title: 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 inter-rater 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.
authors.affiliation: Physiotherapy Department, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, United Kingdom. Physiotherapy Department, Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Hampshire, United Kingdom. marc.berry@hhft.nhs.uk.
authors.forename: Marc P
authors.initials: MP
authors.lastname: Berry
authors.affiliation: Pulmonary Critical Care Unit and Animal Experimentation Division, Thorax Institute, Hospital Clínic, Barcelona, Spain, and the Centro de Investigación en Red-Enfermedades Respiratorias (CIBERES), Mallorca, Spain.
authors.forename: Joan-Daniel
authors.initials: JD
authors.lastname: Martí
authors.affiliation: Physiotherapy Department, Guy's and St Thomas' NHS Foundation Trust, King's Health Partners, London, United Kingdom. University of Technology Sydney, Sydney, New South Wales, Australia.
authors.forename: George
authors.initials: G
authors.lastname: Ntoumenopoulos
mesh_terms: D000368:Aged; D001314:Auscultation / Q000379:methods / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D010173:Palpation / Q000379:methods / Q000706:statistics & numerical data; D000067716:Point-of-Care Testing / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D012121:Respiration, Artificial / Q000706:statistics & numerical data*; D012135:Respiratory Sounds / Q000175:diagnosis; D012122:Ventilators, Mechanical / Q000706:statistics & numerical data*; D058067:Wavelet Analysis
keywords: auscultation; critical care; humans; mechanical; observer variation; palpation; respiratory sounds; ventilators