Pediatric upper airway obstruction: interobserver variability is the road to perdition

Abstract

Purpose: The purposes of the study are to determine the interobserver variability in the clinical assessment of pediatric upper airway obstruction (UAO) and to explore how variability in assessment of UAO may contribute to risk factors and incidence of postextubation UAO.

Materials: This is a prospective trial in 2 tertiary care pediatric intensive care units. Bedside practitioners performed simultaneous, blinded UAO assessments on 112 children after endotracheal extubation.

Results: Agreement among respiratory therapists, pediatric intensive care nurses, and pediatric intensive care physicians was poor for cyanosis (κ = 0.01) and hypoxemia at rest (κ = 0.14) and fair for consciousness (κ = 0.27), air entry (κ = 0.32), hypoxemia with agitation (κ = 0.27), and pulsus paradoxus (κ = 0.23). When looking at "stridor" and "retractions," defined using more than 2 grades of severity from the Westley Croup Score, the interrelater reliability was moderate (κ = 0.43 and κ = 0.47, respectively). This could be improved marginally by dichotomizing the presence or absence of stridor (κ = 0.54) or retractions (κ = 0.53). The overall incidence of UAO after extubation (stridor plus retractions) could range from 7% to 22%, depending on how many providers were required to agree.

Conclusions: Physical findings routinely used for UAO have poor interobserver reliability among bedside providers. This variability may contribute to inconsistent findings regarding incidence, risk factors, and therapies for postextubation UAO.

Keywords: Airway obstruction; Endotracheal; Intensive care; Intubation; Pediatrics.