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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 4  |  Page : 57-61

Utility of PRESS score in predicting the outcomes of children admitted with respiratory distress: A prospective study


Department of Paediatrics, Sri Ramachandra Children’s and Dental Hospital, Guntur, Andhra Pradesh, India

Date of Submission11-Feb-2022
Date of Decision24-May-2022
Date of Acceptance23-Jun-2022
Date of Web Publication23-Sep-2022

Correspondence Address:
Vanitha Lakshmi Jagalamarri
13‑7‑1, 6th Lane Gunturuvarithota, Old Club Road, Guntur 522 001, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/prcm.prcm_1_22

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  Abstract 

Background: Respiratory distress in children must be promptly recognized and aggressively treated because they decompensate quickly leading to adverse outcomes. Objectives: To determine the outcomes of children admitted with respiratory distress based on PRESS score. Study Design: A prospective study which was done between September 2018 and March 2020. A total of 90 children of age group 1 month to 10 years with respiratory distress at the time of admission. Intervention: The PRESS scoring was done and outcomes measured which included use of Respiratory support [nasal cannula, high flow nasal cannula (HFNC), mechanical ventilation (MV)], duration of ICU and hospital stay. Results: Compared to moderate PRESS score, children with severe PRESS score had significantly more admission in PICU (91.30% vs 64.18%, P = 0.016); significantly more number of days of hospital stay (7 vs 5, P = 0.001); significantly more number of days of ICU stay (5 vs 3, P<.0001); significantly more median days of respiratory support (4 vs 3, P<.0001); significantly more use of respiratory support (67 vs 23patients, P < 0.0003) and more HFNC usage (73.91% vs 20.90%, P<.0001). However there was comparable requirement of mechanical ventilation between the two groups (8.7% vs 0%, P = 0.063). Conclusion: PRESS score can be a useful respiratory scoring system in triaging the children at the time of admission and in predicting the requirement of respiratory support and duration of hospital stay. It probably may serve as a useful tool at the community level to consider referral to an appropriate health facility in view of its simplicity.

Keywords: HFNC, respiratory distress, respiratory score, Spo2


How to cite this article:
Jagalamarri VL, Balleda L, Kolla S, Chandra Sekhara Reddy T. Utility of PRESS score in predicting the outcomes of children admitted with respiratory distress: A prospective study. Pediatr Respirol Crit Care Med 2021;5:57-61

How to cite this URL:
Jagalamarri VL, Balleda L, Kolla S, Chandra Sekhara Reddy T. Utility of PRESS score in predicting the outcomes of children admitted with respiratory distress: A prospective study. Pediatr Respirol Crit Care Med [serial online] 2021 [cited 2022 Dec 3];5:57-61. Available from: https://www.prccm.org/text.asp?2021/5/4/57/356801




  Introduction Top


Respiratory distress in children, particularly in infants, must be promptly recognized and aggressively treated because they decompensate quickly due to smaller airways, increased metabolic demands and less respiratory reserves. As such profound respiratory distress in children if not treated early and appropriately leads to respiratory failure and thus to cardiac arrest.[1],[2],[3],[4],[5] So early recognition of respiratory distress and failure is important for implementation of non-invasive or invasive modalities to decrease mortality and morbidity.

Paediatric Respiratory Severity Score (PRESS) is one of the scores used for triaging and assessment of respiratory status.

It is crucial to evaluate the severity of respiratory distress in a timely manner at the initial bedside assessment in emergency department, so that further management can be planned. There are few scoring systems for evaluating respiratory distress at bed side. Paediatric respiratory score is one of the first score developed and used at Seattle children’s hospital in 2004.[6]

Yumiko Miyaji, K. Sugai et al. developed PRESS score in 2010 to evaluate a new simple bedside scoring system for the rapid assessment of paediatric respiratory infections in emergency settings.[6]

After that few studies were done basing on the PRESS score in evaluating the respiratory infections. Population group included was 1 month to 16 years.

Those studies highlighted the importance of PRESS score as a bed side scoring system for respiratory infections, need for hospitalization and need for oxygen therapy.[6],[7],[8] There are also studies comparing CRS score (Clinical Respiratory Score) with PRESS Score.[6],[7] As PRESS score is very simple in its application, we preferred this for our study. It can be used in resource limited settings.

Inclusion criteria

Children of age group 1 month to 10 years with respiratory distress at the time of admission, independent of need for supplemental oxygen, HFNC, mechanical ventilation with or without fever were included in the study.

Exclusion criteria

Children of age less than one month, more than 10 years, and children with non-respiratory causes of respiratory distress were excluded from the study.


  Materials and Methods Top


After taking informed and written consent from the parents, we conducted a prospective observational study on 90 children over a period of 18 months from September 2018 to March 2020. Approval from Ethics committee was taken before commencing the study.

PRESS scoring was done at the time of admission and children were categorized into mild, moderate and severe respiratory distress. PRESS includes five components namely, respiratory rate, wheezing, accessory muscle use, SpO2, and feeding difficulties. Respiratory rate was evaluated based on the WHO guidelines.[4] Wheezing was defined by auscultation performed by experienced paediatricians. Accessory muscle use was defined as visible retraction of one or more of the supraclavicular /suprasternal, intercostal, and subcostal muscles. SpO2 was evaluated as above or below 95% at room air. 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).

Data was collected regarding requirement and duration of respiratory support [by means of nasal oxygen therapy, high flow nasal cannula (HFNC) and mechanical ventilation (MV)], duration of ICU stay, and duration of hospital stay. Children who were given nasal oxygen were weaned off to room air. Children who required HFNC were gradually weaned off to nasal oxygen and then to room air. Likewise children who required mechanical ventilator were weaned off to HFNC and followed by nasal oxygen and subsequently to room air.

Statistical analysis

Collected data was entered in MS excel spreadsheet. Statistical tests were applied as follows-

  1. Quantitative variables were compared using ANOVA / Kruskal wallis Test (when the data sets were not normally distributed.) between the severity.


  2. Qualitative variables were compared using Chi-Square test / Fisher’s exact test.


Analysis was done using Statistical package for social science (SPSS) version 21.0. A p value of <0.05 was considered statistically significant.


  Results Top


Demographic data of the study subjects revealed, the mean age of the children was 12.44 ± 14.83 months with a male preponderance with 59(65.56%) males and 31(34.44%) females. . Of the 90 children, 64 (71.11%) were admitted in PICU and 26 (28.99%) were admitted in ward.

Respiratory support in the form of mechanical ventilation was required in 2 (2.22%) children, HFNC was required in 31 (34.44%) children and nasal oxygen was required in 33 (36.66%) children. Total no of children requiring respiratory support (nasal oxygen/HFNC/MV) was 66 (73.33%) and 24 (26.67%) children did not receive respiratory support in any form.

Mean PRESS score of study subjects was 3.1 ± 0.74. PRESS score was moderate in 67 (74.44%) children and severe in 23(25.56%) children. Compared to moderate PRESS score, children with severe PRESS score had more significant requirement of respiratory support (Nasal oxygen/ HFNC/ MV) [43/67(64.18%) children vs 23/23(100%) children] with a P value of <0.0003 [Table 1].
Table 1: Association of course during hospital stay with severity of PRESS score

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Mean number of days of requirement of respiratory support was 2.64 ± 1.87. Mean number of days of requirement of HFNC support was in 1.22 ± 1.8. Mean number of days of hospital stay was i.e. 6.28 ± 3.02. Mean number of days of ICU stay was 3.06 ± 2.13 [Table 1].

Compared to moderate PRESS score, children with severe PRESS score had significantly more admission in PICU (91.30% vs 64.18%, P = 0.016); significantly more number of days of hospital stay (7 vs 5, P = 0.001); significantly more number of days of ICU stay (5 vs 3, P<.0001); significantly more median days of respiratory support (4 vs 3, P<.0001); significantly more use of HFNC (73.91% vs 20.90%, P<.0001) and comparable requirement of ventilator (8.70% vs 0%, P = 0.063) [Table 1] [Figure 1].
Figure 1: Association of PRESS score with course during hospital stay

Click here to view



  Discussion Top


In our study PRESS score was moderate and severe in 67(74.44%) and 23(25.56%) of study subjects respectively. Mild cases did not require admission and hence not included in the study. In the study by Miyaji et al, it was found that 49.0% participants were classified as mild, 34.7% as moderate, and 16.3% as severe PRESS scores.[6] In another study by Alexandrino et al, revealed that 37.3% of the children had a normal respiratory health condition, 62.7% had a moderate impairment of the respiratory health condition and there were no cases of severe impairment of the respiratory health condition as per PRESS scores.[8]

In our study, on comparing children with severe PRESS score and moderate PRESS score, there was a significant requirement of PICU admission (91.30% vs 64.18%) (P = 0.016). The findings were in line with the western studies.[9],[10],[11],[12],[13],[14],[15],[16],[17],[18] The PICU admission as indicated by the higher PRESS scores suggests utility value in triaging the children in ER. Also, future studies could look at ability of low PRESS to predict successful outpatient management, and ability of high PRESS to predict children in need of early aggressive inpatient care.

On comparing children with severe PRESS score and moderate PRESS score there was significantly more median days of respiratory support (4 vs 3, P<.0001); significantly more use of HFNC (73.91% vs 20.90%, P<.0001) and there was comparable requirement of ventilation. (8.7% vs 0%, P = 0.063). Our findings were in line with Miyaji et al, who reported that oxygen therapy was longer in severe cases compared with mild and moderate cases (3.7 ± 1.8 vs 0.2 ± 0.8 vs 1.5 ± 1.8).[6] This shows higher PRESS score denotes severe respiratory dysfunction thus requiring a prolonged respiratory support in the form of HFNC or oxygen therapy. The present study shows a significant utility value of HFNC as compared to mechanical ventilation.[19] This study probably reinforces the present trend towards non-invasive respiratory management.

As expected, we noted that as compared to children with moderate PRESS score, children with severe PRESS score had significantly more number of days of hospital stay (7 vs 5, P = 0.001); and significantly more number of days of ICU stay (5 vs 3, P<.0001). Similar results were reported by Miyaji et al, who found that the hospitalization rate was 32.3% in mild cases, 91.4% in moderate cases, and 97.0% in severe cases, with significant differences between the hospitalization rates of mild and moderate cases, and between mild and severe cases. Number of days of hospital stay was highest in those with severe PRESS score than mild and moderate PRESS score.[6] This study reinforces the utility value of PRESS score in determining the duration of ICU stay and Hospital stay.

Based on our results, we can assume that the PRESS score can help in triaging the children in ER and in deciding the zone of admission and the probable clinical course. These findings may have clinical implications and usefulness in research as it could be used to determine the severity of respiratory illness. This utility may be especially true in resource limited settings but it requires community level validation.

Limitations of our study

The patients enrolled were at a single academic institution that is a referral centre for numerous local hospitals. As such children who were included in the study were probably more sick than those at other hospitals and at the community level. So the PRESS score in this study is probably skewed in favour of severe cases. Another limitation was small sample size. To offset this aberration larger community level studies and multicentric studies with larger sample size may be needed to further validate the scoring system.


  Conclusion Top


PRESS score can be a useful respiratory scoring system in triaging the children at the time of admission and in predicting the requirement of respiratory support, zone of admission and duration of hospital stay. As it is a simple severity scoring system, healthcare providers at all levels of health care, especially in resource limited settings can apply it as a preliminary patient assessment tool for initial triaging and referral to an appropriate healthcare facility. As of now this score needs to be validated at the community level and if found good it may be applied more efficiently at the community level by health workers also. Early recognition, referral and treatment can save lives of many children. Further large scale studies can look at the ability of PRESS score in deciding the modality of respiratory support and utility value of mild PRESS score in predicting successful outpatient management.

Acknowledgement

None.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Donoghue AJ, Nadkarni V, Berg RA, Osmond MH, Wells G, Nesbitt L, et al; CanAm Pediatric Cardiac Arrest Investigators. Outof-hospital pediatric cardiac arrest: An epidemiologic review and assessment of current knowledge. Ann Emerg Med 2005;46:512-22.  Back to cited text no. 1
    
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Nadkarni VM, Larkin GL, Peberdy MA, Carey SM, Kaye W, Mancini ME, et al; National Registry of Cardiopulmonary Resuscitation Investigators. First documented rhythm and clinical outcome from in-hospital cardiac arrest among children and adults. JAMA 2006;295:50-7.  Back to cited text no. 3
    
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Villar J, Martínez D, Mosteiro F, Ambrós A, Añón JM, Ferrando C, et al; Stratification and Outcome of Acute Respiratory Distress Syndrome (STANDARDS) Network. Is overall mortality the right composite endpoint in clinical trials of acute respiratory distress syndrome? Crit Care Med 2018;46:892-9.  Back to cited text no. 4
    
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Miyaji Y, Sugai K, Kobayashi M, Niwa S, Tsukagoshi H, Kozawa K, et al. Paediatric Respiratory Severity Score (PRESS) for respiratory tract infections in children. Austin Virol Retrovirol 2015;2:1009.  Back to cited text no. 6
    
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Nayani K, Naeem R, Munir O, Naseer N, Feroze A, Brown N, et al. The clinical respiratory score predicts paediatric critical care disposition in children with respiratory distress presenting to the emergency department. Bmc Pediatr 2018;18:339.  Back to cited text no. 7
    
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Alexandrino AM, Santos RI, de Melo MC, Bastos JA, Postiaux G. Subjective and objective parameters in paediatric respiratory conditions: Cultural adaptation to Portuguese population. Fisioter Mov 2017;30:49-58.  Back to cited text no. 8
    
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Feldman AS, Hartert TV, Gebretsadik T, Carroll KN, Minton PA, Woodward KB, et al. Respiratory severity score separates upper versus lower respiratory tract infections and predicts measures of disease severity. Pediatr Allergy Immunol Pulmonol 2015;28:117-20.   Back to cited text no. 9
    
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Duarte-Dorado DM, Madero-Orostegui DS, RodriguezMartinez CE, Nino G. Validation of a scale to assess the severity of bronchiolitis in a population of hospitalized infants. J Asthma 2013;50:1056-61.  Back to cited text no. 10
    
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Thokngaen J, Karoonboonyanan W. Pediatric respiratory severity score evaluates disease severity of respiratory tract infection in children. Chula Med J 2019;63:43.  Back to cited text no. 12
    
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Ducharme FM, Chalut D, Plotnick L, Savdie C, Kudirka D, Zhang X, et al. The pediatric respiratory assessment measure : a valid clinical score for assessing acute asthma severity from toddlers to teenagers. J Pediatr 2008;152:476-80.  Back to cited text no. 13
    
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Gold DL, Mihalov LK, Cohen DM. Evaluating the Pediatric Early Warning Score (PEWS) system for admitted patients in the pediatric emergency department. Acad Emerg Med 2014;21:1249-56.  Back to cited text no. 14
    
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Destino L, Weisgerber MC, Soung P, Bakalarski D, Yan K, Rehborg R, et al. Validity of respiratory scores in bronchiolitis. Hosp Pediatr 2012;2:202-9.  Back to cited text no. 16
    
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Rodriguez H, Hartert TV, Gebretsadik T, et al. A simple respiratory severity score that may be used in evaluation of acute respiratory infection. BMC Res Notes 2016;9:85.  Back to cited text no. 18
    
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Cheng A, et al. Evaluating the Clinical Respiratory Score for Initiating High Flow Nasal Cannula in the Pediatric Emergency Department. Annals of Emergency Medicine 2018;72:S88-S89.  Back to cited text no. 19
    


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