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.