Inter-Rater Agreement of Auscultation, Palpable Fremitus, and Ventilator Waveform Sawtooth Patterns Between Clinicians

Abstract

BACKGROUND: Clinicians often use numerous bedside assessments for secretion retention in participants who are receiving invasive mechanical ventilation. This study aimed to evaluate interrater agreement between clinicians when using standard clinical assessments of secretion retention and whether differences in clinician experience influenced inter-rater agreement. METHODS: Seventy-one mechanically ventilated participants were assessed by a research clinician and by one of 13 ICU clinicians. Each clinician conducted a standardized assessment of lung auscultation, palpation for chest-wall (rhonchal) fremitus, and ventilator inspiratory/expiratory flow-time waveforms for the sawtooth pattern. RESULTS: On the presence of breath sounds, agreement ranged from absolute to moderate in the upper zones and the lower zones, respectively. Kappa values for abnormal and adventitious lung sounds achieved moderate agreement in the upper zones, less than chance agreement to substantial agreement in the middle zones, and moderate agreement to almost perfect agreement in the lower zones. Moderate to almost perfect agreement was established for palpable fremitus in the upper zones, moderate to substantial agreement in the middle zones, and less than chance to moderate agreement in the lower zones. Inter-rater agreement on the presence of expiratory sawtooth pattern identification showed moderate agreement. The level of percentage agreement between the research and ICU clinicians for each respiratory assessment studied did not relate directly to level of clinical experience. CONCLUSIONS: Inter-rater agreement for all assessments showed variability between lung regions but maintained reasonable percentage agreement in mechanically ventilated participants. The level of percentage agreement achieved between clinicians did not directly relate to clinical experience for all respiratory assessments. Therefore, these respiratory assessments should not necessarily be viewed in isolation but interpreted within the context of a full clinical assessment.

Indicators of Airway Secretion Weight in Mechanically Ventilated Subjects

“…Study inclusion criteria included the planned assessment by a physiotherapist for the need for chest physiotherapy intervention with further details provided elsewhere. 16 A physiotherapist is part of the multidisciplinary team in most ICUs. Physiotherapists use a comprehensive multisystem assessment that includes the respiratory, cardiovascular, neurological, and musculoskeletal systems to formulate individualized treatment plans that include respiratory and rehabilitation interventions.…”

“…Physiotherapists then began their clinical assessment of the need for secretion clearance based on local ICU physiotherapy treatment guidelines (ie, presence of adventitious sounds, presence of sawtooth pattern on the ventilator waveform, tactile chest wall/ventilator circuit fremitus). 16 Lung auscultation was undertaken using a dual-limb stethoscope (Classic II SE Teaching Stethoscope, 3M Littmann, St Paul, Minnesota) to allow the ICU and research physiotherapists to independently auscultate the same lung regions at the same time. Six standard anterolateral lung areas (right and left upper, middle, and lower zones) were assessed with the subject in a supine, head-up, 30°position.…”

“…Chest physiotherapy could have included combinations of normal saline lavage (0.9% NaCl), postural drainage, manual chest-wall vibrations, manual-assisted cough, and ventilator/manual lung hyperinflations, depending on clinical indications as previously described. 16,20 The chest physiotherapy interventions selected by the clinical physiotherapist were based on their initial clinical assessments and clinical suspicion for secretion presence, and hence the intervention varied on the basis of the perceived clinical needs of the patient at the time of assessment. Chest physiotherapy interventions were not standardized because the indications for specific interventions were unknown until the assessment by the physiotherapist had been undertaken.…”

Adventitious and Normal Lung Sounds in the General Population: Comparison of Standardized and Spontaneous Breathing

“…An enrollment target of 100 subjects was selected based on convention, as enrollment numbers of 50 -100 subjects are typical in clinical agreement and reliability studies. 5,10,11 The study as a whole was approved by the Regional Committee for Medical and Health Research Ethics. Participants' written informed consent was obtained before data collection.…”

Locating stridor caused by tumor compression by using a multichannel electronic stethoscope: a case report

“…Furthermore, the interpretation of the auscultation results is dependent on the practitioner's hearing ability, training, and expertise. Interpretations can vary considerably, and agreement rate among practitioners is usually fair [4][5][6]. Recent innovation in computerized sound analysis has increased the clinical value of auscultation by the precision improvement in sound recording and acoustic indexes.…”