Abstract

Introduction:

Young children are at high risk of respiratory infections. The severity of the disease is based on the assessment of signs and symptoms, although there is a lack of validated scales to the Portuguese population.

Objective:

The aim of this study was to accomplish the cultural adaptation and validation of the subjective and objective parameters in paediatric respiratory conditions, according to Postiaux.

Methods:

We ensured the cultural adaptation of the “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant”, created by Guy Postiaux. Then we analysed content, conceptual and construct validity, as well as test-retest reliability. The Portuguese version was applied in a sample of 59 children, with a mean age of 23.05 ± 8.34 months, 55.9% male.

Results:

We stablished semantics and construct validity and adopted the title “Paediatric Respiratory Severity Score” (PRSS). PRSS obtained a good internal consistency (α de Cronbach = 0.80) and an excellent intra-rater reliability (ICC = 0.91). Subjective parameters revealed a Cronbach’ α = 0.80 and an ICC = 0.90. Objective parameters obtained a Cronbach’ α = 0.73 and an ICC = 0.85. The application of PRSS to the sample showed that 37.3% of the children had a normal health condition (PRSS = 8) and 62.7% of the children had a moderate impairment of their health condition (9 ≤ PRSS ≤ 16).

Conclusion:

Paediatric Respiratory Severity Score is a valid and reliable measure to assess the severity of acute respiratory infections in children under 36 months of age.

Keywords:
Respiratory Tract Infections; Pediatrics; Health Promotion; Validation Studies

Resumo

Introdução:

As crianças pequenas são uma população de risco para infeções respiratórias, cuja severidade é estabelecida através da avaliação de sinais e sintomas. Há contudo poucas escalas validadas para a população portuguesa.

Objetivo:

O nosso objetivo foi realizar a adaptação cultural e validação dos parâmetros anamnésicos e semiológicos em condições respiratórias pediátricas, segundo Postiaux.

Métodos:

Procedemos à adaptação cultural de “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant”, criada por Guy Postiaux. Seguidamente avaliamos as equivalências semântica, de conteúdo, conceptual e de construção e a confiabilidade teste reteste. A escala foi posteriormente aplicada numa amostra de 59 crianças, com média de idades de 23,05 ± 8,34 meses, 55,9% do sexo masculino.

Resultados:

As equivalências semântica e de conteúdo foram verificadas, sendo atribuído o título de Escala de Severidade Respiratória Pediátrica (ESRP). Realizou-se ainda a equivalência de construção (α de Cronbach = 0,80) e a confiabilidade teste reteste (ICC = 0,91). A análise dos parâmetros anamnésicos revelou um α de Cronbach = 0,80 e um ICC = 0,90. A análise dos parâmetros semiológicos mostrou um α de Cronbach = 0,73 e um ICC = 0,85. A aplicação da ESRP à amostra revelou que 37,3% crianças apresentaram um índice de severidade normal (ESRP=8) e 62,71% um índice moderado (9 ≤ ESRP ≤ 16).

Conclusão:

A ESRP é uma medida válida e confiável para avaliação dos sinais e sintomas de infeção respiratória.

Palavras-chave:
Infecções Respiratórias; Pediatria; Promoção da Saúde; Estudos de Validação

Introduction

Acute respiratory infections (ARI) are the most frequent illness in children under 2 years of age ¹1. Chonmaitree T, Alvarez-Fernandez P, Jennings K, Trujillo R, Marom T, Loeffelholz MJ, et al. Symptomatic and asymptomatic respiratory viral infections in the first year of life: Association with acute otitis media development. Clin Infect Dis. 2014;60(1):1-9.^{) - (4}4. von Linstow ML, Holst KK, Larsen K, Koch A, Andersen PK, Høgh B. Acute respiratory symptoms and general illness during the first year of life: a population-based birth cohort study. Pediatr Pulmonol. 2008;43(6):584-93.. Parents make a considerable use of healthcare services to cope with ARI, thus becoming a burden for children and their families ¹1. Chonmaitree T, Alvarez-Fernandez P, Jennings K, Trujillo R, Marom T, Loeffelholz MJ, et al. Symptomatic and asymptomatic respiratory viral infections in the first year of life: Association with acute otitis media development. Clin Infect Dis. 2014;60(1):1-9.^{) - (4}4. von Linstow ML, Holst KK, Larsen K, Koch A, Andersen PK, Høgh B. Acute respiratory symptoms and general illness during the first year of life: a population-based birth cohort study. Pediatr Pulmonol. 2008;43(6):584-93.. Furthermore, ARI are the main cause of worldwide morbidity, leading to school and work absenteeism ⁵5. Stover CS, Litwin CM. The Epidemiology of Upper Respiratory Infections at a Tertiary Care Center: Prevalence, Seasonality, and Clinical Symptoms. J Respir Med. 2014;2014..

ARI are classified as Upper Respiratory Tract Infections (URTI) and Lower Respiratory Tract Infections (LRTI), depending on which part of the respiratory tract is most severely affected. URTI are very common in children, including initial signs and symptoms, such as, cough, rhinorrhoea, nasal obstruction and fever, however, about one third of these children develop LRTI, which generally have a more severe impact on children´s health. The severity of LRTI depends on the clinician’s interpretation of a constellation of clinical findings, for instance, increased difficult breathing and respiratory rate, paradoxical breathing, chest in drawing, nasal flaring or cyanosis ⁶6. Tregoning JS, Schwarze J. Respiratory viral infections in infants: causes, clinical symptoms, virology, and immunology. Clin Microbiol Rev. 2010;23(1):74-98.^{) - (8}8. Usen S, Weber M. Clinical signs of hypoxaemia in children with acute lower respiratory infection: indicators of oxygen therapy. Int J Tuberc Lung Dis. 2001;5(6):505-10..

There are some severity scores described in literature, such as, the Kristjansson Respiratory Score (KRS), the Wang Respiratory Score (WRS) and the Respiratory Distress Assessment Instrument (RDAI), which help the clinician to assess the severity of ARI ⁹9. Kristjánsson S, Lødrup Carlsen KC, Wennergren G, Strannegård IL, Carlsen KH. Nebulised racemic adrenaline in the treatment of acute bronchiolitis in infants and toddlers. Arch Dis Child. 1993;69(6):650-4.^{) - (11}11. Lowell DI, Lister G, von Koss H, McCarthy P. Wheezing in infants: the response to epinephrine. Pediatrics. 1987;79(6):939-45.. However, these scores are mainly focused in the presence of signs of respiratory distress, so they have a limited use in mild episodes of ARI.

Postiaux G et al. designed a classification system of the severity of ARI in children, including general signs and symptoms, besides the typical signs of respiratory distress, so, it may be applied to a wider range of ARI, including URTI ¹²12. Postiaux G, Bafico JF, Masengu R, Rahafe JM. Paramètres anamnestiques et cliniques utiles au suivi et à l'achévement de la toilette bronchopulmonaire du nourrisson et de l'enfant. Ann Kinésithér. 1991;18(3):117-24. French..

The aim of the present study was to ensure the cultural adaptation of the scale “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant”, according to Postiaux, as well as to analyse its construct validity and intra-rater reliability. This scale will allow an objective assessment of the signs of ARI in children, either in clinical settings, to monitoring the child’s health condition, as in community settings, such as day-care centres, which constitute an environment highly favourable for the transmission of common respiratory pathogens. Moreover, this instrument may be used as a standard assessment of the respiratory health condition of children, thereby facilitating the scientific investigation in paediatric respiratory physiotherapy.

Methods

Ethics

This study was part of a research project which obtained ethical approval from the Ethics Committee of Oporto University’s approval (Nº13/CEUP/2011). After Ethical approval the day-care centres’ administrators were contacted in order to give their formal consent, and then, the children´s caregivers were informed about the aims and procedures of the study, expressing their written formal consent according to the Declaration of Helsinki.

Cross-Cultural Adaptation

The first step was to cross-culturally adapt the “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant” to Portuguese population ¹²12. Postiaux G, Bafico JF, Masengu R, Rahafe JM. Paramètres anamnestiques et cliniques utiles au suivi et à l'achévement de la toilette bronchopulmonaire du nourrisson et de l'enfant. Ann Kinésithér. 1991;18(3):117-24. French.. This process followed international recommendations, including translation to Portuguese, back-translation to French, evaluation by an expert panel and pilot-testing the final version.

The content validity was achieved according to the Delphi’s method, which relied on the analysis of the pre-final Portuguese version by a panel of 3 physiotherapists with experience in the treatment of children with respiratory diseases. The construct validity was analysed against eight questions based on literature, which were related to each item of the scale ¹³13. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res. 2010;19(4):539-49..

Instrument

Postiaux G et al. created a severity score which summarizes the main subjective and objective parameters that are present in children with ARI, allowing to assess the severity of the respiratory impairment ¹²12. Postiaux G, Bafico JF, Masengu R, Rahafe JM. Paramètres anamnestiques et cliniques utiles au suivi et à l'achévement de la toilette bronchopulmonaire du nourrisson et de l'enfant. Ann Kinésithér. 1991;18(3):117-24. French.. The subjective parameters are obtained from a clinical interview to caregivers, who are asked to report the children’s symptoms from the past 24 hours. The objective parameters are obtained from a clinical assessment of the health professional. The evaluator must give a punctuation between 1 (normal) and 3 (severe) to each parameter, according to the severity of the health condition of the child. The final score is calculated as the sum of all the 8 parameters, varying from 8 to 24. The child’s health condition is considered to be Normal if the total score is 8, Moderate if the total score is between 9 and 16, and Severe if total score is between 17 and 24.

Procedures

After obtaining the formal consent from the author of the original scale, we started the cultural adaptation process according to the timeline presented in Figure 1.

1. Translation

In order to prepare the forward translation of the original scale, there were recruited two Portuguese professional translators, native speakers and fluent in French. Each of the translators independently produced a forward translation to Portuguese of the original scale. Then, both translators and the local project investigator agreed on a single reconciled Portuguese version. Afterwards, two French native bilingual translators were recruited to produce the backward translation to French. The backward version and the original version of the scale were compared among each other by a panel of experts, giving rise to a consensus version of the second Portuguese version of the scale “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant” ¹³13. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res. 2010;19(4):539-49.^{), (14}14. Acquadro C, Conway K, Hareendran A, Aaronson N. Literature Review of Methods to Translate Health-Related Quality of Life Questionnaires for Use in Multinational Clinical Trials. Value Health. 2008;11(3):509-21..

2. Content Validity

The content validity was achieved according to the Delphi’s method, which relied on the analysis of the pre-final Portuguese version by a panel of 3 physiotherapists with at least 5 years of experience in the treatment of children with respiratory diseases. They were given a comprehension test, besides the pre-final Portuguese version, in order to obtain a written analysis of all parameters, which allowed to identify and correct any errors introduced by the translation process ¹³13. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res. 2010;19(4):539-49.^{), (14}14. Acquadro C, Conway K, Hareendran A, Aaronson N. Literature Review of Methods to Translate Health-Related Quality of Life Questionnaires for Use in Multinational Clinical Trials. Value Health. 2008;11(3):509-21.. Then, the local project manager meet the 3 experts in order to discuss and correct any suggestions, given rise to the final Portuguese version of the scale “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant”.

3. Construct Validity

The construct validity is obtained when there is a relationship between 2 procedures that measure the same concept ¹³13. Mokkink LB, Terwee CB, Patrick DL, Alonso J, Stratford PW, Knol DL, et al. The COSMIN checklist for assessing the methodological quality of studies on measurement properties of health status measurement instruments: an international Delphi study. Qual Life Res. 2010;19(4):539-49.^{), (14}14. Acquadro C, Conway K, Hareendran A, Aaronson N. Literature Review of Methods to Translate Health-Related Quality of Life Questionnaires for Use in Multinational Clinical Trials. Value Health. 2008;11(3):509-21.. So, the final Portuguese version of the scale was delivered to the parents and physiotherapists of 5 children, along with the following eight questions based on literature, which were related to each item of the scale ¹⁵15. Marques M, Sotto-Mayor R. Tratado de Pneumologia. Lisboa: Permanyer Portugal; 2003. p. 1273-7. Portuguese..

- Subjective parameters

“In the past 24h did your child:

- Objective parameters

“In your clinical evaluation did the child:

4. Pilot-testing

a) Test-retest reliability

In order to perform the test-retest reliability we asked the 3 experts to assess and re-assess the respiratory condition of children, throughout 72h, using the final Portuguese version of the scale ¹⁴14. Acquadro C, Conway K, Hareendran A, Aaronson N. Literature Review of Methods to Translate Health-Related Quality of Life Questionnaires for Use in Multinational Clinical Trials. Value Health. 2008;11(3):509-21.. Additionally, in the second evaluation we asked parents if their child had any change in their respiratory condition. Those who answered yes were excluded from the test-retest analysis.

b) Patient-testing

The final Portuguese version of the scale was then applied to a different sample of children, obtained from two day-care centres of Porto. The subjective parameters were obtained by a clinical interview to children´s caregivers and the objective parameters were obtained by the clinical assessment of a blinded respiratory physiotherapist.

Statistics

All statistical analysis were carried out using IBM^® SPSS^® Statistics 20 (SPSS^® IBM Corporation, Route 100) for Windows 7^®, with a confidence interval of 95% (significance level of α = 0.05).

The Cronbach’s α was used to test the internal consistency of the parameters, using the Nunnally and Bernstein´s classification: : α ≥ 0,9 excellent; 0,7 ≤ α < 0,9 good; 0,6 ≤ α < 0,7 fair; 0,5 ≤ α < 0,6 poor; α < 0,5 unacceptable ¹⁶16. Terwee CB, Bot SDM, Boer MR, van der Windt D, Knol DL, Dekker J, et al. Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34-42.^{), (17}17. Nunnally JC, Bernstein IH. Psychometric theory. New York: McGraw-Hill; 1994.. The intraclass correlation coefficient (ICC) was used for test-retest reliability, according to Fleiss’ classification ¹⁷17. Nunnally JC, Bernstein IH. Psychometric theory. New York: McGraw-Hill; 1994.. Descriptive statistical methods were used to characterize the sample (means, standard deviations and relative frequencies) ¹⁸18. Maroco J. Análise Estatística Com Utilização do SPSS. 3rd ed. Lisboa: Edições Sílabo; 2010. Portuguese..

Results

1. Translation

The versions derived from the forward translation and backward translation were adequate, and did not require grammatical changes. At the end of the meeting we concluded that the Portuguese version of the scale “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant” did not present underlying or ambiguous concepts and it showed to be a simple, brief and understandable instrument.

2. Content Validity

The panel of experts has made some suggestions concerning the content’s analysis of the first Portuguese version of the scale. There were some remarks about the original title, since experts considered it too long. They suggested instead “Paediatric Respiratory Severity Score” (PRSS) (Escala de Severidade Respiratória Pediátrica).

The panel of experts also suggested to include the following instructions: “The purpose of this score is to assess the respiratory health condition of the child. Please fill in the “Subjective Parameters” according to the clinical interview to the child’s caregiver, and the “Objective Parameters” according to your clinical evaluation of the child.”

Experts also suggest to change the concept “pyrexia” by “fever”, since they considered it a more common word. Finally, the experts suggested to alter the order of the parameters, so all subjective parameters could appear before the objective parameters.

Still, the panel of experts considered that the scale was a simple and clear instrument, which may be easily used to assess the respiratory condition of a child.

The final Portuguese version of “Paediatric Respiratory Severity Score” is presented in Table 1.

3. Construct Validity

The PRSS was delivered to the parents and the physiotherapists of 5 children, along with eight questions related to each item of the scale. It was obtained a good internal consistency (Cronbach´s α = 0.80), as it can be seen in Table 2.

4. Pilot-testing:

a) Test-retest Reliability

From an initial sample of 35 children who attended a day-care centre in Porto, 22 children were excluded, so a final sample of 13 children between 10 and 28 moths was obtained. Children had a mean age of 18.69 ± 1.54 months and 53.8% were male. The results revealed an ICC = 0.91 (Table 3), meaning an excellent test-retest reliability ¹⁷17. Nunnally JC, Bernstein IH. Psychometric theory. New York: McGraw-Hill; 1994..

b) Patient-testing

From an initial sample of 72 children under 36 months of age, 13 were excluded because they missed the day-care in evaluation day or because parents did not give their consent, so, a final sample of 59 children was obtained.

The application of PRSS to the final sample revealed that 37.3% (n = 22) of the children had a normal respiratory health condition, and 62.7% (n = 37) had a moderate impairment of the respiratory health condition. There were no cases of severe impairment of the respiratory health condition.

Table 4 shows de frequency of children according to the score given to each parameter. Concerning the subjective parameters, most of the children presented: no cough (71.2%), normal appetite (96.6%), no fever (96.6%), and liquid rhinorrhoea (47.5%). Regarding objective parameters, none of the children presented dyspnoea and all children had normal lung sounds; most of the children presented no adventitious sounds (84.7%) and few secretions (78%).

Discussion

The purpose of this study was to analyse the psychometric characteristics of the scale “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant”. This scale can be used to assess the severity of the acute respiratory infections in children, even in the initial stages of the infection or in mild episodes of ARI, when there are no signs of respiratory distress.

The Pediatric Respiratory Severity Score (PRSS) showed to be a simple instrument, which may be used in a consistent way. According to Postiaux G et al, PRSS seems to be able to detect any changes in the respiratory health condition of a child, so it may be used to assess the effect of therapeutic interventions, such as respiratory physiotherapy techniques ¹²12. Postiaux G, Bafico JF, Masengu R, Rahafe JM. Paramètres anamnestiques et cliniques utiles au suivi et à l'achévement de la toilette bronchopulmonaire du nourrisson et de l'enfant. Ann Kinésithér. 1991;18(3):117-24. French..

In fact, there are very few instruments that can be used on infants and young children in order to evaluate the severity of mild episodes of ARI, such as most URTI. This limits the scientific research concerning cardiopulmonary diseases in children, therefore, most of the existing research concerns LRTI, namely bronchiolitis, and are conducted in hospital settings ¹⁹19. Castro-Rodriguez JA, Rodriguez-Martinez CE, Sossa-Briceño MP. Principal findings of systematic reviews for the management of acute bronchiolitis in children. Paediatr Respir Rev. 2015;16(4):267-75.. Even the existing scores of severity, such as Kristjansson Respiratory Score (KRS), Wang Respiratory Score (WRS), and Respiratory Distress Assessment Instrument (RDAI), are mainly used in children with bronchiolitis with signs of respiratory failure ⁹9. Kristjánsson S, Lødrup Carlsen KC, Wennergren G, Strannegård IL, Carlsen KH. Nebulised racemic adrenaline in the treatment of acute bronchiolitis in infants and toddlers. Arch Dis Child. 1993;69(6):650-4.^{), (20}20. Wang EE, Milner RA, Navas L, Maj H. Observer agreement for respiratory signs and oximetry in infants hospitalized with lower respiratory infections. Am Rev Respir Dis. 1992;145(1):106-9.. Nevertheless, these scores have good psychometric characteristics, being related to gold standard measures, such as O2 saturation, so, they are often used, either in the clinical assessment, as in scientific investigation in children ⁹9. Kristjánsson S, Lødrup Carlsen KC, Wennergren G, Strannegård IL, Carlsen KH. Nebulised racemic adrenaline in the treatment of acute bronchiolitis in infants and toddlers. Arch Dis Child. 1993;69(6):650-4.^{), (10}10. Wang EE, Law BJ, Stephens D, Langley JM, MacDonald NE, Robinson JL, et al. Study of interobserver reliability in clinical assessment of RSV lower respiratory illness: a Pediatric Investigators Collaborative Network for Infections in Canada (PICNIC) study. Pediatr Pulmonol. 1996;22(1):23-7.^{), (21}21. Chin HJ, Seng QB. Reliability and validity of the respiratory score in the assessment of acute bronchiolitis. Malays J Med Sci. 2004;11(2):34.^{), (22}22. Destino L, Weisgerber MC, Soung P, Bakalarski D, Yan K, Rehborg R, et al. Validity of respiratory scores in bronchiolitis. Hosp Pediatr. 2012;2(4):202-9.. However, as these scores evaluates the signs of respiratory distress, they cannot be used in mild cases of ARI or in community settings.

Therefore, Postiaux G et al. developed a severity score, which summarizes the main subjective and objective parameters that are observed in children with ARI, including early signs of ARI, such as cough, secretions or rhinorrhoea, allowing the assessment of the respiratory condition of the child, even in the absence of respiratory distress ¹²12. Postiaux G, Bafico JF, Masengu R, Rahafe JM. Paramètres anamnestiques et cliniques utiles au suivi et à l'achévement de la toilette bronchopulmonaire du nourrisson et de l'enfant. Ann Kinésithér. 1991;18(3):117-24. French..

This study showed that PRSS has good psychometric characteristics, namely, content validity, construct validity and test-retest reliability.

The subjective parameters revealed better values of test-retest reliability than the objective parameters, which enhances the importance of including caregivers in the clinical assessment of their child, since they presented excellent levels of consistency in their answers. This fact is not fully consensual in literature, since some authors stated that objective parameters are more reliable than subjective parameters, while other investigators reported a low consistency between observers regarding children’s assessment ²⁰20. Wang EE, Milner RA, Navas L, Maj H. Observer agreement for respiratory signs and oximetry in infants hospitalized with lower respiratory infections. Am Rev Respir Dis. 1992;145(1):106-9.^{), (21}21. Chin HJ, Seng QB. Reliability and validity of the respiratory score in the assessment of acute bronchiolitis. Malays J Med Sci. 2004;11(2):34..

The subjective parameters “nutrition” and “fever” obtained the best values of construct validity and reliability, which seems to be related to the characteristics of the sample, since children who are in day-care centres generally have a normal appetite and have no fever. In opposition, “rhinorrhoea” obtained the lowest value, which may be due to difficulties in its classification. In fact, there are many types of rhinorrhoea described in literature, concerning a multitude of characteristics, such as rheology, macroscopic features, or aetiology ²³23. Del Giudice AM, Barbara M, Russo GM, Matthews EF, Cassano M. Cell-mediated non-allergic rhinitis in children. Int J Pediatr Otorhinolaryngol. 2012;76(12):1741-5.^{), (24}24. Nathan RA. Intranasal steroids in the treatment of allergy-induced rhinorrhea. Clin Rev Allergy Immunol. 2011;41(1):89-101.. Furthermore, the question that was used along PRSS to assess the construct validity of the parameter “rhinorrhoea” could have been too imprecise, causing some dispersion in the caregivers’ answers.

Nevertheless, Tomé D et al. used in their study a preliminary version of PRSS, detecting a relationship between the score that was given to the parameter “rhinorrhoea” and the middle ear condition of children attending day-care centres, as well as a higher frequency of normal tympanograms in children classified as having no rhinorrhoea ²⁵25. Tome D, Alexandrino AS, Santos RI, Melo MC, Costa DA, Ferreira JP. Characterization of middle-ear condition of Oporto daycare children up-to 3 years-old: a cross sectional study. Int J Pediatr Otorhinolaryngol. 2014;78(12):2132-5.. Also Santos R et al. found better severity scores in children without nasal obstruction in comparison with children with nasal obstruction, when using a similar version of the PRSS ²⁶26. Santos R, Alexandrino A, Tomé D, Melo C, Montes A, Costa D, et al. Inter and intra-rater reliability of nasal auscultation in daycare children? Minerva Pediatr. 2015..

The results concerning the parameter “cough” also suggests some difficulties in its classification, either by caregivers as by experts. In fact, it seems that there is no consensus in literature regarding the semantics of cough, since the classification of cough may depend on its cause, duration, behaviour or characteristics ²⁷27. Chung KF, Bolser D, Davenport P, Fontana G, Morice A, Widdicombe J. Semantics and types of cough. Pulm Pharmacol Ther. 2009;22(2):139-42..

In what concerns the objective parameters, “dyspnoea” and “respiratory sounds” obtained the higher values of internal consistency, as well as test-retest reliability. This is due to the characteristics of our sample, since it was not probable that the children who are at the day-care centre have decreased lung sounds or dyspnoea.

Nevertheless, “adventitious respiratory sounds” and “secretions” showed the lowest values. In the first case, we believe that this was due to the diversity of terminologies used to classify the adventitious lung sounds ²⁸28. Postiaux G. Lung sounds nomenclature: towards a French consensus. Rev Mal Respir. 2009;26(1):93-4. French.. In fact, the Groupe d’Etude Pluridisciplinaire Stéthacoustique, has been evoking that is necessary to achieve an international consensus regarding the classification of the auscultatory findings ²⁸28. Postiaux G. Lung sounds nomenclature: towards a French consensus. Rev Mal Respir. 2009;26(1):93-4. French.^{), (29}29. Postiaux G, Lens E. Nomenclature stéthacoustique pulmonaire: pourquoi pas un consensus mondial? Rev Mal Respir. 1999;16(6):1075-90. French.. This is also a priority for the European Respiratory Society (ERS), who created the ERS Task Force on lung sounds, which includes experts from several countries, aiming the establishment of a consensus’ nomenclature for pulmonary auscultation ³⁰30. Melbye H, Garcia-Marcos L, Everard M, Priftis K, Brand P, Pasterkamp H. Wheezes, crackles, rhonchi: Agreement among members of the ERS task force on lung sounds. Eur Respir J. 2014;44(Suppl 58):P4004.. However, in a recent publication, the ERS reported that a poor to fair agreement (κ < 0.40) was usually found for the detailed descriptions of the adventitious sounds, whereas moderate to good agreement was reached for the combined categories of crackles (κ = 0.62) and wheezes (κ = 0.59) ³¹31. Melbye H, Garcia-Marcos L, Brand P, Everard M, Priftis K, Pasterkamp H. Wheezes, crackles and rhonchi: simplifying description of lung sounds increases the agreement on their classification: a study of 12 physicians' classification of lung sounds from video recordings. BMJ Open Respir Res. 2016;3(1):e000136.. Also the existing studies about pulmonary auscultation in children have reported a poor to fair reliability ³¹31. Melbye H, Garcia-Marcos L, Brand P, Everard M, Priftis K, Pasterkamp H. Wheezes, crackles and rhonchi: simplifying description of lung sounds increases the agreement on their classification: a study of 12 physicians' classification of lung sounds from video recordings. BMJ Open Respir Res. 2016;3(1):e000136.^{), (32}32. Elphick HE, Lancaster GA, Solis A, Majumdar A, Gupta R, Smyth RL. Validity and reliability of acoustic analysis of respiratory sounds in infants. Arch Dis Child. 2004;89(11):1059-63.. Other reasons may be related to these findings, such as the difficulty in performing the technique of pulmonary auscultation in children, since they have small thoraxes, high respiratory rates, irregular breathing patterns and sometimes crying is present ³³33. Postiaux G, Souza Pinto V, Vieira DR, Carvalho CM. Fisioterapia respiratória pediátrica: o tratamento guiado por ausculta pulmonar. Porto Alegre (Brazil): Artmed Editora; 2004. 302 p. Portuguese..

Furthermore, the low results concerning the parameter “secretions” may be related to difficulties in quantifying the secretions. It is known that children do not expel secretions to the exterior, instead they swallow it ³³33. Postiaux G, Souza Pinto V, Vieira DR, Carvalho CM. Fisioterapia respiratória pediátrica: o tratamento guiado por ausculta pulmonar. Porto Alegre (Brazil): Artmed Editora; 2004. 302 p. Portuguese.. So, it is not always possible to see the exact amount of secretions that is expelled from the respiratory tract.

Nonetheless, PRSS seems to be a reliable measure in order to assess the signs of ARI, even in initial stages or in mild episodes. The results concerning test-retest reliability are similar to the most used scores, that is, the Kristjansson Respiratory Score (ICC = 0.89) and the Wang Respiratory Score (ICC = 0.99), and superior to the results of the Respiratory Distress Assessment Instrument (RDAI) (ICC = 0.39) ²¹21. Chin HJ, Seng QB. Reliability and validity of the respiratory score in the assessment of acute bronchiolitis. Malays J Med Sci. 2004;11(2):34.^{), (22}22. Destino L, Weisgerber MC, Soung P, Bakalarski D, Yan K, Rehborg R, et al. Validity of respiratory scores in bronchiolitis. Hosp Pediatr. 2012;2(4):202-9..

Pilot-testing in a sample of children under 36 months attending day-care centres showed that most of the children presented a moderate impairment of the respiratory health condition (8 < PRSS ≤ 16), mainly due to the presence of rhinorrhoea and secretions. Several studies showed that children who attend day-care centres have an increased risk of ARI, due to the close contact among each other, thus increasing the viral transmission ²2. Nesti M, Goldbaum M. Infectious diseases and daycare and preschool education. J Pediatr. 2007;83(4):299-312.^{), (3}3. Chen Y, Williams E, Kirk M. Risk factors for acute respiratory infection in the Australian community. PLoS One. 2014;9(7):e101440.^{), (34}34. Azad K. Risk Factors for Acute Respiratory Infections (ARI) among children under five years in Bangladesh. J Sci Res. 2009;1(1):72-81.. Moreover, the data was collected in winter, so there was a high frequency of ARI due to seasonality ¹1. Chonmaitree T, Alvarez-Fernandez P, Jennings K, Trujillo R, Marom T, Loeffelholz MJ, et al. Symptomatic and asymptomatic respiratory viral infections in the first year of life: Association with acute otitis media development. Clin Infect Dis. 2014;60(1):1-9.^{), (35}35. Moody SA, Alper CM, Doyle WJ. Daily tympanometry in children during the cold season: association of otitis media with upper respiratory tract infections. Int J Pediatr Otorhinolaryngol. 1998;45(2):143-50..

The PRSS seems to have a good potential, not only to assess the effects of respiratory physiotherapy techniques, but also to be used in community settings in order to identify at-risk populations and thus providing early intervention measures. This is a fundamental step to develop health promotion programmes and to the prevention of ARI in children.

This study faced some limitations, that is, the inexistence of a Gold Standard measure, with which PRSS could be compared in order to analyse the criterion validity. Most of the studies about the validation of similar scores used O2 saturation as a Gold Standard measure. However, this would serve no purpose in less severe cases of ARI, since the O2 saturation is normal. Furthermore, the small sample size limits the external validity of these results.

Conclusion

The Portuguese version of “Paramètres anamnestiques et cliniques utiles au suivi et à l’achèvement de la toilette bronchopulmonaire du nourrisson et de l’enfant”, namely, Paediatric Respiratory Severity Score is a valid and reliable measure in order to assess the severity of acute respiratory infections in children under 36 months of age. So, it can be used to assess and monitoring the respiratory health condition of children, either in clinical as in research settings.

Acknowledgments

The authors thank all the caregivers and educators from day-care centres who have accepted to participate in this study. In particular, we thank Professor Inês Azevedo for her collaboration and incentive to the research and Daniel Costa for his support and total commitment during the early stages of the project. We also thank Professor Verônica Parreira for the availability and encouragement to start this investigation.

References

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