Investigators from the Cincinnati Children’s Hospital Medical Center and the University of Cincinnati conducted a prospective study to determine the rate of agreement between 2 examiners, or interrater reliability (IRR), for specific physical examination findings in children with possible community-acquired pneumonia (CAP). Study participants were children 3 months to 18 years old who were seen at a pediatric ED for signs and symptoms of lower respiratory tract infection and who underwent chest radiography. For enrolled participants, 2 clinicians (including pediatric emergency medicine attending physicians and fellows or nurse practitioners) independently conducted a physical examination and recorded their findings on a standardized form. Examination findings included general appearance, behavior (eg, lethargic, playing, or appropriate behavior), skin color, perfusion (eg, capillary refill time), presence of abdominal pain or tenderness, overall impression, and multiple respiratory findings (eg, crackles, decreased breath sounds, wheezing, retractions, rhonchi, tachypnea, respiratory rate, nasal flaring, pleuritic chest pain, grunting, observed cough, and head bobbing). To assess the degree of agreement beyond chance, the investigators used κ statistics for categorical variables and intraclass correlation coefficients (ICCs) for continuous variables. By using accepted criteria, these statistics were classified as indicating poor, fair, moderate, substantial, or near-perfect agreement. The investigators categorized “acceptable agreement” for a specific finding if the lower 95% confidence limit for the κ or ICC statistic was ≥0.4. Subgroup analyses were performed, including those with and those without a radiographic diagnosis of pneumonia and children <5 years old or ≥5 years old.
Data were collected in 128 children, with 98% of physical examinations performed by pediatric emergency medical attending physicians or fellows. There were no physical examination findings for which agreement was rated as substantial or near-perfect. Agreement was classified as moderate to substantial (κ = 0.6–0.8) for the presence or absence of retractions and wheezing. Agreement was moderate (κ = 0.4–0.6) for 8 findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, and crackles/rales); the ICC for respiratory rate was 0.58, which is also indicative of moderate agreement. Only 3 examination findings were categorized as having acceptable agreement: wheezing, retractions, and respiratory rate. The results were similar in various subgroup analyses, with the exception of agreement for the presence or absence of retractions, for which agreement was higher in children ≥5 years old (κ = 0.81) than in younger children (κ = 0.42).
The authors conclude that there is only fair to moderate agreement between different examiners for many of the findings used to diagnose CAP.
Dr Lesser has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
Diagnosing pneumonia can be less straightforward than many of us were led to believe during medical training. Classically, patients who present with fever, cough, crackles...