Search

Acute respiratory distress syndrome (ARDS) is undefined in neonates, despite the long-standing existing formal recognition of ARDS syndrome in later life. We describe the Neonatal ARDS Project: an international, collaborative, multicentre, and multidisciplinary project which aimed to produce an ARDS consensus definition for neonates that is applicable from the perinatal period. The definition was created through discussions between five expert members of the European Society for Paediatric and Neonatal Intensive Care; four experts of the European Society for Paediatric Research; two independent experts from the USA and two from Australia. This Position Paper provides the first consensus definition for neonatal ARDS (called the Montreux definition). We also provide expert consensus that mechanisms causing ARDS in adults and older children-namely complex surfactant dysfunction, lung tissue inflammation, loss of lung volume, increased shunt, and diffuse alveolar damage-are also present in several critical neonatal respiratory disorders., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Objectives: To determine the impact of patient-specific and disease-related characteristics on the severity of illness and on outcome in pediatric patients with acute respiratory distress syndrome with the intent of guiding current medical practice and identifying important areas for future research., Design: Electronic searches of PubMed, EMBASE, Web of Science, Cochrane, and Scopus were conducted. References were reviewed for relevance and features included in the following section., Settings: Not applicable., Subjects: PICU patients with evidence of acute lung injury, acute hypoxemic respiratory failure, and acute respiratory distress syndrome., Interventions: Not applicable., Measurements and Main Results: The comorbidities associated with outcome in pediatric acute respiratory distress syndrome can be divided into 1) patient-specific factors and 2) factors inherent to the disease process. The primary comorbidity associated with poor outcome is preexisting congenital or acquired immunodeficiency. Severity of disease is often described by factors identifiable at admission to the ICU. Many measures that are predictive are influenced by the underlying disease process itself, but may also be influenced by nutritional status, chronic comorbidities, or underlying genetic predisposition. Of the measures available at the bedside, both PaO2/FIO2 ratio and oxygenation index are fairly consistent and robust predictors of disease severity and outcomes. Multiple organ system dysfunction is the single most important independent clinical risk factor for mortality in children at the onset of acute respiratory distress syndrome., Conclusions: The assessment of oxygenation and ventilation indices simultaneously with genetic and biomarker measurements holds the most promise for improved risk stratification for pediatric acute respiratory distress syndrome patients in the very near future. The next phases of pediatric acute respiratory distress syndrome pathophysiology and outcomes research will be enhanced if 1) age group differences are examined, 2) standardized datasets with adequately explicit definitions are used, 3) data are obtained at standardized times after pediatric acute respiratory distress syndrome onset, and 4) nonpulmonary organ failure scores are created and implemented.

Purpose: A new acute respiratory distress syndrome (ARDS) definition has been recently issued: the so-called Berlin definition (BD) has some characteristics that could make it suitable for pediatrics. The European Society for Pediatric Neonatal Intensive Care (ESPNIC) Respiratory Section started a project to evaluate BD validity in early childhood. A secondary aim was reaching a consensus on clinical tools (risk factors list and illustrative radiographs) to help the application of BD., Methods: This was an international, multicenter, retrospective study enrolling 221 children [aged greater than 30 days and less than 18 months; median age 6 (range 2-13) months], admitted to seven European pediatric intensive care units (PICU) with acute lung injury (ALI) or ARDS diagnosed with the earlier definition., Results: Patients were categorized according to the two definitions, as follows: ALI, 36; ARDS, 185 (for the American-European Consensus Conference (AECC) definition); mild, 36; moderate, 97; severe ARDS, 88 (for BD). Mortality (13.9 % for mild ARDS; 11.3 % for moderate ARDS; 25 % for severe ARDS, p = 0.04) and the composite outcome extracorporeal membrane oxygenation (ECMO)/mortality (13.9 % for mild ARDS; 11.3 % for moderate ARDS; 28.4 % for severe ARDS, p < 0.01) were different across the BD classes, whereas they were similar using the previous definition. Mortality [HR 2.7 (95 % CI 1.1-7.1)] and ECMO/mortality [HR 3 (95 % CI 1.1-7.9)] were increased only for the severe ARDS class and remained significant after adjustment for confounding factors. PICU stay was not different across severity classes, irrespective of the definition used. There was significant concordance between raters evaluating radiographs [ICC 0.6 (95 % CI 0.2-0.8)] and risk factors [ICC 0.92 (95 % CI 0.8-0.97)]., Conclusions: BD validity for children is similar to that already reported in adults and mainly due to the introduction of a "severe ARDS" category. We provided clinical tools to use BD for clinical practice, research, and health services planning in pediatric critical care.

Preterm infants with RDS need adequate resuscitation maneuvers and appropriate timing of surfactant replacement but about the latter there is not an universal consensus. A correct evaluation should consider at the same time the administration of antenatal steroids, the radiological criteria, the clinical presentation, the FiO2 level, OI and a/ApO2.

Objective: To understand the risk factors for respiratory distress syndrome (RDS) by comparing the perinatal conditions of preterm infants with different severities of RDS., Methods: A total of 667 preterm infants with RDS were classified into 4 groups according to the chest X-ray severity: grade I (217 cases), grade II (225 cases), grade III (126 cases) and grade IV (99 cases). The perinatal conditions of the preterm infants were reviewed retrospectively., Results: There were no significant differences in the gender, the percentage of twins, the percentage of the younger one in twins, maternal age, the percentage of using antenatal corticosteroids, the percentage of premature rupture of membranes, the percentage of placental abruption, the delivery mode and the fertilization mode in preterm infants with different severities of RDS. With the increasing severity of RDS, the birth weight and the gestational age decreased, and the percentage of the infants with Apgar score ≤7 or maternal pregnancy-induced hypertension increased (P<0.05)., Conclusions: The severity of RDS is related to gestational age, birth weight and perinatal asphyxia in preterm infants.

We report on 12 near-term babies from three families in which an unexplained transient respiratory distress was observed. No known risk factor was present in any family and no sequelae were recorded at follow-up. The most common causes of respiratory distress at birth are Neonatal Respiratory Distress Syndrome (NRD) and Transient Tachypnea of the Newborn (TTN), and their cumulative incidence is estimated to be about 2%. Genetic factors have been identified in NRD (surfactant genes) or suggested for TTN (genes affecting lung liquid clearance). Survivors from NRD may develop clinically relevant sequelae, while TTN does not cause any problem later in life. Our cases do not immediately fit NRD or TTN, while familial recurrence suggests the existence of a previously unreported subgroup on patients with respiratory distress for which autosomal-recessive inheritance is likely.

The prognosis in acute respiratory distress syndrome (ARDS) is poor; its mortality is generally 40-60%. The mortality in patients with ARDS is more commonly associated with the sequels of sepsis and multiple organ dysfunction than with respiratory failure although the latest papers on protective ventilation suggest that death in these patients directly results from lung lesion in a number of cases. There have been encouraging data on the reduced mortality rates due to acute lung lesion/ARDS in the past decade. The development and introduction of new technologies of respiratory support, the emergence of new effective treatments for sepsis, and the improvement of general maintenance therapy in patients with ARDS may be a possible explanation for such changes for the best.

Interstitial pneumonia is a rare disease, posing a diagnostic challenge to pneumologists, pediatricians, radiologists and pathologists. Only by the combined efforts of the European Respiratory Society (ERS) and the American Thoracic Society (ATS) has has been possible to standardize the formerly different European and Northern American nomenclature of interstitial lung diseases (alveolitis versus interstitial pneumonia) in adults and to clearly and unambiguously define the diagnostic criteria. The ATS/ERS classification of 2002 comprises seven entities: usual interstitial pneumonia (UIP), non-specific interstitial pneumonia (NSIP), desquamative interstitial pneumonia (DIP), respiratory bronchiolitis-associated interstitial lung disease (RB-ILD), cryptogenic organizing pneumonia (COP), lymphocyte interstitial pneumonia (LIP), and acute interstitial pneumonia (AIP). Using the ATS/ERS classification of interstitial pulmonary diseases in premature infants, infants and children is problematic, since UIP, RB-ILD and AIP do not occur at this age. Although infants with severe respiratory insufficiency may sometimes show morphological features similar to DIP or NSIP, this entity should rather be classified as chronic pneumonitis of infancy (CPI) because of differences in etiology, pathogenesis and prognostic outcome.

Objective: To determine changes in peri- and neonatal care concerning neonatal mortality and morbidity by comparing 2 cohorts of very prematurely born infants (gestational age [GA] <32 weeks), 1 from the 1980s and 1 from the 1990s., Methods: The Leiden Follow-Up Project on Prematurity (LFUPP-1996/97), a regional, prospective study, includes all infants who were born alive after a GA <32 weeks in 1996 and 1997 in the Dutch health regions Leiden, The Hague, and Delft. The Project On Preterm and Small for Gestational Age Infants (POPS-1983), a national, prospective study from the presurfactant era, includes all liveborn infants <32 weeks' GA and/or <1500 g from 1983 (n = 1338). For comparison, infants from the POPS-1983 cohort with a GA <32 weeks from the same Dutch health regions were selected (n = 102)., Results: The absolute number of preterm births in the study region increased by 30%: 102 in 1983 to on average of 133 in 1996-1997. Centralization of perinatal care improved: the percentage of extrauterinely transported infants decreased from 61% in 1983 to 35% in 1996-1997. A total of 182 (73%) of the LFUPP-1996/97 infants were treated antenatally with glucocorticosteroids compared with 6 (6%) of the POPS-1983 infants. A total of 112 (42%) of the LFUPP-1996/97 infants received surfactant. In-hospital mortality decreased from 30% in the 1980s to 11% in the 1990s. Mortality of the extremely preterm infants (<27 weeks) decreased from 76% to 33%. The incidence of respiratory distress syndrome remained the same: approximately 60% in both groups. Mortality from respiratory distress syndrome, however, decreased from 29% to 8%. The incidence of bronchopulmonary dysplasia increased from 6% to 19%. For the surviving infants, the average length of stay in the hospital and the mean number of NICU days stayed approximately the same ( approximately 67 days total admission time and 44 NICU days in both groups); including the infants who died, the mean NICU admission time increased from 27 days in the 1980s to 41 days in the 1990s. Equal percentages of adverse outcome (dead or an abnormal general condition) at the moment of discharge from hospital were found (+/-40% in both groups)., Conclusions: An increase in the absolute number of very preterm births in this study region was found, leading to a greater burden on the regional NICUs. Improvements in peri- and neonatal care have led to an increased survival of especially extremely preterm infants. However, increased survival has resulted in more morbidity, mainly bronchopulmonary dysplasia, at the moment of discharge from the hospital.

A total of 96 patients with respiratory failure who required mechanical ventilation admitted to the PICU, Chulalongkorn Hospital from July 1998 to June 1999 were reviewed to evaluate the PRISM score for mortality prediction and to identify factors that might influence the outcome. The statistical difference in outcome between the 2 groups (survivors and non-survivors) were underlying diseases, age, maximum positive inspiratory pressure (PIP), maximum positive end expiratory pressure (PEEP), maximum fractional inspiratory oxygen (FiO2) and PRISM score (p < 0.05). However, based on the original logistic regression equation, the predicted mortality from PRISM score in our study was much lower than our actual mortality (2.4% vs 26.0%). The sensitivity and specificity of mortality predicted by PRISM score calculated at cut-off r = 0.0 (expected mortality = 50%) was 4 per cent and 97 per cent respectively. In conclusion, the original PRISM score underpredicted the mortality outcome in our patients with respiratory failure. This suggests that PRISM score is population dependent and should be modified before being used with our patients.

Background: Inhaled nitric oxide improves oxygenation and lessens the need for extracorporeal-membrane oxygenation in full-term neonates with hypoxaemic respiratory failure and persistent pulmonary hypertension, but potential adverse effects are intracranial haemorrhage and chronic lung disease. We investigated whether low-dose inhaled nitric oxide would improve survival in premature neonates with unresponsive severe hypoxaemic respiratory failure, and would not increase the frequency or severity of intracranial haemorrhage or chronic lung disease., Methods: We did a double-blind, randomised controlled trial in 12 perinatal centres that provide tertiary care. 80 premature neonates (gestational age < or = 34 weeks) with severe hypoxaemic respiratory failure were randomly assigned inhaled nitric oxide (n=48) or no nitric oxide (n=32, controls). Our primary outcome was survival to discharge. Analysis was by intention to treat. We studied also the rate and severity of intracranial haemorrhage, pulmonary haemorrhage, duration of ventilation, and chronic lung disease at 36 weeks' postconceptional age., Findings: The two groups did not differ for baseline characteristics or severity of disease. Inhaled nitric oxide improved oxygenation after 60 min (p=0.03). Survival at discharge was 52% in the inhaled-nitric-oxide group and 47% in controls (p=0.65). Causes of death were mainly related to extreme prematurity and were similar in the two groups. The two groups did not differ for adverse events or outcomes (intracranial haemorrhage grade 2-4, 28% inhaled nitric oxide and 33% control; pulmonary haemorrhage 13% and 9%; chronic lung disease 60% and 80%)., Interpretation: Low-dose inhaled nitric oxide improved oxygenation but did not improve survival in severely hypoxaemic premature neonates. Low-dose nitric oxide in the most critically ill premature neonates does not increase the risk of intracranial haemorrhage, and may decrease risk of chronic lung injury.

The investigation was designed to study the impact of respiratory disturbances on the level of glucose in premature infants who, on being born, had a very low body mass. The results obtained showed that blood concentration of glucose in children against the background of respiratory distress is variable. Hypoglycemia often develops irrespective of the degree of respiratory distress but long-continued episodes of low blood glucose are common in severe degree of the condition. With aggravation of respiratory failure resulting in abnormalities of metabolism, particularly that of complicated by generalized infection, extensive intracranial hematomas, there is much probability that hyperglycemia will develop. For the neonates, who, on being born, have a very low body mass, particularly so in the presence of severe respiratory disorders, it is necessary that an hour-to-hour monitoring be conducted of blood glucose levels in order that we might correct possible disturbances in an adequate and timely fashion.

Objective: To determine whether early versus late treatment with porcine surfactant (Curosurf) reduces the requirement of mechanical ventilation in very preterm infants primarily supported by nasal continuous positive airway pressure (nasal CPAP)., Design: Multicenter randomized, controlled trial., Patients: The study population comprised 60 infants <30 weeks' gestation with respiratory distress syndrome (RDS) who had an arterial to alveolar oxygen tension ratio (a/APO2) of 0.35 to 0.22. The cohort from which the study population was generated comprised 397 infants., Results: The need for mechanical ventilation or death within 7 days of age was reduced from 63% in the late-treated infants to 21% in early-treated infants. Increasing numbers of antenatal steroid doses also improved the outcome, especially in the early-treated infants. Six hours after randomization mean a/APO2 rose to 0.48 in the early-treated infants compared with 0.36 in the late-treated. The need of mechanical ventilation before discharge was reduced from 68% in the late-treated to 25% in the early-treated infants., Conclusions: Nasal CPAP in combination with early treatment with Curosurf significantly improves oxygenation and reduces the subsequent need for mechanical ventilation in infants <30 weeks' gestational age with RDS.

Neonatal respiratory distress is a common problem confronting family physicians. Although respiratory distress may represent a benign, self-limited process, it may also be the first sign of sepsis or serious cardiopulmonary disease. Because it is crucial to differentiate the two, we offer a practical approach to the treatment of neonatal respiratory distress at community hospitals. Our method, the Rule of 2 Hours, is based on readily accessible clinical findings. We believe it will help physicians detect babies at risk for serious problems, but will not result in unnecessary referral of neonates that are simply adapting to extrauterine life.

In Japan, chronic lung disease (CLD) is defined as an oxygen requirement greater than that obtainable in room air at 28 days of age, with symptoms of persistent respirator distress and a hazy or emphysematous and fibrous appearance upon chest x-ray. A total of 4964 infants weighing less than 1500 g at birth and born in 1990 were admitted to and cared for at level II and III neonatal care centers in Japan. A total of 4293 infants (86.3%) survived at 28 days after birth. Analyses of infants who developed CLD through their preceding illnesses and chest x-ray findings resulted in the classification of CLD into six types. Types I and II are defined as CLD following the acute stage respiratory distress syndrome (RDS). Type I is the typical case of bronchopulmonary dysplasia (BPD) as described previously, whereas Type II shows atypical radiological findings, namely only diffuse haziness without typical emphysema and fibrosis. Type III has a history of intrauterine inflammation. Chest x-ray shows the typical bubbling and cystic appearance described in the original report of Wilson-Mikity syndrome or neonatal pulmonary emphysema in the very low birth weight infant. Type III also has atypical radiological findings in cases with intrauterine infection. Type IV does not have a history of either intrauterine inflammation or RDS but shows typical emphysematous and fibrous appearance upon chest x-ray. Type V includes those with atypical chest x-ray appearance similar to Type II but without history of RDS and intrauterine inflammation. CLD is a heterogeneous condition which shows different spectra. However, the cardinal event is common to all types--the excessive inflammatory response caused by various insults to the immature airways and alveoli, such as oxygen, barotrauma, infection and so on. The excessive inflammatory response leads to lung tissue damage and the abnormal healing process due to immaturity, (such as vitamin A deficiency and insufficient oxygen radical scavenging system) and results in dysplasia and metaplasia of the respiratory system. The treatment of respiratory distress due to CLD also acts as an insult to the lungs and thus forms a vicious cycle. The different spectra of the disease are most possibly attributed to the difference in the timing and the kind of insults to the lungs. In Type I and II CLD, the insults are given in the first hours of life when the infants with surfactant deficiency receive high concentrations of oxygen for stabilization before the surfactant replacement. In Type III and III' CLD the insults are most likely given before birth. Excessive and sustained inflammatory response in the lungs with different onset times may result in the development of Type IV and V CLD. The strategy for the prevention of CLD should be different according to the origins and causes. The prevention of Type I and II CLD, or CLD following RDS, should be accomplished by successful prophylactic surfactant replacement therapy. Another procedure may be the application of high frequency oscillatory ventilation (HFOV) in the acute stage of RDS or at the time of stabilization right after birth. Types III and III' CLD present the most difficult challenge for prevention strategy because the disease process already started before birth. At the moment there are no effective measures for prevention. The strategy for the prevention of Type IV and V CLD may reside in the early detection and treatment of patent ductus arteriosus, sepsis and airway infection including pneumonia.

Objective: To determine whether number and activation of circulating polymorphonuclear leukocytes (PMNs) and platelets are associated with disease severity in neonatal respiratory distress syndrome (RDS)., Design: Prospective study., Setting: Tertiary neonatal intensive care unit., Patients: Preterm infants with severe (n = 18) or mild to moderate (n = 18) RDS who were consecutively admitted., Interventions: PMN and platelet counts and plasma concentrations of elastase-alpha1-proteinase inhibitor (E-alpha1-PI) and thromboxane B2 (TxB2) were recorded each day during the first 5 days of life. E-alpha1-PI-to-PMN and TxB2-to-platelet ratios were calculated to correct for the influence of the PMN and platelet count on elastase and thromboxane release., Results: From day 2, the severe RDS group had lower median PMN counts (1.5 vs 4.5 x 10/L), lower mean platelet counts (136 vs 230 x 10/L), and more elastase and thromboxane release, indicated by higher median E-alpha1-PI-to-PMN (39.2 vs 13.0 ng/10 PMNs on day 2) and TxB2-to-platelet (2.61 vs 0.52 pg/10 platelets on day 3) ratios than the mild-to-moderate group. Lower PMN and platelet counts and higher elastase and thromboxane release were correlated with birth asphyxia (lower 5-minute Apgar scores and umbilical arterial PH values), higher respiratory requirements (fraction of inspired oxygen and peak inspiratory pressure), and decreased values for continuous measures of RDS severity (ventilatory efficiency index and PaO2-to-alveolar oxygen tension ratio)., Conclusion: Decreased PMN and platelet counts and increased elastase and thromboxane release are correlated with increased RDS severity. Birth asphyxia (hypoxia and acidosis) and tissue injury caused by high-pressure ventilation and hyperoxia may promote this activation process.

This report describes the neonatal outcomes of 1765 very low birth weight (less than 1500 g) infants delivered from November 1987 through October 1988 at the seven participating centers of the National Institute of Child Health and Human Development Neonatal Intensive Care Network. Survival was 34% at less than 751 g birth weight (range between centers 20% to 55%), 66% at 751 through 1000 g (range 42% to 75%), 87% at 1001 through 1250 g (range 84% to 91%), and 93% at 1251 through 1500 g (range 89% to 98%). By obstetric measures of gestation, survival was 23% at 23 weeks (range 0% to 33%), 34% at 24 weeks (range 10% to 57%), and 54% at 25 weeks (range 30% to 72%). Neonatal morbidity included respiratory distress (67%), symptomatic patent ductus arteriosus (25%), necrotizing enterocolitis (6%), septicemia (17%), meningitis (2%), urinary tract infection (4%), and intraventricular hemorrhage (45%, 18% grade III and IV). Morbidity increased with decreasing birth weight. Oxygen was administered for greater than or equal to 28 days to 79% of less than 751-g birth weight infants (range between centers 67% to 100%), 45% of 751- through 1000-g infants (range 20% to 68%), and 13% of 1001- through 1500-g infants (range 5% to 23%). Ventilator support for greater than or equal to 28 days was given to 68% of infants at less than 751 g, 29% at 751 through 1000 g, and 4% at greater than 1000 g. Hospital stay was 59 days for survivors vs 15 days for infants who died. Sixty-nine percent of survivors had subnormal (less than 10th percentile) weight at discharge. The data demonstrate important intercenter variation of current neonatal outcomes, as well as differences in philosophy of care and definition and prevalence of morbidity.

The hemodynamics and patency of ductus arteriosus (PDA) in 51 infants were examined clinically and by echocardiography during the first or second day of life. Gestational ages ranged from 27 to 41 wk (34.0 +/- 3.6); birth weights ranged from 1070 to 4320 g (2256 +/- 923). Ductal flow was apparent by Doppler echocardiography in 24 of 51 infants but clinical examination disclosed only nine of these. Ultrasound is superior to clinical examination in diagnosing both symptomatic and asymptomatic PDA. Doppler ultrasound has the additional advantage of evaluating the size and relative importance of the ductal flow.

The initial chest radiograph obtained in infants with idiopathic respiratory distress syndrome was evaluated in relation to the clinical and biochemical status of the infant as well as to the prognosis. In 101 neonates a statistically significant correlation was demonstrated.

Cytopathologic examinations of tracheobronchial aspirates from 108 infants sampled during mechanical ventilation demonstrated a well-defined progression of cytologic changes in bronchial cells that could be divided into three classes. Seventy percent of infants with respiratory distress syndrome who developed bronchopulmonary dysplasia had pulmonary effluent cytology designated Class III; no infants with RDS but without BPD had these cytologic findings. Additionally, a temporal progression of events involving polymorphonuclear leukocyte and macrophage populations occurred in the absence of infection; these events were associated with duration of assisted ventilation and oxygen exposure. The technique described provides a useful way to monitor the progression of lung injury and repair and offers a cytologic method to predict and diagnose the development of bronchopulmonary dysplasia.

In 46 preterm infants with RDS the patency of the ductus arteriosus was established by single film aortography or by clinical diagnosis and confirmation at surgery. The estimated left-to-right shunt through the PDA by aortogram correlated well with the heart size and the clinical diagnosis of heart failure. In 14 infants massive cardiomegaly and heart failure with a PDA occurred before the appearance of a heart murmur. Twelve infants had severe RDS and 34 had mild or moderate RDS. Massive cardiomegaly occurred significantly earlier in infants with severe RDS. It is suggested that ductal ligation is indicated when an infant with massive cardiomegaly requires IPPV and whose aortagram shows that all of the contrast material is in the pulmonary arteries and none in the aortic arch. A heart murmur may or may not be present.

To test the hypothesis that intarpartum acidosis has a role in the etiology of hyaline membrane disease (HMD), blood was collected from the umbilical artery (UA) at birth from 110 premature infants and analyzed for hydrogen ion concentration ([H+]), PCO2, standard bicarbonate, and lactic acid. The infants were followed until a definite diagnosis was made of HMD (33 infants), type II respiratory distress syndrome (16 infants) or the absence of respiratory distress (61 infants). In general, infants with HMD were more premature and had lower Apgar scores than nondistressed infants; however, there were no significant differences between the two groups in any acid-base measurement. Only in those patients of 32 to 37 weeks' gestational age was it possible to detect a significant increase in UA [H+] in infants with HMD compared to those without respiratory distress. There was evidence that the reduced Apgar score of infants with HMD may be due to immaturity and abnormal pulmonary function secondary to lung disease. It is concluded that acidosis at birth is not a factor in the development of HMD except possibly in more mature infants.

A scoring system was developed to predict the need for transferring infants with respiratory distress syndrome (RDS) from community hospitals to specialized respiratory care centers. Five clinical and laboratory determinations (birthweight, clinical RDS score, FI02, PCO2 and pH) recorded from 100 infants with RDS during one year were utilized in a score with values ranging from 0 to 10. Application of the score to 159 infants with RDS during the following year showed that: (1) 73 per cent of infants scoring less than or equal to 3 received only oxygen by hood; (2) 75 per cent of infants scoring 4--5 required continuous positive airway pressure (CPAP); and (3) 87 per cent of infants scoring greater than or equal to 6 needed mechanical ventilation (7V). Mean scores were significantly different (p less than 0.02) for each type of respiratory therapy employed: oxygen by hood (2.30 +/- 0.19 S.E.M.); CPAP (4.27 +/- 0.16 S.E.M.); MV (6.72 +/- 0.25 S.E.M.). The accuracy and simplicity of the score make it valuable for the physician in the community hospital to assist in deciding when to transfer a neonate with RDS for more intensive respiratory therapy.

Clinical and radiological classifications of the severity of the respiratory distress syndrome (RDS) were made in 55 infants. According to the clinical classification 17 infants belonged to the first class (mild RDS), 22 to the second (moderate RDS), and 16 to the third class (severe RDS). In the classification based on radiological findings the numbers of infants in classes 1, 2 and 3 were 18, 19 and 18 respectively. On the basis of both the clinical and radiological findings, 11 infants belonged to the mild RDS class, 11 to the moderate, and 12 to the severe RDS class. Thus, 34 infants had the same clinical and radiological classification. In 21 infants there were discrepancies between the clinical and the radiological classifications, but only one infant with the most severe radiological findings belonged to the mild RDS class and only one infant with mild radiological findings belonged to the worst RDS class.