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PEDIATRICS Vol. 107 No. 2 February 2001, pp. 241-248
,,
,,, and
From the * Department of Pediatrics, Crippled Children's
Foundation Research Center, Le Bonheur Children's Medical Center,
University of Tennessee, Memphis, Tennessee; Department of
Pediatrics, Children's Memorial Hospital, Northwestern University,
Evanston, Illinois; § Department of Pediatric Critical Care,
Children's Hospital Medical Center of Akron, Akron, Ohio; Division
of Pediatric Critical Care, Cook Children's Medical Center; Fort
Worth, Texas; ¶ Department of Pediatrics, Lucile Salter Packard
Children's Hospital, Stanford University, Stanford, California;
# Department of Pediatrics, Children's Hospital, Medical University of
South Carolina, Charleston, South Carolina; ** Department of Nursing,
University of Chicago Children's Hospital, Chicago, Illinois;
Pediatric Pulmonary and Intensive Care, Children's Hospitals and
Clinics of Minneapolis, Minneapolis, Minnesota; §§ Department of
Pediatrics and Communicable Diseases, C. S. Mott Children's
Hospital, University of Michigan, Ann Arbor, Michigan; || Department
of Pediatrics-Critical Care, Kosair Children's Hospital, Louisville,
Kentucky; ¶¶ Department of Pediatrics, Arkansas Children's Hospital,
University of Arkansas for Medical Sciences, Little Rock, Arkansas;
## Department of Nursing, Miami Children's Hospital, Miami, Florida;
*** Department of Pediatrics, Children's Hospital of Wisconsin,
Milwaukee, Wisconsin; Departments of Anesthesiology and
Pediatrics, Vanderbilt Children's Hospital, Vanderbilt University,
Nashville, Tennessee; and the §§§ Department of Pediatrics,
Children's Hospital of Alabama, University of Alabama-Birmingham,
Birmingham, Alabama.
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ABSTRACT |
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Top
Abstract
Methods
Results
Discussion
References
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Objectives. To determine whether interventions were performed based on portable routine morning chest x-rays (CXRs) in pediatric intensive care unit (PICU) patients and to identify patient subgroups for whom the routine CXR is most useful.
Design. Prospective multiinstitutional study.
Setting. PICUs of 15 tertiary care hospitals.
Patients. PICU patients who received a routine morning CXR were included in the study.
Outcome Measures. Recorded data included: weight, diagnosis, presence of active cardiopulmonary problems, length of stay, and number and type of devices. The number and types of interventions based on the interpretation of the CXR were recorded.
Results. Five hundred twelve routine CXRs were evaluated.
The majority of the routine chest radiographs were obtained on patients
who were admitted for cardiovascular disease (195/512; 38%) or
respiratory failure (186/512; 36%), and 465/512 of the routine CXRs
(91%) were performed on patients with one or more devices. Two hundred thirty-one of the 512 routine CXRs (45%) resulted in 1 or more interventions. One hundred fifty-five of the 284 routine CXRs (55%)
obtained in children 
10 kg resulted in one or more interventions, compared with 61/152 (40%) and 15/76 (20%) of routine CXRs obtained in children 10 to 40 kg and 
40 kg, respectively. The frequency of
interventions increased from 19% in children with no devices to >50%
in children with 2 or more devices. One or more interventions were
performed in 27% of routine CXRs when no active cardiopulmonary problems were present, compared with 51% of routine CXRs when active
cardiopulmonary problems were present. Diagnosis and length of
intensive care unit stay at the time the routine CXR was obtained did
not affect the percentage of CXRs that resulted in interventions.
Conclusions. Routine CXRs are more likely to result in interventions in the smaller, critically ill child with one or more devices and if active cardiopulmonary problems are present. Key words: routine chest radiographs, pediatrics, intensive care unit, interventions.
Chest radiographs are commonly performed in the pediatric
intensive care unit (PICU) setting. Many such radiographs are routinely performed without any specific clinical indication because they help to
confirm the position of various devices such as endotracheal tubes,
chest tubes, and central venous catheters. Indeed, the American College
of Radiology and others suggest that daily chest radiographs are
indicated on mechanically ventilated patients as well as those with
acute cardiopulmonary problems.1-4 The rationale for
these recommendations is based on studies suggesting that the routine
chest radiograph is likely to identify unexpected problems that have
not yet manifested clinically.5-8 Other studies suggest
that there is little value in obtaining the routine chest radiograph in
the intensive care unit (ICU) setting because clinical data can be used
to obtain the information needed to manage the patient9,10
and portable chest radiography is poor at identifying pathophysiologic manifestations of acute respiratory failure.11 In the era
of cost containment in the health care industry, there is economic
pressure to reduce the number of tests that have little impact on
patient management.
Most studies examining the efficacy and value of routine chest
radiographs have been performed in adult ICUs. These studies have
demonstrated a high frequency of unsuspected or abnormal findings on
the chest radiographs obtained on patients in the ICU,5-8
and most of these findings led to changes in the management of the
patient.8 Brainsky and coworkers12 found that
8% of routine chest radiographs in an adult ICU led to interventions
and concluded that routine chest radiographs resulted in decreased
overall costs. Others have concluded that the routine morning chest
radiograph is diagnostically or clinically important5,13-15 particularly in adult patients with
pulmonary or complicated cardiac disorders8 or Swan-Ganz
catheters.16 The usefulness of the routine chest
radiograph in the smaller, critically ill child may be different than
it is in adults for various anatomic and physiologic reasons. In the
only study evaluating the efficacy of routine chest radiographs in a
PICU, Hauser and colleagues17 demonstrated that
significant findings requiring alterations in patient management could
have been missed had the routine chest radiograph not been performed.
They concluded that routine daily chest radiographs have a significant
clinical impact on the management of critically ill children.
We evaluated the usefulness of routine morning chest radiographs in 15 PICUs by examining the frequency of interventions performed based on
the results of the routine chest radiograph. We hypothesize that
routine morning chest radiographs in smaller patients in PICUs would be
more likely to result in interventions than in larger patients. We also
analyzed various subgroups of critically ill children in an effort to
determine those for whom the routine chest radiograph was more likely
to result in an intervention.
Fifteen PICUs participated in the study. The institutions
represent PICUs that are university-affiliated as well as
nonuniversity-affiliated. Admissions to the PICUs ranged from 50 to 120 children per month.
Children admitted to the PICU who had a routine chest radiograph
performed were enrolled in the study. For the purposes of this study, a
routine chest radiograph was defined as one that was ordered before
midnight the previous night and performed the following morning. Chest
radiographs were excluded if they were ordered before midnight the
previous night for the purpose of following up specific therapies or
processes. Each patient had only one chest radiograph evaluated for the
study, and once the patient was enrolled in the study, no further chest
radiographs of that patient were evaluated for the purposes of this
study. All chest radiographs were performed using portable devices.
Approval of the study was obtained from the institutional review boards at the participating institutions. Each institution randomly selected nonconsecutive days over a 6-month period on which to collect the data,
and all patients in the ICUs who met the criteria for having a routine
chest radiograph on that day were included in the evaluation. A
standardized data collection form was used by all participating
institutions to record the following: patient's weight; admission
diagnosis; the presence of active cardiopulmonary problems; length of
ICU stay at the time of the evaluation; primary service to which the
patient was admitted; devices such as endotracheal tubes, central
venous catheters, and chest tubes present at the time of the chest
radiograph; whether the patient was mechanically ventilated; and
adverse events that occurred during radiography. Active cardiopulmonary
problems were defined as infiltrates, atelectasis, pneumonitis,
pneumothorax, pleural effusions, reactive airway disease, congestive
heart failure, pericardial effusion, and cyanotic heart disease. The
interpretation of the routine chest radiographs and decisions regarding
the need for interventions were made by the attending physicians and
PICU fellows making the clinical decisions on the patients; for the
purposes of this study, the interpretations were not confirmed by
radiologists. Physicians were asked whether the result of the routine
chest radiograph led to an intervention; if so, the intervention was
recorded (see Table 4 for reported interventions). All interventions were recorded, and no attempt was made to judge the importance of an
intervention. The collection of data was not performed by individuals
involved in the care of the patient. The physicians interpreting the
chest radiographs and deciding whether interventions were needed were
blinded to the hypothesis of this study.
TABLE 4
METHODS
Top
Abstract
Methods
Results
Discussion
References
Reported Interventions Based on the Result of the Routine Chest
Radiograph
Statistical analysis was performed using 
2
analysis. P values for multiple comparisons are reported.
Univariate logistic regression analysis was performed to obtain odds
ratios between the independent variables weight group, presence of
devices, and the presence of active cardiopulmonary problems and the
outcome measure of interventions. The independent contribution of
hypothesized factors affecting the probability of an intervention was
evaluated using multiple logistic regressions. All hypothesized factors
(listed above) were modeled simultaneously. Statistical analysis was
performed using the statistical software package GB-Stat (New England
Software, Inc, Greenwich, CT).
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RESULTS |
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Top
Abstract
Methods
Results
Discussion
References
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Descriptions of the Participating PICUs
Fifteen PICUs participated in this study (Table 1). All but 2 units had residents or pediatric critical care fellows as part of the decision-making team. The number of beds ranged from 12 to 30, whereas the median daily census was 7 to 21 patients. Two of the 15 units admitted medical and surgical (noncardiovascular) patients and 13 admitted medical, surgical, and postoperative cardiovascular surgery patients.
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Mortalities in the individual PICUs ranged from 2.4% to 8.5%. Policies regarding routine chest radiographs included routine chest radiographs obtained on all intubated patients, all cardiovascular surgery patients, all postoperative or postinstrumented patients, and/or selected patients at the discretion of the clinical management team. No institution had a written policy governing the use of routine chest radiographs, and policies on routine chest radiographs reflected the current practices at the participating PICUs.
Descriptions of the Routine Chest Radiographs
Five hundred twelve chest radiographs met our definition of
routine. These routine chest radiographs were evaluated at each of the
participating institutions on nonconsecutive days from June to December
1997. Each institution contributed 30 to 50 evaluations. Weights of the
patients for whom the routine chest radiographs were obtained ranged
from 2 kg to 103 kg (median: 9 kg). The majority of the chest
radiographs were obtained from patients who were 10 kg (284/512;
55%; Table 2). Almost 75% of the
chest radiographs were obtained from patients with either
cardiovascular disease or respiratory failure. The majority of the
routine chest radiographs were obtained on mechanically ventilated
patients (331/512; 65%). Of those routine chest radiographs that were
obtained on patients 10 kg, 75% (213/284) were obtained on patients
who were also mechanically ventilated. The length of ICU stay for patients at the time the chest radiograph was performed was 1 to 156 days (median: 4 days). Devices were present in 465 of the 512 routine chest radiographs evaluated (91%) and are listed in Table
3.
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There were 3 adverse events recorded that occurred during the
performance of the routine chest radiograph. These included the loss of
peripheral intravenous catheters in 2 patients (1 patient in the
10-kg group, the other patient in the 10-40-kg weight group) and the
dislodgment of an endotracheal tube that was replaced without
difficulty (patient in the 10-kg group). This represents a <1% risk
of adverse events in the performing of routine chest radiographs.
Interventions Performed as a Result of the Routine Chest Radiograph
Physicians were asked whether the interpretation of the routine chest radiograph led to an intervention. The results of the 512 routine chest radiographs led to 1 intervention in 152 cases, 2 interventions in 71 cases, and 3 interventions in 8 cases. Thus, of the 512 routine chest radiographs, 231 resulted in 1 or more interventions (45%). The types and number of interventions are listed in Table 4.
Effect of Diagnosis on Percentage of Chest X-Rays (CXRs) Resulting in Interventions
The percentage of routine chest radiographs that resulted in one or more interventions was compared among the various diagnostic groups (Table 2). Interventions were less likely to be performed as a result of the routine chest radiographs when the chest radiographs were obtained from children who had undergone noncardiovascular surgical procedures (P < .025). There was no difference in the percentage of routine chest radiographs that resulted in one or more interventions among the other diagnostic groups.
Effect of the Presence of One or More Active Cardiopulmonary Problems on Percentage of CXRs Resulting in Interventions
We compared the percentage of routine chest radiographs that resulted in one or more interventions if no active cardiopulmonary problems were present with the percentage of routine chest radiographs that resulted in one or more interventions if one or more active cardiopulmonary problems were present (Table 5). One or more interventions were performed as a result of 27% of the routine chest radiographs when no active cardiopulmonary problems were present. This percentage increased to 51% (P < .001) if active cardiopulmonary problems were present. Univariate logistic regression analysis demonstrated that the odds of an intervention being performed as a result of the chest radiograph increased 2.9 times (95% confidence interval [CI]: 1.8-4.6; corresponding to relative risk of 1.9) with the presence of an active cardiopulmonary problem.
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Effect of Length of Stay on Percentage of CXRs Resulting in Interventions
The median length of stay in the ICU at the time of the routine
chest radiograph for patients for whom the routine chest radiographs were evaluated was 4 days. There was no statistically significant difference in the percentage of routine chest radiographs that resulted
in one or more interventions if the patients had a length of stay of 1 to 2 days (43%), compared with patients whose length of stay was 3 to
4 days (54%; P < .1), 5 to 10 days (44%;
P < .9), or 11 days (43%; P < .9).
Effect of Weight on Percentage of CXRs Resulting in Interventions
Routine chest radiographs obtained on smaller patients (10 kg)
were more likely to result in interventions than chest radiographs obtained on larger patients regardless of whether the patient was
mechanically ventilated or not mechanically ventilated (Table 2). Of
the chest radiographs obtained on patients 10 kg, 155/284 (55%) resulted in one or more interventions. This compared with 61/152
(40%; P < .005) and 15/76 (20%; P < .001) of the chest radiographs obtained on patients 10 to 40 kg and
>40 kg, respectively. Univariate logistic regression analysis
demonstrated that the odds of an intervention being performed as a
result of the chest radiograph increased 4.9 times (95% CI: 2.7-9.0;
corresponding to relative risk of 2.8) in children 10 kg compared
with children >40 kg and 1.8 times (95% CI: 1.2-2.7; corresponding
to relative risk of 2.0) compared with children 10 to 40 kg. The
frequency of routine chest radiographs resulting in one or more
interventions was significantly higher in patients who were 10 kg and
mechanically ventilated (59%) and 10 to 40 kg (52%; P < .005) compared with patients >40 kg who were mechanically
ventilated (23%; P < .001) (Table 2). The frequency
of routine chest radiographs resulting in one or more interventions in
patients who were 10 to 40 kg and mechanically ventilated was not
different (56%; P < .7) from the smaller mechanically
ventilated patient. Patients 10 kg who were not mechanically
ventilated had a significantly higher frequency (29/71; 41%) of
routine chest radiographs that resulted in one or more interventions
than patients who were 10 to 40 kg (12/64; 19%; P < .01) or >40 kg (8/46; 17%; P < .01) and were not
mechanically ventilated.
Effect of the Number of Devices on Percentage of CXRs Resulting in Interventions
Nearly 91% of the routine chest radiographs (465/512) evaluated for this study were performed on patients who had one or more of the devices. The frequency of interventions increased from 19% in routine chest radiographs obtained on patients with no devices to >50% in patients with more than 2 devices (P < .001; Table 5). Univariate logistic regression analysis demonstrated that the odds of an intervention being performed as a result of a chest radiograph increased 2.6 times (95% CI: 1.2-5.6; corresponding to a relative risk of 2.0) in children with 1 or 2 devices and 5.3 times (95% CI: 2.5-11.5; corresponding to a relative risk of 2.9) in children with more than 2 devices.
Effect of Patient Weight and Number of Devices on Percentage of CXRs Resulting in Interventions
As shown in Table 5, the percentage of routine chest radiographs
resulting in one or more interventions is strongly associated with the
number of devices. We determined whether this observation was
consistent in each of the weight groups. Figure
1A demonstrates that the number of
devices present significantly increased the percentage of chest
radiographs resulting in one or more interventions in both the 10-kg
(P < .001) and 10- to 40-kg weight groups
(P < .025) but not in the percentage of chest radiographs resulting in one or more interventions in the >40-kg weight group (P < .5). In contrast, Fig 1B
demonstrates that in patients who were mechanically ventilated the
number of devices present had no significant effect on the percentage
of chest radiographs resulting in one or more interventions in all patient weight groups (10 kg and 10-40 kg, P < .5;
>40 kg, P < .75). However, there was a significant
difference between the percentage of routine chest radiographs that
resulted in one or more interventions between the mechanically
ventilated patients >40 kg and smaller patients with 1 to 2 devices
and between the mechanically ventilated patients >40 kg and smaller
patients with >2 devices (P < .005). This is in sharp
contrast in the group of patients who were not mechanically ventilated
as demonstrated in Fig 1C. As the number of devices present increased, there was a significant increase in the percentage of chest radiographs resulting in one or more interventions in patients 10 kg
(P < .025) but not in larger patients
(P < .5). There was in addition a significantly
greater percentage of routine chest radiographs that resulted in one or
more interventions in the 10-kg weight group with 1 to 2 devices than
either of the other 2 weight groups with a similar number of devices
(P < .001). After inclusion of the variables in a
multiple logistic regression model, all remain statistically
significant independent predictors of whether an intervention was
performed. Adjusted odds ratios for each of the independent variables
were 3.2 (95% CI: 1.5-7.0) for the presence of devices,
2.3 (95% CI: 1.5-3.7) for the presence of active cardiopulmonary problems, and 2.1 (95% CI: 1.5-3.1) for weight 10 kg. Thus, the probability of an intervention being performed is 60% if all 3 variables are present, and 8.7% if none of the variables are
present.
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
References
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Routine diagnostic tests performed in the ICU setting should aid
the clinician in the management of the patient, ideally, without the
addition of high costs or morbidity to the patient. Routine chest
radiographs have been suggested on mechanically ventilated adult
patients as well as those with acute cardiopulmonary problems to help
identify unsuspected problems that might require a change in patient
management.1-4,8 We have evaluated the usefulness of the
routine chest radiograph in critically ill children in a prospective,
multiinstitutional survey by asking physicians what, if any,
interventions were performed as the result of the routine chest
radiograph. Almost 45% of all routine chest radiographs evaluated in
this study resulted in one or more interventions. We were also able to
identify subgroups of patients in whom the routine chest radiograph was
more likely to result in interventions. For example, >50% of routine
chest radiographs performed on critically ill children 10 kg with one or more devices resulted in one or more interventions in our study, suggesting that routine chest radiographs have a significant impact on
the management of this population of critically ill children. Routine
chest radiographs performed on critically ill children >40 kg with 2 or fewer devices, in contrast, were less likely to result in
interventions, suggesting that these routine chest radiographs had a
smaller impact on the management of the child.
Our study differs from previous reports in several ways. First, most studies examining the usefulness of routine chest radiographs have involved the adult ICU population, which is significantly different from the PICU population. Second, our study examines the usual practice of how the routine chest radiograph is interpreted and used; that is, the physician team making the clinical decisions regarding the patient often interprets the chest radiograph early in the morning before or during rounds and makes decisions regarding interventions at that time. Confirmation by a radiologist often occurs after most of those decisions are made. Our study was not designed to examine whether interventions were performed based on the interpretation by the radiologist, rather whether the chest radiograph resulted in an intervention based on a decision made by the clinical management team. That is the current practice in the PICUs that participated in this study. Further analysis of our data is needed to determine whether there is congruence between the interpretation by the clinical decision-making team and the interpretation by the radiologist.
Although there are similarities in our study with a previous report examining routine chest radiographs in the PICU population, there are significant differences. In the study by Hauser et al,17 nearly 24% of chest radiographs resulted in interventions. However, it is difficult to compare the population in their study with the population in our study because detailed information regarding which patients in their study required interventions is lacking. Furthermore, patients had multiple chest radiographs evaluated for the study; that is, 353 chest radiographs from only 101 different patients from the same institution were evaluated, whereas 512 different patients from 15 different institutions were evaluated in our study. It is unclear whether the patients described by Hauser et al who had interventions came from a specific subgroup of the 101 patients. Furthermore, although they summarize that young, intubated, mechanically ventilated patients with indwelling central venous catheters benefited the most from routine chest radiographs, this is based on whether interval changes could be predicted, not whether the routine chest radiograph altered the management of the patient. Our study differs from their study in that the actual interventions performed because of the routine chest radiograph were analyzed rather than whether one could predict the findings on the chest radiograph.
One of the objectives of this study was to identify patient subgroups for whom the routine chest radiograph is most useful. In this manner, we could also identify subgroups for whom the routine chest radiograph was less likely to result in changes in management, thereby reducing costs by decreasing the use of routine chest radiographs. We did not attempt, however, to analyze cost-savings that would have occurred if routine chest radiographs had not been performed. We believe that the type of analysis performed in this study is important because it attempts to identify subgroups of patients in whom certain diagnostic tests need not be performed because of the low likelihood that the test will lead to a change in clinical management.
Based on our study alone, however, the conclusion that routine chest radiographs should not be performed on certain subgroups of patients must be viewed with caution. Less than 20% of the routine chest radiographs obtained in the >40 kg group with no devices led to an intervention; however, some of those interventions such as changes in diuretic therapy and mechanical ventilation could significantly affect patient outcome. Arguably, the use of other clinical data, such as fluid balance and arterial blood gases, might have obviated the need for the chest radiograph in making management decisions regarding diuretics or the ventilator. The patients in this group, however, still had clinically important decisions made based on the results of the routine chest radiograph. It is difficult to judge the level of interventions that would justify not performing routine chest radiographs. For some physicians, even a low level of interventions could potentially be very important in the care of critically ill children. The cost-savings of not performing routine chest radiographs could be substantial; however, without being able to reliably place a value on the interventions performed during this study, it is difficult to determine the additional costs of caring for patients in whom interventions because of the routine chest radiograph prevented bad outcomes. In addition, chest radiographs that did not lead to an intervention but eliminated a potential cause for a clinical finding are not deemed important by the type of analysis performed in this study. These chest radiographs can also be of great significance because they could lead to further clinical decisions. A randomized trial in which patients receive a daily chest radiograph or one less frequently would better evaluate issues of costs and impact on outcome. The need for routine chest radiographs in patients in whom there is a low frequency of interventions based on the radiograph, therefore, should continue to be evaluated carefully.
Some of the interventions that were performed based on the result of the routine chest radiograph might be considered minor and have little clinical importance. We did not attempt to judge how important the intervention was in the care of the patient. There are differing views on the importance of the various interventions that we report in this study and some would argue that even seemingly minor interventions such as an adjustment in a nasogastric tube or the institution of chest physiotherapy could be of significant clinical importance in the management of a critically ill child. A study designed to evaluate the importance of these various types of interventions may be warranted.
In addition, our study design identified interventions based on routine chest radiographs on only one day of the patient's hospital stay of which the median for the entire study population was 4 days. A cumulative risk of interventions based on the median length of stay increases the likelihood that a routine chest radiograph for a given patient would result in an intervention. If one examines the group of patients for whom an intervention was less likely, that is, the >40-kg patient with no devices, ~20% of the routine chest radiographs on any given day led to an intervention. The cumulative risk that an intervention would be performed would increase to ~50% for any given patient in this group over the course of their ICU stay.
This study also emphasizes some of the differences between pediatric
and adult patients. For example, the ausculatory examination in small
children often can be misleading. The routine chest radiograph can aid
the clinician in identifying areas of atelectasis and infiltrates;
indeed, changes in chest physiotherapy were guided by the routine chest
radiograph 62 times, and this intervention was more likely in the child
10 kg than in larger children (Table 4). The distance between the
vocal cords and carina in the child 10 kg is smaller making
appropriate positioning of the endotracheal tube more difficult.
Adjustments in the position of the endotracheal tube based on the
result of the routine chest radiograph accounted for the greatest
number of interventions in the smallest weight group of patients.
Indeed, 75 of the total interventions were adjustments in devices with
the majority (61/75) in the children 10 kg. The data also demonstrate
that as the patients in our study approached adult size, the percentage
of routine chest radiographs that led to one or more interventions is
similar to that reported by others.12,14,15 We also
confirm the findings of others that there is a greater likelihood of
interventions based on the routine chest radiograph in mechanically
ventilated patients, although the differences in those patients >40 kg
are not as large.15 The use of routine chest radiographs
in the smaller critically ill child, therefore, aids in the overall
assessment of these challenging patients but whether routine chest
radiographs have an impact on patient outcomes remains to be
determined.
There are several limitations to this type of analysis. First, there was an unequal number of chest radiographs evaluated by each institution. This number varied between 30 and 50; there is, thus, a selection bias introduced by the practice patterns of physicians from institutions that contributed a larger number of evaluations. We attempted to limit this selection bias by obtaining more evaluations from the smaller ICUs. Second, the design of the study may have led to changes in the practice patterns of the physicians managing the patients, thereby affecting the frequency of interventions. We attempted to minimize this effect by collecting data during different weeks when different teams of physicians may have been making the management decisions on the patients and attempting to keep the decision-making team blinded to the hypothesis of the study. Third, some of the decisions made by the bedside physician to intervene based on the results of the chest radiograph most likely also took into account other clinical data. For example, the decision to use diuretic therapy could also have included fluid balance in the previous 24 hours. We attempted to minimize this by the specific question that we asked (ie, did the result of the routine chest radiograph lead to an intervention?). Finally, this study did not examine whether the use of routine chest radiographs improves patient outcome or reduces costs. We believe that the best approach to examine these issues is a study in which patients are randomized to receive or to not receive a routine daily chest radiograph.
Despite its limitations, we believe that this study identifies
populations of critically ill children in whom the routine chest
radiograph has a significant impact in patient management and
populations in whom the routine chest radiograph is less likely to have
an impact on management decisions. Specifically, critically ill
children who are mechanically ventilated and <40 kg are more likely to
have interventions based on a routine chest radiograph than children
>40 kg. Children who are not mechanically ventilated and 10 kg are
more likely to have interventions based on a routine chest radiograph
than children >10 kg. We hope that additional studies will identify
other patient populations in whom the use of routine tests can be
minimized to reduce health care costs while maintaining high quality
care of critically ill children.
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ACKNOWLEDGMENTS |
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This project was supported in part by the Crippled Children's Foundation and the National Association of Children's Hospitals and Related Institutions.
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FOOTNOTES |
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Received for publication Jan 13, 2000; accepted Jul 20, 2000.
Reprint requests to (M.W.Q.) Division of Critical Care, Department of Pediatrics, Crippled Children's Foundation Research Center, Le Bonheur Children's Medical Center, 50 N Dunlap. Memphis, TN 38103. E-mail: mquasney{at}utmem.edu
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ABBREVIATIONS |
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PICU, pediatric intensive care unit; ICU, intensive care unit; CXR, chest x-rays; CI, confidence interval.
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REFERENCES |
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Abstract
Methods
Results
Discussion
References
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This article has been cited by other articles:
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  M. E. Graat, J. Stoker, M. B. Vroom, and M. J. Schultz Can We Abandon Daily Routine Chest Radiography in Intensive Care Patients? J Intensive Care Med, July 1, 2005; 20(4): 238 - 246. [Abstract] [PDF]
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 M. Krivopal, O. A. Shlobin, and R. M. Schwartzstein Utility of Daily Routine Portable Chest Radiographs in Mechanically Ventilated Patients in the Medical ICU Chest, May 1, 2003; 123(5): 1607 - 1614. [Abstract] [Full Text] [PDF]
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 F. B. Plotz, J. W. Valk, M. W. Quasney, and D. M. Grodman Routine Chest Radiographs in Pediatric Intensive Care Units Pediatrics, August 1, 2002; 110(2): 421 - 421. [Full Text] [PDF]
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