engleski

Impact of current treatment protocol on survival of high-risk patients with isolated congenital diaphragmatic hernia (CDH) – experience without extracorporeal membrane oxygenation

Introduction: Barotrauma is recognized as significant cause of mortality in CDH. One of the biggest single advances in the management of CDH in recent years is implemetation of so called gentle ventilation. This strategy has led to dramatic increase in survival and declining use of ECMO. Objectives: Retrospective reassessment of mortality rates in high-risk CDH patients after introduction of new ventilation strategy in two different time periods. Methods and patients: First group consisted of 26 CDH patients admitted to third level NICU from 1990-2000 y. In second group admitted from 2000-2007 y there were 19 CDH patients. Patients in first group were initially treated with ventilatory support based on paralysis/hyperventilation/alkalinization model. Patients in second group were initially treated with gentle ventilation/spontaneous respiration model. All patients were referred for surgery after stabilisation. Four patients admitted in the study period with associated anomalies were exlcluded. There were no significant differences between the two study group regarding gestational age, birth weight, sex and type of CDH. Results: We report outcomes in 45 consecutive patients with CDH. Overall survival rate in first group was 42, 3%, compared with an 89, 47% survival in the second group of CDH patients. The greatest impact on survival had the time of onset of respiratory distress which significantly differed between survivors and non survivors in each group. Patients presenting with respiratory distress within hours of birth in the first group had a 17, 65% survival compared with the 80% survival in the second treatment group. All patients presenting with respiratory distress after 24 hours survived in second group compared with 88, 89% survival in the first group. Conclusion: Our results support the observation that additional iatrogenic lung injury during conventional mechanical ventilation in patients with CDH adversely influences their outcome. Gentle ventilatory support is far more superior treatment for patients with CDH.

congenital diaphragmatic hernia; gentle ventilation; survival

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