ACR Appropriateness Criteria®
Clinical Condition: Routine Chest Radiograph
Variant 1: Monitoring stable patient.
Radiologic Procedure |
Appropriateness Rating |
Comments |
X-ray, chest, portable, initial admission |
9 |
Not for coronary artery bypass graft. Not for acute upper gastrointestinal bleeding. |
X-ray, chest, portable, follow-up for specific cardiopulmonary indications |
8 |
Clinical worsening only. |
X-ray, chest, portable, routine monitoring |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 2: Respiratory failure. Patient receiving mechanical ventilation.
Radiologic Procedure |
Appropriateness Rating |
Comments |
X-ray, chest, portable, daily |
9 |
|
X-ray, chest, portable, follow-up for specific clinical conditions |
9 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 3: Compromised respiratory function. Patient with endotracheal tubes.
Radiologic Procedure |
Appropriateness Rating |
Comments |
X-ray, chest, portable, immediately after initial tube placement |
9 |
|
X-ray, chest, portable, follow-up for specific clinical indications |
9 |
|
X-ray, chest, portable, subsequent routine for tube position |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 4: Central venous pressure catheter (CVP) insertion.
Radiologic Procedure |
Appropriateness Rating |
Comments |
X-ray, chest, portable, immediately following CVP insertion |
9 |
|
X-ray, chest, portable, follow-up for suspected clinical conditions |
8 |
|
X-ray, chest, portable, subsequent routine follow-up for catheter position |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 5: Cardiopulmonary compromise. Swan-Ganz catheter insertion.
Radiologic Procedure |
Appropriateness Rating |
Comments |
X-ray, chest, portable, immediately after catheter insertion |
9 |
|
X-ray, chest, portable, follow-up for clinical indications only |
8 |
|
X-ray, chest, portable, subsequent follow-up for catheter position |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 6: Potential cardiopulmonary compromise. Nasogastric (NG) tube insertion.
Radiologic Procedure |
Appropriateness Rating |
Comments |
X-ray, chest, portable, immediately after initial small bore feeding tube or NG tube (before first feeding) |
9 |
|
X-ray, chest, portable, immediately after NG tube insertion intended for suction or gas release only |
6 |
Nonfeeding NG tube. |
X-ray, chest, portable, subsequent follow-up for tube position |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Variant 7: Respiratory compromise. Chest tube insertion.
Radiologic Procedure |
Appropriateness Rating |
Comments |
X-ray, chest, portable, immediately following tube insertion |
8 |
|
X-ray, chest, portable, follow-up for specific clinical conditions only |
8 |
|
X-ray, chest, portable, subsequent follow-up of tube position |
2 |
|
Appropriateness Criteria Scale
1 2 3 4 5 6 7 8 9
1 = Least appropriate 9 = Most appropriate
|
Summary of Literature Review
Portable Radiographs in the Intensive Care Unit (ICU) Setting
Portable radiographs can be categorized as: 1) daily or routine radiographs for patient monitoring; 2) radiographs obtained after specific procedures; and 3) radiographs documenting the presence or course of disease.
Routine daily portable radiographs are indicated for patients with acute cardiopulmonary problems. In stable patients admitted for cardiac monitoring, or in stable patients admitted for extrathoracic disease only, an initial admission radiograph is recommended, with follow-up radiographs obtained only for specific clinical indications.
Endotracheal Tubes
Very few malpositioned tubes are detected by physical examination. Routine radiographs immediately postintubation are indicated to insure proper positioning.
Central Venous Pressure (CPV) Catheters
A chest radiograph (CXR) after insertion of a CVP catheter is recommended to demonstrate proper placement and detect any complications. Beyond the initial insertion, follow-up radiographs have a low yield for revealing complications. Follow-up radiographs are suggested only when complications are suspected clinically.
Swan-Ganz Catheters
Portable radiography is suggested after catheter insertion. Once pneumothorax has been excluded and proper positioning has been assured, follow-up radiographs are not required except for specific clinical indications.
Nasogastric Tubes
Based on limited evidence, small-bore feeding tubes may, in a small but significant number of patients, be inadvertently placed in the lungs. This error is not always detected clinically and may lead to injection of feeding material into the lung, or tube penetration of the pleura, with subsequent pneumothorax. A CXR is warranted after initial nasogastric tube insertion and before the first feeding. Beyond the initial radiograph, follow-up radiographs are not required for management of stable tubes.
Chest Tubes
After insertion of a chest tube, a CXR is recommended to show the position of the tube, any success in drainage, and possible complications from insertion. Beyond this point, evaluation of tube position and function is warranted based on management of the pleural space and clinical indications.