VWS for evaluation of vital signs and severity of dyspnoea
| VWS | ||||||||
| Component | Age group | Component subscore | ||||||
| 4 | 2 | 1 | 0 | 1 | 2 | 4 | ||
| Respiratory rate (breaths/min) | <3 months | <15 | 15–19 | 20–29 | 30–60 | 61–80 | 81–90 | >90 |
| 3–12 months | <15 | 15–19 | 20–24 | 25–50 | 51–70 | 71–80 | >80 | |
| 1–4 years | <12 | 12–14 | 15–19 | 20–40 | 41–60 | 61–70 | >70 | |
| Respiratory effort* | All ages | normal | mildly↑ | Moderate↑ | Severe↑ or apnoeic | |||
| Oxygen saturation (%) | All ages | <91 | 91–94 | >94 | ||||
| Oxygen therapy | All ages | Room air | LFNP/HFNC | NRB mask | ||||
| Heart rate (beats/min) | < 3 months | <80 | 80–89 | 90–109 | 110–150 | 151–180 | 181–190 | >190 |
| 3–12 months | <70 | 70–79 | 80–99 | 100–150 | 151–170 | 171–180 | >180 | |
| 1–4 years | <60 | 60–69 | 70–89 | 90–120 | 121–150 | 151–170 | >170 | |
| Capillary refill (s) | All ages | <3 | ≥3 | |||||
| Temperature (°C) | All ages | <36 | 36–36.4 | 36.5–37.5 | 37.6–38.5 | >38.5 | ||
The score is calculated by summing the subscores of each component, resulting in a score 0–24. VWS of ≥8 warrants immediate attention of a physician.
Source: adapted from Fuijkschot et al.18
*Nasal flaring or retractions.
HFNC, high-flow nasal cannula; LFNP, low-flow nasal prong; NRB mask, non-rebreathing mask; VWS, Vital Warning Score.