On-demand chest X-rays for a specific clinical indication or chest ultrasounds are better alternatives for ICU patients than routine daily chest X-rays.

Boston physicians advise peers to abandon routine daily chest X-rays in ICU

July 29, 2020
by John R. Fischer, Senior Reporter
Two physicians in Boston are calling on their peers to abandon the practice of performing routine daily chest X-rays on patients in intensive care without a specific clinical reason.

Dr. Jason Maley and Dr. Jennifer Stevens say that while well-intended, daily chest X-rays in ICUs are outdated and do little to benefit patients.

“For most patients, routine daily imaging of any form is not necessary, whether chest X-ray or another modality,” Maley, a fellow of pulmonary and critical care medicine at Massachusetts General Hospital, Beth Israel Deaconess Medical Center and Harvard Medical School, told HCB News. “Imaging studies in the ICU are best used to answer particular clinical questions rather than routinely monitor patients. Point of care ultrasound performs as well or better than chest x-rays to evaluate most lung processes in the ICU and is an alternative to chest X-rays.”

The two used a real-life example to emphasize their reasoning, in which an inpatient in the ICU with pneumonia received a chest X-ray that appeared to show a collapsed lung. Though the patient’s ventilator showed the patient as stable, a second chest X-ray ordered showed the same as the first, and the surgical resident on call brought in a tube thoracostomy kit to begin prepping to insert a chest tube.

A lung ultrasound, however, showed no pneumothorax to be present and was followed up with a chest CT, which showed resolving pneumonia and no pneumothorax. The procedure was aborted, and after discussions with a radiologist, it was determined that the chest X-rays actually showed a skin fold that mimicked a pneumothorax.

Maley and Stevens note that such situations are common, and that ICU clinicians have historically seen daily chest X-rays as essential for monitoring pulmonary disease and the status of commonly used indwelling devices such as various catheters and tubes. Literature around the practice dates back decades and the American College of Radiology appropriateness criteria rated daily chest X-rays in mechanically ventilated patients as “most appropriate” prior to 2008. This changed in 2011, when in response to emerging evidence, the ACR changed its rating for routine daily chest X-rays in the ICU to “usually not appropriate”. The 2014 American College of Physicians Choosing Wisely recommendations also advise against ordering chest X-rays at regular intervals rather than for specific clinical indications.

A meta-analysis of nine studies Maley and Stevens reference compared routine daily X-rays of the chest to on-demand (for specific clinical indications), and found that only when clinically indicated do chest X-rays not adversely affect mortality, hospital or ICU length of stay, or duration of ventilation. Another multicenter, randomized trial showed similar outcomes.

Reducing the use of these daily scans allows doctors to spend more time at patient bedsides and decreases the total amount of radiation exposure to a patient — something that isn’t often considered when deciding on an X-ray in the ICU, since it is ideally necessary as part of lifesaving care. That said, the practice should not completely disappear according to Maley, who says it can be used for certain specific scenarios, such as monitoring certain catheters.

He adds, however, that the chest X-rays from the case highlighted in the study led to several unnecessary imaging tests that stressed both the patient and their family, and nearly resulted in the patient undergoing a harmful, invasive procedure. Such an example illustrates the challenges associated with this practice, which he and Stevens claim should be addressed through ICU policy changes, evidence-based education and clinician engagement.

“Many ICUs have shifted away from daily chest X-ray use, though practice remains very variable,” he said. “As point of care ultrasound is increasingly used, this will replace the need for chest X-rays in many situations. Overall, I anticipate that routine chest X-ray use will continue to decline as clinicians focus on value-based healthcare and quality improvement at their hospitals.”

The findings were published in JAMA Internal Medicine.