What it is
The Pediatric Respiratory Assessment Measure (PRAM) is a validated clinical severity score for acute asthma. Originally developed in preschoolers and later validated from toddlers (≈1 year) to teenagers (17 years), it has the most thoroughly studied measurement properties of the pediatric asthma scores and is widely embedded in emergency-department asthma pathways.
The five components
| Sign | Scoring |
|---|---|
| Suprasternal retractions | Absent = 0; present = 2 |
| Scalene muscle contraction | Absent = 0; present = 2 |
| Air entry | Normal = 0; ↓ at bases = 1; ↓ apex & base = 2; minimal/absent = 3 |
| Wheezing | Absent = 0; expiratory only = 1; insp. & exp. = 2; audible without stethoscope / silent chest = 3 |
| Oxygen saturation | ≥95% = 0; 92–94% = 1; <92% = 2 |
Total range 0–12. As with other asthma scores, the worst air-entry and wheezing grade is reserved for the silent chest — minimal air movement, not loud wheeze.
Severity bands
- 0–3 — mild
- 4–7 — moderate
- 8–12 — severe
A lower score is the better outcome.
When to use it
Score at presentation and after each treatment cycle in a child with an acute asthma exacerbation. PRAM is responsive, so the change in score is as useful as the absolute number for judging treatment response and disposition.
Worked example
A child with suprasternal retractions (2), no scalene contraction (0), air entry reduced at the bases (1), inspiratory-and-expiratory wheeze (2), and SpO₂ 93% (1) scores 6 — moderate. Treat and re-score.
Escalation mapping
- Mild (0–3): inhaled SABA, reassess; many can be discharged with a plan.
- Moderate (4–7): SABA ± ipratropium and a systemic corticosteroid; observe and re-score.
- Severe (8–12): continuous/back-to-back salbutamol, ipratropium, steroids, IV magnesium sulfate, and early critical-care involvement.
Pitfalls and caveats
- Re-score after every intervention — PRAM is designed to track trajectory, not give a single snapshot.
- A silent chest scores high, not low — do not be reassured by a quiet chest in a fatiguing child.
- SpO₂ contributes only 0–2 points; a near-normal saturation does not exclude a severe exacerbation when work of breathing is high.
- Use one scoring system consistently across your unit; mixing PRAM, PASS, and others muddies trends.
Run it: Pediatric Respiratory Assessment Measure (PRAM)
Decision support for qualified clinicians only — verify against current primary guidelines and your clinical judgement.