A Clinical Score for Predicting The Level of Respiratory Care in Infants With Respiratory

Distress Syndrome George J. Peckham, M.D.,

Joseph Schulman, M.D., GilbertoR. Pereira, M.D.,

John G. Shutack, D.O. A scoring system was developed to predict the need for transferring infants to spewith respiratory distress syndrome (RDS) from community hospitals determinations and five clinical laboratory cialized respiratory care centers. 2 and pH) recorded from 100 infants FI PCO , (birthweight, clinical RDS score, O2 to with RDS during one year were utilized in a score with values ranging from 0 10. Application of the score to 159 with RDS during the following year by showed that: (1) 73 per cent of infants scoring ≤3 received only oxygenaircontinuous positive 4-5 infants of cent required 75 scoring hood; (2) per (3) 87 per cent of scoring ≥6 needed meway (CPAP); and Mean scores were significantly different (p < 0.02) chanical ventilation (MV).

therapy employed: oxygen by hood (2.30 ± 0.19 S.E.M.); CPAP (4.27 ± 0.16 S.EIM.); MV (6.72 ± 0.25 S.E.M.). the physician in for each type of respiratory

The accuracy and simplicity of the score make it valuable for

the community hospital to assist in deciding when to transfer RDS for more intensive respiratory therapy.

! HE Respiratory Distress Syndrome (RDS)



is one of the leading causes of neonatal morMdny and mortality. Recently, it has become

possible to anticipate the occurrence ~~’ 3~~~ by either prenatal studies of- the amniotic fluid, or by postnatal studies - of the gastric


a neonate with

of the infant after delivery.

Since 1956, when ~-aixdrc’ ;; ~

infants with RDS,’ many scoring systems have, been developed that stress the correlation, between severity of RDS and mortality risk. The

has not : . birth ~2 after Howeve., soon infants aspirate of these ~.~~~~~~ ~~ ~r~~ ~~~~~~~ ~~~ ~~i~~~~~ ~r~u~~ ’ ~~r~~~~ ~f ~~i~ ~~,~~~’ i~ ~~’ ~~e~~~t ~,: scoring .;. ~~_~~~~: ~~~~’a.:~~ ~~ ~~~~~~~a~x~ ~~.~ ~~~~ of respira,-;~~ory therapy 4needled’by infants with RDS so From the Division of Neonatology of The Children’s .~. that earlier andm, pre appropriate referral to of PediHospital of Philadelphia and the Department seconIdary or tertiary newborn centers can atrics of the University of Pennsylvania School of Medicine,



type of respiratory therapy needed been directliy correl~ted with The’

be made. ~&dquo; ~~/: ~~’ .~. ~;~

Pennsylvania 19104.


Correspondence to: George J. Peckham, M.D., Division of Neonatology, The Children’s Hospital of Phila- ’

&dquo;~ ..~.

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~~~~~i~~~ ~~~ ’ ’’.~ ~, ~ ~ /:, :~ ’.~ ~. ~~ ~’~ delphia, 34th Street and, Civic Center Boulevard, Philadelphia, PA 19104.30, 1979; revised Sep- ~.: Data for the development of this score were ~~~.. Received for publication May ~ I ~~3 infants ~~~~~ ~~3~ seen ’~;~;; ’-


1979 and accepted September 24, 1979.

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from between July 1, 1974 and June 30, 1 97j the Children’s Hospital of Philadelphia. The criteria for the diagnosis of RDS included: ( l) prematurity; (2) hypoxemia; (3) clinical signs (retractions, grunting, tachypnea, decreased air entry); (4) diffuse atelecta-


Res~irvtc~ry Tlaerafay Score: Scoring S~y,51em M:7M:’Kg’ Five Cliniccal and Labo-ratory


M~a~Mre-mcM~ 4v(zilable in

Cornmunity Hczs~rat~ls


(reticulogranular pattern) with air bronchograms on chest roentgenogram. None of the infants had laboratory (culture or leukopenia) or clinical (maternal fever or premarupture of membranes) evidence of infection. They were treated with a standard medical regimen varying according to severity of disease.&dquo; It included monitoring of arterial blood gases and administration of oxygen by hood, continuous positive airway pressure (CPAP) via nasal cannulae or endotracheal tube or mechanical ventilation (MV). Nasal CPAP was initiated when inspired oxygen concentration by hood was greater than 50 to 60 per cent to maintain the arterial oxygen tension between 50 and 70 mm Hg. Endotracheal CPAP was administered when arterial oxygen tension could not be maintained between 50 and 70 mm Hg at 60 to 70 per cent inspired oxygen concentration .by nasal CPAP. MV was initiated when arterial carbon dioxide tension was greater than 60 mm Hg or when adequate arterial oxygen tension (50-70 mm Hg) could not be maintained with efidotracheal CPAP (6 crn H20) at ~~~- l ~l~ per cent inspired oxygen concentration. ture


* Inspired oxygen concentration necessary to maintain

the inf~nt’s st~:in col~r pink: t Venous blood


Means, standard deviations and standard of the mean were calculated for 17 and laboratory measurements made when infants were between 6 and 12 hours of age. of the means as determined by the Student’s t-test were. significant for 11I of these ~~ri~.~~~~; Five of these variables were selected for a multifactorial score because of the practicality of obtaining these data in the errors


community hospital .setting. They were: (I)’ birthweight; (2) clinical RDS score (Tabie 1); (3) Fio, (inspired oxygen concentration).; (4) Pcog (mm ~~~; and (5) pH. The inspired .

T~~t~~ l. ~°~ir~a~rtl ~e.~~~rcatr~r~ f3a,rtress ~cc~~r~~ ~y~derr~ B ’

oxygen concentration was that amount necessary to maintain the color of the infants’ skin pink. A scoring chart was developed m which each variable assigned a’score of ~a ’ I or 2. The total score had a range from zero to ten where the higher score represented the

more severe respiratory- disease (Table 2). ’.:’~ ’To verify the vaM€,of,this_m’u.!tivarmte score ~




predicting the type of respiratory therapy ’. ’stein was, applied to 159 ’’:.

needed, the

~~~~~~~~i~~ ~~~1~~~~ ;mfants~’wita~RBS~ in the ~. ~ succeeding year, July 1, 1975,tojune30,1976.1 T,e treatment protocol wa’&’che same as L,4a,-’. / ased’m~:th€.;Srst~~y€~ of the, study. The thera- B . peutic decisions were made independently ~~‘ : ~~~ ~~~~e~z~’~ score since the I measurements :~’:,. ~;j ~’t~a~ ~r~~~~ ~-~~r~~~~~:~ ~~~ ~~zalit~ ~~‘ ~r~~~i~~~r~‘ breath . : ,;...~ were ~~~~~~~~ ~:~~~~~ ~~~ fi~~~ ~~- ~ ~2 hours ~~’ .~ . B wunds ~s ~a~~~c~ ~rt ~~~!a~ic~-~~il~~~ ~z~a~.. ’~~~ ..~ is,thr .’~um of the, individual scores for.each&dquo; of the five ?B~’a~~A&.~h~:;dmMaf;situa~o~ ~~~~~~c~- c~~~~ the J~ ~’’ ’..;







observations (reproduced,




frorn, ref-

:’ :~

’ ~~~~’~~~~~~ ~~~ars ~~~ fi~a~ ~~r~~.~~~~s~i~°a~~r~ ’


~’ erence 6). ;~&dquo; ~ :~~~ ~.~ j~’L~’ ~’~&dquo;’ :~ :~~’~.’~’ ’~~. T~:’~~.~: ~’’~ ~’~;.~ ~~ B ~~~~’~~.~ :chosem’ :;:~.~..~~.~ .::~:.~’:.’: :~~;.- ~’ ’~~.~ ~:~.~.’.:~~~:&dquo; ~’~ ’~. ’~;’

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FIG. 1. Mean (tS.E.M.) scores

for the three types

respiratory therapy e~nplc~yed in 159 infants with RI7S (Respiratory Distress Syndrome). Number in parentheses refers of

number of patients. Abbreviations : Hood oxygen administered by plexiglass hood; CPAP continuous positive airway mechpressure; ~tV anical ventilation. Statistical analysis by’s t-test: Hood vs. CPAP p < 0.02; CPAP vs. MV = p < 0,02, Hood vs.

During the development of the score, we observed a group of patients who initially required CPAP but finally needed MV (CPAP failures). Comparing this group of patients who failed CPAP with those infants initially needing MV, there was no significant differ-

in any of the five variables. Clinical RDS score and Fio, were the best single measurements for determining the type of respiratory ence

therapy (oxygen by hood, CPAP,








The scoring system applied to 159 consecutive infants treated for RDS in 1975-1976 demonstrated a significant difference (p


;~1(~ -- p ~ ~?.t30t,

Development of Scoring System Relative to ~~~~rir~t~~°y Therapy ’Z’he difference of the mean value for the five clinical and laboratory parameters used in the .scoring:, system was calculated for significance and a comparison, of the types e~~&dquo; ’ respiratory required was made. When that required comparing the of patients who hood with those required / only oxygen by

only CPAP,- therewas a significant difference (p ~’ 0.05) in clinical RDS score, ~’~~ Pco2l

the pH bui none in birthweightinfants those In contrast, requir~~~ ~~~ ~~

.;: and

ing only ogyg~!n by hood were siginificantlv different from,those needing MVI, in all ~


ables ’

(birthweight,, clinical



’~’~~ ’

and p~4). When those neonates who re-’


~~~. ~, ~~r~e~~~~ ~a~‘ p~c~~~~~ c~r~~~~~t~~ ~~~ r~~~ir~.~


management tory therapy score and type of respiratory in parentheses to to number of ,employed. Number patients. The respiratory therapy ;va~ applied to

compared with the 1,59 ~ ~~~‘~~~ x~~~ ~ ’~~~~~~~~i~ ~~~~’~~ ~~~~~r~~a~~> ..; ~. group needing MV, there was a, s Iignific,,~nt Abbreviations* ~Ho~ ~~~xy~ea~’::admtm$tcred~’ ~~ ple~airway pressure; difference (p < 0.025) in birt,hweight, clinical ~~~:~a;’CPAf~~to~MM&M’po~ ;:M~’~’me ~r~. ~.’ ’. ’.&dquo; Handbook ~~’~’~~ae~~ac ~~~~ ’C~...Somerset, ~*~*~ ~. N.J., Wiley, ’1978,242 pp., $18-00. ~~

/ ~:

~.- ’m.~B~MM!-€.





Wiley, 1979, 1080 pp., no

price ~~~~~1*

:.~..: ~



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A clinical score for predicting the level of respiratory care in infants with respiratory distress syndrome.

NEO AT L GY A Clinical Score for Predicting The Level of Respiratory Care in Infants With Respiratory Distress Syndrome George J. Peckham, M.D., Jo...
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