or tracheal and chest tubes; an increase in oxygen requirement; or a change in pulmonary secretions with or without fever. Only if one of these indications was present and after consulting the supervisor (in case of residents/interns) was an on-demand chest radiograph obtained.”

Key Results: Baseline characteristics were not significantly different. “In the ICU, the total number of chest radiographs per patient decreased after the intervention. In phase 1 3.5 ± 4.3 chest radiographs per patient were obtained, and in phase 2 this number decreased to 1.7 ± 1.2 (mean difference, 1.8; 95% CI, 1.1–2.5). On the post–ICU ward, the total number of chest radiographs per patient was 2.4 ± 1.4 and 2.8 ± 1.4 in phases 1 and 2, respectively (mean difference, –0.4; 95% CI, –0.7 to –0.1).  In the ICU after the intervention, the number of chest radiographs per patient per day decreased from 1.8 ± 0.6 to 1.1 ± 0.6 (mean difference, 0.7; 95% CI, 0.6–0.8). On the post-ICU ward, this number did not change.” No significant change in ICU or hospital LOS and readmission rated did not change.  See article for change in timing (daily distribution) of CXR

Summary: “In conclusion, elimination of daily routine chest radiographs in post–cardiothoracic surgery patients in our ICU did not result in changes in ICU and hospital LOS, nor did the readmission rate change. The intervention did not result in any important changes in chest radiography performance in the ICU and the post-ICU ward.”

This list originally compiled by Dr. Jonathon Thorp, at Johns Hopkins Bayview Medical Center.