J Pediatr Surg

. 2023 Sep 23:S0022-3468(23)00545-6.

 doi: 10.1016/j.jpedsurg.2023.09.008. Online ahead of print. https://pubmed.ncbi.nlm.nih.gov/37865575/

Early Ventilator Management for Infants With Congenital Diaphragmatic Hernia: Impact of a Standardized Clinical Practice Guideline

Katrin C Lichtsinn ¹, Joseph T Church ², Paul K Waltz ², Abeer Azzuqa ³, Jacqueline Graham ³, Jennifer Troutman ³, Runjia Li ⁴, Burhan Mahmood ³

Affiliations expand

• PMID: 37865575
• DOI: 10.1016/j.jpedsurg.2023.09.008

Abstract

Background: Infants with congenital diaphragmatic hernia (CDH) experience high morbidity and mortality due to pulmonary arterial hypertension and hypoplasia. Mechanical ventilation is a central component of CDH management. Our objective was to evaluate the impact of a standardized clinical practice guideline (implemented in January 2012) on ventilator management for infants with CDH, and associate management changes with short-term outcomes, specifically extracorporeal membrane oxygenation (ECMO) utilization and survival to discharge.

Methods: We conducted a retrospective pre-post study of 103 CDH infants admitted from January 2007-July 2021, divided pre- (n = 40) and post-guideline (n = 63). Clinical outcomes, ventilator settings, and blood gas values in the first 7 days of mechanical ventilation were compared between the pre- and post-guideline cohorts.

Results: Post-guideline, ECMO utilization decreased (11% vs 38%, p = 0.001) and survival to discharge improved (92% vs 68%, p = 0.001). More post-guideline patients remained on conventional mechanical ventilation without need for escalation to high-frequency ventilation or ECMO, and had higher pressures and PaCO₂ with lower FiO₂ and PaO₂ (p < 0.05).

Conclusions: Standardized ventilator management optimizing pressures for adequate lung expansion and minimizing oxygen toxicity improves outcomes for infants with CDH.

Level of evidence: III.

Keywords: Clinical practice guideline; Congenital diaphragmatic hernia; Extracorporeal membrane oxygenation; Survival; Ventilator management.

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