Chest
Volume 122, Issue 6, December 2002, Pages 2087-2095
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Clinical Investigations in Critical Care
Findings on the Portable Chest Radiograph Correlate with Fluid Balance in Critically Ill Patients

https://doi.org/10.1378/chest.122.6.2087Get rights and content

Study objectives

Fluid balance concerns occur daily in critically ill patients, complicated by difficulties assessing intravascular volume. Chest radiographs (CXRs) quantify pulmonary edema in acute lung injury (ALI) and total blood volume in normal subjects. We hypothesized that CXRs would reflect temporal changes in fluid balance in critically ill patients.

Design

Standardized scoring of 133 supine, portable, anteroposterior CXRs. Outcomes included subjective and objective measures of intravascular volume and pulmonary edema.

Setting

Academic university medical center and affiliated Veterans Affairs hospital.

Patients

Thirty-seven patients with ALI receiving mechanical ventilation blindly randomized to treatment with diuretics and colloids or dual placebo for 5 days.

Measurements and results

Treated patients experienced a 3.3-L diuresis and 10-kg weight loss during the 5-day period. A significant correlation was observed in all patients between changes in vascular pedicle width (VPW) and net intake/output (r = 0.50, p = 0.01) or weight (r = 0.51, p = 0.01). The correlation between VPW and fluid balance was greatest for weight changes in the treatment group alone (r = 0.71, p = 0.005). Pulmonary artery occlusion pressure correlated highly with changes in VPW (r = 0.70, p < 0.001). After day 1, CXRs revealed significant between-group differences in VPW without changes in cardiothoracic ratio or subjective measures of edema. The proportion of patients with VPW < 70 mm did not differ at baseline but was significantly more in the treatment group on all subsequent days (p < 0.05).

Conclusions

We conclude that temporal fluid balance changes are reflected on commonly utilized portable CXRs. Objective radiographic measures of intravascular volume may be more appropriate indicators of fluid balance than subjective measures, with VPW appearing most sensitive. If systematically quantitated, serial CXRs provide a substantial supplement to other clinically available data for the purpose of fluid management in critically ill patients.

Section snippets

Materials and Methods

This investigation was approved by the institutional review boards of Vanderbilt University Medical Center and Nashville Veterans Affairs Medical Center, and informed consent was obtained for each patient.

Results

Thirty-seven patients were enrolled and completed the study protocol. CXRs from 1 treated patient were unavailable, yielding 36 patients for subsequent analysis (treatment, n = 18; control, n = 18). Eleven subsequent daily CXRs were unavailable (treatment, n = 6; control, n = 5), resulting in interpretation of 133 supine, portable, anteroposterior CXRs. There were no significant differences in any measured variable comparing the analog and digital radiographic formats. Randomization groups were

Discussion

Fluid balance is one of the most frequently manipulated clinical care variables in the ICU. The risks associated with invasive monitoring and its relationship to heightened mortality make the evaluation and utilization of other modalities for tracking volume status in critically ill patients vitally important. In this blinded systematic evaluation of portable CXRs in the ICU, we have shown that changes in fluid balance are reflected radiographically in critically ill patients. More importantly,

Chest Radiograph Data Collection Form Fluid Balance in Crirically Ill Patients*

ACKNOWLEDGMENT

The authors thank Linda Collins, RN, Susan Bozeman, RN, and our ICU patients and families. We also thank Drew Imhulse at Emory University for technical and artistic assistance.

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    Supported by grants HL 07123 (Dr. Martin), HL 67739 (Dr. Martin), and AG 01023 (Dr. Ely) from the National Institutes of Health, and the AFAR Pharmacology in Aging Grant, Paul Beeson Faculty Scholar Award, and Geriatric Research and Education scholar award (Dr. Ely).

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