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Reliability of some clinical exam findings is dubious in children with suspected pneumonia
Clinical Question
In children with suspected community-acquired pneumonia, what is the reliability of clinical findings?
Bottom line
The message is either: Don't trust the clinical exam findings of others, or don't trust your own. In this study, only 3 findings—the presence of wheezing, the presence of retractions, and the determination of respiratory rate—resulted in reproducibility between clinicians that was not in the "poor" range. Clinicians did not consistently agree with each other on the presence of rales, decreased breath sounds, rhonchi, overall impression, and other signs. 2b
Reference
Study design: Cohort (prospective)
Funding: Foundation
Setting: Emergency department
Synopsis
This study enrolled a convenience sample of 128 children aged 3 months to 18 years who presented to a pediatric emergency department with lower respiratory signs or symptoms and who received a chest radiograph. Each child was examined independently by 2 clinicians using a standardized case report form. The examinations occurred within 20 minutes of each other without any intervening respiratory treatment. These clinician pairings varied based on the availability of (nonresident) clinicians at the time; in other words, these were not specifically trained investigators. The clinicians usually had the chest x-ray results at the time of the examination. Overall, no examination finding resulted in complete agreement (kappa > 0.8) between the paired clinicians. Clinicians substantially agreed with each other regarding the presence of retractions and wheezing (agreement 0.6 - 0.8), whereas they only had fair to moderate agreement (0.4 - 0.6) on overall impression, findings of crackles/rales, and even more objective findings such as tachypnea and respiratory rate. There was poor agreement (< 0.4) on decreased breath sounds, capillary refill time, rhonchi, and general appearance. The study did not investigate the rate of inaccurate diagnoses as a result of these discrepancies.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
I loved your take on this “study”. I think the most worrisome part is that a number of people didn’t read the children’s general appearance similarly. We can detect so much just by looking carefully at a child or anyone for that matter. That is the art of medicine.
the paper did not help at all with proper management and diagnosis of community acquired pneumonia. It did tell me that doctor to doctor variation and patient variation from minute to minute is high. we need a better way of diagnosing bacterial pneumonia in order to do better anti microbial stewardship and educate the public
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Very useful info, especially whilst doing medicine in foreign country.
When we assess children, their co-operation during the exam changes from moment to moment. Sometimes they take deep breaths, sometimes they are afraid and crying etc. Is there really no inter-observer reliability or is this study just stating the obvious and what we already know-each time you examine them, they are a little different.