Can Two Clinicians Agree on a Child’s Lung Exam? What It Means for Pneumonia Care

Have you ever watched two clinicians listen to the same child’s lungs and describe different sounds? One may hear crackles while another hears coarse breathing or no abnormal sound at all. A new PECARN study found that this kind of disagreement is common, even among experienced pediatric emergency clinicians.

The Reliability of Physical Examination Findings in Youths Diagnosed With Pneumonia study, published in JAMA Network Open, examined whether two clinicians evaluating the same child with community-acquired pneumonia recorded the same physical examination findings [1]. No individual finding met the study’s predefined standard for acceptable reliability.

Study Design

Hooli et al. studied 252 children ages 3 months through 17 years at seven academic pediatric emergency departments participating in the ongoing PECARN Pediatric Community-Acquired Pneumonia Severity (PedCAPS) study. Each child had been diagnosed with community-acquired pneumonia. Nearly all, 98.8%, also had chest x-ray findings consistent with pneumonia.

Two emergency clinicians independently examined each child within 60 minutes of one another. The clinicians recorded whether they observed findings such as:

  • Decreased breath sounds
  • Crackles or rales
  • Rhonchi or coarse breath sounds
  • Wheezing
  • Retractions or use of accessory muscles to breathe
  • Grunting, altered mental status, or delayed capillary refill

The researchers measured how consistently the two clinicians identified each finding, accounting for agreement that could occur by chance.

Results

When the second clinician examined the same child less than an hour later, the findings often changed. For classic pneumonia sounds such as crackles, coarse breath sounds, and decreased breath sounds, the two clinicians agreed only about half the time. They agreed more often about wheezing and visible signs that a child was working harder to breathe, but even those findings were only moderately reliable. No single finding met the study’s standard.

Agreement was similar among children discharged home and those hospitalized. The study was not large enough to determine confidently whether reliability differed by age or by whether clinicians knew the chest x-ray results.

Why This Matters

National guidelines advise that routine chest x-rays are not needed to confirm suspected pneumonia in children who are well enough to be treated at home [2]. Clinicians therefore often rely on the child’s history and examination. This study shows why a single lung sound should not carry too much weight: different clinicians may interpret the same child’s breathing differently.

The study measured agreement between clinicians. Diagnostic accuracy was outside its scope. Routine chest x-rays remain unnecessary for children well enough to be treated at home. Doctors can consider the whole picture, including symptoms, breathing rate and effort, oxygen level, overall appearance, illness course, and whether additional testing would change treatment.

“Our results emphasize the need to look at multiple features of the clinical presentation rather than exam findings in isolation when making the diagnosis of pneumonia.”

Todd A. Florin, MD, MSCE, senior author

This reliability study is part of the larger PedCAPS project, which is developing and validating a tool to estimate the severity of pneumonia in children [3]. That future tool is intended to help clinicians assess how sick a child with diagnosed pneumonia may become. The initial diagnosis remains a separate clinical decision.

Take Home Message

Listening to the lungs remains an important part of examining a child with possible pneumonia, but no single sound should decide the diagnosis. When clinicians hear different things, they should return to the full clinical picture and seek additional information when that uncertainty would change care.

Why is this important for patients and caregivers

  • Two clinicians may describe a child’s lung sounds differently. That does not necessarily mean that either clinician examined the child incorrectly.
  • A pneumonia assessment should include more than one sound heard through a stethoscope. Breathing effort, oxygen level, symptoms, overall appearance, and changes over time all matter.
  • Ask the care team what information supports the diagnosis and what changes should prompt reevaluation. Routine chest x-rays remain unnecessary for many children who are well enough to recover at home.

This blog post is a summary of the following journal publication:
Hooli S, Reeder R, Cutler L, et al. Reliability of Physical Examination Findings in Youths Diagnosed With Pneumonia. JAMA Netw Open. 2026;9(8):e2630074. PMID: 42623068. doi:10.1001/jamanetworkopen.2026.30074

Interested in other PECARN research?

Other PECARN research on pediatric pneumonia:

References

  1. Hooli S, Reeder R, Cutler L, et al. Reliability of Physical Examination Findings in Youths Diagnosed With Pneumonia. JAMA Netw Open. 2026;9(8):e2630074. PMID: 42623068. doi:10.1001/jamanetworkopen.2026.30074
  2. Bradley JS, Byington CL, Shah SS, et al. The Management of Community-Acquired Pneumonia in Infants and Children Older Than 3 Months of Age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011;53(7):e25-e76. PMID: 21880587. doi:10.1093/cid/cir531
  3. Florin TA, Reeder R, Ambroggio L, et al. Derivation and Validation of the Pediatric Community-Acquired Pneumonia Severity (PedCAPS) Score: A Prospective Cohort Study. J Hosp Med. 2026;21(5):590-598. PMID: 41272952. doi:10.1002/jhm.70220
Michelle Lin, MD

Michelle Lin, MD

Professor of Emergency Medicine | University of California, San Francisco

This website is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of the Emergency Medical Services for Children Data Center award totaling $3,200,000 with 0% financed with non-governmental sources. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government. For more information, please visit HRSA.gov.

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