CLASSIFICATION OF ACUTE RESPIRATORY DISORDERS
Experience suggests that many newborn infants with acute respiratory disorders do not fit classic diagnostic patterns. There also is considerable variation among authors about which particular diagnostic criteria should be relied upon to define common disorders, such as respiratory distress syndrome (RDS), also known as hyaline membrane disease (HMD). In 1962, Miller classified patients having RDS based on oxygen therapy, grunting, and respiratory rate but used no radiographic criteria for diagnosis, despite the fact that Donald and Steiner had described the reticulogranular or ground glass pattern now regarded as the “classic” radiographic picture of RDS in 1953. In a review of 39 pediatric and neonatology textbook and articles in 1991, Teji and David found the presence of a reticulogranular pattern on chest film the most widely agreed upon criterion for establishing the diagnosis of RDS, with 70% of authors in agreement.Clearly, diagnostic criteria evolve over time with our understanding of the features, pathophysiology and treatment of diseases.
In 1981, Hjalmarson carried out what has become the definitive study of clinical respiratory epidemiology in the newborn. He evaluated a population of 32,281 infants born at 12 Swedish hospitals, classifying all 931 infants with respiratory findings. He used early onset of illness, a reticulogranular pattern on chest x-ray and clinical deterioration (increasing 02 requirement) to define RDS. Disease patterns have changed over the intervening years, however. With the introduction of surfactant, the clinical course and radiographic findings of RDS have been dramatically altered. The chest film may clear up rapidly and worsening of disease may not be seen. Similar changes have occurred in other groups of patients. In Hjalmarson’s study, many of the smallest infants died from prematurity and respiratory failure without meeting the diagnostic criteria for RDS. He called this entity “Immaturitas pulmonum.” Many of these infants survive these days, often after receiving surfactant. The disease course and outcome has changed for many diseases over the past two decades and, hence, there is a need to reevaluate the subject.
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Few authors have tried to apply Hjalmarson’s classification, and to our knowledge none has tried to appraise these criteria in the current context. In the present study we attempted to replicate Hjalmarson’s work of classifying all newborns with any evidence of respiratory disturbance in the first day of life. We used a modified set of diagnostic criteria based on current sources and analyzed all births at a tertiary center over one year.
