Physical exams alone may not reliably diagnose pneumonia in children, national study finds

When a child has symptoms that could be pneumonia, doctors often listen to the child’s lungs with a stethoscope to help make a diagnosis. But a new national study led by physician-scientists at Ann & Robert H. Lurie Children’s Hospital of Chicago and PECARN finds that doctors may not always hear or interpret the same things when examining the same child, illustrating limitations of the physical examination.

The study, published Aug. 20 in JAMA Network Open, found that doctors often disagreed about common lung sounds used to help diagnose pneumonia, including crackles, decreased breath sounds and rhonchi. The findings suggest that a physical exam alone may not always provide enough information to confidently diagnose pneumonia in children.

“Doctors rely heavily on what they hear when listening to a child’s lungs, but our study shows that two doctors can examine the same child and come away with different findings,” said the study’s principal investigator and senior author Todd Florin, MD, MSCE, associate division head for academic affairs and research and attending physician in emergency medicine at Lurie Children’s; scientific director of research development and co-director of the Center for Pediatric Acute & Critical Care Research & Innovation at Stanley Manne Children’s Research Institute; and professor and associate chair of research in the Department of Pediatrics at Northwestern University Feinberg School of Medicine. “This can make diagnosing pneumonia challenging and points to the need for better tools to help us make these decisions.”

Pneumonia is one of the most common respiratory infections in children, leading to nearly 2 million outpatient visits and 375,000 emergency department visits each year in the United States. Current guidelines recommend that doctors diagnose pneumonia based on a child’s symptoms and physical exam, without routinely using a chest X-ray, when children are otherwise healthy and can be treated at home.

Doctors did not always hear the same thing

Researchers looked at 252 children ages 3 months to 17 years who were diagnosed with pneumonia at one of seven pediatric emergency departments across the country. Each child was examined by two doctors within an hour of each other. The doctors independently recorded what they heard and saw during the physical exam.

The researchers found that some of the most common lung sounds used to identify pneumonia were not consistently recognized by both doctors.

Wheezing and signs that a child was working harder to breathe were more consistently identified but still did not reach the study’s standard for strong agreement.

“The results showed that several findings traditionally considered important—such as decreased breath sounds and crackles—were identified inconsistently between emergency department providers,” said Shubhada Hooli, MD, MPH, assistant professor of pediatrics at Baylor College of Medicine.

The researchers also found similar results among children who went home from the emergency department and those who were admitted to the hospital.

Better tools could help doctors make decisions

Accurately diagnosing pneumonia is important because a wrong diagnosis can mean a child receives treatment they do not need or does not receive treatment they do need.

The study notes that about two-thirds of children with community-acquired pneumonia experience side effects from antibiotics. Better ways to identify pneumonia could help doctors determine which children are most likely to benefit from antibiotics and which children may not need them.

The researchers say more objective tools could eventually help doctors make more consistent diagnoses. These could include electronic stethoscopes that record lung sounds, computer programs that analyze those sounds, improved imaging techniques and blood or other tests that look for signs of pneumonia.

“A stethoscope will continue to be an important tool for doctors,” said Florin. “But we need to find ways to make the diagnosis of pneumonia more accurate and consistent. Better tools could help us avoid unnecessary antibiotics while making sure children who truly have pneumonia get the treatment they need.”

The study was conducted through the Pediatric Emergency Care Applied Research Network (PECARN), a national research network that brings together pediatric emergency departments across the country to improve emergency care for children.

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