Postmortem biopsy to obtain lung tissue in congenital diaphragmatic hernia

Preliminary study on the predictive value of the vasoactive-inotropic score for the prognosis of neonatal congenital diaphragmatic hernia

BACKGROUND

No study has reported on the relationship between the vasoactive-inotropic score (VIS) and the prognosis of neonates with a severe congenital diaphragmatic hernia (CDH). This study aimed to identify potential risk factors for mortality in patients with CDH. We calculated the VIS based on the vasoactive drugs used during the perioperative period to investigate the relationship between VIS and infant prognosis.

METHODS

We retrospectively analyzed the clinical data of 75 neonates with CDH who were treated at our center between January 2016 and October 2021. We calculated the maximum and mean VIS during the first 24 h of hospitalization (hosVIS [24max] and hosVIS [24mean], respectively) and after surgery (postVIS [24max] and postVIS [24mean], respectively). The relationship between the VIS and the prognosis of neonates with CDH was analyzed using a receiver operating characteristic (ROC) curve, t-test, chi-square test, rank-sum test, and logistic regression analysis.

RESULTS

In total, 75 participants with CDH were included in the study. The chance of survival was 80%. Our results showed that hosVIS (24max) was an accurate predictor of prognosis (area under the ROC curve = 0.925, p = 0.007). The calculated optimal critical value of hosVIS (24max) for predicting a poor prognosis was 17 (J = 0.75). Multivariate analysis revealed that hosVIS (24max) was an independent risk factor for death in neonates with CDH.

CONCLUSION

In neonates with CDH, a higher VIS, especially hosVIS (24max), suggests worsened cardiac function, a more severe condition, and a higher risk of death. The rising VIS score in infants prompts physicians to implement more aggressive treatment to improve cardiovascular function.

Establishment of a biobank for human lung tissues of congenital diaphragmatic hernia and congenital pulmonary airway malformation

BACKGROUND

Human tissue samples are an invaluable and little available source of information for translational studies of congenital lung diseases such as Congenital Diaphragmatic Hernia (CDH) or Congenital Pulmonary Airway Malformation (CPAM).

PURPOSE

We aimed to establish a human lung tissue biobank of CDH and CPAM patients together with age-matched controls, coupled with a clinical database.

METHODS

Pathology records from autopsies or surgical specimens for CDH and CPAM cases between 1980 and 2017 were reviewed. For surviving individuals, clinical patient data was obtained from corresponding pediatric surgery reports. Formalin-fixed, paraffin-embedded tissues of patients and age-matched controls were systematically stored for further translational studies. RNA integrity was determined on selected CDH blocks.

RESULTS

A total of 16 CDH and 18 CPAM and age-matched control lung tissue blocks were included in our biobank. Ages ranged from 22 to 41 weeks of gestation (GA) in CDH (33.9 ± 6.35 weeks) and 26 weeks (GA) and 12 years in CPAM (2.3 ± 3.7 y). RNA isolation from CDH and control blocks yielded good RNA quality (OD 260/280 ratio: 2.01-2.09, OD 260/230 ratio: 2.04-2.09).

CONCLUSION

We established a unique human biobank for CDH and CPAM tissues. The combination with clinical patient data will allow us to design future translational studies to improve our understanding of the disease pathogenesis of these congenital malformations.

Assessment of Carina Position Antenatally and Postnatally in Infants with Congenital Diaphragmatic Hernia

OBJECTIVE

To determine whether endotracheal tube (ETT) insertion depth should be modified in infants with congenital diaphragmatic hernia (CDH) to reduce the risk of main-stem intubation.

STUDY DESIGN

The distance from the thoracic inlet to the carina was measured antenatally by fetal magnetic resonance imaging (MRI) between 20-28 weeks' (early) and 30-34 weeks' (late) gestation in 30 infants with CDH and compared with 12 early and 36 late MRIs in control infants without CDH. Postnatal tube position was assessed by chest radiograph in the same 30 infants with CDH and compared with 20 control infants with postnatal birth depression.

RESULTS

The carina position was displaced upward in fetuses and newborns with CDH. Distance from the thoracic inlet to the carina compared with controls was 1.04 ± 0.1 cm vs 1.42 ± 0.07 cm on early MRI (P < .05), 1.43 ± 0.14 cm vs 1.9 ± 0.04 cm on late MRI (P < .01), and 2.36 ± 0.07 cm vs 3.28 ± 0.05 cm on postnatal radiographs (P < .01). Adjusting the ETT depth by 1 cm resulted in a median distance of 1.27 cm from the tip of the ETT to the carina.

CONCLUSION

Cephalad displacement of the carina in infants with CDH may predispose them to right main-stem intubation and subsequent development of pneumothorax. We speculate that modifying the ETT insertion depth to 5.5 cm + weight in newborns born at term may prevent pneumothoraces and improve outcomes for infants with CDH.

Differences in preductal and postductal arterial blood gas measurements in infants with severe congenital diaphragmatic hernia

OBJECTIVE

To determine whether right-to-left shunting across the ductus arteriosus (DA) in patients with congenital diaphragmatic hernia (CDH) with suprasystemic pulmonary hypertension (PH) results in differences between preductal and postductal arterial blood gas (ABG) measurements.

DESIGN

Demographics, baseline echocardiographic parameters and differences in simultaneous right upper extremity (preductal) and umbilical artery (postductal) ABG samples were determined in newborns with PH and CDH.

SETTING

Newborn intensive care unit at Children's Hospital Colorado.

PATIENTS

30 newborns with CDH and systemic or suprasystemic PH.

INTERVENTIONS

Simultaneous preductal and postductal ABGs were compared in 30 newborns with PH and CDH, and ventilator settings and fraction of inspired oxygen (FiO2) were adjusted based on preductal ABG samples. Differences in respiratory support before and after obtaining preductal ABG samples were compared.

RESULTS

All patients had severe PH by echocardiogram with right-to-left DA shunting. However, only two newborns (6.6%) had right-to-left shunting across the foramen ovale. When compared with postductal ABG samples, preductal arterial pH was 7.35±0.02 vs 7.30±0.02, PaCO2 40.8±1.9 vs 48.3±1.9, PaO2 99.3±7.8 vs 46±3, oxygen saturation 95.6±1.2 vs 85.2±1.7 and oxygenation index 14.1±2.3 vs 30.1±5.1 (p<0.05 for all comparisons). Targeting preductal ABG measurements allowed for significant weaning of FiO2.

CONCLUSIONS

Right-to-left DA shunting decreases postductal PaO2, oxygen saturation and pH, and increases PaCO2. Targeting preductal ABG measurements may allow for a more physiological approach to ventilator management, and potentially reduce lung injury.