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Inter-observer agreement in interpreting chest X-rays on children with acute lower respiratory tract infections and
Carlos Bada1, Nilton Yhuri Carreazo, Juan Pablo Chalco
1Instituto de Salud del Niño, Lima, Peru.
Insights
Interpreting chest x-rays for children with acute lower respiratory tract infections (ALRI) and wheezing showed poor agreement among doctors. This impacts reliable pneumonia diagnosis in emergency settings.
Area of Science:
- Pediatric Radiology
- Respiratory Medicine
- Medical Imaging Interpretation
Background:
- Acute lower respiratory tract infections (ALRI) with concurrent wheezing are common in young children presenting to emergency departments.
- Chest x-rays are frequently used to rule out pneumonia in these cases, but their interpretation can be challenging.
Purpose of the Study:
- To evaluate the inter-observer agreement among pediatric residents in interpreting chest x-rays of children under two years old with ALRI and wheezing.
- To identify specific radiographic findings with the highest and lowest agreement levels.
Main Methods:
- A prospective study involving 200 chest x-rays from children under two years with ALRI and wheezing.
- Independent interpretation of x-rays by three pediatric residents unaware of clinical details beyond respiratory infection.
- Exclusion of lobar and complicated pneumonia cases.
Main Results:
- The overall kappa index for inter-observer agreement was low (0.2).
- Agreement was poor for findings like air trapping (kappa 0.05-0.20) and bronchovascular network reinforcement (kappa 0.10-0.16).
- Intermediate agreement was observed for alveolar infiltrate (kappa 0.14-0.21) and air bronchogram (kappa 0.13-0.23).
Conclusions:
- There is poor inter-observer agreement in interpreting chest x-rays for pediatric ALRI with wheezing.
- This variability may hinder accurate pneumonia diagnosis, particularly in settings where residents manage patient care.
- Further research is needed to explore the impact of training on improving inter-observer agreement.
Context And Objective:
Many children with acute lower respiratory tract infections (ALRI) present to the emergency ward with concurrent wheezing. A chest x-ray is often requested to rule out pneumonia. We assessed inter-observer agreement in interpreting x-rays on such children. DESIGNS AND SETTING: Prospective consecutive case study at Instituto de Salud del Niño, Lima, Peru.
Methods:
Chest x-rays were obtained from eligible children younger than two years old with ALRI and concurrent wheezing who were seen in the emergency ward of a nationwide pediatric referral hospital. The x-rays were read independently by three different pediatric residents who were aware only that the children had a respiratory infection. All the children had received inhaled beta-adrenergic agonists before undergoing chest x-rays. Lobar and complicated pneumonia cases were excluded from the study.
Results:
Two hundred x-rays were read. The overall kappa index was 0.2. The highest individual kappa values for specific x-ray findings ranged from 0.26 to 0.34 for rib horizontalization and from 0.14 to 0.31 for alveolar infiltrate. Inter-observer variation was intermediate for alveolar infiltrate (kappa 0.14 to 0.21) and for air bronchogram (kappa 0.13 to 0.23). Reinforcement of the bronchovascular network (kappa 0.10 to 0.16) and air trapping (kappa 0.05 to 0.20) had the lowest agreement.
Conclusions:
There was poor inter-observer agreement for chest x-ray interpretation on children with ALRI and concurrent wheezing seen at the emergency ward. This may preclude reliable diagnosing of pneumonia in settings where residents make management decisions regarding sick children. The effects of training on inter-observer variation need further studies.
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