Paediatric Respiratory Assessment Measure (PRAM)

The Paediatric Respiratory Assessment Measure (PRAM) is a validated 12-point clinical tool to reliably assess the severity of respiratory distress and the response to treatment in children aged 2 to 17 years with acute asthma. It shows promising results for use in children under 2 years of age, including those with bronchiolitis.

To standardise the assessment of asthma severity in children with acute respiratory distress by health care professionals to facilitate the implementation of acute care asthma guidelines.

This tool was initially developed for use in 145 preschoolers aged 3 to 6 years, using respiratory resistance measured by forced oscillation as the gold standard lung function test. Using a test group, we identified a total of 19 potential signs of airway obstruction including, respiratory and heart rates, speech impairment, pulsus paradoxus, accessory muscle use, auscultation findings, and oxygen saturation. In the multivariate regression, five variables were retained. The weight of each of these variables in the final score corresponds to the standardised beta coefficient in the multivariate model. The tool was called the Preschool Respiratory Assessment Measure.

This score underwent two validations. The first one in the validation group of 72 children aged 3 to 6 years where its ability to discriminate across severity and to identify change in status (improvement or deterioration) as compared to respiratory resistance was confirmed.¹

In 2008, we published the validation of this score in a larger group of 782 children aged 2 to 17 years, where the PRAM score at triage correlated significantly with the risk of hospital admission; we showed good internal consistency, inter-rater reliability, and responsiveness to change.² Using the same acronym (PRAM), the name was changed to Paediatric Respiratory Assessment Measure.

Briefly, the PRAM is a 12-point weighted score (best=0; worst=12) rating suprasternal retractions (0 to 2), scalene muscle contraction (0 to 2), air entry (0 to 3), wheezing (0 to 3) and oxygen saturation (0 to 2).

Scores of 1 to 3, 4 to 7, and 9 to 12 are indicative of mild, moderate, and severe exacerbations, respectively. 2 A change of 3 points or more is indicative of a clinically important change.

The PRAM is currently used for assessing asthma severity and response to treatment in the following emergency department settings:

• Montreal Children’s Hospital
  • Contact person: Dominic Chalut, MD. :
    dominic.chalut@muhc.mcgill.ca
• Children’s Hospital of Eastern Ontario
  • Contact Person: Roger Zemek, M.D. :
    RZemek@cheo.on.ca
• Calgary Health Care Region
  • Contact Person: David Johnson, M.D. :
    david.johnson@albertahealthservices.ca
• Ontario Emergency Departments, sponsored by the Ontario Lung Association and the Ministry of Health and Long-term Care;
  • Contact person: Mona Jabbour, M.D.:
    Jabbour@cheo.on.ca
• Our Lady’s Children’s Hospital, Crumlin, Ireland
  • contact person: John Cronin, M.D.:
    croninjj@gmail.com
• And many others.

The PRAM has been used as a research instrument to assess the severity and response to treatment in several randomised controlled trials. ³

• Canadian French
• Canadian English

1. Chalut DS, Ducharme FM, Davis GM. The preschool respiratory assessment measure (PRAM): a responsive index of acute asthma severity. J Pediatr 2000;137(6):762-8. http://www.ncbi.nlm.nih.gov/pubmed/11113831
2. Ducharme FM, Chalut D, Plotnick L et al. The Pediatric Respiratory Assessment Measure: a valid clinical score for assessing acute asthma severity from toddlers to teenagers. J Pediatr. 2008;152(4):476-80, 480. http://www.ncbi.nlm.nih.gov/pubmed/18346499
3. Panickar J, Lakhanpaul M, Lambert PC, et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med 2009;360:329-338. http://www.ncbi.nlm.nih.gov/pubmed/19164186
4. Cronin J, Kennedy U, McCoy S, an Fhailí S, Crispino-O’Connell G, Hayden J, Wakai A, Walsh S, O’Sullivan R. Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial. Trials 2012 ; 13:1;141. http://www.trialsjournal.com/content/13/1/141
5. Schuh S et al. Use of montelukast to treat children with mild to moderate acute asthma: NCT00213252. http://clinicaltrials.gov/ct2/show/NCT00213252
6. Schuh S. et a. Efficacy and Safety of Increasing Doses of Inhaled Albuterol Administered by Metered Dose Inhalers in Children With Acute Wheezing Episodes. NCT01323010.
7. Schuh S et al. Inhaled Magnesium in Refractory Pediatric Acute Asthma. NCT01429415. http://clinicaltrials.gov/ct2/show/study/NCT01429415
8. Mauger D. Treatment of preschool children with upper respiratory tract illnesses using azythromycin and lower respiratory tract symptoms using oral corticosteroids. (APRIL - OCELOT) NCT01272635. http://clinicaltrials.gov/ct2/show/NCT01272635
9. Ducharme et al. Determinants Of Oral corticosteroid Responsiveness in Wheezing Asthmatic Youth (DOORWAY).