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Is routine admission chest radiograph of any clinical value in non-intensive care burn patients without inhalation injury?
Burns 29 (2003) 499–500
Commentary
Is routine admission chest radiograph of any clinical value in non-intensive care burn patients without inhalation injury? G. Alexander a,∗ , J. Saldanha b , M.K. Ebrahim a , I. Ghoneim a a
Al-Babtain Center for Plastic, Reconstructive Surgery and Burns, Ibn-Sina Hospital, P.O. Box 25427, Safat 13115, Kuwait b Department of Radiology, Ibn-Sina Hospital, P.O. Box 25427, Safat 13115, Kuwait
Over the past few decades, the concept of ‘routine investigations’ has undergone a sea change. What was once considered an important prerequisite has now evolved into a financial bugbear. With ever increasing cuts in government health budgets, rising costs of public health care projects and hawk eyeing of medical bills by insurance companies, ‘cost effectiveness’ has become the keyword in recent years. The non-burn medical literature abounds with numerous papers questioning the usefulness of routine admission chest radiographs. Studies carried out in patients with the diagnosis of acute stroke, acute asthma, acute gastrointestinal hemorrhage, adult obstructive airway disease and ‘clinical sepsis’ have shown that routine admission chest radiographs are of no significance in the absence of definite clinical indications [1–5]. Similarly, routine preoperative chest radiographs were found to have a positive yield of 2% in patients <60 years while a 34% positive yield resulted when the investigations were indicated by history and physical examination [6]. The burn literature appears to have totally focused on the usefulness of routine admission chest radiographs in patients with inhalation injury where it can serve as a baseline reference and suggest a poor prognosis in the presence of signs of inhalation injury notwithstanding the fact that some authors have considered it to be an insensitive indicator with the possibility of significant lung damage being present in spite of a normal initial chest radiograph [7,8]. However, non-intensive care burn patients without inhalation injury are also often subjected to routine admission chest radiographs and we decided to objectively assess their value in the subsequent management as we felt that in general they were non-contributory and did not significantly influence the management. An English literature Medline search (from 1966) did not reveal a similar study. At the AI-Babtain center for Burns and Plastic surgery, from January 2001 to December 2001, 201 patients were ∗
Corresponding author. Tel.: +965-483-4785; fax: +965-481-1784. E-mail address: [email protected] (G. Alexander).
0305-4179/$30.00 © 2003 Elsevier Science Ltd and ISBI. All rights reserved. doi:10.1016/S0305-4179(03)00054-8
admitted to the burn wards (child below 20% TBSA, adult below 25% TBSA). 35 patients had signs suggestive of inhalation injury and were excluded from the study. Of the remaining 166 patients studied, 124 were males and 42 females. Most of the patients had scald burns (84) and flame burns (52), while the rest had electrical (20), chemical (5) and contact burns (5). The patients ranged from 4 months to 90 years with a mean age of 20.7 years (S.D. = 19.2). While the mean TBSA was 8.1% (S.D. = 5.1%) and mean hospital stay calculated for all patients was 11.1 days (S.D. = 8.0) with a range of 1 to 34 days, 51 (30.7%) patients underwent skin grafting for their deep burns. Two of the patients developed septicemia but none of these developed respiratory complications. All 166 patients underwent routine admission chest radiographs in the first 24 h. 67 (40.3%) radiographs were technically imperfect either due to rotation or poor inspiration, though no significant abnormalities were detected in them. In all, 12 (7.2%) abnormalities were detected in the chest radiographs. Table 1 shows the summary of the abnormalities. Of the five patients who had cardiomegaly, two patients had a history of hypertension while the rest did not yield any finding on clinical evaluation. None of these patients had any change in their subsequent management. Other abnormalities noted were lung fibrosis (2), pleural thickening (2) and chronic obstructive pulmonary disease (1). Again, these findings did not change or influence the management in any way. One of the pediatric patients demonstrated a mediastinal shadow, which needed additional views to diagnose it as a thymus. Subcutaneous emphysema was seen in one radiograph but this patient was involved in a vehicular accident and sustained traumatic wounds in addition to the burn. Bronchopneumonia was diagnosed in a child who was admitted for the diagnosis of ‘clinical sepsis’ with a burn of 1% TBSA. Thus in only two patients was there any influence on the management. Three of the patients developed fluid overload, cardiac failure and consolidation respectively, during the course of the hospital stay, none of which could have been
500
G. Alexander et al. / Burns 29 (2003) 499–500
Table 1 Abnormalities noted on the admission chest radiograph Abnormalities Cardiomegaly Pleural thickening Lung fibrosis Bronchopneumonia Subcutaneous emphysema Chronic obstructive pulmonary disease Total
Number of patients (n = 166) 5 2 2 1 1 1 12
predicted by the initial chest radiographs, all of which were normal. Routine chest radiographs in patients admitted with acute burns are carried out with the aim of identifying unsuspected abnormalities or tracking the status of a known disease that could influence the management. While the chest radiograph is thought to be of moderate accuracy in visualizing opacification caused by cardiopulmonary abnormalities, intrathoracic disease can be mimicked by anatomic variations of the superimposed bony thorax, soft tissue, artifacts and by intrathoracic changes [9,10]. Since the incidence of pulmonary complications in septicemic burn patients is high, it would be rational to do an admission chest radiograph as part of the routine work up when a burn patient is admitted with the diagnosis of ‘clinical sepsis’. Further as burn patients may receive enormous amounts of fluids during the resuscitation phase, elderly and high-risk patients can develop cardiopulmonary complications and therefore the chest radiograph can serve as a baseline investigation in such candidates. Burn patients who may have additional chest trauma as well as those with specific medico-legal indications are possible contenders for chest radiographs on admission. While two patients developed chest complications during the course of the burn management, it is important to note that none of these could have been predicted by the admission chest radiograph. Some of the X-rays were technically imperfect due to the improper positioning and inadequate inspiration, as patients were uncooperative in the acute stage of burns. In our series of patients only 12 (7.2%) had abnormal findings on their admission chest radiographs. In seven of these patients the findings did not alter the management in any way. The remaining five patients had clinical indications for
an admission chest radiographs, though only 2 (1.2%) patients had significant findings on their chest X-rays that influenced the management. We believe that routine ordering of chest radiographs may lead to unnecessary consultations, additional investigations and immense discomfort to the burn patient, besides the risk of exposure to radiation. The avoidance of routine radiographs can be crucial in reducing patient charges and decreasing the workload of health care staff. Projected worldwide significant amount of money can be saved which should be diverted to upgrade other burn care facilities. In conclusion our findings indicate that the overall occurrence of unsuspected abnormalities or those likely to change the burn management is miniscule to warrant routine admission chest radiographs in all non-intensive care burn patients without inhalation injury; they should be selectively advised on the basis of a sound clinical assessment. References [1] Sagar G, Riley P, Vohrah A. Is admission chest radiography of any clinical value in acute stroke patients? Clin Radiol 1996;51(7):499– 502. [2] Ismail Y, Loo CS, Zahary MK. The value of routine chest radiographs in acute asthma admissions. Singapore Med J 1994;35(2):171–2. [3] Tobin K, Klein J, Barbieri C, Heffner JE. Utility of routine admission chest radiographs in patients with acute gastrointestinal hemorrhage admitted to an intensive care unit. Am J Med 1996;101(4):349–56. [4] Tsai TW, Gallagher EJ, Lombardi G, Gennis P, Carter W. Guidelines for the selective ordering of admission chest radiography in adult obstructive airway disease. Ann Emerg Med 1993;22(12):1854–8. [5] Torres J, Rodriguez G. Value of performing a chest radiograph in patients with diagnosis of “clinical sepsis”. Bol Asoc Med P R 1995;87(34):42–5. [6] Sommerville TE, Murray WB. Information yield from routine pre-operative chest radiography and electrocardiography. S Afr Med J 1992;81(4):190–6. [7] Coblentz CL, Chiles C, Putman CE. Radiologic evaluation. In: Harponik EF, Munster AM, editors. Respiratory injury: smoke inhalation and burns. 1st ed. New York: McGraw-Hill; 1990. p. 179–94. [8] Wittram C, Kenny JB. The admission chest radiograph after acute inhalation injury and burns. Br J Radiol 1994;67(800):751–4. [9] Henschke CI, Yankelevitz DF, Wand A, Davis SD, Shiau M. Accuracy and efficacy of chest radiography in the intensive care unit. Radiol Clin North Am 1996;34(1):21–31. [10] Gronner AT, Ominsky SH. Plain film radiography of the chest: findings that simulate pulmonary disease. AJR Am J Roentgenol 1994;163(6):1343–8.
Commentary
Is routine admission chest radiograph of any clinical value in non-intensive care burn patients without inhalation injury? G. Alexander a,∗ , J. Saldanha b , M.K. Ebrahim a , I. Ghoneim a a
Al-Babtain Center for Plastic, Reconstructive Surgery and Burns, Ibn-Sina Hospital, P.O. Box 25427, Safat 13115, Kuwait b Department of Radiology, Ibn-Sina Hospital, P.O. Box 25427, Safat 13115, Kuwait
Over the past few decades, the concept of ‘routine investigations’ has undergone a sea change. What was once considered an important prerequisite has now evolved into a financial bugbear. With ever increasing cuts in government health budgets, rising costs of public health care projects and hawk eyeing of medical bills by insurance companies, ‘cost effectiveness’ has become the keyword in recent years. The non-burn medical literature abounds with numerous papers questioning the usefulness of routine admission chest radiographs. Studies carried out in patients with the diagnosis of acute stroke, acute asthma, acute gastrointestinal hemorrhage, adult obstructive airway disease and ‘clinical sepsis’ have shown that routine admission chest radiographs are of no significance in the absence of definite clinical indications [1–5]. Similarly, routine preoperative chest radiographs were found to have a positive yield of 2% in patients <60 years while a 34% positive yield resulted when the investigations were indicated by history and physical examination [6]. The burn literature appears to have totally focused on the usefulness of routine admission chest radiographs in patients with inhalation injury where it can serve as a baseline reference and suggest a poor prognosis in the presence of signs of inhalation injury notwithstanding the fact that some authors have considered it to be an insensitive indicator with the possibility of significant lung damage being present in spite of a normal initial chest radiograph [7,8]. However, non-intensive care burn patients without inhalation injury are also often subjected to routine admission chest radiographs and we decided to objectively assess their value in the subsequent management as we felt that in general they were non-contributory and did not significantly influence the management. An English literature Medline search (from 1966) did not reveal a similar study. At the AI-Babtain center for Burns and Plastic surgery, from January 2001 to December 2001, 201 patients were ∗
Corresponding author. Tel.: +965-483-4785; fax: +965-481-1784. E-mail address: [email protected] (G. Alexander).
0305-4179/$30.00 © 2003 Elsevier Science Ltd and ISBI. All rights reserved. doi:10.1016/S0305-4179(03)00054-8
admitted to the burn wards (child below 20% TBSA, adult below 25% TBSA). 35 patients had signs suggestive of inhalation injury and were excluded from the study. Of the remaining 166 patients studied, 124 were males and 42 females. Most of the patients had scald burns (84) and flame burns (52), while the rest had electrical (20), chemical (5) and contact burns (5). The patients ranged from 4 months to 90 years with a mean age of 20.7 years (S.D. = 19.2). While the mean TBSA was 8.1% (S.D. = 5.1%) and mean hospital stay calculated for all patients was 11.1 days (S.D. = 8.0) with a range of 1 to 34 days, 51 (30.7%) patients underwent skin grafting for their deep burns. Two of the patients developed septicemia but none of these developed respiratory complications. All 166 patients underwent routine admission chest radiographs in the first 24 h. 67 (40.3%) radiographs were technically imperfect either due to rotation or poor inspiration, though no significant abnormalities were detected in them. In all, 12 (7.2%) abnormalities were detected in the chest radiographs. Table 1 shows the summary of the abnormalities. Of the five patients who had cardiomegaly, two patients had a history of hypertension while the rest did not yield any finding on clinical evaluation. None of these patients had any change in their subsequent management. Other abnormalities noted were lung fibrosis (2), pleural thickening (2) and chronic obstructive pulmonary disease (1). Again, these findings did not change or influence the management in any way. One of the pediatric patients demonstrated a mediastinal shadow, which needed additional views to diagnose it as a thymus. Subcutaneous emphysema was seen in one radiograph but this patient was involved in a vehicular accident and sustained traumatic wounds in addition to the burn. Bronchopneumonia was diagnosed in a child who was admitted for the diagnosis of ‘clinical sepsis’ with a burn of 1% TBSA. Thus in only two patients was there any influence on the management. Three of the patients developed fluid overload, cardiac failure and consolidation respectively, during the course of the hospital stay, none of which could have been
500
G. Alexander et al. / Burns 29 (2003) 499–500
Table 1 Abnormalities noted on the admission chest radiograph Abnormalities Cardiomegaly Pleural thickening Lung fibrosis Bronchopneumonia Subcutaneous emphysema Chronic obstructive pulmonary disease Total
Number of patients (n = 166) 5 2 2 1 1 1 12
predicted by the initial chest radiographs, all of which were normal. Routine chest radiographs in patients admitted with acute burns are carried out with the aim of identifying unsuspected abnormalities or tracking the status of a known disease that could influence the management. While the chest radiograph is thought to be of moderate accuracy in visualizing opacification caused by cardiopulmonary abnormalities, intrathoracic disease can be mimicked by anatomic variations of the superimposed bony thorax, soft tissue, artifacts and by intrathoracic changes [9,10]. Since the incidence of pulmonary complications in septicemic burn patients is high, it would be rational to do an admission chest radiograph as part of the routine work up when a burn patient is admitted with the diagnosis of ‘clinical sepsis’. Further as burn patients may receive enormous amounts of fluids during the resuscitation phase, elderly and high-risk patients can develop cardiopulmonary complications and therefore the chest radiograph can serve as a baseline investigation in such candidates. Burn patients who may have additional chest trauma as well as those with specific medico-legal indications are possible contenders for chest radiographs on admission. While two patients developed chest complications during the course of the burn management, it is important to note that none of these could have been predicted by the admission chest radiograph. Some of the X-rays were technically imperfect due to the improper positioning and inadequate inspiration, as patients were uncooperative in the acute stage of burns. In our series of patients only 12 (7.2%) had abnormal findings on their admission chest radiographs. In seven of these patients the findings did not alter the management in any way. The remaining five patients had clinical indications for
an admission chest radiographs, though only 2 (1.2%) patients had significant findings on their chest X-rays that influenced the management. We believe that routine ordering of chest radiographs may lead to unnecessary consultations, additional investigations and immense discomfort to the burn patient, besides the risk of exposure to radiation. The avoidance of routine radiographs can be crucial in reducing patient charges and decreasing the workload of health care staff. Projected worldwide significant amount of money can be saved which should be diverted to upgrade other burn care facilities. In conclusion our findings indicate that the overall occurrence of unsuspected abnormalities or those likely to change the burn management is miniscule to warrant routine admission chest radiographs in all non-intensive care burn patients without inhalation injury; they should be selectively advised on the basis of a sound clinical assessment. References [1] Sagar G, Riley P, Vohrah A. Is admission chest radiography of any clinical value in acute stroke patients? Clin Radiol 1996;51(7):499– 502. [2] Ismail Y, Loo CS, Zahary MK. The value of routine chest radiographs in acute asthma admissions. Singapore Med J 1994;35(2):171–2. [3] Tobin K, Klein J, Barbieri C, Heffner JE. Utility of routine admission chest radiographs in patients with acute gastrointestinal hemorrhage admitted to an intensive care unit. Am J Med 1996;101(4):349–56. [4] Tsai TW, Gallagher EJ, Lombardi G, Gennis P, Carter W. Guidelines for the selective ordering of admission chest radiography in adult obstructive airway disease. Ann Emerg Med 1993;22(12):1854–8. [5] Torres J, Rodriguez G. Value of performing a chest radiograph in patients with diagnosis of “clinical sepsis”. Bol Asoc Med P R 1995;87(34):42–5. [6] Sommerville TE, Murray WB. Information yield from routine pre-operative chest radiography and electrocardiography. S Afr Med J 1992;81(4):190–6. [7] Coblentz CL, Chiles C, Putman CE. Radiologic evaluation. In: Harponik EF, Munster AM, editors. Respiratory injury: smoke inhalation and burns. 1st ed. New York: McGraw-Hill; 1990. p. 179–94. [8] Wittram C, Kenny JB. The admission chest radiograph after acute inhalation injury and burns. Br J Radiol 1994;67(800):751–4. [9] Henschke CI, Yankelevitz DF, Wand A, Davis SD, Shiau M. Accuracy and efficacy of chest radiography in the intensive care unit. Radiol Clin North Am 1996;34(1):21–31. [10] Gronner AT, Ominsky SH. Plain film radiography of the chest: findings that simulate pulmonary disease. AJR Am J Roentgenol 1994;163(6):1343–8.