Florin Todd A, Ambroggio Lilliam, Brokamp Cole, Rattan Mantosh S, Crotty Eric J, Kachelmeyer Andrea, Ruddy Richard M, Shah Samir S
Divisions of Emergency Medicine,
Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
Pediatrics. 2017 Sep;140(3). doi: 10.1542/peds.2017-0310.
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 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 examinations and completed identical forms reporting examination findings. Interrater reliability for each finding was reported by using Fleiss' kappa (κ) for categorical variables and intraclass correlation coefficient (ICC) for continuous variables.
No examination finding had substantial agreement (κ/ICC > 0.8). Two findings (retractions, wheezing) had moderate to substantial agreement (κ/ICC = 0.6-0.8). Nine findings (abdominal pain, pleuritic pain, nasal flaring, skin color, overall impression, cool extremities, tachypnea, respiratory rate, and crackles/rales) had fair to moderate agreement (κ/ICC = 0.4-0.6). Eight findings (capillary refill time, cough, rhonchi, head bobbing, behavior, grunting, general appearance, and decreased breath sounds) had poor to fair reliability (κ/ICC = 0-0.4). Only 3 examination findings had acceptable agreement, with 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 considered in the clinical management and research of pediatric CAP.
国家指南的作者强调利用病史和检查结果来诊断门诊儿童社区获得性肺炎（CAP）。对于疑似CAP儿童体格检查的评分者间可靠性知之甚少。
这是一项对2013年7月至2016年5月到儿科急诊科就诊的疑似CAP儿童进行的前瞻性队列研究。纳入年龄在3个月至18岁、有下呼吸道体征或症状且接受了胸部X线检查的儿童。我们排除了在研究就诊前住院≤14天的儿童以及患有慢性疾病或有误吸的儿童。两名临床医生进行独立检查并填写报告检查结果的相同表格。对于每个结果，分类变量采用Fleiss卡方（κ）、连续变量采用组内相关系数（ICC）报告评分者间可靠性。
没有检查结果具有高度一致性（κ/ICC>0.8）。两项结果（吸气凹陷、哮鸣音）具有中度至高度一致性（κ/ICC = 0.6 - 0.8）。九项结果（腹痛、胸膜炎性疼痛、鼻翼扇动、皮肤颜色、总体印象、四肢发凉、呼吸急促、呼吸频率、啰音/湿啰音）具有一般至中度一致性（κ/ICC = 0.4 - 0.6）。八项结果（毛细血管再充盈时间、咳嗽、鼾音、点头呼吸、行为、呻吟、一般外观、呼吸音减弱）具有低至一般的可靠性（κ/ICC = 0 - 0.4）。只有三项检查结果具有可接受的一致性，其95%置信下限>0.4：哮鸣音、吸气凹陷和呼吸频率。
在本研究中，我们发现用于诊断CAP的许多结果的可靠性为一般至中度。只有三项结果具有可接受的可靠性水平。在儿科CAP的临床管理和研究中必须考虑这些结果。
