Using the Clinical Respiratory Score Can Improve Outcomes In Children With Respiratory Distress

Acute respiratory infection is the largest contributor to under 5-year-old mortality per the global burden of disease. It is a common ED presentation in Low-to-Middle Income Countries (LMICs) such as Pakistan. Respiratory distress is typically characterized by head bobbing, grunting, tachypnea, nasal flaring, use of accessory muscles, retractions, and decreased oxygen saturation. These clinical findings as part of a clinical scoring system form the basis of identification of severity of the respiratory distress.

In our study¹ we utilized one such scoring system called the Clinical Respiratory Score (CRS), which was first introduced in high-income counties (HICs) and validated for asthma and acute chest syndrome presentation in sickle cell disease patients presenting to the ED. Our study was conducted in the ED of the Aga Khan University Hospital (AKUH) in Karachi, one of the largest urban tertiary/quaternary care centers in Pakistan. The ED at AKUH is a 62-bed facility, including a 15-bed pediatric ED that caters to over 50 children daily and more than 20,000 annually.

In our study we enrolled children with respiratory distress, regardless of etiology, presenting to the ED. The CRS was obtained on a total of 112 pediatric patients, aged between one month to 16 years, enrolled over a course of five months. For data analysis, the CRS was divided into three categories: mild, moderate and severe. Our analysis showed that a CRS of 3 or greater distinguished between severe and non-severe illness; furthermore, the CRS effectively predicted whether a child needed to be shifted from the ED to pediatric critical care.

Although the CRS was originally validated for a small subset of children with respiratory symptoms in HICs, we demonstrated its applicability to a broader range of pediatric respiratory distress patients in an LMIC setting. This demonstrated flexibility of the CRS has implications for US-based low-resource EDs where triage, patient flow, and possibly outcomes could be affected by nursing use of the CRS for pediatric respiratory distress presentations.

The simplicity of our study was likely one of the reasons why our paper was recognized as one of the top 5% of global emergency medicine articles of 2018 by the Global Emergency Medicine Literature Review (GEMLR)², a US-based group of EM researchers who systematically identify, assess, and publicize high-quality research emanating from LMICs.

We accomplished this project without any grant support, indicating that if the research hypothesis and study design are robust enough then pursuing the study is worth the team’s time and effort, regardless of setting (HIC or LMIC) or access to a budget.

References

• The clinical respiratory score predicts paediatric critical care disposition in children with respiratory distress presenting to the emergency department
• Global Emergency Medicine: A Review of the Literature from 2018

About the authors

Rubaba Naeem is research specialist and Asad Mian is Chair of the Department of Emergency Medicine at the Aga Khan University, Karachi, Pakistan.

Rubaba Naeem and Asad Mian