120 not treated (6 lethal anomalies, 10 overwhelming pulmonary hypoplasia, 3 prerepair ECMO-related neurocomplications), 84.4% survived to discharge. A total of 67/120 were
inborn. Non-ECMO ancillary treatments had no impact on
survival rate. ECMO was used in 13.3%. Surgery was transabdominal; prosthetics were used in 7%. Tube thoracostomy
was rare. Every inborn patient (n 11) requiring a chest tube
for pneumothorax died. Respiratory support before surgery
was peak inspiratory pressure (PIP), 22, FIO2, .43 with PaO2, 66
torr; PaCO2, 41 torr; and pH, 7.32. The survivors discharged on
oxygen (n 2) died at 4 and 7 months.
357
From the Childrens Hospital of New York, Divisions of Neonatology and Surgery, New York Presbyterian Hospital and Columbia
University, College of Physicians and Surgeons, New York, NY.
Presented at the 32nd Annual Meeting of the American Pediatric
Surgical Association, Naples, Florida, May 20-23, 2001.
Sponsored in part by The Charles Edison Fund and The Anya Fund.
Address reprint requests to Jen-Tien Wung, MD, Childrens Hospital
of New York, Room BHN 1201, 3959 Broadway, New York, NY 10032.
Copyright 2002 by W.B. Saunders Company
0022-3468/02/3703-0018$35.00/0
doi:10.1053/jpsu.2002.30834
358
BOLOKER ET AL
Study Population
Data from 120 consecutive neonates with CDH admitted between
August 1992 and February 2000 was analyzed retrospectively with
approval from the institutional review board. All CDH newborns were
included regardless of associated anomalies, degree of pulmonary
hypoplasia, and medical condition at birth or on arrival. All patients
had respiratory insufficiency severe enough to require intubation,
mechanical respiratory support, and supplemental oxygen. Patients
transferred postoperatively were not included.
sufficient included severe paradoxical chest movement, severe retractions, tachypnea, inadequate or labile oxygenation (preductal
SaO2 80%), or PaCO2 greater than 60 mm Hg. In this case, the second
configuration, high-frequency positive pressure ventilation (HFPPV),
was used. To deliver HFPPV, the ventilator was set at an IMV, 100;
inspiratory time, 0.3; gas flow, 10 to 12 L; PIP, 20; and PEEP, 0 (to
account for inadvertent PEEP generated by the short expiratory time).
Respiratory rates between 40 and 100 very rarely were used. For both
configurations, PIP was adjusted as needed based on chest excursion,
with care taken to avoid excessive chest movement. Similarly, for both
modes, attempts were made to limit PIP to 25, though occasionally a
PIP up to 30 was used briefly. A PIP of greater than 30 was used only
when all other advanced ventilation techniques including HFOV and
inhaled iNO means had failed. HFOV (SensorMedics 3100A; SensorMedics, Yorba Linda, CA) was used for hypoxia (preductal saturation
consistently 80%) and/or persistent hypercarbia (pCO2 65) refractory to an adequate trial (usually 30 minutes to 1 hour) of HFPPV.
Oxygen administration was monitored by pulse oximetry, aiming for
a preductal saturation between 90% and 95%, with 80% to 89%
tolerated if the infant appeared comfortable, and other organ function
was stable. Only the minimum supplemental FIO2 was administered to
maintain a preductal saturation within this range. FIO2 was weaned
aggressively to avoid excessive oxygen delivery. Permissive hypercapnia (60 to 65 mm Hg) was accepted as long as the infant appeared
comfortable, with, again, ample time given for stabilization. Infants
never were hyperventilated to induce alkalosis. Pressure and rate were
weaned as oxygenation and pCO2 improved. Babies requiring HFPPV
were weaned directly from a rate of 100 to conventional ventilation at
a rate of 40 as tolerated.
Postoperatively, infants were extubated when they had been weaned
to minimal ventilator support: IMV, 10; PIP, 20; PEEP, 5; and FIO2 less
than 0.4. All were extubated to bubbly nasal continuous positive
airway pressure (CPAP) of 5 cm H2O. CPAP was delivered via the
Hudson CPAP system (Hudson-RCI, Temecula, CA) with flow of 8
L/min provided by blended wall oxygen and positive pressure generated by immersion of the distal expiratory tubing in a bottle of acetic
acid to a depth of 5 cm. Weaning from CPAP was based on oxygen
saturation and clinical assessment of work of breathing.
Medications
After 1994, any infant failing to achieve a stable preductal pO2 of
greater than 80% despite good chest excursions while breathing 100%
oxygen was treated with iNO at 25 ppm, rather than continuing to
increase PIP. From 1992 to 1994, babies with similar hypoxemia were
treated with an intravenous tolazoline bolus of 1 mg/kg followed by a
drip of 1 mg/kg/h if improvement had been seen. Surfactant (Survanta
4 ml/kg) was only given as a rescue therapy to the most severe infants
failing to improve despite iNO therapy. A successful response to
surfactant and iNO was recorded based on clinical observation of
increased SaO2 and a decrease in FIO2 requirement of 0.15 for more
than 1 hour.
No patients were given muscle relaxants. Spontaneous breathing
was preserved. Sedation was avoided by vigilantly emphasizing airway care, developmentally appropriate positioning, and environmental
maintenance. Rare patients required intermittent doses of analgesia and
sedation preoperatively for excessive agitation despite good airway
maintenance and comfort measures (morphine [0.1 mg/kg], fentanyl [2
g/kg], versed [0.05 to 0.1 mg/kg], or phenobarbitol [5mg/kg]). Narcotics were given liberally postoperatively as needed for pain management. Continuous infusions were not used. Cardiac inotropic support
(dopamine and dobutamine, 5 to 10 g/kg/min) and fluid boluses were
used to maintain adequate perfusion as indicated but rarely were
required. Sodium bicarbonate was only administered for severe metabolic acidosis (respiratory acidosis was not treated with medication).
ECMO
Prerepair ECMO was reserved for patients without lethal anomalies,
no ECMO contraindications, and able to maintain preductal saturations
greater than 85% using the outlined strategy for at least 1 hour at any
time in their clinical course. This was interpreted as evidence of
adequate lung parenchyma.26 Ventilator pressures considered were
generally maximal at a PIP of 30 with conventional ventilation modes
(includes HFPPV) or MAP of 20 with HFOV. Patients failing to meet
the preductal saturation goal despite maximal support were considered
to have strong evidence for lethal lung hypoplasia.26 ECMO rescue was
only instituted in babies displaying a reasonable expectation of adequate lung parenchyma and potentially reversible pulmonary hypertension. If ECMO criteria were met, support was considered in any infant
with evidence of inadequate oxygen delivery, progressive metabolic
acidosis, and/or organ failure despite maximal therapy. ECMO support
was initiated before extreme ventilator pressures were required. A
declining preductal oxygen saturation below 80% (refractory to ventilator manipulation, iNO, and 100% oxygen) generally was considered
an indication for ECMO. Initiation of ECMO was a decision made by
the pediatric surgeon and neonatologist based on the infants clinical
course, rather than any calculated respiratory index (ie, oxygenation
index).
Either venovenous (VV) or venoarterial (VA) ECMO was used. The
(VA) extrathoracic cannulation was accomplished at the bedside using
a 10F to 12F end-hole arterial perfusion canula and a 12F to 14F
multiple side-hole venous drainage catheter (Biomedicus, San Diego,
CA). VV canulation was undertaken using a double lumen 12F to 14F
cannula (Jostra/Origen, Rotterdam, The Netherlands). ECMO support
was carried out via standard techniques previously outlined.14 Patients
placed on ECMO preoperatively underwent CDH repair after maximal
reduction of ECMO flows. ECMO was discontinued as soon as possible
after repair.
Surgery
Surgical repair was delayed until the preductal to postductal saturation gradient had subsided, echocardiographic examination confirmed
minimal evidence of pulmonary hypertension, and ventilator support
had minimized. An abdominal approach was taken for all diaphragm
repairs. A subcostal exposure allowed reduction of abdominal viscera
from the ipsilateral thorax. Primary repair of the defect was undertaken
only if minimal dissection was required. For more extensive cases, a
Gore-tex (W.L. Gore and Associates, Flagstaff, AZ) prosthesis (1 mm)
was fixed in an anatomic position with nonabsorbable, interrupted
sutures. No prophylactic ipsilateral tube thoracostomy was performed.
Special adjuncts, including soft tissue flaps, abdominal wall stretching,
manual extrusion of meconium through the anus, and correction of
malrotation with appendectomy were not performed. A second GoreTex prosthesis was used if the abdominal wall could not be closed
without undue tension. Infants requiring abdominal wall prosthesis
underwent serial reduction and subsequent primary abdominal wall
closure. Patients who underwent repair while on ECMO support were
treated with Amikar (- caproic acid) preoperatively, and most cut
surfaces were treated with calcium-activated fibrinogen intraoperatively to assist hemostasis.
Data Analysis
Statistical analysis of the data was performed with the SPSS 8.0 for
Windows and Episode statistics programs. Continuous variables were
compared using a Students t test for independent variables. Categorical
variables were compared with statistical analysis of 2 2 tables as
calculated via 2 analysis with Yates correction. The FIO2 as well as
arterial blood Ph and PaCO2 were recorded at 6-hour intervals using the
blood gas closest to each interval midpoint provided that the gas was
359
RESULTS
General Characteristics
Associated anomalies. All general characteristics of
patients are shown in Table 1. Inborn CDH infants had a
25% (17 of 67) incidence of associated secondary anomalies. Of the 17 infants with anomalies, 9 had severe
congenital heart disease: 3 with hypoplastic left heart
syndrome, 2 atrial-ventricular canal, 2 tetrology of Fallot, and 2 coarctation of the aorta. CDH with isolated
severe cardiac disease was not considered, a priori, a
lethal anomaly. Six of the 17 infants were considered to
have a hopeless, lethal constellation of defects: 1 pentology of Cantrell, 1 Fryns syndrome, 2 infants with
bilateral diaphragmatic defects and multiple anomalies,
and 2 with unilateral defects and multiple anomalies.
Two of these 6 infants had severe congenital heart
disease as part of their constellation of defects.
Outborn infants tended to have fewer anomalies than
their inborn counterparts (6 of 53 v 17 of 67; P value, not
significant). They had significantly less associated cardiac disease, noting only 1 infant with tetralogy of Fallot
(1 of 53 v 9 of 67; P .05). Only one outborn infant was
noted to have a syndrome (Killian-Teschler-Nicola).
This suggested a preselection of infants before transfer
referral.
Preoperative Respiratory Management
Intubation. A total of 97% (65 of 67) of the inborn
infants were intubated immediately in the delivery suite
as part of the management of prenatally diagnosed CDH.
Table 1. Perinatal Data
Inborn
(n 67)
Outborn
(n 53)
Analysis
37.9 2.0
2.98 .59
8 (12%)
38.0 2.0
3.03 .64
4 (8%)
Not significant
Not significant
Not significant
4.6/7.0
58 (87%)
7 (10%)
2 (3%)
17 (25%)
9 (13%)
5.6/7.3
39 (74%)
14 (26%)
0
6 (11%)
1 (2%)
Not significant
Not significant
P .05
Not significant
Not significant
P .05
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BOLOKER ET AL
with HFPPV and required escalation of respiratory support. More advanced technologies were used infrequently in inborn survivors. HFOV use (5 of 44; 11%),
and inhaled nitric oxide (5 of 44; 11%) use was low with
only 1 patient showing a response. Surfactant was only
used in 2 inborn patients without response in either.
Compared with inborn survivors, the rate of HFPPV
failure in inborn patients who died was higher, with 66%
(12 of 18) being treated with advanced technologies
(P .05). Overall, 52% attempted HFOV (12 of 23; P
.05). Inhaled nitric oxide was provided to 12 of 23
patients (52%; P .05) with only 3 (25%; P value, not
significant) demonstrating response. Again, surfactant
administration rarely was attempted (2 patients) with no
response.
Preoperatively, outborn survivors had statistically similar needs for adjuvant therapies, although they tended to
require more HFOV (21%, 10 of 47; P value, not
significant) and iNO (19%, 9 of 47; P value, not significant) than their inborn counterparts. Outborn survivors
only tended to be more likely to respond to iNO (77%, 7
of 9; P value, not significant). Surfactant administration
rates were low as well (9%, no responders).
ECMO. ECMO was used infrequently, in only 8.9%
of inborn patients (6 of 67) and 18.9% of outborn
patients (10 of 53; P value, not significant).
Blood Gas and Oxygenation Data: Inborn Group
(outborn data were too incomplete for analysis)
Blood gases. Inborn blood gas data were plotted in
Fig 2 and 3 to show trends in pH and pCO2, showing
improvement in survivor blood gases over the first 24
hours followed by a plateau in values. The inborn death
group values are graphed for comparison, although the
plot was influenced heavily by the high death rate over
the time period (only 3 patients remained in the death
group by 36 hours). The inborn deaths tended to have
worse pH and pCO2 values at all time-points than the
death group despite using higher peak inspiratory pressures (P value, not significant).
Oxygen requirement. Inborn FIO2 requirement is
shown in Fig 4, with inborn survivors exhibiting decreasing oxygen requirements over the first 36 hours of life.
Carbon dioxide range. In the first 24 hours of life,
inborn survivors showed an average PaCO2 of 47.2 9.3,
ranging from 35.5 7.4 (average best PaCO2) to 68.6
20.9 (average worst PaCO2). In 63.6% of inborn survivors
(28 of 44), the worst PaCO2 was the first blood gas drawn
after intubation and umbilical line placement.
Perioperative Data
361
Number
Surfactant
HFPPV
HFOV
iNO
ECMO
Outborn (n 53)
Deaths
Survivors
Deaths
Preoperative
Postoperative
Preoperative
Preoperative
Postoperative
Preoperative
44
2 (5%)
22 (50%)*
5 (11%)*
5 (11%)
3 (7%)
44
0
16 (36%)
1 (2%)
1 (2%)
0
23
2 (9%)
18 (78%)
12 (52%)
12 (52%)
3 (13%)
47
4 (9%)
19 (40%)
10 (21%)
9 (19%)
7 (15%)
47
0
16 (34%)
4 (9%)
3 (6%)
0
6
2 (33%)
5 (83%)
5 (83%)
5 (83%)
3 (50%)
Postoperative Characteristics
Mortality Rate
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BOLOKER ET AL
Total
Code in delivery suite*
Preoperative chest tube
ECMO
Death 24 hours
Severe cardiac disease
Overall anomalies
44
1 (2%)
0
3 (7%)
2 (5%)
3 (7%)
Deaths
Outborn (n 53)
Survivors
23
47
4 (17%)
1 (2%)
11 (48%)
6 (13%)
3 (13%)
7 (15%)
14 (61%)
7 (30%)
1 (2%)
14 (61%)
6 (13%)
Deaths
6
1 (17%)
4 (67%)
3 (50%)
2 (33%)
0
0
363
postductal oxygenation variability and eliminated ventilator adjustments designed to maintain an artifically
elevated postductal PaO2. Despite the frequent presence
of initial PPHN, abandoning more rigid parameters did
not prove problematic as evidenced by the steady improvement in oxygenation and ventilation over the first
36 hours of life in inborn survivors. Tolerance of acute
variability may prevent chronic iatrogenic lung damage
caused by aggressive ventilator manipulation in an attempt to create consistently ideal blood gas levels.
Hyperventilation often requires a PIP above 30 to
achieve CO2 levels in the desired alkalotic range. Animal
models have shown significant iatrogenic lung injury as
a result of both brief, high-volume manual inflations (6
bagged breaths) and prolonged moderate-pressure mechanical ventilation (PIP, 30).21,22 Both situations are
seen consistently during the resuscitation and ventilation
of the hyperventilated CDH patient. In the human, autopsy data have shown high rates of hyaline membrane
formation, parenchymal hemorrhage, bronchopneumonia, and pneumothoraces in the hyperventilated CDH
infant using high PIP.23 Avoiding hyperinflation of the
lung additionally helps minimize interference with systemic vascular return and decreases pulmonary vascular
resistance, helping to alleviate PPHN.24 In this study,
escalating ventilator PIP to high levels did not change
any inborn patients eventual outcome because no survivors were treated with a PIP greater than 25 (although
some did require HFOV). The use of high ventilator
pressures may have been further avoided by the use of
HFPPV, which allowed increases in minute ventilation
and alleviated paradoxial chest wall motion without
increasing PIP. Providing ample accommodation time
before making ventilator changes in anticipation of expected short-term variation in oxygenation (barring severe decompensation) may have similarly prevented PIP
escalation and additional morbidity and mortality.
Iatrogenic lung injury can result from other sources.
Ipsilateral prophylactic chest tube placement in the operating suite often is a routine part of CDH repair, with
76% of patients undergoing thoracostomy in a recent
review.3 The natural course of the potential space created
by hernia reduction; however, is to passively fill with
fluid, a process that is delayed by placement of the tube.
Additionally, the forces generated by this tubes negative
pressure can be potentially damaging. During expiration,
the suction of the chest tubes negative pressure prevents
ipsilateral lung deflation.11 This force is theorized to
cause the hypoplastic ipsilateral lung to grossly hyperinflate within the first 24 to 48 hours, potentially creating a
dangerous increase in pulmonary vascular resistance and
leading to avoidable pulmonary damage.11,25 The rapid
hyperinflation and resultant lung injury may cause cardiopulmonary instability. This potential for harm may
364
BOLOKER ET AL
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congenital diaphragmatic hernia? J Pediatr Surg 34:720-725, 1999
3. Clark RH, Hardin WD, Hirschl RB, et al: Current surgical
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4. Reickert CA, Hirschl RB, Atkinson JB, et al: Congenital diaphragmatic hernia survival and use of extracorporeal life support at
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6. Wilson JM, Lund DP, Lillehei CW, et al: Congenital diaphragmatic herniaA tale of two cities: The Boston experience. J Pediatr
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7. Kays DW, Langham MR, Ledbetter DJ, et al: Detrimental effects
of standard medical therapy in congenital diaphragmatic hernia. Ann
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8. Katz AL, Wiswell TE, Baumgart S: Contemporary controversies
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Discussion
D. Kays (Gainesville, FL): Congratulations, Charlie,
for a superb series and presentation, and thank you for
asking me to review your manuscript. I must tell the
audience that I am a disciple of Dr Stolar and Dr Wung,
having trained at Babies Hospital from 1990 to 1992.
This allows me to both applaud you and to ask difficult
questions. I know you would do the same for me.
What we have heard is a very large consecutive
unselected series of CDH with a 76% survival rate from
the center that has defined gentle ventilation. This is a
remarkable achievement, and I congratulate you. The
central message that you have been teaching for 15 years,
that lung parenchyma must be preserved and not injured,
by the application of a strict pressure-limited ventilation
strategy, is crucial. What is equally important in this era
of high technology is that a new machine or a new drug
is not the answer. Application of high-frequency oscillatory ventilation, nitric oxide, and surfactant did not
affect survival rate appreciably. Lest the audience think
that these results are unique to Charlie Stolar and Jen
Wung and cannot be exported, we have been treating
patients similarly since 1992 and have reported 60 consecutive patients in the Annals of Surgery. We currently
have 80 consecutive patients with an 80% overall survival rate and 92% survival rate of inborn patients with
isolated CDH. I will limit myself to 2 questions.
First, what is the anatomic distribution of your
defects? How did patients with liver in the left chest
do? Your outstanding survival rate may help to define
the indications, or lack thereof, for prenatal surgical
interventions.
Two, why did you do a calculation of survival of a
subset of patients after removal of 10 patients with lethal
lung hypoplasia? Although I understand removing pa-
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BOLOKER ET AL