EuropeanJournalof

Eur. J. Pediatr. 130, 271--278 (1979)

Pediatrics
9 by Springer-Verlag 1979

Comparison
Between Clinical and Radiological Classifications
of Infants with the Respiratory Distress Syndrome (RDS)

P. O. Kero 1* and E. O. M~ikinen 2

Departments of Pediatrics 1, Radiology 2 and Cardiorespiratory Research Unit,
University of Turku, 20520 Turku 52, Finland

Abstract. Clinical and radiological classifications of the severity of the re-

spiratory 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.
Key words: Respiratory distress syndrome - Clinical classification - Radio-
logical classification.

Clinical and Radiological Classification of RDS Infants

The respiratory distress syndrome (RDS) is still one of the main problems in
premature infants, although the mortality from this disease has decreased dra-
matically during the past few years [6]. The treatment in RDS consists of both
prevention and active therapy of the disease [2, 8, 16]. The results, however, vary
greatly from one hospital to another in spite of the same treatment regimes. One
reason for this is that different criteria for grading the syndrome are applied.
Comparing results is of no use if there is no standard method for assessing the
severity of the disease.
One of the most useful single diagnostic aids in RDS is the chest roentgeno-
gram [4, 5]. Radiological examination of the chest in an infant with respiratory

* Corresponding author

0340-6199/79/0130/0271/$ 01.60
272 P.O. Kero and E. O. Mgkinen

difficulties is a prerequisite in the detection of c o n d i t i o n s requiring immediate

surgical therapy. M o d e r n t h e r a p y in R D S often consists of nasotracheal in-
t u b a t i o n , C P A P a n d respiratory t h e r a p y [7, 11]; in these cases the position of the
i n t u b a t i o n tube is checked a n d m a n y possible complications, such as p n e u m o -
thorax, are detected by X-ray. The p u r p o s e of this study was to describe a clinical
classification of the severity of R D S a n d c o m p a r e it with the a n a l o g o u s radio-
logical classification of RDS.

Material and Methods

The material included 55 patients, who started to have respiratory difficulties shortly after birth.
Most of them had difficulty in initiating normal respiration and therefore needed neonatal
intensive care. Infants with the meconium aspiration syndrome or 'Wet Lung Disease' were
excluded.

Criteria for the Diagnosis of RDS

The diagnosis of respiratory distress syndrome was based on the following criteria:
1. Respiration rate > 60/rain or apnea
2. Chest retraction
3. Expiratory grunting
4. Cyanosis in spite of oxygen administration
5. Radiological findings (reticulo-granular infiltration throughout the lungs, air bronchogram).
The average birth weight of the infants studied was 2200 g and the mean gestational age
33weeks (Table 1).

Table 1. Classification of the infants on the basis of their gestational age and birth weight

Gestationalage No. % Birth weight No. %

(weeks) of cases (g) of cases

Total 55 55
Under 29 7 12.7 Under 1250 7 12.7
29--33 21 38.2 1250--2000 17 30.9
33--37 22 40.0 2000--2500 12 21.8
Over 37 5 9.1 Over 2500 19 34.6

Mean gestation 33 weeks Mean birth weight 2200g

age (range) (26--40 weeks) (range) (790--3670)

Table 2. Concomitant clinical data

Clinical data RDS (n = 55) of the RDS infants
infants
Apgar score < 8 at 1 min 23 42%
Respirator therapy 40 73%
Pneumothorax 4 7%
Exchange transfusion 16 29%
Caesarean section 9 16%
Diabetic mothers 5 9%
Died 11 20%
Table 3. Symptoms in the clinical classification of RDS infants

Score Cyanosis Intercostal retraction Rate of breathing Pulmonary auscultation * PaO2, * PCO2, * FiO2

1 point Slight peripheral cyanosis Slight difficulties in 60--80/min G o o d air entry to the lungs PaO2 = 7--10 kPs
breathing and slight PCO2= 6--7 kPs
retraction FiO2 = 21--40%
g
2 points Stationary moderate Moderate difficulties in 81--100/rain Air entry poor with spontaneous PaO2 = 5--7 kPs t~
peripheral cyanosis breathing and retraction Infant in need of breathing. Much whirring and PCO2 = 7--10 kPs
therapy with CPAP fine rales heard FiO: = 4 1 - - 5 0 %

3 points Stationary grey-blue Severe difficulties in Over 100/rain or Air entry poor also with art. PaO2 < 5 kPs
cyanosis also on breathing and retractions, apnea. Respirator ventilation. Superficial PCO2 > 10 kPs ~J
respirator therapy paradoxal breathing therapy spontaneous breathing. Breath FiO2 > 51%
sounds weak

* Worst finding accepted

C P A P = continuous positive airway pressure; kPs = kilopascal; Fi02 = inspirated oxygen concentration (%)

b.a
274 E O. Kero and E. O. Mgkinen

Within our material a birth weight of 1250 g corresponded on average to 29 week's gesta-
tion and 2000g to 33 weeks. The most important clinical data are listed in Table 2.

Clinical Classification of RDS Infants, Groups I, II and III,

on the Basis of the Severity of the Syndrome
All the infants were examined by the author (P. K.) every day during the first five days of life.
The severity of the RDS was estimated every day on the basis of the following clinical para-
meters: cyanosis; sternal and intercostal retraction; rate of breathing and need of therapy with
CPAP or respirator; pulmonary auscultation and the levels of PaO2, PCO2, and FiO2 (Table 3).
To quantify the severity of the disease the following score was designed: for the most severe
symptoms the infant scored 3 points, for moderate symptoms 2 and for very slight symptoms
1 point. In this investigation the infants were divided into three clinical groups (I, II and III)
every day and the final classification was made on the basis of the worst day. The infants who
scored 0--5 points belonged to the first group, the infants who got 6--10 points to the second
group and the rest to the third group.

Radiological Classification of RDS Infants

A chest X-ray was done on all 55 infants on the first day after birth, usually within the first few
hours after delivery. A second X-ray was taken on the third day, often earlier if the clinical
condition deteriorated or if pneumothorax was suspected, and (in the case of intubation) to
estimate the position of the endotracheal tube. On the basis of the chest X-rays the infants were
divided into three categories of severity by the author (E.M.) without prior knowledge of the
clinical history. The criteria for each category [4, 13] are given in Table 4. The worst clinical
findings for each infant were used in the final classification.

Table 4. Criteria in the radiological classification of RDS infants

Class 1. Slight reticulo-granular infiltration due to slight peribronchial atelectasis, mostly in the
central part of the lung field. Air bronchogram present. The peripheral part of the lungs
still normal (Fig. 1)
Class 2. In addition a pattern of alveolar opacification in the air bronchogram confluent
opacification and a dense reticulo-granular pattern making the borders of the heart,
thymus and diaphragm unclear (Fig. 2)
Class 3. Lungs quite airless and an air bronchogram seen in the major parts of the bronchi and
the trachea, or only in the trachea. Impossible to distinguish the borders of the heart,
thymus and diaphragm (Fig. 3)

Results

Clinical Classification
A c c o r d i n g to t h e clinical c l a s s i f i c a t i o n , 17 o f the R D S i n f a n t s b e l o n g e d to the first
class ( m i l d R D S ) , 22 to t h e s e c o n d class ( m o d e r a t e R D S ) a n d 16 to the t h i r d a n d
w o r s t class ( s e v e r e R D S ) . T h e m e a n b i r t h w e i g h t was 2 2 0 0 g f o r all 55 R D S
i n f a n t s . I n t h e m i l d class it w a s 2076 g, in the m o d e r a t e class 2576 g a n d in the
s e v e r e class 1 8 1 5 g ( T a b l e 5).
Respiratory Distress Syndrome (RDS) 275

Fig. 1. R D S class 1. An air bronchogram is seen in the central part of the lung fields (q'). A very
slight reticulo-granular pattern is also seen due to alveolar atelectasis

Fig. 2. R D S class 2. Confluent opacification and dense reticulo-granular patterns make the
borders of the heart (thymus) and diaphragm (t) unclear, but in the X-ray they are still clearly
distinguished from the lung parenchyma

Fig. 3. R D S class 3. The borders of the diaphragm (I") are mostly undistinguishable. The lungs
are quite airless. An air bronchogram (?) is seen in the proximal parts of the bronchi
276 R O. Kero and E. O. M~ikinen

Table 5. Clinical classification of the infants

Group and score Group I Group II Group III Total No.

(0--5) (6--10) (11--15) of infants
Number of cases 17 22 16 55
Mean birth weight 2076 g 2576 g 1815 g 2200 g
Mean gestational age 33 weeks 34 weeks 31 weeks 33 weeks

Table 6. Comparison between clinical and radiological classes

Clinical class Radiological class Total No.

of infants
1 2 3

I 11 5 I 17
II 6 11 5 22
III 1 3 12 16

Total 18 19 18 55

Radiological Classification
On the basis of the radiological classification, 18 of the infants belonged to the
first class, 19 to the second class and 18 to the third class (Table 6). The
comparison between the clinical and the radiological classification is shown in
Table 6. Quite a number of infants belonged to different classes according to
these two classification systems, but there were only two infants who differed by
more than one class. One infant was clinically in a very serious condition (third
class), but the radiological findings were small. This infant, whose birth weight
was 3050 g, had severe asphyxia during delivery and perhaps this explains the
discrepancy between the classifications. The other infant was in quite a good
condition clinically (first class), but the X-ray findings were very severe. This
infant had a possible pulmonary infection and this made it difficult to classify the
infant radiologically. In 34 (62%) of the 55 RDS infants the clinical and the
radiological classifications agreed.

Classification in the Different Weight Groups

The birth weight for 8 infants was below 1250g, for 15 infants from 1250 to
2000 g and for 32 infants over 2000 g (Table 1). The classification on the basis of
clinical and radiological findings showed that in the group with birth weights
under 1250g, 6 (75%) of the 8 infants belonged to the same class. In the group
with birth weights of 1251--2000g, 1(~ (67%) of the 15 infants belonged to the
same class and in the group over 2001 g, 18 (56%) of the 32 infants belonged to
the same class. A m o n g the infants who died (11 cases) only 6 (55%) infants
belonged to the same class.
Respiratory Distress Syndrome (RDS) 277

Discussion

Necessity for Classifying RDS Infants

During the past 10 years the prognosis for RDS infants has improved markedly
due to modern treatment [12]. On the other hand trials with antepartum treat-
ment for the prevention of RDS in premature infants have also been carried out
[2, 8, 10, 16]. When comparing the results in different hospitals, it is necessary to
use the same standard criteria for the syndrome and its severity. RDS is not a
single disease entity but a syndrome and it is not wise to compare mild and very
severe RDS with one another. A system of classifying RDS infants on the basis of
the heart rate variation in infants with RDS has been tried out [9]. However, this
system requires a computer and is not yet feasible for routine clinical work.
In the present study a trial was made of dividing RDS infants into three
clinical classes on the basis of the severity of the RDS. A new clinical classifi-
cation system was used (Table 4) since no other system takes the modern treat-
ment used in RDS into account. Criteria for a radiological classification of the
severity of RDS have been used before [3, 13, 14, 17, 19], but the number of classes
varies from 3 to 7 [3, 13]. We have chosen a system with mild, moderate and
severe groups as this is useful for clinical work as well.
The purpose was to compare these two systems with each other and the results
show that the two systems correspond reasonably well. Thirty four RDS infants
were classified to belong to the same class by the clinical and the radiological
scoring systems. When studying the feasibility of a classification into different
weight groups, it was found that most of the infants weighing under 1250g
belonged to the same class on the basis of both the clinical and the radiological
classification (there were only eight infants in this group). In the group of infants
weighing 1250--2000 g the infants appeared to be better clinically than they were
according to the radiological classification, but in the group of infants weighing
over 2000 g the situation was reversed. The reason for this is not clear, but we can
speculate that in the bigger infants pulmonary maturity is further developed than
in the smallest infants and the cause of the RDS lies perhaps more in hypo-
perfusion of the pulmonary circulation, rather than in deficiency of surfactant.
Minor shifts from one class to the neighbouring class can also be due to other
conditions in addition to the RDS, such as severe asphyxia during the labour.
G r o u p B Streptococcus pneumonia and Wet Lung Disease must also be taken
into consideration in the differential diagnosis [1,3, 15, 18].
We still have no good criteria for the severity of the syndrome. However, the
prognosis and possible etiology are quite different in infants with slight RDS and
in infants with severe RDS. The estimation of the severity of the disease with the
criteria used is of course quite subjective. In different hospitals, for example, the
criteria for intubating the infant differ and the management of during labour and
subsequent treatment of the infants varies. In spite of this, the prognosis can be
predicted on the basis of the severity of the RDS. It is necessary to have standard
criteria for the severity of RDS and this study provides a clinical and a
radiological classification ranging from mild RDS to moderate and severe RDS.
278 E O. Kero and E. O. Mfikinen

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Received July 14, 1978