The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts


D. Montoto1

The Respiratory Assessment Score (RAS) has been used in the NICU at Saint Francis Hospital in Tulsa, Oklahoma since 1998. This scoring system is used as an aide to determine the severity of respiratory distress based on physical signs and symptoms. It is quick and easy for caregivers to perform, has no cost associated with it, and paints a fairly objective picture of the patient's clinical condition. Similar to the APGAR score, the RAS employs a point system for 5 different categories: respiratory rate, oxygen requirement, degree of retractions, quality of breath sounds, and presence of grunting. Each category can score 0, 1, or 2 points for a maximum of 10 points. Unlike the APGAR score, the sickest patients are those that score the highest. Because of the grunting category, the RAS is designed for infants who are not intubated.
In 1970 Dr. John J. Downes et al published the paper "New Clinical Scoring System (RDS score) with Acid-Base and Blood Gas Correlations", (Clinical Pediatrics, June 1970). This study used the RDS score to develop a prognosis for infants in respiratory distress. The Respiratory Assessment Score used in our institution is a modern adaptation of this RDS Score.
The NICU Transport Team from The Children's Hospital at Saint Francis is comprised of specially trained neonatal nurses and neonatal respiratory therapists. Because the physician is not at the referral hospital with the team, the RAS is used to relate the respiratory condition of the patient and to determine the need for intubation. The Respiratory Assessment Score, along with blood gases and CXR interpretation will determine what intervention needs to take place. The following is a list of indications for intubation on transport:

PaCO2 > 55 with pH < 7.25;
PaCO2 > 50 with RAS > 6;
PaO2 < 50 on 60% O2 with RAS > 6;
SpO2 < 90 on 60% O2 with RAS > 6;
Patient's gestational age < 28 weeks;
Apnea requiring repeated stimulation or bag/mask ventilation.

If the RAS does not quite meet the criteria for intubation, nasal CPAP is another treatment option. In a retrospective study of the intubation protocol, we looked at what percentage of infants required intubation during their hospital stay because of respiratory distress. It was found that 8.7% of patients with a score of 6 or less during transport required intubation for respiratory distress at some point during their hospital stay while 84.6% of patients with a score of greater than 6 required intubation.

Respiratory Assessment Score for Newborns
  0 1 2
Respiratory Rate <60 60 - 80 > 80 or apnea
O2 Requirement* 21 - 30% 30 - 40% > 40%
Retractions None Mild Moderate to Severe
Breath Sounds Clear, good aeration bilaterally Coarse with good aeration or slight wheezing Decreased, tight or diminished
Presence of Grunting None Occasional Constant

*O2 Requirement to maintain SpO2 > 89%