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Updated: Feb 3, 2026
Breath Collection from Children for Disease Biomarker Discovery
Published on: February 14, 2019
Derivation and Validation of an Objective Effort of Breathing Score in Critically Ill Children
Steven L Shein1, Justin Hotz2, Robinder G Khemani2,3
1Division of Pediatric Critical Care Medicine, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, OH.
Insights
A new scoring system accurately predicts a child's breathing effort after extubation. This tool, developed by a multidisciplinary team, aids in identifying patients needing advanced respiratory support.
Area of Science:
- Pediatric critical care medicine
- Respiratory physiology
- Clinical score development
Background:
- Assessing a child's effort of breathing post-extubation is crucial for timely intervention.
- Objective measurements of respiratory effort can be complex and invasive.
Purpose of the Study:
- To derive and validate a clinical score correlating with objective measurements of a child's breathing effort.
- To identify key clinical signs indicative of increased respiratory work.
Main Methods:
- Secondary analysis of an observational study involving 409 pediatric patients undergoing extubation.
- Effort of breathing measured via esophageal manometry (pressure rate product) and a validated clinical assessment tool.
- A multivariate model identified significant predictors, forming the basis for the Effort of Breathing score, derived and validated on separate cohorts.
Main Results:
- The derived Effort of Breathing score demonstrated acceptable performance in predicting elevated pressure rate product (AUC 0.8359 derivation, 0.7930 validation).
- The score also showed utility in predicting the need for reintubation (AUC 0.7548 for team-based assessment).
- Key components included retractions, stridor, and pulsus paradoxus, with results consistent across provider disciplines.
Conclusions:
- A novel, validated scoring system effectively predicts increased breathing effort and the potential need for advanced respiratory support in pediatric patients post-extubation.
- The score performs best when utilized by a multidisciplinary clinical team.
- This tool offers a practical approach to respiratory assessment in critically ill children.
Objectives:
To derive and validate a score that correlates with an objective measurement of a child's effort of breathing.
Design:
Secondary analysis of a previously conducted observational study.
Setting:
The pediatric and cardiothoracic ICUs of a quaternary-care children's hospital.
Patients:
Patients more than 37 weeks gestational age to age 18 years who were undergoing extubation.
Interventions:
Effort of breathing was measured in patients following extubation using esophageal manometry to calculate pressure rate product. Simultaneously, members of a multidisciplinary team (nurse, physician, and respiratory therapist) assessed respiratory function using a previously validated tool. Elements of the tool that were significantly associated with pressure rate product in univariate analysis were identified and included in a multivariate model. An Effort of Breathing score was derived from the results of the model using data from half of the subjects (derivation cohort) and then validated using data from the remaining subjects (validation cohort) by calculating the area under the receiver operator characteristic curve for pressure rate product greater than 90th percentile and for the need for reintubation.
Measurements And Main Results:
Among 409 subjects, the median age was 5 months, and nearly half were cardiac surgery patients (49.1%). Retractions, stridor, and pulsus paradoxus were included in the Simple Score. Area under the receiver operator characteristic curve for pressure rate product greater than 90th percentile was 0.8359 (95% CI, 0.7996-0.8722) in the derivation cohort and 0.7930 (0.7524-0.8337) in the validation cohort. Area under the receiver operator characteristic curve for reintubation was 0.7280 (0.6807-0.7752) when all scores were analyzed individually and was 0.7548 (0.6644-0.8452) if scores from three clinicians from different disciplines were summated. Results were similar regardless of provider discipline or training.
Conclusions:
A scoring system was derived and validated, performed acceptably to predict increased effort of breathing or need for advanced respiratory support and may function best when used by a team.
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