Pediatric Pneumonia Exam Unreliable - CARPE DIEM Study

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Substantial agreement on clinical exam findings in children with suspicion of pneumonia was only present for wheezing and retractions.  All other clinical exam findings had poor to moderate agreement between clinician examiners.

Why does this matter?
The Pediatric Infectious Disease Society and IDSA, "provide a strong recommendation that routine chest radiographs (CXRs) are not necessary to confirm suspected CAP in patients well enough to be cared for at home after office or ED evaluation, stressing that the clinician should diagnose CAP by using historical and examination findings."  But if you recall, last month we looked at the JAMA article on clinical diagnosis of pneumonia in children.  We learned that no clinical criteria were powerful diagnostic discriminators of the presence or absence of pneumonia in children, though some were fair.   This study helps explain why that is the case.  If my exam and your exam are not the same, can we trust this to determine treatment?

This cleverly named study, Catalyzing Ambulatory Research in Pneumonia Etiology and Diagnostic Innovations in Emergency Medicine - CARPE DIEM, was a prospective assessment of the interrater reliability (IRR) of exam findings for pneumonia in children 3 months to 18 years without immunocompromise or other conditions predisposing to lung problems.  Patients were enrolled as a convenience sample and examined by a pair of clinicians, who documented their findings separately.  The only clinical findings with substantial agreement were wheezing and retractions, each with a kappa of about 0.6. Other findings had only moderate agreement (kappa = 0.4 - 0.6): abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, and crackles/rales.  "Capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds had poor to fair reliability [kappa 0 - 0.4]."  What this means is that clinical exam for pneumonia in children is challenging.  Basing antibiotic prescribing on history and exam may lead to overtreatment and poor antibiotic stewardship.  Obviously, it is not possible to have on site CXR in all locations outside the ED, and we have to be good stewards of radiation exposure as well.  But this paper and the one linked above raise concerns that exam alone may less reliable than previously thought.

Reliability of Examination Findings in Suspected Community-Acquired Pneumonia.  Pediatrics. 2017 Sep;140(3). pii: e20170310. doi: 10.1542/peds.2017-0310.

Peer reviewed by Thomas Davis, MD.

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