Original article
Preliminary observations of the use of high-frequency jet ventilation as rescue therapy in infants with congenital diaphragmatic hernia

https://doi.org/10.1016/j.jpedsurg.2009.07.025Get rights and content

Abstract

Background/Purpose

Congenital diaphragmatic hernia (CDH) is associated with mortality of 10% to 50%. Several investigators have reported outcomes from centers using high-frequency oscillatory ventilation in their management of CDH, but there are no recent reports on use of high-frequency jet ventilation.

Methods

During the study period from January 2001 until August 2007, infants with CDH who were cared for at Duke University Medical Center received high-frequency jet ventilation as a rescue mode of high-frequency ventilation. We compared actual survival with predicted survival for infants treated only with conventional ventilation vs those rescued with high-frequency jet ventilation after failing conventional ventilation.

Results

Survival for the 16 infants that received high-frequency jet ventilation was predicted to be 63%; actual survival was 75%. Survival for the 15 infants that received only conventional ventilation was predicted to be 83%; actual survival was 87%. We observed no significant survival benefit for high-frequency jet ventilation, 8.0% (95 confidence interval, −22.0% to 38.1%; P = .59).

Conclusions

Although our sample size was small, we conclude with consideration of the absolute results, the degree of illness of the infants, and the biologic plausibility for the intervention that high-frequency jet ventilation is an acceptable rescue ventilation mode for infants with CDH.

Section snippets

Methods

We included all infants admitted to Duke University Medical Center Intensive Care Nursery with the diagnosis of CDH between January 2001 and August 2007. Patients were excluded from analysis if they had major congenital anomalies other than CDH or gestational age <37 weeks. Patients with CDH received HFJV when conventional mechanical ventilation (CMV) failed. Failure of CMV was defined as requiring a PIP greater than 26 cmH2O or MAP greater than 12 cmH2O to achieve a Paco2 less than 65 mm Hg.

Results

Thirty-one infants met inclusion criteria of gestational age 37 weeks or more and absence of other major congenital anomalies. Although the median birth weights of the HFJV and CMV groups were similar (Table 1), the patients that required HFJV during their care were initially more critically ill than the patients who only required CMV. Patients that required HFJV during their care had a lower median 5-minute Apgar score compared to the CMV group. The HFJV group received inhaled nitric oxide

Discussion

Congenital diaphragmatic hernia remains a complex and challenging disease, and clinicians caring for newborns with CDH are often faced with multiple pathophysiologic challenges including hypoplastic and dysmature lungs and maldeveloped pulmonary vasculature [13], [14]. Recent reports suggest improved survival from lung protective ventilation strategies, but there are no well-powered randomized clinical trials for testing any ventilatory strategies in these infants [9], high-frequency

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