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Reliability of Physical Examination Findings in Youths Diagnosed With Pneumonia
Shubhada Hooli1, Ron Reeder2, Lauren Cutler3
1Department of Pediatrics, Division of Pediatric Emergency Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston.
Insights
Physical exam findings for diagnosing pediatric community-acquired pneumonia (CAP) in emergency departments show low reliability. Wheezing and retractions had the highest interrater reliability, but no single finding was sufficient for diagnosis.
Area of Science:
- Pediatric emergency medicine
- Respiratory medicine
- Clinical diagnostics
Background:
- Community-acquired pneumonia (CAP) is a common pediatric illness, leading to millions of outpatient and emergency department visits annually in the US.
- Current guidelines emphasize physical examination over imaging for diagnosing CAP in outpatients.
- The reliability of physical examination findings in diagnosing CAP in children requires further investigation.
Purpose of the Study:
- To assess the interrater reliability (IRR) of physical examination findings in diagnosing CAP in pediatric patients within emergency departments.
- To determine if specific physical examination findings meet acceptable reliability thresholds for clinical use.
Main Methods:
- A prospective cohort study involving 252 youths aged 3 months to 17 years diagnosed with CAP in 7 academic pediatric emergency departments.
- Two independent examiners evaluated patients within 60 minutes, recording physical examination findings.
- Interrater reliability was measured using raw agreement and Fleiss kappa (κ), with a lower bound of 0.4 for κ considered acceptable.
Main Results:
- No single physical examination finding met the predefined significance for IRR across the entire study population.
- Wheezing (κ=0.50) and retractions (κ=0.49) demonstrated the highest IRR, though still below optimal thresholds for independent diagnostic use.
- IRR of physical examinations was consistent between children discharged home and those hospitalized.
Conclusions:
- Individual auscultation findings (e.g., decreased breath sounds, crackles, rhonchi) lack sufficient reliability for independent diagnosis of CAP in children.
- Current physical examination methods may not consistently support the guideline-recommended reliance on clinical findings for CAP diagnosis in pediatric emergency settings.
Importance:
Community-acquired pneumonia (CAP) accounts for nearly 2 million pediatric outpatient and 375 000 emergency department (ED) visits annually in the US. Guidelines recommend relying on physical examination findings, not imaging, to diagnose CAP in youths who can be treated as outpatients.
Objective:
To determine the interrater reliability (IRR) of physical examination findings in youths diagnosed with CAP in EDs.
Design, Setting, And Participants:
This was a planned analysis from an ongoing prospective cohort study (pediatric CAP severity [PedCAPS]). Youths aged 3 months to 17 years with CAP were recruited at 7 academic pediatric EDs within the US from August 1, 2023, until May 24, 2025; participants had signs of lower respiratory tract infections, fever within 48 hours, and pneumonia on chest radiography, if performed. Youths with chronic pulmonary diseases (except asthma), sickle cell disease, immunodeficiency, cardiac disease, neurological disorders affecting respiration, and aspiration pneumonia were excluded, as were those hospitalized within the preceding 30 days or transferred from other EDs or hospitals.
Main Outcomes And Measures:
Two examiners evaluated the same patient within 60 minutes of each other and independently recorded their findings. IRR of physical examination findings was reported by raw agreement and Fleiss κ. A lower bound of the 95% CI of 0.4 for κ was considered acceptable reliability.
Results:
Among 252 youths with paired physical examinations (median [IQR] age, 5.7 [3.4-8.8] years; 127 female [50.4%]), the most frequent comorbidity was asthma (56 youths [22.2%]). In the overall study population, no physical examination finding met predefined significance for IRR. Wheezing (κ = 0.50; 95% CI, 0.39-0.62) and retractions (κ = 0.49; 95% CI, 0.37-0.60) had the highest IRR. In subanalyses of 124 youths discharged home and 128 youths who were hospitalized, IRRs of physical examinations were similar between the 2 groups.
Conclusions And Relevance:
In this study, individual auscultation findings, such as decreased breath sounds, crackles, or rhonchi, did not demonstrate sufficient reliability to be used alone for diagnosis.
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