Utility of postintubation chest radiographs in the intensive care unit

Objective:
To determine the clinical usefulness of immediate (stat) chest
radiographs after endotracheal intubation when performed by experienced
critical care personnel.

      Patients and methods:
      This was a prospective study. Endotracheal intubations in an
            11-bed intensive care unit and a nine-bed intermediate intensive care unit were
            included. After intubations were performed by an experienced critical care
            operator, that individual recorded demographic and procedural data, and
            predicted radiographic findings on a data collection sheet. Experience at
            intubation was stratified into four levels of lifetime experience: fewer than
            10 procedures, 10-20 procedures, 20-50 procedures, and more than 50 procedures.
            Radiographic findings evaluated included endotracheal tube position and
            procedure-related complications. The postintubation chest radiograph was then
            reviewed and the actual findings were also recorded.


      Results:
      A total of 101 evaluable intubations were recorded, two of which
            were predicted to show tube malposition. Actual radiographic findings revealed
            10 malpositions, three of which were too high and seven were too low (one at
            the level of the carina). A single witnessed aspiration that occurred during
            intubation was not radiographically apparent until 24 h later. Only the tube
            positioned at the carina was felt to be of acute clinical significance or to
            place the patient at any acute risk.


      Conclusions:
      The incidence of endotracheal tube malposition after intubation
            was underestimated. However, when performed by experienced critical care
            personnel, acutely significant malpositions were rare (one out of 101
            intubations). We conclude that, in the absence of specific pulmonary
            complications, endotracheal intubations performed by experienced operators may
            be followed by routine, rather than 'stat' chest radiographs.