Pediatric Respiratory Severity Score (PRESS) for Respiratory Tract Infections in Children

Research Article

Austin Virol and Retrovirology. 2015;2(1): 1009.

Pediatric Respiratory Severity Score (PRESS) for Respiratory Tract Infections in Children

Yumiko Miyaji1,2,5*, Kazuko Sugai³, Asako Nozawa², Miho Kobayashi4, Shoichi Niwa4, Hiroyuki Tsukagoshi4, Kunihisa Kozawa4, Masahiro Noda5, Hirokazu Kimura5 and Masaaki Mori2

1Department of Pediatrics, National Hospital Organization Yokohama Medical Center, Japan

2Department of Pediatrics, Yokohama City University Graduate School of Medicine, Japan

3Department of Pediatrics, National Hospital Organization Fukuyama Medical Center, Japan

4Department of Health Science, Gunma Prefectural Institute of Public Health and Environmental Sciences, Japan

5Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Japan

*Corresponding author: Yumiko Miyaji, Department of Pediatrics, National Hospital Organization Yokohama Medical Center3-60-2 Harajuku, Totsuka-ku, Yokohama, Kanagawa, Japan

Received: April 29, 2015; Accepted: July 07, 2015; Published: July 10, 2015


Background: Respiratory tract infections are common diseases in children. It is crucial therefore to evaluate the severity of the condition during the initial bedside assessment in the emergency department so that further examinations and hospital treatment can be conducted as appropriate. However, there are few such scoring systems for acute respiratory infection in childhood.

Objective: To evaluate a new simple bedside scoring system for the rapid assessment of pediatric respiratory infections in emergency settings.

Methods: We established a respiratory scoring system, namely “Pediatric Respiratory Severity Score (PRESS)”, and examined its utility for assessing severity in 202 children who visited our hospital due to respiratory symptoms between January 2010 and November 2011. The PRESS assessed tachypnea, wheezing, retraction (accessory muscle use), SpO2, and feeding difficulties, with each component given a score of 0 or 1, and total scores were classified as mild (0–1), moderate (2–3), or severe (4–5). In addition, we performed RT-PCR techniques to detect respiratory viruses from nasal swabs and the detected viruses were evaluated in relation to severity.

Results: According to the PRESS scores, the hospitalization rate was significantly higher in the moderate and severe groups than in the mild group. Oxygen therapy was longer in severe cases compared with other cases. There were no significant differences in the viral detection rate between the severity groups.

Conclusion: The PRESS scoring system is useful for the initial assessment of respiratory tract infections in children to identify the need for hospitalization and further examination in emergency settings.

Keywords: Severity score; Child; Respiratory infection; Virus; Triage


PRESS: Pediatric Respiratory Severity Score; ARI: Acute Respiratory Illness; RSV: Respiratory Syncytial Virus; HRV: Human Rhinovirus; HPIV: Human Parainfluenza Virus; HMPV: Human Metapneumovirus; HEV: Human Enterovirus; HBoV: Human Bocavirus; AdV: Adenovirus


Various viruses cause acute respiratory illness in children, including Respiratory Syncytial Virus (RSV), Human Rhinovirus (HRV), Human Parainfluenza Virus (HPIV), and Human Metapneumovirus (HMPV). Various symptoms (e.g., respiratory rate, wheezing, cyanosis, and use of the accessory respiratory muscles) may reflect the severity of respiratory disease and these clinical findings could be important for early diagnosis and treatment. Moreover, it is crucial to treat acute respiratory infection appropriately to avoid the risk of respiratory failure, which is sometimes fatal in children. Severe cases must be triaged and treated immediately; therefore, respiratory condition should be assessed at first contact, in a similar way that the APGAR scoring system is used to assess neonates [1]. In 2006, the American Academy of Pediatrics highlighted the importance of assessing severity for selecting the appropriate outpatient or inhospital treatment in Diagnosis and Management of Bronchiolitis, a guideline for acute bronchiolitis in infants [2]. Although some studies have evaluated the severity of bronchial asthma and acute respiratory infections in children, few suggest simple methods of bedside assessment [3-10].

To address this issue, we established a scoring system of the severity of respiratory infections in children, which we named the Pediatric Respiratory Severity Score (PRESS), and evaluated its utility for assessing the severity of infection caused by various pathogens and for deciding the necessity of further clinical examinations and the treatment to start. We focused on the severity of the respiratory symptoms because the supportive care required by the patients is not available at home and only available at the hospital. In addition, we examined the relationship between the severity of illness and pathogens profiles.

Materials and Methods

Subjects and samples

This study was carried out at the Department of Pediatrics, National Hospital Organization Yokohama Medical Center, an urban emergency hospital in Japan, between January 2010 and November 2011. We enrolled 202 children who visited the outpatient clinic or emergency department because of acute respiratory symptoms. Nasopharyngeal swabs were collected after written informed consent was obtained from the children’s parents. The study protocol was approved by the Ethics Committee on Human Research of the National Hospital Organization Yokohama Medical Center.

We collected nasal fluid samples using Advanced Flocked Swabs and Universal Transport Medium (Copan Innovation, Brescia, Italy), and stored the samples at -80 °C until used for viral detection. White blood cell counts (normal range: 7,000-11,000/μL in child) and C-reactive protein (CRP, normal range for children :< 1.2mg/dL) were measured at the first visit. We collected samples for bacterial culture before antibiotic therapy was initiated. We collected clinical data, radiographic evidence, and laboratory data from hospital charts.

PRESS score

We collected data on five components using the PRESS, namely, respiratory rate, wheezing, accessory muscle use, SpO2, and feeding difficulties (Table 1). Accessory muscle use was defined as visible retraction of one or more of the sternomastoid/suprasternal, intercostal, and subcostal muscles. Wheezing was defined by auscultation performed by experienced pediatricians. SpO2 was evaluated as above or below 95%. Feeding difficulties were assessed using information provided by the parents. Each component was given 0 or 1 point and the PRESS total score was classified as mild (0–1 points), moderate (2–3 points), or severe (4–5 points). Respiratory rate was evaluated based on the American Heart Association guidelines (Table 1) [11].