Lancet: On-demand chest x-ray sufficient for mechanically ventilated patients

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On-demand chest radiographs for mechanically ventilated intensive care patients, instead of daily radiographs, can reduce costs and decrease radiation exposure without compromising patient care or safety, according to a study published online Nov. 4 in the Lancet.

According to Gilles Hejblum, PhD, and colleagues from the Institute National de la Santé et de la Recherche Médicale in Paris, current guidelines recommend that chest radiographs on mechanically ventilated patents in intensive care be performed on a daily basis. 

In the study, the authors assigned 21 intensive care units at 18 hospitals in France to either a routine or an on-demand strategy for radiographs for the first of two treatment periods—with the alternate strategy used in the second treatment period.

Each treatment period lasted for the time taken for enrollment and study of 20 consecutive patients per intensive care unit and patients were monitored until discharge or for up to 30 days of mechanical ventilation.

Hejblum and colleagues found that 424 patients had 4,607 routine chest radiographs, while 425 had 3,148 on-demand radiographs—corresponding to a 32 percent reduction in radiographs using the on-demand strategy. No change was recorded in any secondary outcomes such as length of stay in the intensive care unit or mortality.

The authors concluded that results from their 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."

In an accompanying editorial, Mark D. Siegel, MD, from the department of internal medicine at Yale University School of Medicine in New Haven, Conn., and Ami N. Rubinowitz, MD, from the department of diagnostic radiology at Yale, wrote that the study authors “have provided persuasive evidence that routine daily chest radiographs are unnecessary in most intubated mechanically ventilated patients, and can be safely replaced by an on-demand approach reserving studies for clinical indications.”

Siegel and Rubinowitz added that a decision to adopt such a strategy needs to be decided by each individual intensive care unit, but should only be adopted if “skilled physicians are available to promptly identify patients requiring chest radiography, images can be made and interpreted efficiently, [and] abnormalities can be acted on throughout the day.”