Lowell DI et al. 1987

RDAI. Respiratory Distress Assessment Instrument

Bronchiolitis severity scoring. Wheezing and retraction components, total score 0–17. Validated in infants with bronchiolitis.

RDAI Components

Wheezing Max 8 pts

Score wheezing in upper and lower lung fields. 0 None · 1 End-expiratory · 2 Entire expiration · 3 Inspiration and expiration · 4 Audible without stethoscope or silent chest.

1
Wheezing. Upper lung fields
2
Wheezing. Lower lung fields
Retractions Max 9 pts

Score each of 4 anatomic sites 0–3 (None / Mild / Moderate / Severe). Site sum is capped at 9 per the published Lowell 1987 RDAI.

3
Supraclavicular Retractions
4
Intercostal Retractions
5
Substernal Retractions
6
Subcostal Retractions
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Frequently Asked Questions About RDAI and Bronchiolitis

The Respiratory Distress Assessment Instrument (RDAI) was developed by Lowell et al. (1987) as a standardized scoring tool for assessing severity of respiratory distress in infants with bronchiolitis. It quantifies wheezing graded across upper and lower lung fields (0–8) and retractions across four anatomic sites. Supraclavicular, intercostal, substernal, and subcostal (0–9, capped). For a total of 0–17.

It was originally used to measure response to epinephrine in infants with wheezing. RDAI is useful for tracking clinical response to therapy and communicating disease severity.

RDAI scores are typically interpreted as:

  • 0–3: Mild respiratory distress. Suitable for discharge home with return precautions
  • 4–8: Moderate respiratory distress. Further treatment and observation warranted
  • 9–12: Severe respiratory distress. Escalation of care required
  • ≥13: Impending respiratory failure. Immediate stabilization, consider PICU

These bands guide management but should be interpreted in context with O₂ saturation, respiratory rate, feeding ability, and parental concerns.

Per AAP 2014 (updated) bronchiolitis guidelines:

  • Supportive care: Supplemental O₂ if SpO₂ <90–92%, nasal suctioning, hydration (oral or IV if needed)
  • Bronchodilators (albuterol, racemic epinephrine): Not routinely recommended; may be trialed but continued only if objective improvement documented
  • Steroids: Not recommended (no proven benefit)
  • Antibiotics: Not recommended unless bacterial co-infection confirmed
  • Hypertonic saline (3%): May be considered for inpatients; evidence mixed

Treatment decisions should be based on the clinical picture, O₂ saturation, feeding, and RDAI response to any trialed interventions.

Consider hospitalization when: SpO₂ <90–92% on room air, significant respiratory distress (RDAI ≥4 with inadequate response to supportive care), apnea or cyanotic episodes, inability to feed, age <12 weeks (especially <3 months), prematurity (<34 weeks), hemodynamically significant congenital heart disease, or significant immunocompromise.

Social factors (parental reliability, distance from care, no transportation) also factor into admission decisions.

The RDAI has several limitations: (1) it focuses on wheezing and retractions but does not capture O₂ saturation, respiratory rate, or feeding ability. Important clinical parameters; (2) inter-rater variability exists in assessing wheezing extent and retraction severity, especially across raters of differing experience; (3) it was validated in the context of epinephrine response in bronchiolitis, not as a standalone discharge/admission tool; (4) several modified versions exist in the literature (varying retraction-site sets, addition of nasal flaring/grunting). Document the version used when tracking serial scores.