Elsevier

Critical Care Clinics

Volume 23, Issue 3, July 2007, Pages 539-573
Critical Care Clinics

Thoracic Imaging in the ICU

https://doi.org/10.1016/j.ccc.2007.06.001Get rights and content

Imaging in the ICU plays a crucial role in patient care. The portable chest radiograph (CXR) is the most commonly requested radiographic examination, and, despite its limitations, it often reveals abnormalities that may not be detected clinically. Recent advances in CT technology have made it possible to obtain diagnostic-quality images even in the most dyspneic patient. This article reviews the significant contribution thoracic imaging makes in diagnosing and managing critically ill patients.

Section snippets

Portable chest radiograph

The CXR is one of the most commonly requested radiographic examinations and is an integral supplement to the physical examination in the critically ill patient. At their institution, the authors perform, on average, 250 portable CXRs per day, half of which are on adult patients in the ICU. They are readily available, easy and quick to perform at the patient's bedside, and much less expensive than any other imaging modality. The CXR plays a key role in aiding diagnosis and management and

Picture archiving and communication systems

Before the introduction of CR and PACS, radiology departments struggled to offer prompt, reliable access to ICU CXRs; a certain number of films would be lost either temporarily or permanently when frustrated clinicians would remove them from the radiology department for rounds and patient management. This occasionally would result in overlooking subtle but important findings and delay the radiologist's interpretation, potentially resulting in a negative impact on patient care.

The introduction

Chest radiographs: technical issues

The quality of the portable CXR can be highly variable, ranging from good to uninterpretable. Obtaining diagnostic quality studies on unstable, uncooperative patients, or patients who have numerous support devices poses unique challenges to the technologist and is not always possible. There are limitations to obtaining quality portable CXRs, including the inability of critically ill patients to cooperate, the nature of the ICU environment with critically ill patients (some on life-support

Chest CT

Chest CT plays a crucial role in the care of the critically ill patient. A study performed by Miller and colleagues [33] concluded that the most common indications for requesting a CT scan were sepsis of unknown origin, evaluation of pleural effusion, evaluation of patient with malignancy, and assessment of complications of thoracic surgery. At the authors' institution, approximately 25 chest CTs are performed on ICU patients per month. It is not uncommon for the clinicians to request a CT in

Pulmonary edema

Pulmonary edema can be divided into two categories depending on its etiology: cardiogenic or noncardiogenic (Fig. 5). In the ICU setting, the most common causes of pulmonary edema are CHF, fluid overload, and damage to the pulmonary microvasculature resulting in capillary leak edema [5]. There are many causes of noncardiogenic edema, some of which include uremia, sepsis, neurogenic, trauma, drug overdose, toxic fume inhalation, and near-drowning.

Cardiogenic edema can be graded as mild,

Summary

ICU radiology plays an integral role in the care of the most critically ill patients in the hospital. Although there are limitations to the portable CXR, on a routine basis, it serves as an indispensable tool in evaluating these patients, especially when the physical examination is difficult to perform or noncontributory. A systematic approach should be applied when interpreting these films, and knowledge of the radiographic features of the disease states common to this group of patients is of

References (80)

  • L.E. Mattison et al.

    Pleural effusions in the MICU: prevalence, causes, and clinical implications

    Chest

    (1997)
  • M. Talmor et al.

    Beneficial effects of chest tube drainage of pleural effusion in acute respiratory failure refractory to positive end-expiratory pressure ventilation

    Surgery

    (1998)
  • S.J. Swensen et al.

    Radiology in the intensive care unit

    Mayo Clin Proc

    (1991)
  • C.I. Henschke et al.

    Accuracy and efficacy of chest radiography in the intensive care unit

    Radiol Clin North Am

    (1996)
  • D.A. Zuckerman et al.

    Safety of pulmonary angiography in the 1990s

    J Vasc Interv Radiol

    (1996)
  • B. Trotman-Dickenson

    Radiology in the intensive care unit (Part I)

    J Intensive Care Med

    (2003)
  • H.L. Kundel et al.

    Prospective study of a PACS: information flow and clinical action in a medical intensive care unit

    Radiology

    (1996)
  • M.E. Graat et al.

    Chest radiography practice in critical ill patients: a postal survey in the Netherlands

    BMC Med Imaging

    (2006)
  • M.E. Graat et al.

    The clinical value of daily routine chest radiographs in a mixed medical–surgical intensive care unit is low

    Crit Care

    (2006)
  • Hendrikse K, Gratama JW, Hove WT, et al. Low efficacy of daily routine chest radiographs in the ICU [abstract #...
  • ACR appropriateness criteria—routine chest radiograph. American College of Radiology....
  • C.I. Henschke et al.

    Bedside chest radiography: diagnostic efficacy

    Radiology

    (1983)
  • D.S. Strain et al.

    Value of routine daily chest x-rays in the medical intensive care unit

    Crit Care Med

    (1985)
  • M.E. Graat et al.

    Can we abandon daily routine chest radiography in intensive care patients?

    J Intensive Care Med

    (2005)
  • Y. Fong et al.

    Utility of routine chest radiographs in the surgical intensive care unit. A prospective study

    Arch Surg

    (1995)
  • D.S. Silverstein et al.

    The utility of routine daily chest radiography in the surgical intensive care unit

    J Trauma

    (1993)
  • S. Bhagwanjee et al.

    Routine daily chest radiography is not indicated for ventilated patients in a surgical ICU

    Intensive Care Med

    (1996)
  • R.J. Graham et al.

    Postoperative portable chest radiographs: optimal use in thoracic surgery

    J Thorac Cardiovasc Surg

    (1998)
  • M.D. Siegel et al.

    Chest radiology in the intensive care unit, Part I

    Clinical Pulmonary Medicine

    (1999)
  • C.E. Ravin et al.

    Hazards of the intensive care unit

    AJR Am J Roentgenol

    (1976)
  • L.R. Goodman et al.

    Radiographic evaluation of endotracheal tube position

    AJR Am J Roentgenol

    (1976)
  • P. Gray et al.

    Value of postprocedural chest radiographs in the adult intensive care unit

    Crit Care Med

    (1992)
  • D.E. Schwartz et al.

    Women are at greater risk than men for malpositioning of the endotracheal tube after emergent intubation

    Crit Care Med

    (1994)
  • R.J. Rollins et al.

    Early radiographic signs of tracheal rupture

    AJR Am J Roentgenol

    (1987)
  • I. Tocino

    Chest imaging in the intensive care unit

  • A. Yilmazlar et al.

    Complications of 1303 central venous cannulations

    J R Soc med

    (1997)
  • P. Frassinelli et al.

    Utility of chest radiographs after guidewire exchanges of central venous catheters

    Crit Care Med

    (1998)
  • C.E. Amshel et al.

    Are chest x-rays mandatory following central venous recatheterization over a wire?

    Am Surg

    (1998)
  • I.M. Tocino et al.

    Impending catheter perforation of superior vena cava: radiographic recognition

    AJR Am J Roentgenol

    (1986)
  • W.R. Miller et al.

    Thoracic CT in the intensive care unit: assessment of clinical usefulness

    Radiology

    (1998)
  • Cited by (0)

    View full text