Scores used in pulmonary and critical care medicine, ICU and emergency medical wards etc. It includes glasgow coma scale,Dyspnea scoring,Clubbing, Anemia, edema, shock,SGRQ, CAT Score, ABCD assessment of COPD, BODE index, asthma,abpa,byssinosis,cURB-65,SOAR, PSI,CPIS, APACHE,WELLS score, YEARS sore,GENEVA score, PIOPED criteria, LIghts criteria,OSA, Berlin questionnaire, Lung cancer, Cancer staging, ICU and critical care, mallampati score, Revised trauma score, SOFA score, SAPS, Scadding staging of sarcoidosis etc. Scores are adapted from various internet and other sources and combined by Dr. Jebin Abraham

1. Scores in Pulmonary Medicine
Dr. Jebin Abraham
Junior Resident
Department of Pulmonary Medicine
GMC Patiala
21 January 2019 1

2. CLINICAL MEDICINE
21 January 2019 2

3. Glasgow Coma Scale (GCS)
21 January 2019 3

4. Modified Borg Category Scale of
Dyspnea
Rating Intensity of Sensation
0 Nothing at all
0.5 Very, very slight (just noticeable)
1 Very slight
2 Slight
3 Moderate
4 Somewhat Severe
5 Severe
6
7 Very Severe
8
9 Very, very Severe (almost maximal)
10 Maximal
21 January 2019 4

5. MMRC Grading of Dyspnea
21 January 2019 5

6. NYHA Grading of Dyspnea
21 January 2019 6

7. Sherwood Jones grading of Dyspnea
21 January 2019 7
Grade Subtype Feature
1 a Able to do housework or job with moderate
difficulty
b Carrying out job or housework with great
difficulty
2 a Confined to chair or bed but able to get up with
moderate difficulty
b Confined to chair or bed but able to get up with
great difficulty
3 Totally confined to chair or bed
4 Moribund

8. Grades of Clubbing
Grade Feature
1 Increased fluctuation of nail bed
2 Obliteration of Lovibond angle
3 Parrot beak/ Drumstick appearance
4 Hypertrophic Pulmonary Osteoarthropathy
21 January 2019 8

9. Grades of Anemia
Grade Severity NCI WHO
0 None WNL* >11
1 Mild 10-N 9.5-10
2 Moderate 8-10 8-9.4
3 Severe 6.5-7.9 6.5-7.9
5 Life threatening <6.5 <6.5
*14-18g/dl for Men, 12-16 for women
Reference: Groopman & Itri, 1999
21 January 2019 9

10. Grades of Edema
*Assessment Chart for Pitting Edema adapted from the Guelph General Hospital
Congestive Heart Failure Pathway
21 January 2019 10

11. Grades of Fever
• An a.m. temperature of >37.2°C (>98.9°F) or
• A p.m. temperature of >37.7°C (>99.9°F) would
define a fever.
• A fever of >41.5°C (>106.7°F) is called
hyperpyrexia.*
21 January 2019 11
*Harrisons Principles of internal medicine, 19E

12. Grades of Drug Induced Liver Injury
1+ Mild: Raised serum aminotransferase or alkaline phosphatase levels or both,
but total serum bilirubin <2.5 mg/dL and no coagulopathy (INR <1.5)
2+ Moderate: Raised serum aminotransferase or alkaline phosphatase levels or
both and total serum bilirubin level >2.5 mg/dL or coagulopathy
(INR >1.5) without hyperbilirubinemia
3+ Moderate
to Severe:
Raised serum aminotransferase or alkaline phosphatase levels and total
serum bilirubin level >2.5 mg/dL and hospitalization (or preexisting
hospitalization is prolonged) because of the drug induced liver injury.
4+ Severe: Raised serum aminotransferase or alkaline phosphatase levels and
serum bilirubin >2.5 mg/dL and at least one of the following:
Prolonged jaundice and symptoms beyond 3 months, or
Signs of hepatic decompensation (INR >1.5, ascites, encephalopathy), or
Other organ failure believed to be related to drug induced liver injury.
5+ Fatal: Death or liver transplantation for drug induced liver injury
*https://livertox.nih.gov/Severity.html21 January 2019 12

13. Tennis Criteria- Stages of Shock
21 January 2019 13

14. OBSTRUCTIVE AIRWAY DISEASE
21 January 2019 14

15. St. George's Respiratory Questionnaire (SGRQ)
• Disease-specific instrument designed to measure impact on
overall health, daily life, and perceived well-being in patients
with obstructive airways disease.
• 50 items, 2 parts (3 components)
• Part 1 : Symptoms component (frequency & severity)
• Part 2: Activities that cause or are limited by breathlessness;
Impact components
• Scores range from 0 to 100, with higher scores indicating
more limitations. Healthy subjects <25.
• The SGRQ-C is a shorter version of the SGRQ, developed for
COPD.
21 January 2019 15
*http://www.healthstatus.sgul.ac.uk

16. Classification of Airflow Limitation in Patients
with FEV1/FVC < 0.7
21 January 2019 16

17. CAT Score
21 January 2019 17
Healthy subjects- Score<10

18. ABCD Assessment Tool
21 January 2019 18

19. 21 January 2019 19

20. 21 January 2019 20

21. American Thoracic Society’s (ATS) Asthma Impairment
Rating Guideline
21 January 2019 21

22. ACCP Case Definition of Occupational Asthma
A. Physician diagnosis of asthma
B. Onset of asthma after entering workplace
C. Association between symptoms of asthma and work
D. One of the following:
1. Workplace exposure to agent known to cause occupational asthma
2. Work-related changes in FEV1 or PEF
3. Work-related changes in bronchial responsiveness
4. Positive response to specific inhalation challenge test
5. Onset of asthma with a clear association with a symptomatic exposure
to an inhaled irritant agent in the workplace
Definite occupational asthma requires A, B, C, and D(2) or D(3) or D(4) or D(5)
Likely occupational asthma requires A, B, C, and D(1)
21 January 2019 22

23. Diagnostic criteria for ABPA
Major
• Asthma (ABPA is also common in persons with cystic fibrosis)
• Positive immediate hypersensitivity skin-prick test to Aspergillus
• Precipitating antibodies against Aspergillus
• Elevated total IgE
• Elevated serum Aspergillus–specific IgE, IgG
• History of pulmonary infiltrates
• Peripheral blood eosinophilia
• ± Central bronchiectasis
Minor
• Expectoration of thick brown mucus plugs
• Aspergillus in sputum
• Dual cutaneous reaction to Aspergillus
The presence of 6 of eight major criteria strongly suggests the diagnosis.
21 January 2019 23

24. Stages of ABPA
Stage I: Acute
• Acute asthma symptoms ± constitutional symptoms
• Elevated serum IgE (typically >1000 ng/mL)
• Elevated Aspergillus-specific IgE and IgG
• Infiltrate on chest radiograph
• Peripheral blood eosinophilia
• Immediate skin reactivity to Aspergillus
• Positive precipitating antibodies to Aspergillus fumigatus
Stage II: Remission
• Resolution of symptoms (concurrent decrease in total IgE needed to confirm remission)
• Radiographic clearing
• Reduction or stabilization of IgE levels (normalization rare)
Stage III: Exacerbation
• Recurrence of elevated IgE levels (greater than twofold over baseline)
• ± Development of a new pulmonary infiltrate on chest radiograph
• ± Escalation of asthma symptoms
Stage IV: Steroid-dependent Asthma
• Difficult to control, steroid-dependent asthma
• Persistently elevated total IgE, Aspergillus precipitins and Aspergillus-specific IgE and IgG
• despite corticosteroid therapy
• ± Transient infiltrates and/or bronchiectasis on chest radiograph or CT
Stage V: Fibrotic lung disease
• Persistent steroid-dependent asthma
• Fibrotic lung disease with gas exchange disturbances
21 January 2019 24

25. Criteria for the Diagnosis of Severe Asthma
with Fungal Sensitivity (SAFS)
1. History of poorly controlled asthma (>500 μg/d of fluticasone
or the equivalent, near continuous oral corticosteroids
for >6 mo, or >2 oral steroid tapers per year)
2. Total serum IgE <1000 IU/mL
3. Positive immediate skin test reactivity to Aspergillus fumigatus
OR elevated specific serum IgE to A. fumigatus
4. Absence of serum precipitins (by gel diffusion) and elevated
specific serum IgG to A. fumigatus
5. No radiographic evidence of bronchiectasis or infiltrates
21 January 2019 25

26. Schilling’s Clinical Grading of Byssinosis
GRADE FEATURES
Grade 0 No symptoms on first day of work
Grade 1/2 Occasional chest tightness or irritation of
respiratory tract on the first workday of
the week
Grade 1 Chest tightness on every first day of work
week
Grade 2 Chest tightness on first and other days of
work week
Grade 3 Chest tightness on first and other days of
work week & physiological evidence of
permanent disability
21 January 2019 26

27. FACED score for Bronchiectasis
21 January 2019 27

28. Shwachman-Kulczycki Score for Cystic
Fibrosis
21 January 2019 28

29. Diagnostic Criteria for Reactive Airway
Dysfunction Syndrome (RADS)
1. There is an absence of pre-existing respiratory disorder, asthma
symptomatology, or a history of asthma in remission and an
exclusion of conditions that can simulate asthma.
2. The onset of asthma occurs after a single exposure or an accident.
3. The exposure is to an irritant vapor, gas, fumes, or smoke in very
high concentrations.
4. The onset of asthma symptoms develops within minutes to hours
and less than 24 h after the exposure.
5. There is a positive methacholine challenge test finding or equivalent
test, which signifies hyperreactive airways, following the exposure.
6. There may or may not be airflow obstruction confirmed with
pulmonary function testing.
7. There is exclusion of another pulmonary disorder that explains the
symptoms and findings.
21 January 2019 29

30. WHO Functional Classification of Patients with
Pulmonary Hypertension
• Class I: Patients with PH but without resulting limitation of physical activity.
Ordinary physical activity does not cause undue dyspnea or fatigue, chest pain,
or near syncope.
• Class II: Patients with PH resulting in slight limitation of physical activity. They
are comfortable at rest. Ordinary physical activity causes undue dyspnea or
fatigue, chest pain, or near syncope.
• Class III: Patients with PH resulting in marked limitation of physical activity. They
are comfortable at rest. Less than ordinary activity causes undue dyspnea or
fatigue, chest pain, or near syncope.
• Class IV: Patients with PH with inability to carry out any physical activity without
symptoms. These patients manifest signs of right heart failure. Dyspnea and/or
fatigue may even be present at rest. Discomfort is increased by any physical
activity.21 January 2019 30

31. PNEUMONIA & INFECTIOUS
DISEASES
21 January 2019 31

32. CURB-65
21 January 2019 32

33. SOAR Score
Score Management 30 day mortality
0-1 OP <8%
>=2 IP 33%
Parameter Value Score
Systolic BP
Or Diastolic BP
<90 mmHg
<60 mmHg
1
Oxygenation, PaO2/FiO2 <250 1
Age >=60 yrs 1
Respiratory rate >30/min 1
*https://doi.org/10.1093/ageing/afs158
21 January 2019 33

34. Pneumonia Severity Index (PSI)
21 January 2019 34

35. Pneumonia Severity Index (PSI)…
21 January 2019 35

36. Clinical Pulmonary Infection Score
(CPIS)
21 January 2019 36A score >6 s/o VAP

37. MRC Staging of TBM
Stage Type Features
I Mild No altered consciousness or focal
neurological signs
II Moderate With altered consciousness (but not
comatose) & moderate neurological signs
Eg- Single CN palsy, paraparesis,
hemiparesis etc
III Severe Comatose or multiple CN palsies,
hemiplegia or paraplegia or both
*MRC, 1948, Index TB guidelines
21 January 2019 37

38. PULMONARY EMBOLISM
21 January 2019 38

39. WELLS’ Score
21 January 2019 39

40. YEARS Score
Parameter Score
Clinical evidence of Deep Vein Thrombosis
(DVT)
1
Hemoptysis 1
Pulmonary Embolism most likely cause on
differential diagnosis
1
Score D-Dimer cut off
Score 0 1.0
Score 1-3 0.5
YEARS Criteria
Interpretation
*Arora and Menchine in Herbert (2017) EM:Rap 17(12):20-121 January 2019 40

41. Geneva score
ORIGINAL REVISED
21 January 2019 41

42. Charlotte Rule
21 January 2019 42

43. PERC Score
If none of the 8 criteria are present, pulmonary embolism can be
ruled out clinically.
21 January 2019 43

44. Pulmonary Embolism Severity Index (PESI)
Variable Original PSI Simplified PSI
Age>80y Age in yrs 1
Male sex +10
H/o Cancer +30 1
H/o Heart failure +10 1
H/o Chronic lung disease +10
Pulse>/=110/min +20 1
SBP <100 +30 1
Resp Rate>/=30/min +20
Temp<36 deg C +20
Altered mental status +60
SpO2 <90% +20 1
21 January 2019 44

45. Pulmonary Embolism Severity Index (PESI)
• Original PESI
• Simplified PESI
21 January 2019 45
Class Score
I <=65
II 66-85
III 86-105
IV 106-125
V >125
Score Risk
0 Low
>=1 High

46. Revised PIOPED Criteria for Interpretation of
Lung Scans
21 January 2019 46

47. PLEURAL DISEASES
21 January 2019 47

48. Lights Criteria
Lights Criteria for Exudative pleural effusion
1 Pleural fluid: Serum Protein > 0.5
2 Pleural fluid: Serum LDH > 0.6
3 Pleural fluid LDH >2/3 upper limit normal for serum
One or more of Lights criteria met Exudate
21 January 2019 48

49. Light Index
• Percentage of Pneumothorax
= 1oo [1- (diameter of lung)3/(diameter of hemithorax)3
Collin’s Method
% Pneumothorax = 4.2+{ 4.7 (A+B+C)}
21 January 2019 49

50. Size of Pneumothorax
ACCP BTS
Small Apex-cupula <3cm Rim of air at hilum <2cm
Large Apex-cupula >3cm Rim of air at hilum >2cm
21 January 2019 50

51. OBESITY AND SLEEP MEDICINE
21 January 2019 51

52. Diagnostic Criteria for Obesity
Hypoventilation Syndrome
• BMI >30 kg/m2
• Daytime PaCO2 >45 mm Hg
• Rise in PaCO2 of >5 mm Hg during sleep
• Sleep disordered breathing
• Absence of other known causes of hypoventilation
21 January 2019 52

53. 21 January 2019 53

54. Epworth Sleepiness Scale
21 January 2019 54
Score <10 Normal

55. Diagnostic Testing Options for Sleep-
Disordered Breathing
21 January 2019 55

56. STOP-BANG Scoring Model for Preoperative
Assessment of OSA Risk
• Snoring: Do you snore loudly?
• Tired: Do you often feel tired, fatigued, or sleepy during daytime?
• Observed: Has anyone observed you stop breathing during your sleep?
• Pressure: Do you have or are you being treated for high blood pressure?
• BMI: BMI more than 35?
• Age: Age over 50 y?
• Neck circumference: Neck circumference greater than 40 cm?
• Gender: Male?
High risk of OSA, answering yes to three or more items.
Low risk of OSA, answering yes to less than three items.
*Adapted with permission from Chung F , Elsaid H. Screening for obstructive sleep apnea before
surgery: why is it important? Curr Opin Anaesthesiol. 2009;22(3):405–411.
21 January 2019 56

57. TRANSPLANTATION
21 January 2019 57

58. Grading System for Primary Graft Dysfunction
(PGD)
Grade PaO2/Fio2 Radiographic Infiltrates Consistent
with Pulmonary Edema
0 >300 Absent
1 >300 Present
2 200-300 Present
3 <200 Present
21 January 2019 58

59. Working Formulation for Classification and
Grading of Pulmonary Allograft Rejection
Based on degree of perivascular infiltrates & degree of airway
inflammation
A. Acute rejection—(with/without [B])
• Grade A0, none
• Grade A1, minimal
• Grade A2, mild
• Grade A3, moderate
• Grade A4, severe
• Grade AX, ungradable because of insufficient tissue, sampling
problem, infection, tangential cutting, etc.
21 January 2019 59

60. B. Airway inflammation—lymphocytic bronchitis/bronchiolitis
• B0, no airway inflammation
• B1R, minimal–mild airway inflammation
• B2R, moderate–severe airway inflammation
• BX, ungradable because of insufficient tissue, sampling
problem, infection, tangential cutting, etc.
C. Chronic airway rejection—bronchiolitis obliterans
D. Chronic vascular rejection—accelerated graft vascular
sclerosis
21 January 2019 60

61. Staging Classification of Bronchiolitis Obliterans
Syndrome
Stage Severity FEV1(%Baseline)
0 Nil >80
1 Mild 66-80
2 Moderate 51-65
3 Severe </=50
21 January 2019 61

62. LUNG CANCER
21 January 2019 62

63. TNMStagingofCaLung
21 January 2019 63

64. Stage classification
21 January 2019 64

65. Classification of Mediastinal Disease by
Radiographic Characteristics
Group Description
A Mediastinal infiltration: tumor invasion such that normal anatomic
boundaries cannot be distinguished
B Enlarged discrete mediastinal nodes: nodes measuring >/=1cm in short
axis diameter in transv CT scan
C Clinical stage II or central stage I tumor; normal sized mediastinal nodes
but enlarged N1 nodes or central tumor
D Peripheral clinical stage1 tumor: normal mediastinal and hilar nodes with
a peripheral tumor
21 January 2019 65

66. Regional Lymph Node Stations (International
Association for the Study of Lung Cancer)
21 January 2019 66
Zone LN Station
Supraclavicular 1 Low cervical, supraclavicular, sternal notch
Superior mediastinal 2R R. Upper paratracheal
2L L. Upper paratracheal
3a Prevascular
3p Retrotracheal
4R R. Lower paratracheal
4L L. Lower paratracheal
Aortic/Aortopulmonary window 5 Subaortic
6 Para aortic
Inferior mediastinal 7 Subcarinal
8 Paraesophageal
9 Pulm ligament
Hilar 10 Hilar
11 Interlobar
Peripheral 12 Lobar
13 Segmental
14 Subsegmental

67. Mediastinal Staging
21 January 2019 67

68. ICU & CRITICAL CARE
21 January 2019 68

69. Berlin criteria for ARDS
21 January 2019 69

70. Mallampati Score
21 January 2019 70

71. American Society of Anesthesiologists’ (ASA) Classification
• 103.7
21 January 2019 71

72. Scoring System for Estimating Risk of Postoperative Respiratory
Failure: Parameters Used and Score Assigned
21 January 2019 72

73. Scoring System for Estimating Risk of
Postoperative Respiratory Failure
Score range Risk level Predicted
probability of
PRF(%)
<8 Low 0.2
8-12 Medium 1.0
>12 High 6.5
21 January 2019 73

74. Revised Trauma Score (RTS)
21 January 2019 74

75. Sequential Organ Failure Assessment
(SOFA) Score
21 January 2019 75

76. Quick SOFA score
Assessment qSOFA score
Low blood pressure (SBP ≤ 100 mmHg) 1
High respiratory rate (≥ 22 breaths/min) 1
Altered mentation (GCS <=13) 1
21 January 2019 76
The presence of 2 or more qSOFA points near the onset of infection
was associated with a greater risk of death or prolonged intensive
care unit stay
*Critical Care Medicine. 44 (3): e113–e121.

77. Multiple Organ Dysfunction
Score(MODS)
21 January 2019 77

78. MODS…
21 January 2019 78

79. APACHE II
• Acute Physiology & Chronic Health Evaluation
• The APACHE II scoring system was released in 1985 and
included a reduction in the number of variables to 12.
• The APACHE II scoring system is measured during the first
24 h of ICU admission with a maximum score of 71.
• A score of 25 represents a predicted mortality of 50% and a
score of over 35 represents a predicted mortality of 80%.
• APACHE II score is sum of:
• Acute physiology score
• Age
• Chronic health score
21 January 2019 79

80. 21 January 2019 80

81. 21 January 2019 81

82. APACHE III
• Released in 1991
• Developed with the objectives of improved statistical power,
ability to predict individual patient outcome, and identify the
factors in ICU that influence outcome variations
• More complex than the 2 previous scoring systems.
• 17 physiological variables & Total score (0 – 299)
• Acid-base disturbances
• GCS score – based on the worst
• Age score
• 7 co-morbidities (cardiac, respiratory & renal failures
excluded)
21 January 2019 82

83. APACHE IV
• The APACHE IV scoring system was published
in 2006.
• Limitations:
Complexity – has 142 variables.
But web-based calculations can be done.
Developed and validated in ICUs of USA
only
21 January 2019 83

84. SAPS II
21 January 2019 84

85. Predicted mortality = -14.4761 + 0,0844 * SAPS II + 6.6158 * log (SAPS II+1)
21 January 2019 85

86. Logistic Organ Dysfunction System
(LODS)
• Worst values in 1 st 24 hrs of ICU stay.
• Worst value in each of 6 organ systems.
• Total score ranges from 0-22.
21 January 2019 86

87. 21 January 2019 87

88. Mortality Probability Model (MPM)
► MPM score:
Admission MPM (MPM0) →11 variables
MPM at 24 Hrs (MPM24) → 14 variables
MPM at 48 Hrs (MPM48) → 11 variables
MPM over the time (MPMOT) → (MPM24-MPM0)
(MPM48-MPM24)
► Probability is derived directly from these variables.
► MPMOT predicted better than MPM0 for long term
patients.
21 January 2019 88

89. MPM0
21 January 2019 89

90. MISCELLANEOUS
21 January 2019 90

91. Scadding Staging of Sarcoidosis
21 January 2019 91

92. Fagerstrom Test for Nicotine Dependence
21 January 2019 92
Interpretation
1-2 Low
3-4Low to moderate
5-7Moderate
>8High
*ndri.curtin.edu.au/btitp/documents/Fagerstrom_test.pdf

93. Thank You
21 January 2019 93