Congenital Diaphragmatic Hernia: Improving Outcomes using a Maximal Lung Protection Strategy and Early Surgery

Abstract

Abstract Purpose: To evaluate the effectiveness of a novel protocol, adopted in our institution, for improving outcomes of congenital diaphragmatic hernia (CDH) Mehtods: A maximal lung protection (MLP) protocol was implemented in 2019. This strategy included immediate use of high frequency oscillatory ventilation (HFOV) after birth, during stay at the Neonatal Intensive Care Unit (NICU) and during surgical repair. HFOV strategy included low distending pressures and higher frequencies (15 Hz) with subsequent lower tidal volumes. Surgical repair was performed early, within 24 hours of birth, if possible. A retrospective study of all inborn neonates prenatally diagnosed with CDH and without major associated anomalies was performed at the NICU of Schneider Children's Medical Center of Israel between 2009 and 2022. Survival rates and pulmonary outcomes of neonates managed with MLP were compared to standard care. Results: 33 neonates were managed with the MLP protocol vs. 39 neonates that were not. Major adverse outcomes decreased including death rate from 46% to 18% (p= 0.012), extracorporeal membrane oxygenation from 39% to 0% (p<0.001) and pneumothorax from 18% to 0% (p=0.013). Conclusion(s): MLP with early surgery significantly improved survival and additional adverse outcomes of neonates with CDH. Prospective randomized studies are necessary to confirm the findings of the current study.