Routine Chest X-Ray (CXR) after tracheostomy remains a widely accepted practice despite lack of evidence supporting clinical utility. We examine whether establishment of a policy utilizing clinical exam after tracheostomy will reduce cost and minimize patient exposure to radiation.

A retrospective review of all tracheostomy at a trauma intensive care unit over a 5 year period was performed. Preoperative and postoperative CXR and chart documentation were evaluated to determine clinical significance. Significant findings on CXR included new pneumothorax/subcutaneous emphysema or an increase in consolidation or effusion. The cost of portable CXR was estimated to be $500 per event.

A total of 255 tracheostomies were included: 131 open tracheostomies (105 male, 26 female) and 112 percutaneous tracheostomies (93 male and 19 females) and 22 patients were excluded due to inadequate documentation. Age ranged from 12-93 years. Procedures were performed from hospital day 1 to day 46. Indications included respiratory failure (214) and traumatic brain or spinal cord injury (41). Positive findings were found on 7 CXR after the procedure: 6 patients were managed prior to CXR based on clinical presentation, and the 7th patient was observed for a deep sulcus sign which resolved spontaneously. An additional 4 patients had worsening clinical picture without change in CXR. The remaining 244 patients (95.6%) had no change in CXR after the procedure and a stable clinical picture. A cost savings of $122,000 could have been realized if a protocol utilizing clinical exam been utilized.

Routine CXR following tracheostomy fails to provide additional information above clinical examination. Clinical deterioration should be the stimulus for radiographic examination. Such a protocol can result in significant cost savings and minimize patient exposure to radiation.