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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
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.
A 43-year-old woman presented with a 1-year history of recurring symptoms of sudden onset of fatigue, palpitations, dyspnea, chest pain, lightheadedness, and nausea that were associated with standing and resolved with sitting. These symptoms began 1 month after mild COVID-19 infection. At presentation, while supine, blood pressure (BP) was 123/70 mm Hg and heart rate (HR) was 90/min; while seated, BP was 120/80 and HR was 93/min; after standing for 1 minute, BP was 124/80 and HR was 119/min. Physical examination results were normal. Oxygen saturation was 98% at rest while breathing room air. She had no oxygen desaturation during a 6-minute walk test but walked only 282 m (45% predicted). Complete blood cell count, morning cortisol, and thyrotropin blood levels were normal. Electrocardiogram (ECG), chest computed tomography, pulmonary function testing, methacholine challenge, bronchoscopy, echocardiography, and cardiac catheterization findings were normal. During tilt table testing, the patient experienced lightheadedness and nausea when moved from horizontal to the upright position. Results of the tilt table test are shown in the Table and Figure.
A 43-year-old woman presented with a 1-year history of recurring symptoms of sudden onset of fatigue, palpitations, dyspnea, chest pain, lightheadedness, and nausea that were associated with standing and resolved with sitting. These symptoms began 1 month after mild COVID-19 infection. At presentation, while supine, blood pressure (BP) was 123/70 mm Hg and heart rate (HR) was 90/min; while seated, BP was 120/80 and HR was 93/min; after standing for 1 minute, BP was 124/80 and HR was 119/min. Physical examination results were normal. Oxygen saturation was 98% at rest while breathing room air. She had no oxygen desaturation during a 6-minute walk test but walked only 282 m (45% predicted). Complete blood cell count, morning cortisol, and thyrotropin blood levels were normal. Electrocardiogram (ECG), chest computed tomography, pulmonary function testing, methacholine challenge, bronchoscopy, echocardiography, and cardiac catheterization findings were normal. During tilt table testing, the patient experienced lightheadedness and nausea when moved from horizontal to the upright position. Results of the tilt table test are shown in the Table and Figure.
