In a recent study, researchers investigated the reliability of doctors’ examination findings in assessing children with suspected pneumonia.
How Do We Diagnose Pneumonia?
Children with respiratory illnesses are often assessed in hospital emergency departments to check for pneumonia which may need treatment with antibiotics. The Pediatric Infectious Diseases Society Consensus Guidelines strongly recommend that routine chest X-rays are not necessary to confirm the diagnosis of pneumonia in children who are well enough to be cared for at home after assessment. They suggest that doctors should be able to diagnose pneumonia based on medical history and physical examination.
If this practice is to be followed, it is important that examination findings can be consistently reproduced by different doctors – this is known as “interrater reliability”. If a physical sign has a poor interrater reliability, it cannot be used to make a reliable diagnosis. Studies in adults with suspected pneumonia showed that the interrater reliability of examination findings was very variable. Researchers in Ohio, USA investigated the interrater reliability of examination findings for children with suspected pneumonia. They recently published their findings in the journal Pediatrics.
The CARPE DIEM Study
The CARPE DIEM study (Catalyzing Ambulatory Research in Pneumonia Etiology and Diagnostic Innovations in Emergency Medicine) is an ongoing research project on children with suspected pneumonia. A total of 128 children aged between 3 months and 18 years who attended the emergency department at the Cincinnati Children’s Hospital with signs of lower respiratory tract infection and had received a chest X-ray were included in this analysis. Two doctors performed independent examinations and completed standardized forms reporting their examination findings. Doctors assessed signs of pneumonia including general appearance, behavior, circulatory perfusion, respiratory signs (e.g. a cough, wheezing, crackles in the lungs, chest pain, respiratory rate) and overall final clinical impression after completing the examination. The chest X-rays were independently reviewed by two radiologists to make a radiographic diagnosis of pneumonia. A thorough statistical analysis was performed to calculate the interrater reliability for each examination finding.
Little Agreement on Physical Examination Findings
No examination finding had a substantial agreement. Only three examination findings had an acceptable agreement – wheezing, respiratory rate, and retraction of chest muscles on breathing. Most findings had only fair to moderate (9 findings), or poor to fair (8 findings) interrater reliability.
The researchers suggest that changes in trainee doctors’ education on physical examination and the availability of advanced imaging and laboratory testing may have affected the clinical skills of current physicians. There may be a need to improve their examination skills and precision. The current limited interrater reliability of most physical examination findings must be considered when making recommendations about the clinical management of children with suspected pneumonia.
Written by Julie McShane, Medical Writer
Reference: Florin T, Ambroggio L, Brokamp C, et al. Reliability of examination findings in suspected community-acquired pneumonia. Pediatrics 2017; 140(3): e20170310.