Utility of postintubation chest radiographs in the intensive care unit

Objective: To determine the clinical usefulness of immediate (stat) chest r adiographs after endotracheal intubation when performed by experienced crit ical care personnel. Patients and methods: This was a prospective study. Endotracheal intubation s in an 11-bed intensive care unit and a nine-bed intermediate intensive ca re unit were included. After intubations were performed by an experienced c ritical care operator, that individual recorded demographic and procedural data, and predicted radiographic findings on a data collection sheet. Exper ience at intubation was stratified into four levels of lifetime experience: fewer than 10 procedures, 10-20 procedures, 20-50 procedures, and more tha n 50 procedures. Radiographic findings evaluated included endotracheal tube position and procedure-related complications. The postintubation chest rad iograph was then reviewed and the actual findings were also recorded. Results: A total of 101 evaluable intubations were recorded, two of which w ere predicted to show tube malposition. Actual radiographic findings reveal ed 10 malpositions, three of which were too high and seven were too low (on e 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 signific ance or to place the patient at any acute risk. Conclusions: The incidence of endotracheal tube malposition after intubatio n was underestimated. However, when performed by experienced critical care personnel, acutely significant malpositions were rare (one out of 101 intub ations). We conclude that, in the absence of specific pulmonary complicatio ns, endotracheal intubations performed by experienced operators may be foll owed by routine, rather than 'stat' chest radiographs.