Permissive hypercapnia in the management of congenital diaphragmatic hernia

Our institutional experience

Christopher A. Guidry, Tjasa Hranjec, Bradley M. Rodgers, Bartholomew Kane, Eugene D. McGahren

Research output: Contribution to journalArticle

24 Citations (Scopus)

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. Study Design: 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.

Original languageEnglish (US)
Pages (from-to)640-645
Number of pages6
JournalJournal of the American College of Surgeons
Volume214
Issue number4
DOIs
StatePublished - Apr 2012

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Hypercapnia
Extracorporeal Membrane Oxygenation
Ventilation
Length of Stay
Neonatology
Lung Injury
Mechanical Ventilators
Standard of Care
Congenital Diaphragmatic Hernias
Artificial Respiration
Pulmonary Hypertension
Pediatrics
Morbidity
Lung
Survival
Mortality
Population

Keywords

  • CDH
  • congenital diaphragmatic hernia
  • ECMO
  • extracorporeal membrane oxygenation
  • FiO
  • fraction of inspired oxygen
  • HFOV
  • high frequency oscillatory ventilation
  • intraventricular hemorrhage
  • IVH
  • PaCO
  • partial pressure of carbon dioxide
  • peak inspiratory pressure
  • PIP
  • University of Virginia Children's Hospital
  • UVACH

ASJC Scopus subject areas

  • Surgery

Cite this

Permissive hypercapnia in the management of congenital diaphragmatic hernia : Our institutional experience. / Guidry, Christopher A.; Hranjec, Tjasa; Rodgers, Bradley M.; Kane, Bartholomew; McGahren, Eugene D.

In: Journal of the American College of Surgeons, Vol. 214, No. 4, 04.2012, p. 640-645.

Research output: Contribution to journalArticle

Guidry, Christopher A. ; Hranjec, Tjasa ; Rodgers, Bradley M. ; Kane, Bartholomew ; McGahren, Eugene D. / Permissive hypercapnia in the management of congenital diaphragmatic hernia : Our institutional experience. In: Journal of the American College of Surgeons. 2012 ; Vol. 214, No. 4. pp. 640-645.
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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. Study Design: 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.",
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KW - partial pressure of carbon dioxide

KW - peak inspiratory pressure

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