title: Permissive hypercapnia in the management of congenital diaphragmatic hernia: our institutional experience.
abstract: BACKGROUND
  Congenital diaphragmatic hernia (CDH) is a potentially lethal anomaly associated with pulmonary hypoplasia and persistent pulmonary hypertension. Permissive hypercapnia is a strategy designed to reduce lung injury from mechanical ventilation in infants. It has been shown to be a potentially superior method of ventilator management for patients with CDH. In 2001, the Divisions of Neonatology and Pediatric Surgery at the University of Virginia Children's Hospital established permissive hypercapnia as the management strategy for treatment of CDH. We hypothesized that permissive hypercapnia would be associated with improved outcomes in this patient population.
  
  
  METHODS
  This retrospective review compares outcomes of infants treated for CDH in the extracorporeal membrane oxygenation (ECMO) era before and after initiation of permissive hypercapnia at a single institution. Outcomes were compared using univariate statistical analysis.
  
  
  RESULTS
  Ninety-one patients were available for analysis and were divided into 2 groups: 42 (Group 1) treated before and 49 (Group 2) treated after implementation of permissive hypercapnia. Survival was higher in Group 2 (85.8% vs 54.8%; p = 0.001; relative risk [RR] 3.17). Morbidity was lower in Group 2 and approached statistical significance (65.3% vs 83.3%; p = 0.052). Patients in Group 2 were repaired later, had a lower rate of ECMO use, and were extubated earlier. There was no difference in hospital stay.
  
  
  CONCLUSIONS
  The use of permissive hypercapnia for infants with CDH was associated with decreased mortality, a longer period of ventilation before repair with a shorter period of ventilation after repair, a lower rate of ECMO use, and no lengthening of hospital stay. Permissive hypercapnia remains the standard of care for ventilation of infants with CDH at our institution.
authors.affiliation: Department of Surgery, University of Virginia Health System, Charlottesville, VA 22908-0709, USA.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Guidry
authors.forename: Tjasa
authors.initials: T
authors.lastname: Hranjec
authors.forename: Bradley M
authors.initials: BM
authors.lastname: Rodgers
authors.forename: Bartholomew
authors.initials: B
authors.lastname: Kane
authors.forename: Eugene D
authors.initials: ED
authors.lastname: McGahren
mesh_terms: D015199:Extracorporeal Membrane Oxygenation / Q000706:statistics & numerical data; D005260:Female; D006548:Hernia, Diaphragmatic / Q000150:complications / Q000401:mortality / Q000601:surgery / Q000628:therapy; D065630:Hernias, Diaphragmatic, Congenital; D006801:Humans; D006935:Hypercapnia / Q000209:etiology*; D007231:Infant, Newborn; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D017410:Practice Guidelines as Topic; D012121:Respiration, Artificial / Q000379:methods* / Q000706:statistics & numerical data; D012189:Retrospective Studies; D015996:Survival Rate; D055397:Ventilator-Induced Lung Injury / Q000517:prevention & control*