NEW YORK (Reuters Health) – Experts have issued the first specific definition for neonatal acute respiratory distress syndrome (ARDS), the Montreux definition, with the endorsement of the European Society of Neonatal Intensive care and the European Society for Paediatric Research.
“There has been no official recognition of neonatal ARDS so far,” Dr. Daniele De Luca from GHU Paris Sud-APHP and South Paris University told Reuters Health by email. “Most physicians ignore it. Thus, it is not even diagnosed, and the biology/physiopathology behind it is ignored: this prevents correct clinical management and research.”
ARDS was originally reported in 1967, and a consensus definition emerged in 1994. The definition of pediatric ARDS came later.
Dr. De Luca and a panel of experts in neonatal, pediatric, and adult respiratory critical care describe the Neonatal ARDS Project and provide details of their consensus Montreux definition in their July 4 Lancet Respiratory Medicine online position paper.
Similar to older children and adults, neonatal ARDS is characterized by extensive lung inflammation and surfactant catabolism leading to lung dysfunction.
Although the Montreux definition of neonatal ARDS closely resembles the definition of ARDS in patients of other ages, it has several distinguishing features. First, the definition applies to infants from birth until 44 weeks post-menstrual age or four weeks postnatal age. Beyond that age, ARDS should be diagnosed using the definition for pediatric ARDS.
Second, conditions specific to the neonatal period – congenital anomalies, genetic disorders of the surfactant system, respiratory distress syndrome and transient tachypnea of the neonate – represent exclusion criteria.
Third, congenital heart disease should be ruled out as an explanation for pulmonary edema.
The Montreux definition uses the same oxygenation index (OI) concentrations as in the pediatric definition to simplify the evaluation and diagnosis of mild, moderate, and severe ARDS across the pediatric ages.
All criteria in the definition must be fulfilled to make the diagnosis of neonatal ARDS.
“ARDS does exist in neonates!” Dr. De Luca said. “There are indeed peculiarities, but the main biology and physiology are the same. The Montreux definition takes into account neonatal peculiarities and links them with the critical respiratory physiology from adult and pediatric worlds.”
“Neonatologists need to know physiological principles of respiratory critical care to manage correctly these cases,” he concluded.
Dr. Kanwaljeet J. S. “Sunny” Anand from Stanford University School of Medicine, Stanford, California told Reuters Health, “Clinicians who practice in the NICU (or other ICUs that admit newborns) should start applying this definition to their patient populations right away. In addition, they should strictly apply the severity criteria defined by the oxygenation deficit (expressed as OI) to individual patients, so that the natural history and epidemiology of neonatal ARDS can be defined clearly in the near future.”
“Researchers that are studying the various conditions that cause respiratory failure in newborns should also apply this definition right away, so that the pathophysiology and outcomes of neonatal ARDS can be differentiated from those other neonatal diseases associated with respiratory failure,” he said in an email.
“In keeping with the old adage that ‘children are not small adults,’ pediatric intensivists and other pediatric specialists would be well-served to always remember that ‘newborns are not tiny children,’” Dr. Anand said. “This distinction is something that I have taught and advocated for over the past 30-plus years, and all the accumulating evidence to date seems to have supported my perspective.”
“Why limit the definition of neonatal ARDS to only 44 weeks post-menstrual age (PMA) or 4 weeks of postnatal age?” he added. “There is nothing magical that happens at 28 days or 30 days after full-term birth, to announce that this infant is no longer a newborn! Moreover, at least in the U.S. and also in Europe, many of the infants who still require intensive care after 44 weeks PMA will continue to be cared for in the Neonatal Intensive Care Unit; they are only transferred to the Pediatric ICU if there is a shortage of NICU beds. I suggest, therefore, that the authors allow the pathophysiological features of neonatal ARDS to define the upper age limit at which this definition will no longer be applicable.”
SOURCE: http://bit.ly/2uuwOHW
Lancet Respir Med 2017.
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