A New Clinical Score for Assessing Acute Asthma Severity in Children
A New Clinical Score for Assessing Acute Asthma Severity in Children
Ducharme FM, Chalut D, Plotnick L, et al
J Pediatr. 2008;152:476-480, 480.e1
The authors note that there is a need for valid and reproducible measures of clinical status in pediatric patients experiencing an asthma exacerbation. This evaluation of the Preschool Respiratory Assessment Measure (PRAM) sought to determine whether it performed well when used in the care of older children, as it had with preschool children.
This study enrolled children 2-17 years old experiencing an asthma exacerbation and presenting to 1 emergency department in 2003. Eligibility criteria included a diagnosis of asthma (at least 2 episodes of wheezing that had responded to beta-agonists) and that the patient required at least 1 treatment with beta agonist at the enrollment presentation.
The PRAM is a 12-point clinical scoring rubric that captures a patients' condition in scalene muscle contraction, suprasternal retractions, wheezing, air entry, and oxygen saturation. A PRAM score was recorded at triage (by nursing), a second score was recorded within 60 minutes after the first bronchodilator dose (usually by providers), and then subsequent measures were taken every 1-2 hours until a disposition on admission or discharge was made.
While some attending physicians may have used PRAM scores to determine disposition, this was not a universal requirement. All attending physicians and nursing personnel received training in measuring the PRAM. The authors evaluated internal consistency (how well the instrument items correlated with each other) and predictive validity of the instrument (if higher scores prove predictive of who was admitted).
The authors also evaluated the "responsiveness" of the instrument by assessing whether patients who were discharged from the emergency department demonstrated greater improvement in PRAM scores compared to those admitted.
During the study period, 964 eligible patients presented for asthma exacerbation, with 81% having an initial PRAM score completed. The median age of subjects was 5.8 years, and 63% were male. Fifty-seven percent of children had a second PRAM recorded.
The internal consistency of the instrument was very good, and the predictive validity was considered "strong" by the authors. The PRAM recorded after initial bronchodilation had a better correlation with outcome, but the initial PRAM, taken during triage, also had good correlation (predictive validity). The authors also demonstrated that the instrument was responsive to change in patient condition.
The PRAM performed equally well in the 7-17 year old group as it did in the 2-6 years old ("preschool") group. The authors suggest the following qualitative groupings for PRAM scores: score 0-3 = "low risk" for admission (< 10% in this study); score 4-7 = "moderate risk" for admission (10%-50% in this study); and score 8-12 = "high risk" for admission (≥ 50%).
They also suggest that these data indicate that the score could now be called the "Pediatric" Respiratory Assessment Measure because it has now been validated in a group other than preschool children.
The authors note that there are 2 scoring systems for asthma symptoms that are considered
valid -- the PRAM and the Pediatric Asthma Severity Score. I suspect that institutions use one or the other depending on familiarity, past training, and preference. The authors note that the responsiveness of the PRAM is greater than the published responsiveness of the Pediatric Asthma Severity Score. However, one would really need to conduct a prospective, head-to-head comparison to determine which score might have better predictive validity and responsiveness. In the meantime, practitioners could use either, since a systematic method to assess and make decisions on asthmatic patients can improve care. However, remember that training and education in the use of the instruments were part of these studies. Implementing use of the score without the training will likely make the instrument less useful in daily practice.
Abstract
The Pediatric Respiratory Assessment Measure: A Valid Clinical Score for Assessing Acute Asthma Severity from Toddlers to Teenagers
Ducharme FM, Chalut D, Plotnick L, et al
J Pediatr. 2008;152:476-480, 480.e1
Summary
The authors note that there is a need for valid and reproducible measures of clinical status in pediatric patients experiencing an asthma exacerbation. This evaluation of the Preschool Respiratory Assessment Measure (PRAM) sought to determine whether it performed well when used in the care of older children, as it had with preschool children.
This study enrolled children 2-17 years old experiencing an asthma exacerbation and presenting to 1 emergency department in 2003. Eligibility criteria included a diagnosis of asthma (at least 2 episodes of wheezing that had responded to beta-agonists) and that the patient required at least 1 treatment with beta agonist at the enrollment presentation.
The PRAM is a 12-point clinical scoring rubric that captures a patients' condition in scalene muscle contraction, suprasternal retractions, wheezing, air entry, and oxygen saturation. A PRAM score was recorded at triage (by nursing), a second score was recorded within 60 minutes after the first bronchodilator dose (usually by providers), and then subsequent measures were taken every 1-2 hours until a disposition on admission or discharge was made.
While some attending physicians may have used PRAM scores to determine disposition, this was not a universal requirement. All attending physicians and nursing personnel received training in measuring the PRAM. The authors evaluated internal consistency (how well the instrument items correlated with each other) and predictive validity of the instrument (if higher scores prove predictive of who was admitted).
The authors also evaluated the "responsiveness" of the instrument by assessing whether patients who were discharged from the emergency department demonstrated greater improvement in PRAM scores compared to those admitted.
During the study period, 964 eligible patients presented for asthma exacerbation, with 81% having an initial PRAM score completed. The median age of subjects was 5.8 years, and 63% were male. Fifty-seven percent of children had a second PRAM recorded.
The internal consistency of the instrument was very good, and the predictive validity was considered "strong" by the authors. The PRAM recorded after initial bronchodilation had a better correlation with outcome, but the initial PRAM, taken during triage, also had good correlation (predictive validity). The authors also demonstrated that the instrument was responsive to change in patient condition.
The PRAM performed equally well in the 7-17 year old group as it did in the 2-6 years old ("preschool") group. The authors suggest the following qualitative groupings for PRAM scores: score 0-3 = "low risk" for admission (< 10% in this study); score 4-7 = "moderate risk" for admission (10%-50% in this study); and score 8-12 = "high risk" for admission (≥ 50%).
They also suggest that these data indicate that the score could now be called the "Pediatric" Respiratory Assessment Measure because it has now been validated in a group other than preschool children.
Viewpoint
The authors note that there are 2 scoring systems for asthma symptoms that are considered
valid -- the PRAM and the Pediatric Asthma Severity Score. I suspect that institutions use one or the other depending on familiarity, past training, and preference. The authors note that the responsiveness of the PRAM is greater than the published responsiveness of the Pediatric Asthma Severity Score. However, one would really need to conduct a prospective, head-to-head comparison to determine which score might have better predictive validity and responsiveness. In the meantime, practitioners could use either, since a systematic method to assess and make decisions on asthmatic patients can improve care. However, remember that training and education in the use of the instruments were part of these studies. Implementing use of the score without the training will likely make the instrument less useful in daily practice.
Abstract
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