OptimizatiOn Of chest radiOgraphy practice fOr critically ill patients

background. Intensive care unit (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. methods. 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. results. 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 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. conclusion. The strategy of daily routine CXRs for critically ill and mechanically ventilated patients has turned from 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. backGround Intensive care unit (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 intensive care units in The Netherlands, a daily routine CXr strategy was still common practice [35]. Intensivists at that time assumed a higher value of a 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 was not sufficiently evaluated [33]. 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.