Tidal volumes at birth as predictor for adverse outcome in congenital diaphragmatic hernia

Abstract

ObjectiveTo assess the predictive value of tidal volume (Vt) of spontaneous breaths at birth in infants with congenital diaphragmatic hernia (CDH).DesignProspective study.SettingTertiary neonatal intensive care unit.PatientsThirty infants with antenatally diagnosed CDH born at Hospital Sant Joan de Déu in Barcelona from September 2013 to September 2015.InterventionsSpontaneous breaths and inflations given in the first 10 min after intubation at birth were recorded using respiratory function monitor. Only expired Vt of uninterrupted spontaneous breaths was included for analysis. Receiver operating characteristics (ROC) analysis was performed and the area under the curve (AUC) was estimated to assess the predictive accuracy of Vt.Main outcome measuresMortality before hospital discharge and chronic lung disease (CLD) at day 28 of life.ResultsThere were 1.233 uninterrupted spontaneous breaths measured, and the overall mean Vt was 2.8±2.1 mL/kg. A lower Vt was found in infants who died (n=14) compared with survivors (n=16) (1.7±1.6 vs 3.7±2.1 mL/kg; p=0.008). Vt was lower in infants who died during admission or had CLD (n=20) compared with survivors without CLD (n=10) (2.0±1.7 vs 4.3±2.2 mL/kg; p=0.004). ROC analysis showed that Vt ≤2.2 mL/kg predicted mortality with 79% sensitivity and 81% specificity (AUC=0.77, p=0.013). Vt ≤3.4 mL/kg was a good predictor of death or CLD (AUC=0.80, p=0.008) with 85% sensitivity and 70% specificity.ConclusionVt of spontaneous breaths measured immediately after birth is associated with mortality and CLD. Vt seems to be a reliable predictor but is not an independent predictor after adjustment for observed/expected lung to head ratio and liver position.

Knowledge Gaps in the Fetal to Neonatal Transition of Infants With a Congenital Diaphragmatic Hernia

“…For instance, as described above, the need to supplement with a high FiO 2 concentration in the delivery room appears to be associated with higher morbidity and mortality for CDH infants ( 13 , 41 ). Likewise, similar observations were reported regarding expiratory tidal volumes, end-tidal carbon dioxide levels and dynamic lung compliance ( 41 , 42 ). Respiratory monitors now allow real-time measurements of several lung function parameters.…”

Respiratory Support of Infants With Congenital Diaphragmatic Hernia

“…An expiratory tidal volume of >3.8 ml/kg and a lung compliance of >0.12 ml/cmH 2 0/kg was reported to be predictive of survival with 85% sensitivity and 90% specificity. Furthermore, tidal volumes of spontaneous breaths measured during the first 10 min after intubation have been described to be lower in those in those who either died prior to discharge or in those who developed chronic lung disease compared to survival without chronic lung disease (2.0 vs. 4.3 ml/kg; p = 0.004) (3). The achievement of higher maximal pre-ductal oxygen saturations (100 vs. 93%; p = 0.037) prior to transfer to neonatal intensive care have also been associated with greater survival in infants with a diagnosis of CDH (4).…”

Initiating resuscitation before umbilical cord clamping in infants with congenital diaphragmatic hernia: a pilot feasibility trial

“…Brouwer et al 16 targeted vital sign parameters as well as exhaled tidal volume >4 mL/kg as an indicator of lung aeration among preterm infants. This may not be a reasonable target for infants with CDH and related pulmonary hypoplasia, in whom tidal volumes after birth are often <4 mL/kg for both spontaneous breaths and manual inflations 22 23. In addition, tidal volume monitoring is not standard of care in most delivery rooms, and we sought to avoid introducing additional equipment into a crowded physical space for the study intervention.…”