Value of chest radiographs in the critically ill newborn - Tips from Other Journals

Date: Feb 1, 1994

The critically ill newborn in the neonatal intensive care unit is susceptible to a variety of primary and iatrogenic disorders. Portable chest radiography is routinely performed in this population to assess the initial clinical situation or the status of clinical disease. Chest radiographs are also routinely obtained after such procedures as intubation, extubation and umbilical line placement. To determine the value of routine portable chest radiography in the neonatal intensive care population, Spitzer and associates prospectively compared a series of routine screening chest radiographs with radiographs that were obtained for specific clinical indications.

A series of 41 full-term and preterm infants with cardiopulmonary disease were evaluated in the neonatal intensive care setting. Thirty-nine (95 percent) of the infants required positive pressure ventilation. Chest radiographs were obtained to assess a specific clinical situation ("indication" radiographs) or to determine the general status of the disease and support apparatus ("screening" radiographs). In each of the infants, chest radiographs were compared with the most recent ones obtained, if available. Each radiograph was assigned one of three levels of significance: level 1 exhibited changes that required an immediate alteration in patient management; level 2 exhibited changes that did not require an immediate alteration in management, and level 3 exhibited no changes and no alteration in management plan was indicated.

A total of 198 radiographs were obtained. Of those, 70 (35 percent) were ordered for a specific indication and 128 (65 percent) were ordered for screening purposes. Of the radiographs obtained for a specific indication, 33 (47 percent) demonstrated a significant change from the previous radiograph, compared with 63 (49 percent) of the screening films. Twenty-four (34 percent) of the indication radiographs and 42 (33 percent) of the screening radiographs had level 1 abnormalities, indicating a need for an immediate change in patient management. Twenty-one (16 percent) of the screening radiographs and nine (13 percent) of the indication radiographs were level 2 and required no intervention. Thirty-seven (53 percent) of the indication radiographs and 65 (51 percent) of the screening radiographs were classified as level 3 and demonstrated no interval change and required no action.

For level 1 indication and screening radiographs, the most common abnormalities demonstrated were malpositioned endotracheal or gastric tubes. Major pulmonary abnormalities (diffuse microatelactasis, lobar and/or segmental collapse, air leak syndromes) occurred in five (7 percent) of the indication and five (4 percent) of the screening radiographs.

The majority of screening films revealed several potential complications, such as a high endotracheal tube or a malpositioned nasogastric tube--problems that can often be best treated on an elective basis rather than during a deteriorating clinical situation. Physician awareness of these situations may help attenuate the number of sudden clinical interventions common in the neonatal intensive care unit.

The authors conclude that the screening chest radiograph in the critically ill new-born can add information that is clinically significant to patient management and can be helpful in anticipating and preventing common complications. However, they caution clinicians to consider the cost and radiation-exposure risk when making a decision regarding the appropriateness of chest radiographs in the neonatal intensive care unit. (Clinical Pediatrics, September 1993, vol. 32, p. 514.)

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