Routine Chest Radiographs in Pediatric Intensive Care Units
Frans B. Plötz, MD, PhDJody W. Valk, MD
St Antonius Hospital, Department of Pediatrics
3430 EM Nieuwegein, the Netherlands
To the Editor.—
We read with great interest the article by Quasney et al.1 They showed that routine chest radiographs (CXRs) often alter the management of critically ill children, in particular in the smaller, critically ill child with 1 or more devices and if active cardiopulmonary problems are present.
The value of routine CXRs is measured by their efficacy. The American College of Radiology (ACR) has divided the issues of efficacy into 3 parts: 1) diagnostic efficacy, or the influence of a test result on diagnosis; 2) therapeutic, or the effect of a test result on clinical management; and 3) outcome efficacy, or the effect a test result will have on patient outcome.2 Although the therapeutic efficacy of CXRs is difficult to assess since interventions are based on more than radiographic findings alone, the study by Quasney et al clearly showed the therapeutic efficacy of routine CXRs in critically ill pediatric patients: 45% of the routine CXRs resulted in 1 or more interventions. Unfortunately, the study was not designed to evaluate the importance of these interventions. Their results are in concert with 2 other studies evaluating the therapeutic efficacy of CXRs in children.3,4
We have recently performed a prospective study evaluating the diagnostic value of routine CXRs in a pediatric intensive care unit.5 A reasonable parameter for diagnostic efficacy is to determine the incidence of new diagnostic findings or changes in previous findings on the CXR. In our study we found a surprisingly high percentage of malpositioned medical devices. Marked changes in radiologic cardiopulmonary status were also frequently observed; more children showed worsening of the radiologic cardiopulmonary status rather than an improvement. Therefore, our study also supports the importance of routine CXRs in critically ill pediatric patients.
To increase the diagnostic and therapeutic efficacy, it is important to establish pediatric guidelines for obtaining routine CXRs. The ACR has published recommendations for adult patients.3 We demonstrated that the indication for the majority of CXRs taken in our pediatric intensive care unit appeared to be in accordance with these recommendations.5 Sixty-seven percent of the obtained CXRs were in accordance with the ACR guidelines, whereas in patients in whom no CXR was taken this was 74%. However, we feel that (minor) adjustments for pediatric patients are needed. Most tertiary pediatric intensive care units treat a mixed population of infants and children with a large variation in underlying primary diagnosis. This inhomogeneous pediatric population will have different CXRs needs, which can be described and protocoled. In addition, this may limit the number of CXRs taken and will result in cost savings. Future studies are necessary to evaluate the diagnostic and therapeutic efficacy of these adjusted ACR guidelines for pediatric patients.
REFERENCES
- Quasney MW, Goodman DM, Billow M, et al. Routine chest radiographs in pediatric intensive care units.
Pediatrics.2001; 107
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[Abstract/Free Full Text] - American College of Radiology Panel. American College of Radiology Thoracis Expert Panel Report. Reston, VA: American College of Radiology; 1996
- Hauser GJ, Pollack MM, Sivit CJ, Taylor GA, Bulas DI, Guion CJ. Routine chest radiographs in pediatric intensive care: aprospective study.
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[Abstract/Free Full Text] - Levy FH, Bratton SL, Jardine DS. Routine chest radiographs following repositioning of endotracheal tubes are necessary to assess correct position in pediatric patients.
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[Abstract/Free Full Text] - Valk JW, Plotz FB, Schuerman FA, van Vught H, Kramer PP, Beek EJ. The value of routine chest radiographs in a paediatric intensive care unit: a prospective study. Pediatr Radiol.2001; 31 :343 –347[CrossRef][Web of Science][Medline]
Routine Chest Radiographs in Pediatric Intensive Care Units
Michael W. Quasney, MD, PhDDepartment of Pediatrics
Crippled Children’s Foundation Research Center
Le Bonheur Children’s Medical Center
University of Tennessee
Memphis, TN
Denise M. Grodman, MD
Department of Pediatrics
Children’s Memorial Hospital
Northwestern University
Evanston, IL
In Reply.—
We have no dispute with Valk et al1 that the value of routine chest radiographs (CXRs) can be measured not only by their diagnostic efficacy, as they have demonstrated, but also by their therapeutic efficacy, which was the focus of other articles in addition to our own. However, there is much overlap between diagnostic and therapeutic efficacies and such distinctions are most important if they affect patient outcomes. The authors state that they performed a "prospective study evaluating the diagnostic value of routine CXRs"; our study also incorporated diagnostic value if the radiograph findings led to a change in patient management. For example, an adjustment of a medical device based on the result of the CXR implies a diagnostic finding of a malpositioned device. Indeed, the data in Table 4 of our study suggests at least 75 malpositioned devices since our intervention was adjustment of those devices in 465 CXRs that had at least 1 device. Furthermore, what is the value of diagnosing a malpositioned device if its position is not adjusted? How important are the diagnostic findings? The more important question and certainly more difficult study to perform is to assess the patient outcome attributable to the radiograph. Patients would have to be randomized to receive the routine CXR or to not receive the CXR and then be followed for various outcome measures. The cost savings of performing or not performing those CXRs and the costs of both positive and negative outcomes should also be examined. Only in this way can the more important issue of clinical effectiveness be determined.
REFERENCE
- Valk JW, Plotz FB, Schuerman FA, van Vught J, Kramer PP, Beek EJ. The value of routine chest radiographs in a paediatric intensive care unit: a prospective study. Pediatr Radiol.2001; 31 :343 –347
PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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