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    Brescia-COVID Respiratory Severity Scale (BCRSS)/Algorithm

    Step-wise management approach to COVID-19 patients based on clinical severity as of June 2, 2020.


    • Launched during COVID-19 crisis. Not externally validated. Use with caution; this is being used in Italy for assessment, trending, and treatment recommendations.

    • See our expert interview with Italian intensivist, Dr. Simone Piva, for an in-depth discussion of how the BCRSS is being used practically to simplify and communicate the respiratory status of patients.


    • This algorithm is a step-wise approach to managing patients with confirmed/presumed COVID-19 pneumonia. 

    • If not intubated, follow management and then each 4 testing criteria should be repeated to assess for improvement or deterioration. Repetition frequency based on clinical judgment to downgrade/upgrade score.

    • Not only is the management important; the numerical score is used to easily compare and summarize patients to treating clinicians.

    • NIV concerning for aerosolization; included in score due to ventilator scarcity in Italy.

    When to Use
    Why Use
    • In Italy, this score is being used in patients who have COVID-19 pneumonia OR have had COVID-19 symptoms for ≥7 days AND are either PCR+ OR high clinical suspicion for COVID-19.

    • This is used for every single patient with these diagnoses, and is critical in the hospital in Brescia, Italy where it was developed to compare and quickly summarize a patient’s clinical severity during this pandemic.

    • This score was rapidly developed in Italy during their COVID-19 crisis, and has not been validated or tested in other populations; it was also developed while the world is still learning more daily about COVID-19.

    • Doctors in Brescia are referring to these patients mostly by number, and in the ICU these patients have their assigned level taped above their beds, which is updated daily. 

    • This score is meant to be dynamic and frequently reassessed and re-scored after interventions; frequency of reassessment is by clinical judgment. A brand new patient in the ED may need to be reassessed every 15 minutes, for example, while a stable patient on the medical floor may only need reassessment every 6-12 hours. If a patient is assigned a new score based on these criteria, the medical and respiratory management should then change as well.

    • Patients are also assigned a sub-score using daily CXR findings to help stratify patients further; 3 quadrants of each lung are each assigned a score, 0-3, with zero points showing no opacification, 3 points being full opacification of the lung quadrant, and these points are then tallied. For example, a patient at “Level 3 with 12 points on CXR” would be much more serious than a patient at “Level 3 with 2 points on CXR.” 

    • Note: While many in North America have raised concerns about risk of viral particle spread from NIV/HFNC and healthcare worker exposure, Italian doctors included these ventilation strategies in their pathways because they simply do not have enough ventilators to accommodate all the patients and the only other alternative for these patients would be death.

    • This score uses both patient exam features as well as need for escalating levels of respiratory support (NIV, intubation, proning) to recommend increasing treatment recommendations.

    • It drastically simplifies the clinical summary of a patient’s status and makes it incredibly easy to compare patients to one another as well as to trend patients’ levels over time. It also allows healthcare workers to monitor patients nearing a critical action point more closely (example: Level 3, possibly nearing the need for intubation).

    [Patient has COVID-19 pneumonia or COVID-19 symptoms for ≥7 days]
    [Patient is PCR+ OR high suspicion for COVID-19/PCR pending]
    Confirmed positive
    Confirmed negative


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    Next Steps
    Creator Insights
    Brescia-COVID Group

    About the Creator

    The Brescia-COVID group is a collaboration of infectious disease and critical care physicians in Brescia, Italy (in the Lombardy region of Italy) who developed this scale together while caring for patients in their hospital.

    Are you Brescia-COVID Group? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    Content Contributors
    • Andrea Duca, MD
    About the Creator
    Brescia-COVID Group
    Are you Brescia-COVID Group?
    Partner Content
    Content Contributors
    • Andrea Duca, MD