Liver position in fetal congenital diaphragmatic hernia retains a prognostic value in the era of lung-protective strategy.
OBJECTIVE
The aims of this study were to analyze the outcomes of fetuses with congenital diaphragmatic hernia (CDH) treated by a lung-protective strategy using high-frequency oscillatory ventilation (HFOV) in a single center with a perinatology service and extracorporeal membrane oxygenation (ECMO) capability and to define the natural history of CDH in the era of lung-protective ventilation.


METHODS
A retrospective chart review of 30 neonates with CDH seen between April 2002 and October 2004 was conducted. All fetuses with a prenatal diagnosis were evaluated by fetal magnetic resonance imaging to define the liver position, and those with a significant volume of the liver in the chest were regarded as liver-up. Patients were managed by a lung-protective strategy using pressure-limited (maximum mean airway pressure [MAP], 18 cm H(2)O) HFOV. The patients were initially placed on HFOV with a fraction of inspired oxygen (Fio(2)) of 1.0 and a MAP of 12 cm H(2)O. Hypercapnea and preductal saturation as low as 85% were accepted. Inhaled nitric oxide and ECMO were introduced when the baby could not be oxygenated with a MAP of 18 cm H(2)O.


RESULTS
Twenty-six neonates (22 inborns with prenatal diagnosis and 4 outborns) were treated with this protocol. Four cases were not treated or died in utero because of severe associated anomalies. Thirteen of the 14 liver-down cases survived without ECMO and were discharged home (93% survival). On the contrary, 4 of 12 liver-up cases survived (33% survival). ECMO was required for initial stabilization in 5 cases with 1 survivor.


CONCLUSIONS
Liver-down CDH babies have a good chance for survival without ECMO by a planned delivery and the lung-protective strategy using HFOV. Liver herniation demonstrated by prenatal magnetic resonance imaging retains a poor prognostic value even with this approach.
Kitano
Yoshihiro
Y
Division of General Surgery, National Center for Child Health and Development, Tokyo 157-8535, Japan. kitano-y@ncchd.go.jp
Nakagawa
Satoshi
S
Kuroda
Tatsuo
T
Honna
Toshiro
T
Itoh
Yushi
Y
Nakamura
Tomoo
T
Morikawa
Nobuyuki
N
Shimizu
Naoki
N
Kashima
Kyoko
K
Hayashi
Satoshi
S
Sago
Haruhiko
H
D035641:Chest Wall Oscillation; D015199:Extracorporeal Membrane Oxygenation; D005333:Fetus; D006548:Hernia, Diaphragmatic / Q000175:diagnosis / Q000628:therapy*; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D008099:Liver / Q000033:anatomy & histology / Q000473:pathology*; D008279:Magnetic Resonance Imaging; D011296:Prenatal Diagnosis; D011379:Prognosis; D012189:Retrospective Studies; D016019:Survival Analysis