Interobserver variability in applying a radiographic definition for ARDS.

CONTEXT Acute lung injury (ALI) and ARDS are currently defined by the American-European Consensus Conference (AECC) definition criteria, which contain a radiographic criterion. The accuracy or reliability of this consensus radiographic definition has not been evaluated, and no radiographic definition of ALI-ARDS has been evaluated by a large international group of experts. OBJECTIVE To study the interobserver variability in applying the AECC radiographic criterion for ALI-ARDS. DESIGN Survey. PARTICIPANTS A convenience sample of 21 experts selected from participants attending the 1997 Toronto Mechanical Ventilation Workshop and from members of the National Institutes of Health ARDS Network. OUTCOME MEASURES Participants reviewed 28 randomly selected chest radiograph from critically ill, hypoxemic (PaO(2)/fraction of inspired oxygen ratio, < 300) patients and decided whether the radiograph fulfilled the AECC definition for ALI-ARDS. RESULTS Interobserver agreement in applying the AECC definition for ALI-ARDS was moderate (kappa = 0.55; 95% confidence interval, 0.52 to 0.57). Thirteen radiographs (43%) showed nearly complete agreement (defined as 20 or 21 readers in agreement). Nine radiographs (32%) had more than or equal to five dissenting readers. The percentage of radiographs interpreted as consistent with ALI-ARDS by individual readers ranged from 36 to 71%. Participants commented that mild infiltrates, pleural effusions, atelectasis, isolated lower lobe involvement, radiographic technique, and overlying monitoring equipment posed the most difficulties. CONCLUSIONS The radiographic criterion used in the current AECC definition for ALI-ARDS showed high interobserver variability when applied by expert investigators in the fields of mechanical ventilation and ARDS. This variability may result in differences in ALI-ARDS populations at different clinical research centers and may make it difficult for clinicians to apply the results of clinical trials to their patients. Modifications to the radiographic criterion or annotated reference radiograph may improve the reliability of future definitions for ALI-ARDS.

[1]  J. Yelle,et al.  Adult respiratory distress syndrome: A systematic overview of incidence and risk factors , 1996 .

[2]  M. Lamy,et al.  The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. , 1994, American journal of respiratory and critical care medicine.

[3]  D. Schuster,et al.  What is acute lung injury? What is ARDS? , 1995, Chest.

[4]  J F Murray,et al.  An expanded definition of the adult respiratory distress syndrome. , 1988, The American review of respiratory disease.

[5]  A R Feinstein,et al.  The impact of clinical history on mammographic interpretations. , 1997, JAMA.

[6]  C. Carvalho,et al.  Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. , 1998, The New England journal of medicine.

[7]  T L Petty,et al.  Acute respiratory distress in adults. , 1967, Lancet.

[8]  Rater Agreement in Lung Scintigraphy , 1996, Acta radiologica.

[9]  W. Knaus,et al.  Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. , 1992, Chest.

[10]  R. Bone,et al.  Sepsis, the sepsis syndrome, multi-organ failure: a plea for comparable definitions. , 1991, Annals of internal medicine.

[11]  A. Jackson,et al.  Interobserver variation in the chest radiograph component of the lung injury score , 1995, Anaesthesia.

[12]  J. Fleiss.  Statistical methods for rates and proportions , 1974 .

[13]  K. Dale,et al.  Interobserver Variability in the Radiographic Diagnosis of Adult Outpatient Pneumonia , 1992, Acta radiologica.

[14]  W. Grove.  Statistical Methods for Rates and Proportions, 2nd ed , 1981 .

[15]  J. Elmore,et al.  Variability in radiologists' interpretations of mammograms. , 1994, The New England journal of medicine.

[16]  Stephen E. Lapinsky,et al.  Evaluation of a Ventilation Strategy to Prevent Barotrauma in Patients at High Risk for Acute Respiratory Distress Syndrome , 1999 .

[17]  M. A. de la Cal,et al.  Radiographic findings for the adult respiratory distress syndrome in patients with peritonitis. , 1983, Critical care medicine.

[18]  A. Feinstein,et al.  Problems of spectrum and bias in evaluating the efficacy of diagnostic tests. , 1978, The New England journal of medicine.

[19]  W. Shoemaker,et al.  Temporal patterns of radiographic infiltration in severely traumatized patients with and without adult respiratory distress syndrome. , 1994, The Journal of trauma.

[20]  Arthur S Slutsky,et al.  Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and Volume-Limited Ventilation Strategy Group. , 1998, The New England journal of medicine.

[21]  M D Attfield,et al.  Chest radiography in dust-exposed miners: promise and problems, potential and imperfections. , 1993, Occupational medicine.