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Chase Binion C, Agala CB, Ebanks AH, Marzinsky A, McLean SE. Fetal biophysical predictors of pulmonary hypertension severity, management, and treatment in infants born with congenital diaphragmatic hernia. Am J Surg 2024; 236:115821. [PMID: 39047338 DOI: 10.1016/j.amjsurg.2024.115821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/12/2024] [Accepted: 07/01/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Pulmonary hypertension (PHTN) causes significant morbidity and mortality in patients with congenital diaphragmatic hernia (CDH). Currently, there is no routinely obtained prenatal prognostic marker to reliably predict postnatal CDH-associated PHTN severity. METHODS The CDH Study Group (CDHSG) registry was queried for infants born from 2015 to 2021 with a graded (1-4) PHTN diagnosis. Fetal observed-to-expected lung volume to head circumference ratio (o/e LHR), percent predicted lung volume (PPLV), and total lung volume (TLV) were classified by severity. RESULTS Of 4056 patients, 1047 and 785 infants had prenatal ultrasound or magnetic resonance imaging, respectively. Both moderate and severe o/e LHR were associated with increased odds of postnatal development of moderate (OR 2.913) and severe PHTN (OR 4.924). CONCLUSIONS In infants with CDH, prenatal predictor severity was associated with higher severity of PHTN and increased ECLS usage. Overall, patients with worse prenatal prognostic indicators were less likely to receive pulmonary vasodilator treatment.
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MESH Headings
- Humans
- Hernias, Diaphragmatic, Congenital/complications
- Hernias, Diaphragmatic, Congenital/diagnostic imaging
- Hernias, Diaphragmatic, Congenital/therapy
- Hernias, Diaphragmatic, Congenital/mortality
- Hernias, Diaphragmatic, Congenital/diagnosis
- Hypertension, Pulmonary/etiology
- Hypertension, Pulmonary/diagnosis
- Female
- Severity of Illness Index
- Infant, Newborn
- Male
- Pregnancy
- Ultrasonography, Prenatal
- Magnetic Resonance Imaging
- Registries
- Prognosis
- Retrospective Studies
- Extracorporeal Membrane Oxygenation
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Affiliation(s)
- C Chase Binion
- University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA; University of Virginia School of Medicine, Department of Biomedical Engineering, Charlottesville, VA, USA
| | - Chris B Agala
- University of North Carolina Chapel Hill, Department of Surgery, Chapel Hill, NC, USA
| | - Ashley H Ebanks
- Department of Pediatric Surgery, McGovern Medical School at the University of Texas Health Science Center and Children's Memorial Hermann Hospital, Houston, TX, USA
| | - Amy Marzinsky
- University of North Carolina, Department of Surgery, Division of Pediatric Surgery, Chapel Hill, NC, USA
| | - Sean E McLean
- University of North Carolina Chapel Hill School of Medicine, Chapel Hill, NC, USA; University of North Carolina, Department of Surgery, Division of Pediatric Surgery, Chapel Hill, NC, USA.
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Wild KT, Rintoul N, Hedrick HL, Heimall L, Soorikian L, Foglia EE, Ades AM, Herrick HM. Delivery Room Resuscitation of Infants with Congenital Diaphragmatic Hernia: Lessons Learned through Video Review. Fetal Diagn Ther 2024:000538536. [PMID: 38531327 DOI: 10.1159/000538536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/22/2024] [Indexed: 03/28/2024]
Abstract
INTRODUCTION Delivery room (DR) interventions for infants with congenital diaphragmatic hernia (CDH) are not well described. This study sought to describe timing and order of DR interventions and identify system factors impacting CDH DR resuscitations using a human factors framework. METHODS Single center observational study of video recorded CDH DR resuscitations documenting timing and order of interventions. The team used the Systems Engineering Initiative for Patient Safety (SEIPS) model to identify system factors impacting DR resuscitations and time to invasive ventilation. RESULTS We analyzed 31 video recorded CDH resuscitations. We observed variability in timing and order of resuscitation tasks. The 'Internal Environment' and 'Tasks' components of the SEIPS model were prominent factors affecting resuscitation efficiency; significant room and bed spatial constraints exist, and nurses have a significant task burden. Additionally, endotracheal tube preparation was a prominent barrier to timely invasive ventilation. CONCLUSION Video review revealed variation in event timing and order during CDH resuscitations. Standardization of room set-up, equipment, and event order and reallocation of tasks facilitate more efficient intubation and ventilation, representing targets for CDH DR improvement initiatives. This work emphasizes the utility of rigorous human factors review to identify areas for improvement during DR resuscitation.
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Wild KT, Mathew L, Hedrick HL, Rintoul NE, Ades A, Soorikian L, Matthews K, Posencheg MA, Kesler E, Van Hoose KT, Panitch HB, Flibotte J, Foglia EE. Respiratory function after birth in infants with congenital diaphragmatic hernia. Arch Dis Child Fetal Neonatal Ed 2023; 108:535-539. [PMID: 36400455 DOI: 10.1136/archdischild-2022-324415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 10/31/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To characterise the transitional pulmonary physiology of infants with congenital diaphragmatic hernia (CDH) using measures of expiratory tidal volume (TV) and end-tidal carbon dioxide (ETCO2). DESIGN Prospective single-centre observational study. SETTING Quaternary neonatal intensive care unit. PATIENTS Infants with an antenatal diagnosis of CDH born at the Children's Hospital of Philadelphia. INTERVENTIONS TV and ETCO2 were simultaneously recorded using a respiratory function monitor (RFM) during invasive positive pressure ventilation immediately after birth. MAIN OUTCOME MEASURES TV per birth weight and ETCO2 values were summarised for each minute after birth. Subgroups of interest were defined by liver position (thoracic vs abdominal) and extracorporeal membrane oxygenation (ECMO) treatment. RESULTS RFM data were available for 50 infants from intubation until a median (IQR) of 9 (7-14) min after birth. TV and ETCO2 values increased for the first 10 min after birth, but intersubject values were heterogeneous. TVs were overall lower and ETCO2 values higher in infants with an intrathoracic liver and infants who were ultimately treated with ECMO. On hospital discharge, survival was 88% (n=43) and 34% (n=17) of infants were treated with ECMO. CONCLUSION Respiratory function immediately after birth is heterogeneous for infants with CDH. Lung aeration, as evidenced by expired TV and ETCO2, appears to be ongoing throughout the first 10 min after birth during invasive positive pressure ventilation. Close attention to expired TV and ETCO2 levels by 10 min after birth may provide an opportunity to optimise and individualise ventilatory support for this high-risk population.
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Affiliation(s)
- K Taylor Wild
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Leny Mathew
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie E Rintoul
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne Ades
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leane Soorikian
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Kelle Matthews
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
| | - Michael A Posencheg
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Erin Kesler
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - K Taylor Van Hoose
- Department of Pediatric General, Thoracic, and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Howard B Panitch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - John Flibotte
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth E Foglia
- Department of Pediatrics, The Children's Hospital of Philadelphia Division of Neonatology, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Sferra SR, Guo M, Gonzalez Salazar AJ, Penikis AB, Engwall-Gill AJ, Ebanks A, Harting MT, Collaco JM, Kunisaki SM. Sex-Specific Differences in Congenital Diaphragmatic Hernia Mortality. J Pediatr 2023; 259:113481. [PMID: 37196780 DOI: 10.1016/j.jpeds.2023.113481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 04/26/2023] [Accepted: 05/08/2023] [Indexed: 05/19/2023]
Abstract
OBJECTIVE To compare disease severity and mortality differences between female and male patients with congenital diaphragmatic hernia (CDH). STUDY DESIGN We queried the CDH Study Group (CDHSG) database for CDH neonates managed between 2007 and 2018. Female and males were compared in statistical analyses using t tests, χ² tests, and Cox regression, as appropriate (P ≤ .05). RESULTS There were 7288 CDH patients, of which 3048 (41.8%) were female. Females weighed less on average at birth than males (2.84 kg vs 2.97 kg, P < .001) despite comparable gestational age. Females had similar rates of extracorporeal life support (ECLS) utilization (27.8% vs 27.3%, P = .65). Although both cohorts had equivalent defect size and rates of patch repair, female patients had increased rates of intrathoracic liver herniation (49.2% vs 45.9%, P = .01) and pulmonary hypertension (PH) (86.6% vs 81.1%, P < .001). Females had lower survival rates at 30-days (77.3% vs 80.1%, P = .003) and overall lower survival to discharge (70.2% vs 74.2%, P < .001). Subgroup analysis revealed that increased mortality was significant among those who underwent repair but were never supported on ECLS (P = .005). On Cox regression analysis, female sex was independently associated with mortality (adjusted hazard ratio 1.32, P = .02). CONCLUSION After controlling for the established prenatal and postnatal predictors of mortality, female sex remains independently associated with a higher risk of mortality in CDH. Further study into the underlying causes for sex-specific disparities in CDH outcomes is warranted.
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Affiliation(s)
- Shelby R Sferra
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Matthew Guo
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andres J Gonzalez Salazar
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Annalise B Penikis
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Abigail J Engwall-Gill
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ashley Ebanks
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Matthew T Harting
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children's Memorial Hermann Hospital, Houston, TX
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Shaun M Kunisaki
- Division of General Pediatric Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
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Gien J. Timing of umbilical cord clamping in infants with congenital diaphragmatic hernia. Semin Perinatol 2023:151746. [PMID: 36997450 DOI: 10.1016/j.semperi.2023.151746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
Congenital diaphragmatic hernia (CDH) is a severe birth anomaly where a defect in the diaphragm allows abdominal organs to herniate into the chest with compression of the intrathoracic structures, specifically the lungs and heart. Pulmonary and left ventricular hypoplasia result in respiratory insufficiency after birth with disordered transition and persistent pulmonary hypertension of the newborn (PPHN). As a result, infants need immediate intervention after birth to support the transition. Delayed cord clamping (DCC) is recommended for all healthy newborns and improves outcomes in infants born preterm and in infants with congenital heart disease; however, DCC may not be feasible in newborns needing immediate intervention after birth. Recent studies have explored resuscitation with intact umbilical cords, to determine feasibility, safety, and efficacy in infants with CDH, with promising results. In this report we discuss the physiologic basis for intact cord resuscitation in infants with CDH and review the above reports with a view to determining optimal timing of umbilical cord clamping in infants with CDH.
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Affiliation(s)
- Jason Gien
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, 13121 E. 17th Avenue, MS 8402, Room 4304, Aurora, CO 80045, USA.
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Zhang F, Wu Y, Zhang L, Xia B. Case Report: Congenital diaphragmatic hernia associated with esophageal atresia and tracheoesophageal fistula. Front Surg 2023; 9:1061951. [PMID: 36684248 PMCID: PMC9845759 DOI: 10.3389/fsurg.2022.1061951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 12/07/2022] [Indexed: 01/05/2023] Open
Abstract
The coexistence of congenital diaphragmatic hernia and esophageal atresia with or without tracheoesophageal fistula is extremely rare; only 36 cases have been reported. We report a case of a preterm male newborn infant with left congenital diaphragmatic hernia, esophageal atresia, and tracheoesophageal fistula and review 27 related cases.
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Affiliation(s)
- Feihong Zhang
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Yang Wu
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China
| | - Li Zhang
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China
| | - Bin Xia
- Department of Pediatrics, West China Second Hospital, Sichuan University, Chengdu, China,Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu, China,Correspondence: Bin Xia
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