Assessment of severity of respiratory conditions

Key points

• Children with respiratory distress should generally have minimal handling.
• Severity can mostly be assessed without touching the child; parents can be asked to uncover the chest and abdomen.
• Careful observation is important, because oxygen saturations may be misleading.
• Severity is graded as mild, moderate, severe or life-threatening using behaviour, colour, respiratory rate, work of breathing, oxygenation, heart rate and blood pressure.
• Any child with severe respiratory distress should be discussed with a senior clinician.

Overview

This Royal Children's Hospital Melbourne guideline provides a structured way to grade the severity of respiratory conditions in children. It relies mainly on careful observation rather than monitors, and management of individual conditions such as asthma, bronchiolitis, croup or pneumonia is covered in their own guidelines.

Grading severity

In mild illness, behaviour and colour are normal, the child can vocalise normally, respiratory rate and heart rate are normal or slightly increased, and work of breathing is absent or minimal. Moderate illness shows intermittent irritability, reduced activity, some limitation of vocalising, pallor, increased respiratory rate, moderate work of breathing and mildly increased heart rate. Severe illness shows increasing irritability or lethargy, speech limited to single words, pallor or cyanosis, marked work of breathing, significantly increased heart rate or bradycardia, and SpO2 below 90% in room air; any oxygen requirement in croup is classed as severe. Life-threatening illness shows drowsiness or unconsciousness, inability to vocalise, cyanosis, markedly increased respiratory rate or bradypnoea or apnoea, severe accessory muscle use or poor respiratory effort, arrhythmia or bradycardia, and hypotension. Blood pressure should not be measured in croup.

Work of breathing and other considerations

Signs of increased work of breathing include intercostal, suprasternal and costal margin retractions, accessory muscle use such as nasal flaring, head bobbing and forward posturing, and grunting. Fever may increase respiratory and heart rates. Wheeze, stridor and especially reduced air entry help in assessment. Feeding and hydration should also be assessed, as they may be affected early. Effortless tachypnoea may reflect compensation for metabolic acidosis, for example in sepsis or diabetic ketoacidosis.

Frequently asked questions

Is pulse oximetry enough to judge severity?

No. Oxygenation is of limited use in many paediatric respiratory conditions; the guideline advises looking at the other signs rather than focusing on the monitor.

When should the child be transferred?

When management is beyond the capability of the local health care facility.

Source

The Royal Children's Hospital Melbourne. Clinical Practice Guidelines: Assessment of severity of respiratory conditions. Last updated September 2024. Endorsed by the Paediatric Improvement Collaborative (PIC). This summary was prepared by Medpresso from the original guideline and is not a substitute for the full text or for medical advice.