575 - Reliability of Physical Examination Findings in Children Diagnosed with Pneumonia

Publication Number: 1552.575

Shubhada Hooli, Baylor College of Medicine, HOUSTON, TX, United States; Ron Reeder, University of Utah School of Medicine, Salt Lake City, UT, United States; Lauren Cutler, Utah Data Coordinating Center, University of Utah, Salt Lake City, UT, United States; Laura Sartori, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Geoffrey A. Capraro, The Warren Alpert Medical School of Brown University, Providence, RI, United States; Amy Cheng, University of Texas Southwestern Medical School, Dallas, TX, United States; Allison Cator, University of Michigan Medical School, Ann Arbor, MI, United States; Matthew J. Lipshaw, University of Michigan Medical School, Ann Arbor, MI, United States; Lilliam Ambroggio, Children's Hospital Colorado, Aurora, CO, United States; Chris A. Rees, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, United States; Son H. McLaren, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, United States; Justin Moher, University of Washington School of Medicine, Seattle, WA, United States; Leah Tzimenatos, University of California, Davis, School of Medicine, Sacramento, CA, United States; Patrick S. Walsh, Medical College of Wisconsin, Milwaukee, WI, United States; Chari D.. Larsen, University of Utah School of Medicine, Salt Lake City, UT, United States; Richard M. Ruddy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Samir S. Shah, Cincinnati Children's Hospital, Cincinnati, OH, United States; Nathan Kuppermann, Children's National Health System, Washington, DC, United States; Todd A. Florin, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States

Background: Community-acquired pneumonia (CAP) accounts for up to 2 million outpatient and 375,000 emergency department (ED) visits annually among children in the United States. Although guidelines recommend and many clinicians use physical examination findings, rather than imaging, to diagnose CAP, prior literature suggests that some examination findings may not be reliable, potentially leading to misdiagnosis.

Objective: To determine the interrater reliability (IRR) of respiratory physical examination findings in children diagnosed with CAP in EDs.

Design/Methods: This was a planned secondary analysis of an ongoing multicenter prospective cohort study to derive and validate a Pediatric CAP Severity (PedCAPS) score. Participants were enrolled across 7 U.S. academic pediatric EDs from 8/1/23-5/24/25. Eligible participants included children ages 3 months to 17 years diagnosed with CAP by an ED clinician. Participants exhibited signs of acute lower respiratory infections, had fevers within 48 hours of presentation, and, if performed, had confirmed pneumonia on chest radiography (CXR). Children with chronic medical conditions (except asthma), aspiration pneumonia, prior enrollment or hospitalization within 30 days, or transferred from other EDs were excluded. Raw agreement was calculated for examination findings. Interrater reliability was evaluated using Fleiss' kappa (κ) to account for agreement above what would be expected by chance given involvement of multiple raters. Consistent with prior work, we defined substantial agreement as a k > 0.7 with a lower 95% confidence interval (CI) limit of 0.4. Assuming a 5% prevalence of a finding, 122 paired examinations of unique patients were required.

Results: Of the 252 children enrolled, the median age was 5.7 years (interquartile range [IQR] 3.4, 8.8 years) and the most frequent comorbidity was asthma (22.2%) (Table 1). Nearly all patients had a CXR performed (n=249). No physical examination findings had substantial agreement . Decreased breath sounds, crackles, and rhonchi had poor IRR (Figure 1), while wheezing (κ = 0.50, 95% (CI) 0.39, 0.62) and retractions (κ = 0.49, 95% CI 0.37, 0.60) had moderate IRR. Findings were similar among children discharged home and those hospitalized (Figure 2).

Conclusion(s): Individual physical examination findings, especially auscultatory findings such as decreased breath sounds, crackles, or rhonchi, did not demonstrate sufficient reliability to be used alone to diagnose children with CAP, regardless of ED disposition.

Table 1. Patient Demographics, Characteristics and Outcomes


Figure 1. Interrater Reliability and Agreement on Physical Examination Findings in Study Population
The dotted vertical line represents the lower bound of the 95% confidence interval for Fleiss' Kappa that denotes acceptable reliability based on prior literature.

Figure 2. Interrater Reliability and Agreement on Physical Examination Findings in Children Hospitalized (N=128) Compared with Those Discharged (N=124) from the Emergency Center
The dotted vertical line represents the lower bound of the 95% confidence interval for Fleiss' Kappa that denotes acceptable reliability based on prior literature.