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Reliability of Examination Findings in Suspected Community- Acquired Pneumonia

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Reliability of Examination Todd A. Florin, MD, MSCE,a, b Lilliam Ambroggio, PhD, MPH, b, c, d Cole Brokamp, PhD,c Mantosh S. Rattan, MD, b, e FindingsEric J. Crotty, MD, b, e Andrea Kachelmeyer,in Suspected BS, CCRP, a Richard M. Ruddy, Community- MD, a, b Samir S. Shah, MD, MSCEa, b, d, f Acquired Pneumonia BACKGROUND: abstract The authors of national guidelines emphasize the use of history and examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known about the interrater reliability of the physical examination in children with METHODS: suspected CAP. This was a prospective cohort study of children with suspected CAP presenting to a pediatric emergency department from July 2013 to May 2016. Children aged 3 months ≤ to 18 years with lower respiratory signs or symptoms who received a chest radiograph were included. We excluded children hospitalized 14 days before the study visit and those with a chronic medical condition or aspiration. Two clinicians performed independent ’ κ examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss kappa ( ) for categorical variables RESULTS: and intraclass correlation coefficient (ICC) for continuous variables.κ κ – No examination finding had substantial agreement ( /ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement ( /ICC = 0.6 0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, κ – cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement ( /ICC = 0.4 0.6). Eight findings (capillary refill time, cough, rhonchi, head κ – bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability ( /ICC = 0 0.4). Only 3 examination findings had acceptable agreement, with CONCLUSIONS: the lower 95% confidence limit >0.4: wheezing, retractions, and respiratory rate. In this study, we found fair to moderate reliability of many findings used to diagnose CAP. Only 3 findings had acceptable levels of reliability. These findings must be NIH considered in the clinical management and research of pediatric CAP. Divisions of aEmergency Medicine, cBiostatistics and Epidemiology, dHospital Medicine, and fInfectious Diseases, WHAT’s KNOWN ON THIS SUBJECT: The authors of and eDepartment of Radiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio; and bDepartment national guidelines emphasize the use of history and of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio examination findings to diagnose community-acquired pneumonia (CAP) in outpatient children. Little is known Dr Florin conceptualized and designed the study, interpreted the data, and drafted the initial about the interrater reliability of the physical examination manuscript; Drs Ambroggio, Ruddy, and Shah played substantial roles in study design and data in children with suspected CAP. interpretation and critically reviewed the manuscript; Dr Brokamp conducted the initial data analyses, interpreted the data, and critically reviewed the manuscript; Drs Rattan and Crotty WHAT THIS STUDY ADDS: In this study, we found fair to interpreted all chest radiographs in this study (data acquisition) and critically reviewed the moderate reliability of many findings used to diagnose manuscript; Ms Kachelmeyer coordinated and supervised data collection and critically reviewed CAP. Only 3 of the 19 findings examined had acceptable the manuscript; and all authors approved the final manuscript as submitted and agree to be reliability. The fair reliability of the examination must be accountable for all aspects of the work. Dr Florin and Dr Brokamp had full access to all the data considered in the clinical management and research of in the study and take responsibility for the integrity of the data and the accuracy of the data pediatric CAP. analysis. To cite: Florin TA, Ambroggio L, Brokamp C, et al. Reliability of Examination Findings in Suspected Community-Acquired Pneumonia. Pediatrics. 2017;140(3):e20170310 Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 140, number 3, September 2017:e20170310 ARTICLE Florin et al https://doi.org/10.1542/peds.2017-0310 September 2017 Reliability of Examination Findings in Suspected Community-Acquired Pneumonia 3 140 Pediatrics 2017 ROUGH GALLEY PROOF Children with a respiratory illness in pediatric CAP, our objective was or chronic medical conditions commonly require emergency to evaluate the IRR of examination known to predispose to severe department (ED) evaluation. findings specifically for children with or recurrent pneumonia (eg, Distinguishing community-acquired suspected CAP. We hypothesized that immunodeficiency, chronic pneumonia (CAP) from other examination measures frequently corticosteroid use, cystic fibrosis, causes of respiratory illness can be used to diagnose CAP in children chronic lung disease, malignancy, challenging. Consequently, there is would demonstrate only fair to sickle cell disease, congenital heart substantial variation in ED evaluation moderate IRR. disease, tracheostomy-dependent of children with CAP because METHODS patients, and neuromuscular clinicians attempt to distinguish disorders affecting the lungs) were upper from lower respiratory tract Study Design not included, nor were children with infection (LRTI) 1,and 2 viral from a history of aspiration or aspiration bacterial causes. pneumonia. These criteria were This study is part of an ongoing developed to include otherwise The Pediatric Infectious Diseases prospective cohort study of children healthy children with suspected CAP. Society and Infectious Diseases with suspected CAP called Catalyzing Patients who were enrolled within 30 Society of America published Ambulatory Research in Pneumonia days before the study ED visit were consensus guidelines for CAP Etiology and Diagnostic Innovations excluded to ensure a distinct episode management in children to in Emergency Medicine (CARPE ’ of infection during the study visit. minimize unnecessary variation DIEM). Patients who presented to the Study Protocol and encourage judicious3 use of ED at Cincinnati Children s Hospital testing and antibiotics. Citing Medical Center (CCHMC) and were high-quality evidence, the authors enrolled in CARPE DIEM from July The current study was composed of the guidelines provide a strong 2013 to May 2016 were eligible of a convenience sample of patients recommendation that routine chest for inclusion in this analysis. The from the CARPE DIEM cohort for radiographs (CXRs) are not necessary study was approved by the CCHMC whom 2 clinicians were able to to confirm suspected CAP in patients ’ Institutional Review Board. Informed perform independent physical well enough to be cared for at consent was obtained from all legal examinations. The patient s primary home after office or ED evaluation, ≥ guardians of patients and assent from treating clinician (attending stressing that the clinician should Schildrentudy Population 11 years of age. physician, pediatric emergency diagnose CAP by using historical and medicine [PEM] fellow, or nurse examination findings. practitioner), the first assessor, Given the importance of the physical Children 3 months to 18 years of age completed a standardized physical examination in the diagnosis of with signs and symptoms of LRTI examination on a case report form. children with suspected CAP, it is who received a CXR for suspicion A second assessor completed an critical that examination findings are of CAP were enrolled. Signs and examination on the same child reliable. Interrater reliability (IRR), symptoms of LRTI were defined as and an identical form independent the ability to obtain similar results having one or more of the following: of the first assessor. The second by different examiners under similar new or different cough, new or assessor was identified on the basis conditions, is a key component of any different sputum production, chest of available clinicians in the ED examination measure. If a measure pain, dyspnea and/or shortness at the time of enrollment; it could has poor IRR, it cannot be used to of breath, documented tachypnea, have been a fellow working with the make an accurate diagnosis that or abnormal findings consistent first assessor or another clinician is generalizable across providers with LRTI on physical examination9 working elsewhere in the ED. It and practice settings. Among adults (eg, rales/crackles, wheezing). was required that the examination with CAP, the IRR of examination There are no uniform standards was not discussed between the 2 findings was highly variable, with for use of CXRs with suspected assessors before completion of the most4 demonstrating poor to fair pneumonia at our institution; case report forms. Ideally, both IRR. Studies of children with cough, in 2016, 83% of children with a examinations would be performed asthma, and bronchiolitis have diagnosis of pneumonia received a before knowledge of the CXR results; ≤ revealed mixed results,– ranging CXR in our ED. We excluded children however, this was challenging from poor to good reliability5 8 of hospitalized 14 days before the for practical reasons of clinical examination findings. Given the index ED visit to exclude possible flow in a busy ED. In our study, variability in these respiratory hospital-acquired pneumonia. 71% of first assessors and 63%
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