Impact of new treatments for respiratory failure on outcome of infants with congenital diaphragmatic hernia.
Term and near-term newborn infants with congenital diaphragmatic hernia (CDH), symptomatic in the first 24 h of life or diagnosed antenatally, without other significant malformations were treated at our hospital with high-frequency oscillatory ventilation (HFOV) as a primary modality of ventilation and elective delay in surgical repair after a period of stabilisation. When unresponsive to HFOV, infants were treated with surfactant, inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO) to achieve pre-operative stabilisation. From October 1994 to August 1998, 28 newborn infants with CDH were managed with such treatment; mean birth weight was 3184 +/- 535 g and gestational age 38.5 +/- 1.85 weeks. Age at operation was 68 +/- 35 h. In 9 cases, large diaphragmatic defects required the use of a prosthetic patch (Gore-tex). HFOV was used for primary ventilation in inborn patients (n = 16); outborn infants (n = 12) were placed on HFOV at admittance. A total of 15 patients (53%) were stabilised using only HFOV. Bovine surfactant was administered in 12 infants and 4 responded. iNO was used in eight infants and five responded. ECMO was used in three outborn patients and one survived. Overall, out of 28 infants, 25 survived (89%). Neurological examination (Amiel-Tison and Grenier) of 15 infants showed transient anomalies at 6 months in 40% of infants, while a normal neurological examination was present in all patients at 1 year. The development quotient (Griffiths scales) was within normal values in ten and mildly abnormal in two infants tested at 1 year.


CONCLUSIONS
Management based on early HFOV, eventually associated with surfactant, iNO and ECMO to achieve preoperative stabilisation, resulted in a good survival rate (89%) and good neurodevelopmental outcome at 1 year of age in infants with CDH.
Somaschini
M
M
Divisione di Patologia Neonatale, Ospedali Riuniti, Largo Barozzi 1, I-24128 Bergamo, Italy.
Locatelli
G
G
Salvoni
L
L
Bellan
C
C
Colombo
A
A
D000818:Animals; D002417:Cattle; D003131:Combined Modality Therapy; D002658:Developmental Disabilities / Q000209:etiology; D015199:Extracorporeal Membrane Oxygenation; D005500:Follow-Up Studies; D005865:Gestational Age; D006548:Hernia, Diaphragmatic / Q000150:complications / Q000401:mortality; D065630:Hernias, Diaphragmatic, Congenital; D006612:High-Frequency Ventilation; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007234:Infant, Premature; D007235:Infant, Premature, Diseases / Q000401:mortality / Q000628:therapy; D009569:Nitric Oxide / Q000627:therapeutic use; D011663:Pulmonary Surfactants / Q000627:therapeutic use; D012131:Respiratory Insufficiency / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D015996:Survival Rate
D011663:Pulmonary Surfactants; D009569:Nitric Oxide