Assess | Score 0 | Score 1 | Score 2 |
---|---|---|---|
Respiratory Rate | Age 1–5 years: < 30 Age > 5 years: < 20 | Age 1–5 years: 30–40 Age > 5 years: 20–30 | Age 1–5 years: > 40 Age > 5 years: > 30 |
Auscultation | Good air movement, Expiratory scattered wheezing or loose rales/crackles | Depressed air movement, inspiratory and expiratory wheezes or rales/crackles | Diminished or absent breath sounds, severe wheezing or rales/crackles or marked prolonged expiration |
Use of Accessory Muscles | Mild to no use of accessory muscles. Mild to no retractions or nasal flaring on inspiration | Moderate intercostal retractions, mild to moderate use of accessory muscles, nasal flaring. | Severe intercostal and substernal retractions, nasal flaring |
Mental Status | Normal to Mildly irritable | Irritable, agitated, restless | Lethargic |
Room Air Sp02 | > 95% | 90–95% | < 90% |
Color | Normal | Pale to normal | Cyanotic, dusky |