Respiratory Score for Asthma

Respiratory Rate

Wheezing

Accessory Muscle Use

Respiratory Score: 0

Mild

Score 0: Mild asthma exacerbation. Consider bronchodilator therapy and reassess.

Stratifies severity of asthma exacerbation in pediatric patients.

Why Use

Provides a standardized method for assessing asthma severity, ensuring consistent evaluations across clinicians and guiding treatment and disposition decisions. Enhances communication among physicians, nurses, and respiratory therapists, promoting coordinated care.

When to Use

Use during the initial evaluation of children (ages 1–18) presenting to the emergency department (ED) with acute asthma symptoms to determine exacerbation severity. Reassess throughout treatment, both in the ED and inpatient units, to monitor patient response and guide therapeutic decisions.

Formula

Addition of the selected points: Variable Points Respiratory rate, breaths per minute <2 months ≤60 1 61-69 2 ≥70 3 2 months to <1 year ≤50 1 51-59 2 ≥60 3 1 to <2 years ≤40 1 41-44 2 ≥45 3 2 to 3 years ≤34 1 35-39 2 ≥40 3 4 to 5 years ≤30 1 31-35 2 ≥36 3 6 to 12 years ≤26 1 27-30 2 ≥31 3 >12 years ≤23 1 24-27 2 ≥28 3 Retractions None 0 Intercostal 1 Intercostal and substernal 2 Intercostal, substernal, and supraclavicular 3 Dyspnea <2 years Normal feeding, vocalizations, and activity 0 1 of the following: difficulty feeding, decreased vocalization, or agitated 1 2 of the following: difficulty feeding, decreased vocalization, or agitated 2 Stops feeding, no vocalizations, or drowsy or confused 3 2 to 4 years Normal feeding, vocalizations, and play 0 1 of the following: decreased appetite, increased coughing after play, hyperactivity 1 2 of the following: decreased appetite, increased coughing after play, hyperactivity 2 Stops eating or drinking, stops playing, or drowsy or confused 3 ≥5 years Counts to ≥10 in one breath 0 Counts to 7-9 in one breath 1 Counts to 4-6 in one breath 2 Counts to ≤3 in one breath 3 Wheezing Normal breathing, no wheezing present 0 End-expiratory wheeze only 1 Expiratory wheeze only (greater than end-expiratory wheeze) 2 Inspiratory and expiratory wheeze and/or diminished breath sounds 3

Pearls / Pitfalls

Demonstrated good interobserver agreement among various healthcare team members, supporting its reliability in clinical settings.

Management

The following is a basic example of how the Respiratory Score can be used in the ED. Please refer to your institution’s protocols for more detailed guidance, such as the Seattle Children’s Hospital algorithm. Low risk (score 0–4): For initial management, consider systemic corticosteroids and bronchodilator therapy. Rescore frequently (e.g., hourly). If scores remain low with good response to therapy, stable oxygenation, and the absence of worsening symptoms, the patient may be appropriate for discharge. Moderate risk (score 5–8): For initial management, provide systemic corticosteroids and bronchodilator therapy. Rescore frequently. If the score decreases to the low-risk category, the patient may be appropriate for discharge or short observation, depending on the clinical context. If the score remains in the moderate category after several hours of therapy, continue bronchodilator therapy and consider inpatient management. High risk (score 9–12): For initial management, consider systemic corticosteroids, intensive bronchodilator therapy, and magnesium sulfate. Rescore frequently. If the score decreases to the low-risk category, consider a short observation period prior to discharge. If the score remains in the moderate or high-risk categories, continue therapy and consider inpatient management. Patients with persistently high scores (≥9) should be strongly considered for ICU admission for closer monitoring and advanced interventions, particularly if signs of impending respiratory failure are present.

Critical Actions

Although this score does not utilize SpO₂ in its calculations, monitoring oxygen saturation is recommended for patients with acute asthma exacerbations. Be sure to monitor for other signs of clinical deterioration, such as drowsiness, confusion, and hypercapnia. Consider early consultation with ICU teams for patients with persistent distress despite therapy or signs of impending respiratory failure.

Advice

This tool should be used as part of a comprehensive assessment; clinical judgment remains essential. Use initial and follow-up scores to guide treatment intensity and disposition decisions. Lower scores may indicate the need for less intensive therapy, while higher scores may require escalated therapy, respiratory support, admission, or critical care.

More Information

Interpretation: Respiratory Score for Asthma Risk Group 1-4 Low 5-8 Moderate 9-12 High From Seattle Children’s Hospital asthma pathway .