Lower Distending Pressure Improves Respiratory Mechanics in Congenital Diaphragmatic Hernia Complicated by Persistent Pulmonary Hypertension

Guevorkian, David; Mur, Sébastien; Cavatorta, E; Pognon, L.; Rakza, Thameur; Storme, Laurent

doi:10.1016/j.jpeds.2018.04.027

Cited by 27 publications

(13 citation statements)

References 30 publications

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“…Positive end-expiratory pressure (pEEP) levels following surgical repair can affect respiratory system compliance and resistance in those with mild-moderate CDH and persistent pulmonary hypertension. In a randomised 1-h crossover trial, lung compliance increased by 30% when PEEP levels of 2 cmH 2 O were applied in comparison to use of 5 cmH 2 O of PEEP (p = 0.0001) (27). The improvement in oxygenation that occurred at the lower level of PEEP of 2 cmH 2 O, suggests higher PEEP levels are associated with over-distension of aerated "open" alveoli primarily within the ipsilateral lung (27).…”

Section: Ventilatory Management Post-surgical Repairmentioning

confidence: 99%

Respiratory Support of Infants With Congenital Diaphragmatic Hernia

Williams

Greenough

2021

Front. Pediatr.

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Optimisation of respiratory support of infants with congenital diaphragmatic hernia (CDH) is critical. Infants with CDH often have severe lung hypoplasia and abnormal development of their pulmonary vasculature, leading to ventilation perfusion mismatch. It is vital that lung protective ventilation strategies are employed during both initial stabilisation and post-surgical repair to avoid ventilator induced lung damage and oxygen toxicity to prevent further impairment to an already diminished gas-exchanging environment. There is a lack of robust evidence for the routine use of surfactant therapy during initial resuscitation of infants with CDH and thus administration cannot be recommended outside clinical trials. Additionally, inhaled nitric oxide has been shown to have no benefit in reducing the mortality rates of infants with CDH. Other therapeutic agents which beneficially act on pulmonary hypertension are currently being assessed in infants with CDH in randomised multicentre trials. The role of novel ventilatory modalities such as closed loop automated oxygen control, liquid ventilation and heliox therapy may offer promise for infants with CDH, but the benefits need to be determined in appropriately designed clinical trials.

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Section: Ventilatory Management Post-surgical Repairmentioning

confidence: 99%

Respiratory Support of Infants With Congenital Diaphragmatic Hernia

Williams

Greenough

2021

Front. Pediatr.

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“…When respiratory and circulatory functions are stabilized, the sooner the surgery is completed, the more the patient can benefit from it. First, the lungs can be freed from compression caused by the abdominal viscera, which facilitates the re-expansion of the lungs, relieves acid res- piration and PAH, and accelerates improvements in pulmonary function (15). When the lungs are compressed by the hernia content, there is a chance of lung consolidation and dead space, leading to retention of carbon dioxide and acid respiration.…”

Section: Discussionmentioning

confidence: 99%

“…Meanwhile, pulmonary hypoplasia in CDH is often associated with lung overexpansion and poor tolerance to elevated expansion pressure. After CDH repair, a relatively low expansion pressure may improve the respiratory mechanics in neonates with mild-tomoderate CDH (15). Second, since PAH not only leads to right ventricular volume overload, but also causes a left ventricular dysfunction, early repair can reduce the pressure from the hernia contents on the heart, promote left ventricular function recovery, and accelerate the overall rehabilitation (3).…”

Section: Discussionmentioning

confidence: 99%

Surgical Timing in Left Mild-to-Moderate Congenital Diaphragmatic Hernia

Liu

Hong

et al. 2021

Iran J Pediatr

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Background: The optimal timing of surgery for left-sided mild-to-moderate congenital diaphragmatic hernia (CDH) remains unknown. Objectives: To determine the optimal timing of surgery for left-sided mild-to-moderate CDH. Methods: Thirty newborns were randomly divided into emergency (EAR) and delayed (DEL) surgery groups. Thoracoscopic repair of CDH was performed within 48 hours after birth in the EAR group and then in the DEL group. Next, the baseline data, primary and secondary endpoints, and adverse reactions were assessed. Results: Differences between the two groups were not significant in terms of the measured lung-to-head ratio (LHR), preoperative pulmonary artery hypertension (PAH)-free/mild PAH ratio, surgery duration, duration of postoperative mechanical ventilation, incidence of postoperative moderate-to-severe PAH, postoperative mortality, and recurrence rate in the follow-up (P > 0.05 for all). Meanwhile, age at surgery (P = 0.001), duration of fasting (P = 0.001), and hospital stay (P = 0.032) were significantly different between the two groups. Conclusions: Timing of thoracoscopy, performed within 85 hours of birth for left-sided CDH repair, does not affect the therapeutic outcomes of children with left-sided mild-to-moderate CDH.

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“…More recently, in a study that compared lower versus higher end-expiratory pressures in post-repair CDH neonates on conventional mechanical ventilation (CMV), Guevorkian and colleagues reported improved lung mechanics and perfusion with lower distending pressures, further supporting the benefits of minimizing pulmonary overdistention in infants with relative lung hypoplasia (34). Currently, all published guidelines recommend preferential lower airway pressures while allowing for permissive hypercapnia (5)(6)(7)35).…”

Section: Gentle Ventilationmentioning

confidence: 99%

Congenital diaphragmatic hernia: a narrative review of controversies in neonatal management

Yang¹,

Russell²,

Yoder³

et al. 2021

Transl Pediatr

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A congenital diaphragmatic hernia (CDH) results from the inadequate formation of the diaphragm during embryogenesis and causes a cascade of events which can present in a newborn child varying clinically from mild to very severe to fatal. The incidence of CDH is 1 in 2,500 to 1 in 3,500 live births and occurs 90% of the time in the posterolateral aspect of the diaphragm known as a Bochdalek hernia with over 85% occurring on the left side (1). The diaphragmatic defect in the embryo allows for abdominal viscera to enter the thoracic cavity causing a mass effect on the developing lungs resulting in pulmonary hypoplasia and pulmonary hypertension. The degree of clinical severity is often proportional to the size of the defect (Figure 1) (2,3). Although the consequences of other hernias can be avoided when repaired surgically, often there is no quick fix to this underlying dysgenesis of the lungs. In fact, past review of immediate repair demonstrated a worsening in the physiology of CDH neonates, which helped shift repair to a more delayed approach (4). These issues are most often addressed through medical management Review Article on Fetal Surgery

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Lower Distending Pressure Improves Respiratory Mechanics in Congenital Diaphragmatic Hernia Complicated by Persistent Pulmonary Hypertension

Cited by 27 publications

References 30 publications

Respiratory Support of Infants With Congenital Diaphragmatic Hernia

Respiratory Support of Infants With Congenital Diaphragmatic Hernia

Surgical Timing in Left Mild-to-Moderate Congenital Diaphragmatic Hernia

Congenital diaphragmatic hernia: a narrative review of controversies in neonatal management

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