Inter‐observer variability in chest radiograph reading for diagnosing acute lung injury in children

Abstract

Acute lung injury (ALI), including its most serious form called acute respiratory distress syndrome (ARDS), is a devastating disease that can occur at any age. ALI/ARDS accounts for only 5-8% of admissions to pediatric intensive care units (PICUs) but is fatal in 30-60% of cases. International multicenter prospective studies are needed to better understand pediatric ALI/ARDS. However, a reproducible definition of ALI/ARDS is crucial to ensure that study populations are homogeneous. We designed a retrospective review to test the inter-observer variability of chest radiograph interpretation for presence of the American-European Consensus Conference (AECC) radiographic criterion for ALI/ARDS. The medical files of 24 children ventilated for ALI/ARDS in our PICU between January 1993 and December 2002 were reviewed. Five pediatric radiologists and five pediatric intensivists interpreted one frontal chest radiograph (FCR) per patient taken on the day of ALI/ARDS diagnosis. Each reader indicated whether the radiograph showed the AECC radiographic criterion for ALI/ARDS. Data analysis involved comparing each reader to all the others based on the raw agreement and Kappa coefficient (kappa). Features in the 24 patients were consistent with earlier studies. Global inter-observer agreement beyond chance was fair (kappa = 0.29 +/- 0.02) among the five radiologists (kappa = 0.26 +/- 0.05) and among the five intensivists (kappa = 0.29 +/- 0.05). Thus, considerable inter-observer variability occurred in assessing the radiographic criterion for ALI/ARDS, as previously shown in adults. Given the low incidence of ALI/ARDS in children, this variability may have a large impact in studies of pediatric ALI/ARDS.

The use of the Berlin definition for acute respiratory distress syndrome during infancy and early childhood: multicenter evaluation and expert consensus

“…A data set of clinical vignettes and radiographs (Electronic Supplementary Material 2) was also important because the chest X-ray criterion is known to have moderate interobserver reliability, as confirmed by our ICC coefficient [26]. However, this may be improved through the routine use of a training set of radiographs [26][27][28] and thus this part of our project will help the bedside application of BD.…”

“…However, this may be improved through the routine use of a training set of radiographs [26][27][28] and thus this part of our project will help the bedside application of BD.…”

Lung imaging during acute chest syndrome in sickle cell disease: computed tomography patterns and diagnostic accuracy of bedside chest radiograph

“…The main difference between these criteria concerns the lung imaging definition which is more or less restrictive, including: ‘a new pulmonary opacity’,3 ‘an acute pulmonary disease involving at least one complete lung segment’,4 or ‘a new pulmonary opacity involving at least one complete lung segment that is consistent with the presence of alveolar consolidation, but excluding atelectasis’ 5. Identifying the characteristic lung imaging abnormalities of ACS may be challenging, especially when using bedside CR, which has been shown to have moderate accuracy in other forms of acute lung injury 6. To be consistently useful, interpretation of a radiological investigation must be reliable.…”

The Design of Future Pediatric Mechanical Ventilation Trials for Acute Lung Injury

“…Second, the AECC requirement for ''bilateral pulmonary infiltrates'' on chest radiograph is open to considerable interpretation and has very poor interobserver variability in both pediatric and adult critical care (69,70). The presence of such infiltrates was meant to help distinguish the distinct pathophysiologic processes of ALI/ARDS from lobar pneumonia, atelectasis, or simply radiographic technique.…”