Guidelines for Reading and Interpreting Chest Radiographs In Patients Receiving Mechanical
Vlntllltlon*
Helen T. Winer-Muram, M.D., F.C.C.P.; Sanford A. Rubin, M.D.; Mamma Mlniati, M .D .; and ]ames V. EUis, M.D.
TEcHNICAL CoNSIDERATIONS
Background
T
he ~echnicallimitations of portable chest radiography, the Jack of lateral radiographs, and the difficulties in positioning critically ill patients hinder the radiologic diagnosis of pneumonia, especially in patients receiving mechanical ventilation (MV).t.t Optimally, anteroposterior (AP) portable radiographs are obtained utilizing high kilovoltage (120 to 130 kV}, short exposure time, and fast filmscreen combinations to increase radiographic latitude and decrease motion unsharpness. Whenever possible, constant source-tofilm and source-to-patient distance should be maintained to allow for proper assessment of changes in mediastinal or cardiac diameters. Multiple factors should be recorded, including radiographic technique, focus-film distance, kilovoltage (kV), milliampere (mA), patient position, and ventilator settings for positive end-expiratory pressure (PEEP) and peak inspiratory pressure (PIP). 3 ·•
Recommendotlons Adherence to these recommendations reduces the number of films unsuitable for interpretation. Similarly, uniformity in procedures will facilitate comparison among serial 6Ims obtained during the course of the hospitalization. STANDARD READING FORMS
Background 1b facilitate research, investigators use standard reading forms in the interpretation of chest radiographs. During the past 50 years, for example, the International Labor Office (ILO) has promoted and published a series of guidelines that enable classification of abnormalities seen on chest radiographs in persons with pneumoconioses. The guidelines attempt to standardize the description, classification, and reporting methods for pneumoconioses. Standard reading forms also facilitate international communication, thus permitting comparison of epidemiologic data and promoting multicenter research. The 1980 Classification of the ILO is acc:ompanied by a set of standardized radiographs that illustrate and in some cases define the features described. • In addition to the standard reading forms, researchers have devised various interpretation guides to suit their own particular focus of investigation. In the evaluation of cardi-
•From the Department of Radiology, The University of Tennessee, Memphis; tJie ~ent of Radiology, University of 1eus MediCal Branch, G8lvestnn; CNR Institute of Clinical Physiology, Pisa Italv; and the ~ent of Radiology, ~terans AfFairs M~ Center, Memphis.
ogenic vs noncardiogenic pulmonary edema, for example, researchers constructed an interpretation guide for the purpose of introducing as much objectivity as possible into analysis of the data.u Controoersy A predetermined classification may interfere with the thought process of the clinician and may adversely affect ability to freely and properly evaluate and interpret a radiograph. Such classiflcations may not take into account the vast variability of abnormalities that can exist in patients with complex medical conditions. Other investigators argue that a standard reading form restricts the reader to a systematic approach that must be followed step by step. Conversely, such a rigid approach may force the interpreter to complete all required steps, thereby reducing the l1kelihood of omitting important data from consideration or analysis.
Recommendationa ~ propose the use of the submitted standardized form to document radiographic findings in critically ill patients being ventilated. Those with expertise in radiologic interpretation need to review and interpret selected films. Formats that have been used in the past to delineate abnormalities in patients with pulmonary edema are not useful in patients with adult respiratory distress syndrome (ARDS) or pneumonia. New formats should be developed and tested. ~ suggest utilizing the format depicted in Figure 1. The standardized form will facilitate multiinstitutional collaboration. METHOD OF RANKING FOR THE PROBABILITY OF DIFFERENT ABNORMALITIES, Suca AS
ARDS,
PNEUMONIA, AND EDEMA
Background Risk: In patients with ARDS, the risk of nosocomial infection in the form of pneumonia or sepsis is high.a.• Bacterial pneumonia is present in the lungs from 35 to 74 percent of patients who die of ARDS and is a common complication in patients with ARDS who survive.•u Bryant et al13 reviewed clinical findings and chest radiographs in 60 patients in the ICU suspected of having pneumonia. Of these 60 patients, only 18 (30 percent) were ultimately found to have pneumonia. With the improved bronchoscopic techniques now available, we are better able to definitively diagnose pneumonia in the living patient. Using these data, we should be able to evaluate the utility of the portable chest radiograph in the diagnosis of ventilatol"associated pneumonia (VAP). CHEST 1102 I 5 I NOIIEMBER, 1882 I Suppllnw1l
5158
D CD Dote C=:::J D T- . . y lnodoqulte (exclude) Dlf ASO Foe ASO Air 11< 10 RU D D D D RL D D D D LU D D D 0 u D D D D "'- No.
D
l.oc.
D
8lop
Ate lee
Field
RUL
R14l ALL
LUL llL
To denote abnormdty UN: N-new W•wcne S-ame
....,_
Covl!otlonl Elfuslon/
DR DL
~7
Scorrlng
DR OL
-
Perib
Vlntllltlon*
Helen T. Winer-Muram, M.D., F.C.C.P.; Sanford A. Rubin, M.D.; Mamma Mlniati, M .D .; and ]ames V. EUis, M.D.
TEcHNICAL CoNSIDERATIONS
Background
T
he ~echnicallimitations of portable chest radiography, the Jack of lateral radiographs, and the difficulties in positioning critically ill patients hinder the radiologic diagnosis of pneumonia, especially in patients receiving mechanical ventilation (MV).t.t Optimally, anteroposterior (AP) portable radiographs are obtained utilizing high kilovoltage (120 to 130 kV}, short exposure time, and fast filmscreen combinations to increase radiographic latitude and decrease motion unsharpness. Whenever possible, constant source-tofilm and source-to-patient distance should be maintained to allow for proper assessment of changes in mediastinal or cardiac diameters. Multiple factors should be recorded, including radiographic technique, focus-film distance, kilovoltage (kV), milliampere (mA), patient position, and ventilator settings for positive end-expiratory pressure (PEEP) and peak inspiratory pressure (PIP). 3 ·•
Recommendotlons Adherence to these recommendations reduces the number of films unsuitable for interpretation. Similarly, uniformity in procedures will facilitate comparison among serial 6Ims obtained during the course of the hospitalization. STANDARD READING FORMS
Background 1b facilitate research, investigators use standard reading forms in the interpretation of chest radiographs. During the past 50 years, for example, the International Labor Office (ILO) has promoted and published a series of guidelines that enable classification of abnormalities seen on chest radiographs in persons with pneumoconioses. The guidelines attempt to standardize the description, classification, and reporting methods for pneumoconioses. Standard reading forms also facilitate international communication, thus permitting comparison of epidemiologic data and promoting multicenter research. The 1980 Classification of the ILO is acc:ompanied by a set of standardized radiographs that illustrate and in some cases define the features described. • In addition to the standard reading forms, researchers have devised various interpretation guides to suit their own particular focus of investigation. In the evaluation of cardi-
•From the Department of Radiology, The University of Tennessee, Memphis; tJie ~ent of Radiology, University of 1eus MediCal Branch, G8lvestnn; CNR Institute of Clinical Physiology, Pisa Italv; and the ~ent of Radiology, ~terans AfFairs M~ Center, Memphis.
ogenic vs noncardiogenic pulmonary edema, for example, researchers constructed an interpretation guide for the purpose of introducing as much objectivity as possible into analysis of the data.u Controoersy A predetermined classification may interfere with the thought process of the clinician and may adversely affect ability to freely and properly evaluate and interpret a radiograph. Such classiflcations may not take into account the vast variability of abnormalities that can exist in patients with complex medical conditions. Other investigators argue that a standard reading form restricts the reader to a systematic approach that must be followed step by step. Conversely, such a rigid approach may force the interpreter to complete all required steps, thereby reducing the l1kelihood of omitting important data from consideration or analysis.
Recommendationa ~ propose the use of the submitted standardized form to document radiographic findings in critically ill patients being ventilated. Those with expertise in radiologic interpretation need to review and interpret selected films. Formats that have been used in the past to delineate abnormalities in patients with pulmonary edema are not useful in patients with adult respiratory distress syndrome (ARDS) or pneumonia. New formats should be developed and tested. ~ suggest utilizing the format depicted in Figure 1. The standardized form will facilitate multiinstitutional collaboration. METHOD OF RANKING FOR THE PROBABILITY OF DIFFERENT ABNORMALITIES, Suca AS
ARDS,
PNEUMONIA, AND EDEMA
Background Risk: In patients with ARDS, the risk of nosocomial infection in the form of pneumonia or sepsis is high.a.• Bacterial pneumonia is present in the lungs from 35 to 74 percent of patients who die of ARDS and is a common complication in patients with ARDS who survive.•u Bryant et al13 reviewed clinical findings and chest radiographs in 60 patients in the ICU suspected of having pneumonia. Of these 60 patients, only 18 (30 percent) were ultimately found to have pneumonia. With the improved bronchoscopic techniques now available, we are better able to definitively diagnose pneumonia in the living patient. Using these data, we should be able to evaluate the utility of the portable chest radiograph in the diagnosis of ventilatol"associated pneumonia (VAP). CHEST 1102 I 5 I NOIIEMBER, 1882 I Suppllnw1l
5158
D CD Dote C=:::J D T- . . y lnodoqulte (exclude) Dlf ASO Foe ASO Air 11< 10 RU D D D D RL D D D D LU D D D 0 u D D D D "'- No.
D
l.oc.
D
8lop
Ate lee
Field
RUL
R14l ALL
LUL llL
To denote abnormdty UN: N-new W•wcne S-ame
....,_
Covl!otlonl Elfuslon/
DR DL
~7
Scorrlng
DR OL
-
Perib
