Pediatric Pulmonology

Severity Scoring Systems: Are They Internally Valid,

Reliable and Predictive of Oxygen Use in Children With
Acute Bronchiolitis?
Gabrielle B. McCallum, MPH,1* Peter S. Morris, PhD,1,2 Clare C. Wilson, MPH,1
Lesley A. Versteegh, ENurs,1 Linda M. Ward, M. Med. Sci.(Clin.Epi),1
Mark D. Chatfield, MA, Msc,1 and Anne B. Chang, PhD1,3,4
Summary. Background: Severity scores are commonly used in research and clinically to as-
sess the severity of bronchiolitis. However, there are limitations as few have been validated.
The aim of our study was to: (i) determine the validity and reliability of a bronchiolitis scoring
system, and (ii) examine if the score predicted the need for oxygen at 12 and 24 hrs. Children
aged <24 months presenting to Royal Darwin Hospital with a clinical diagnosis of bronchiolitis
were eligible to participate. Study Design: We reviewed published papers that used a bronchi-
olitis score and summarized the data in a table. We chose the Tal score that was easy to use
and encompassed clinically important parameters. Three research nurses, trained to assess
children, used two scoring systems (Tal and Modified-Tal; respiratory rate, accessory muscle
use, wheezing, cyanosis, and oxygen saturation), blindly evaluated children within 15 min of
each other. Results: The children’s (n ¼ 115) median age was 5.4 months (IQR 2.9, 10.4);
65% were male and 64% were Indigenous. Internal consistency was excellent (Tal: Cronbach
a ¼ 0.66; Modified-Tal: a ¼ 0.70). There was substantial inter-rater agreement; weighted kap-
pa of 0.72 (95% CI: 0.63, 0.83) for Tal and 0.70 (95% CI: 0.63, 0.76) for Modified-Tal. For
predicting requirement for oxygen at 12 and 24 hrs; area under receiver operating curve
(aROC) was 0.69 (95% CI: 0.13, 1.0) and 0.75 (95% CI: 0.34, 1.0), respectively. Conclusion:
The Tal and Modified-Tal scoring systems for bronchiolitis is repeatable and can reliably be
used in research and clinical practice. Its utility for prediction of O2 requirement is limited.
Pediatr Pulmonol. ß 2012 Wiley Periodicals, Inc.

Key words: bronchiolitis severity scoring; respiratory distress assessment instrument;

RDAI.

Funding source: NHMRC, Numbers: 605809, 545216.

INTRODUCTION criteria for hospitalization of a child with bronchiolitis

are the need for oxygen or fluid management. Like
Worldwide, bronchiolitis is the most common severe Alaskan Native infants,2 Indigenous Northern Territory
acute lower respiratory tract infection.1 The usual (NT) infants have very high hospitalization rates of

1
Child Health Division, Menzies School of Health Research, Charles
Darwin University, Darwin, Northern Territory, Australia.
2
Department of Paediatrics, Royal Darwin Hospital, Darwin, Northern
Territory, Australia.
3
Queensland Children’s Respiratory Centre, Royal Children’s Hospital,
Brisbane, Queensland, Australia.
4
Queensland Children’s Respiratory Centre, Queensland’s Medical Re-
search Institute, Royal Children’s Hospital, Brisbane, Queensland, Australia.
The authors declare that they have no financial competing interests.
The results of this study were presented as a poster at the Thoracic
Society of Australia and New Zealand (TSANZ) in Canberra, Australia
(April 2012).
G.M. set up and coordinated the study, performed the data analysis and
drafted the manuscript. A.C. conceptualized the study, interpreted the data
and edited the manuscript. P.M. assisted in data interpretation and contrib-
uted to the manuscript. M.C. and L.W. assisted in the data analysis and
edited the manuscript. L.V. and C.W. participated in recruiting participants
and edited the manuscript. All authors read and approved the manuscript.
*Correspondence to: Gabrielle B. McCallum, MPH, Menzies School of
Health Research, PO Box 41096, Casuarina, Darwin, NT 0811, Australia.
E-mail: gabrielle.mccallum@menzies.edu.au
Received 30 April 2012; Accepted 30 May 2012.
DOI 10.1002/ppul.22627
Published online in Wiley Online Library
(wileyonlinelibrary.com).

ß 2012 Wiley Periodicals, Inc.

2 McCallum et al.
bronchiolitis (352 per 1,000) and the majority are
retrieved from remote communities.3 In these settings,
there are often no resident medical practitioners and
nurses are the acute care providers. Availability of a
scoring system for bronchiolitis that is valid when
used by different providers, as suggested by Liu et al.4
would be beneficial as acute assessment of the
severity of bronchiolitis will contribute to good clinical
management.
Standardization of severity scoring is also important
for clinical research purposes. A number of clinical
scoring systems, some with modifications, have been
used in the many research studies on bronchiolitis5
(Table 1). Despite their widespread use, many of these
scoring systems have limited validity when systemati-
cally evaluated and often were modified to suit individ-
ual research outcomes (Table 1 and table in Gajdos
et al5). These scoring systems have different levels of
complexity (such as auscultation in ‘‘segmental lobes’’
and distinction of wheeze through parts of inspiratory
and expiratory phases), clinical parameters (e.g. the
widely used Lowell score6 does not take into account
SpO2 or cyanosis) and varying degrees of validation
(many were not validated), thus making it difficult to
evaluate across clinical research studies. Not surprising-
ly, the Scottish Intercollegiate Guidelines Network
(SIGN) bronchiolitis guideline stated ‘‘No good quality
evidence on the use of formal clinical scoring systems
in infants with acute bronchiolitis was identified.’’7
Gadjos et al.5 reviewed available bronchiolitis scor-
ing systems and validated a system that encompassed
three parameters (respiratory rate (RR), wheeze, and
retractions). However their validation, like many other
scoring systems, consisted only of inter-rater agree-
ment. At face value, the scoring system devised by
Bierman et al. for asthma and modified by Tal et al.8
for bronchiolitis that included a 4th clinical parameter
(cyanosis) is the most clinically appropriate and most
user-friendly. The known poor agreement of absence/
presence of wheeze (kappa 0.29),9 and other clinical
signs on auscultation among general practitioners exam-
ining young children (kappa of 0.12–0.39),10 means
that a complex system that incorporates detection of
wheeze at various parts of the inspiration/expiratory
ABBREVIATIONS:
aROC Area under receiver operating curve
ED Emergency department
NT Northern Territory
RACS Respiratory assessment change in score
RDAI Respiratory distress assessment instrument
RDH Royal Darwin Hospital
SpO2 Oxygen saturation measured on a pulse oximeter
K Kappa
Pediatric Pulmonology
phases at ‘‘segmental lobes’’ is unlikely to be repeat-
able outside of a specialist setting. The validation of
various scoring systems8 (see Table 1) only looked at
inter-rater agreement (some between doctors only). To
date, none of the scoring systems has been used to pre-
dict oxygen requirement; examined the other compo-
nents of validation of a scale to the level described by
Ducharme et al.11 for asthma; or been applied to differ-
ent populations and settings. Indeed, the lack of reliable
clinical tools to evaluate disease severity in clinical
practice is evident. Measurement of infant lung function
is limited to research laboratories.
The aim of this study was to determine if a bronchi-
olitis scoring system (Tal et al.8 and its modification)
undertaken by trained nurses is valid (inter-rater reli-
ability and internal consistency) and a useful predictor
of disease severity (need for supplementary oxygen at
12 and 24 hr post assessment).
METHODS
Study Design
A prospective cohort study of children presenting to
Royal Darwin Hospital (RDH) with a clinical diagnosis
of bronchiolitis were recruited from October 2010 to
December 2011. Informed consent was obtained from
parents or legal guardians and the study was approved
by our institution’s Human Research Ethics Committee.
Three study nurses visited the paediatric ward and
emergency department twice daily to assess eligible
children. Children were eligible to be enrolled if they
were aged <24 months and presented to RDH where a
clinical diagnosis of bronchiolitis was made by the
admitting medical team. Children were excluded if they
were known to have another reason for respiratory
distress, for example, chronic lung disease or bronchi-
ectasis, gastroenteritis, liver function impairment, and
congenital heart disease.
Clinical Assessment
Standardized data forms were used to collect demo-
graphic, medical history and clinical information from
each child. Two scoring systems were completed inde-
pendently, that is, blinded to the other assessment by a
pair of ‘‘raters’’ who were study nurses (G.M. with L.V.
or G.M. with C.W.). Two nurses were experienced
while the other was junior. Children were assessed in a
calm state (i.e., no <5 minutes after a procedure or
breast feeding). Training in the use of the scoring sys-
tems included an education training session along with
a written protocol.
Four specific respiratory components as described by
Tal et al8 (RR, accessory muscle use, degree of wheez-
ing, and cyanosis) were collected. We further modified
 Validated Severity Tools for Bronchiolitis 3
6
TABLE 1— Lowell et al. Score and Papers That Used This Score

Authors Components of score How validated How were scores reported?

6
Lowell et al. scores
Lowell et al.6 Composite score 0–17 Inter rater agreement Wheezing: K ¼ 0.9
Wheezing (0–8) Respiratory retractions: K ¼ 0.64
Respiratory retractions (0–9)
Schuh et al.23 Lowell et al. None Mean RDAI score
Corneli et al.24 Lowell et al. None Change in RACS
Kuyucu et al.25 Lowell et al. None Mean RDAI score
De Brasi et al. Lowell et al. None Mean RDAI score
Modified scores of Lowell et al.6 and papers that used this score
Mesquita et al.26 Lowell et al. None Mean RDAI score
Bar et al.27 Lowell et al. None Mean RDAI score
Abul-Ainine et al.28 Lowell et al. None Mean RDAI score
Klassen et al.29 Lowell et al. Inter rater agreement Overall kappa for RDAI
score 0.93 (95% CI: 0.89–0.97)
Tal et al.8 scores
Tal et al.8 Composite score (0–12) None Mean score
Wheezing (0–3)
Respiratory retractions (0–3)
Cyanosis (0–3)
Respiratory rate (0–3)
De Boeck et al.30 Tal et al. None Mean score
van Woensel et al.31 Tal et al. None Mean score
Berger et al.32 Tal et al. None Mean score
Bierman et al.18 Tal et al. None Mean score
Modified scores of Tal et al.8 and papers that used this score
Vieira et al.33 Tal et al. None Mean score
Wang et al.14 scores (bronchiolitis and pneumonia)
Wang et al.14 Composite score (0–12) Inter rater agreement Respiratory rate K ¼ 0.38,
Wheezing: K ¼ 0.31
Respiratory rate (0–3) Respiratory retractions: K ¼ 0.21
Wheeze (0–3)
Respiratory retractions (0–3)
General condition (0–3)
Postiaux et al.34 Wang et al. None Mean score
Modified scores of Wang et al.14 and papers that used this score
Beck et al.35 Wang et al. None Mean score
Other scores used
Walsh et al.20 Severity model (score not described) Inter rater agreement Wheezing: K ¼ .0.189
Respiratory retractions: K ¼ 0.304
Liu et al.4 Validated composite score (0–12) Inter rater agreement Respiratory rate: K ¼ 0.34
Age related respiratory rate (0–3) Respiratory retractions: K ¼ 0.39
Wheezing: K ¼ 0.43
Respiratory retractions (0–3) Dyspnoea: K ¼ 0.43
Wheezing (0–3)
Dyspnoea (0–3)
Kristjansson et al.15 Composite score (0–10; respiratory rate, None Mean score
respiratory retractions, cyanosis,
and wheeze general condition)

NB: Published clinical scores in the literature. Note that only scores where components were described and we could access the papers have
been included (including adaption from Gadjos paper).

this system to replace cyanosis with SpO2 (termed mod-
ified-Tal score, Table 2). Each component scored
between 0 and 3, providing a composite score of 0–12.
The components used were defined to ensure standardi-
zation between staff. Wheezing was defined as a high
pitched whistling sound assessed by listening to all
lung fields with a Littman’s II stethoscope. Cyanosis
was assessed by observing the child throughout the
clinical assessment. RR was counted over 60 seconds.
Accessory muscle use and SpO2 (oxygen saturation
measured on pulse oximetry using Philips SureSigns
VM8) were documented after observing the child for
60 seconds after oxygen had been turned off (if applica-
ble). Both assessors reviewed SpO2 at the same time, to
Pediatric Pulmonology
4 McCallum et al.
TABLE 2— Tal and Modified-Tal Scoring Systems

Tal scoring system

Respiratory rate
Score (breaths/min) Wheeze Cyanosis Accessory respiratory muscle utilization

0 <30 None None None (no chest in-drawing, i.e., absence of

1 30–45 Terminal expiration only
2 46–60 Entire expiration and inspiration
with stethoscope only
3 >60 Entire expiration and inspiration
without stethoscope only
lower part of the chest moves in or retracts
when inhalation occurs)
Peri-oral on crying only þ
presence of mild intercostal in-drawing (just
visible), no head bobbing or tracheal tug
Perioral in rest þþ
moderate amount of intercostal in-drawing, no
head bobbing or tracheal tug
Generalized in rest þþþ
moderate or marked intercostal in-drawing
with presence of head bobbing or tracheal tug

Modified-Tal scoring system

Respiratory rate
Score (breaths/min) Wheeze SpO2 Accessory respiratory muscle utilization

0 <30 None >95 None (no chest in-drawing, i.e., absence of

lower part of the chest moves in or retracts
when inhalation occurs)
1 30–45 Terminal expiration only 94–95 þ
presence of mild intercostal in-drawing (just
visible), no head bobbing or tracheal tug
2 46–60 Entire expiration and inspiration 90–93 þþ
with stethoscope only moderate amount of intercostal in-drawing, no
head bobbing or tracheal tug
3 >60 Entire expiration and inspiration <89 þþþ
without stethoscope only moderate or marked intercostal in-drawing
with presence of head bobbing or tracheal tug

reduce the amount of time the child was off oxygen.
If the child’s SpO2 fell below the cut off of <89%
SpO2, oxygen was immediately recommenced and a
score of 3 was assigned (both remained blinded to the
other score). All assessments were completed within
15 minutes of each other with no change in medical
treatment between assessments, reducing the chance of
a clinical change in the child.
Statistical Methods
Data were entered on an Access database and
analyzed using Stata version 11 (Stata Corp., College
Station, TX). As data were not normally distributed;
non-parametric measures were used. Participant charac-
teristics are presented as median and interquartile range
(IQR: 25–75% and/or range).
We examined the internal consistency of each scoring
system, to establish how individual components contrib-
uted to the overall score using Cronbach a coefficient.
A score of >0.6 was regarded as good internal consis-
tency. Reliability was defined in terms of good inter-
Pediatric Pulmonology
rater agreement using weighted kappa (K), with
descriptors described by Landis and Koch.12 Values of
>0.6 was considered substantial and >0.8 almost per-
fect. For weighted overall kappa, the most experienced
nurse’s (GM) score was used as the gold standard to
calculate weighted kappa using bootstrapping, and
confidence intervals (95% CI). To determine whether
the baseline score predicted the need for oxygen at 12
or 24 hr, we calculated the area under the receiver oper-
ator curve (aROC). An aROC of
0.75 was chosen to
be clinically relevant.13
RESULTS
Of 138 eligible children, 23 families (17%) declined
participation. The median age of the 115 children en-
rolled was 5.4 months (IQR: 2.9–10.4) with 75 (65%)
boys. More than two thirds of the study cohort 87/115
(76%) were Indigenous and 74 (64%) lived in remote
Indigenous communities. The median number of days
children experienced any respiratory symptoms at time
of enrolment was 3 (IQR: 2–5). The median composite

TABLE 3— Internal Consistency (Cronbach a Values) for Tal and Modified-Tal Scoring Systems and Inter-Rater
Reliability: Weighted Kappa Score Between Raters
Scoring system
Variable Tal Modified-Tal
Respiratory rate 0.55 0.63
Wheezing 0.69 0.73
Cyanosis 0.74 N/A
Accessory muscle use 0.62 0.68
SpO2 N/A 0.72
Overall score 0.66 0.70
See Table 2 for description.
Nurse 1 and 2 (experienced nurses) and nurse 3 (junior nurse).
a
NB: where 95% CI is not described in table, perfect agreement was not analyzed.
b
N/A: Overall Kappa described in results.
score for the group was 5 (range 1–11); 27 children had
a score of 1–3, 56 scored 4–6, 29 scored 7–9, and 3
scored 10–11.
The internal consistency of the scoring systems was
good, all components of the Modified-Tal score contrib-
uted significantly to the overall score (Table 3). Of
the Tal score, other than RR, the other components
exceeded the cut-off of 0.6 (Table 3).
Overall inter-rater reliability for Modified-Tal was
excellent K ¼ 0.70 (95% CI: 0.63–0.76) and also for
Tal K ¼ 0.72 (95% CI: 0.63–0.83). Overall agreement
between raters was very good (Table 3). The lowest
kappa recorded was RR (K ¼ 0.53).
With regard to whether the score predicted require-
ment for supplementary oxygen at 12 and 24 hrs in the
children (n ¼ 57) who were not on oxygen at enrol-
ment. At 12 and 24 hrs aROCs were 0.68 (95%
CI: 0.13, 1.0) and 0.75 (95% CI: 0.34, 1.0), respective-
ly. Both scores had very wide confidence intervals.
From the aROC graphs, the best cut off for both time
points was a score of >3. For the children already on
oxygen at enrolment (n ¼ 58), the Modified-Tal score
did not predict oxygen requirement at either 12 or
24 hrs, with an aROC of 0.60 (95% CI: 0.46, 0.75).
DISCUSSION
In 115 children with bronchiolitis, we have shown
the internal validity and reliability of both the Tal and
Modified-Tal scoring systems. Both systems performed
well although the modified-Tal had slightly better face
validity and was slightly more meaningful, with each
component significantly contributing to the overall
score. To the best of our knowledge, no other severity
scoring system for bronchiolitis have examined for
internal consistency. Based on an aROC of
0.75 as a
clinically useful scoring system,13 the modified-Tal may
predict O2 requirement at 24 hrs but not at 12 hrs,
Validated Severity Tools for Bronchiolitis 5
Weighted kappa scores (95% CI)
Nurse 1 versus Nurse 2 Nurse 1 versus Nurse 3
0.71 (0.58, 0.84) 0.53 (0.40, 0.7)
0.77 (0.66, 0.88) 0.70 (0.55, 0.88)
1.00a 0.91 (0.80, 1.0)
0.78 (0.68, 0.88) 0.65 (0.51, 0.78)
1.00a 1.00a
b b
however, the 95% CI were very wide and thus has
limited utility.
On reviewing the various scoring systems in the
study of bronchiolitis (Table 1), we found a variety of
systems. Some utilized systems only included respirato-
ry distress assessment with wheezing and retractions;
others used modified systems that included respiratory
rate, cyanosis, and more recently SpO2.4,6,8,14–16 The
RDAI developed by Lowell et al.6 includes only two
components for assessment (wheezing and respiratory
retractions), whilst that developed by Wang et al.14
includes respiratory rate, wheezing, respiratory retrac-
tions, and general appearance. Both were validated only
for inter-rater reliability and used by doctors yet in clin-
ical research, these scores (with some modification)
were used by nurses and some papers provided little
descriptions of training or how various raters scored.
Of the papers that assessed agreement of these com-
ponents, they varied considerably among studies. In our
study, we found that items of individual and overall in-
ter-rater reliability were excellent between the study
nurses, often higher than other scores described. Al-
though, the study nurses’ clinical paediatric experience
varied considerably, the inter-rater agreement was very
good for both wheezing and respiratory retractions, K
of >0.7 and 0.65, respectively. This is unlike Wang
et al.14 and Walsh et al.’s17 findings with K values of
0.189–0.31. Our high agreement score is likely related
to the training and calibration sessions in assessment of
the components using a standardized protocol and edu-
cation sessions (including video recordings) prior to
commencement of the study. Thus, as suggested by Liu
et al.4 we evaluated the Tal scoring system which was a
modified originally from Bierman and Pierson18 in our
context. We substituted SpO2 readings for cyanosis as it
is a simple and informative part of management, and
oximeters are easily accessible. The Modified-Tal score
was better than the Tal score. For those resource limited
Pediatric Pulmonology
6 McCallum et al.
settings where oximeters are limited, the Tal score
could feasibly be used in place of the Modified-Tal
score, as our results showed cyanosis had a very strong
internal validity of 0.74 and substantial inter-rater
agreement.
For those children not on oxygen at enrolment, the
Modified-Tal score was predictive of oxygen require-
ment at 24 hrs with an aROC of 0.75 but not at 12 hrs
(aROC 0.68). There was however a wide confidence in-
terval thus predictability must be viewed with caution.
Our study did not aim to determine a model for predict-
ing admission as undertaken by Marlais et al.19 and
Walsh et al.20 for two reasons. Firstly, our intent was to
examine the validity of the scoring system as utilized
by nurses of varying experience not only for clinical
purposes but also for research purposes. Secondly, for
logistic reasons, the majority of children were already
admitted although 57 did not require oxygen throughout
their hospitalization. Not surprisingly, the aROC of our
study is not as good as that described by Marlais
et al.’s19 study that aimed to develop a model for requir-
ing admission (aROC of 0.81, 95% CI: 0.77–0.85).
Walsh et al.20 did not determine aROC of their model
but only measured K agreement scores of the various
components of their prediction model. With a cut off
score >3 and the median number of days of respiratory
symptoms experienced was 3, the likelihood of a child’s
condition deteriorating and thus requiring hospitaliza-
tion and possible oxygen requirement increases.
A strength of our study was participants represented
all ethnic backgrounds and regions of the NT, thus
allowing the results to be generalizable to other popula-
tions. All assessments were done within 15 minutes of
each other. Other scores in the literature were complet-
ed between 10 min and 2 hrs. The longer time between
scoring increases the chance of a child’s clinical con-
dition changing, thus reflecting clinically different
score.21,22
Limitations of our study are several fold. We were
unable to access the Emergency Department (ED) until
the later half of the recruitment period, due to logistical
reasons, thus potentially missing milder cases that were
discharged home. We attempted to enrol as many chil-
dren in the ED, however many children presented
during the evening or the few that were enrolled in ED
were eventually admitted. Thus, admission to hospital
could not be used an endpoint.
CONCLUSION
Our study has demonstrated that both the Tal and
Modified-Tal scoring systems were easy to use by
nurses with varying levels of experience. With training,
the scores were highly reproducible. The Tal and Modi-
fied-Tal scoring systems for bronchiolitis are repeatable
Pediatric Pulmonology
and can be reliably used in research and clinical prac-
tice. However, its utility for prediction of O2 require-
ment within 24 hrs is limited.
ACKNOWLEDGMENTS
We thank the medical and nursing staff for their on-
going support and identifying the children for the study.
We are grateful for all the children and families who
participated in this study. Study supported by NHMRC
grant 605809 and A.C. is supported by a NHMRC prac-
titioner fellowship (grant number 545216).
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