University of Oklahoma Health Sciences Center

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Author/s:

Shubhada Hooli, Ron Reeder, Lauren Cutler, Laura F Sartori, Geoff Capraro, Amy Y. Cheng, Allison Cator, Matthew J. Lipshaw, Lilliam Ambroggio, Chris A. Rees, Son H. McLaren, Justin Moher, Leah Tzimenatos, Patrick S. Walsh, Chari D. Larsen, Richard M. Ruddy, Samir S. Shah, Nathan Kuppermann, Todd A. Florin

Date Added:

August 22, 2026

Journal/Publication:

JAMA Network Open

Publisher:

American Medical Association

Publication Date:

August 20, 2026

Issue:

Volume:

Pages:

1-11

URL:

Reliability of Physical Examination Findings in Youths Diagnosed With Pneumonia

Type:

Clinical Research Results

Format:

Article

DOI (1):

doi:10.1001/jamanetworkopen.2026.30074

Keywords

pneumonia

youth

Physical Examination

MeSH

RPR Commentary

RPR Exchange: Results of a study of the reliability and predictive value of physical examination findings for diagnosing community-acquired pneumonia in children. James W. Mold, MD, MPH

Abstract

Abstract
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.