Pediatric upper airway obstruction: interobserver variability is the road to perdition

Area of Science:

• Pediatric Critical Care Medicine
• Respiratory Medicine
• Clinical Assessment Methodology

Background:

• Postextubation upper airway obstruction (UAO) is a significant concern in pediatric intensive care.
• Accurate clinical assessment is crucial for timely diagnosis and management of UAO.
• Interobserver variability in assessing UAO may affect reported incidence and risk factors.

Purpose of the Study:

• To quantify interobserver variability in the clinical assessment of pediatric UAO.
• To explore the contribution of assessment variability to the incidence and risk factors of postextubation UAO.

Main Methods:

• Prospective trial conducted in two tertiary pediatric intensive care units.
• Simultaneous, blinded UAO assessments performed by bedside practitioners (respiratory therapists, nurses, physicians) on 112 children post-extubation.
• Utilized clinical signs including cyanosis, hypoxemia, consciousness, air entry, pulsus paradoxus, stridor, and retractions.

Main Results:

• Poor agreement observed for cyanosis (κ=0.01) and resting hypoxemia (κ=0.14).
• Fair agreement for consciousness (κ=0.27), air entry (κ=0.32), agitated hypoxemia (κ=0.27), and pulsus paradoxus (κ=0.23).
• Moderate agreement for stridor (κ=0.43) and retractions (κ=0.47), improving slightly with dichotomization (κ=0.53-0.54). Overall UAO incidence varied from 7% to 22% based on provider agreement.

Conclusions:

• Routine physical findings for pediatric UAO exhibit poor interobserver reliability among bedside providers.
• This variability likely contributes to inconsistent data on UAO incidence, risk factors, and treatment efficacy.
• Standardization of UAO assessment criteria is needed to improve diagnostic accuracy and clinical decision-making.