CONGENITAL DIAPHRAGMATIC-HERNIA - A TALE OF 2 CITIES - THE TORONTO EXPERIENCE

Purpose: The optimal therapy for congenital diaphragmatic hernia (CDH) is evolving. This study analyzes the results of treatment of CDH in a large tertiary care pediatric center using conventional and high-freq uency oscillatory ventilation (HFOV) without extracorporeal membrane o xygenation (ECMO) contrasting these with a parallel study from a simil ar large urban center using conventional ventilation with ECMO. Method s: Between 1981 and 1994, 223 consecutive neonates who had CDH diagnos ed in the first 12 hours of life were referred for treatment before re pair. Conventional ventilation was used with conversion to HFOV for re fractory hypoxemia or hypercapnia, and a predicted near 100% mortality rate. ECMO was used in only three patients, all of whom died. A retro spective database was collected. Thirty-one clinical variables were te sted for their association with the outcome. Common ventilatory and ox ygenation indices were tested for their prognostic capability. Results : Apgar scores, birth weight, right-sided defects, pneumothorax, total ventilatory time, and the use of high frequency oscillatory ventilati on were the only variables associated with outcome. A modified ventila tory index and postductal A-aDo(2) were strong prognostic indicators. From 1981 to 1984 surgery was performed on an emergency basis. Since 1 985 surgery was deferred until stabilization had been achieved. This r esulted in a shift in the mortality from postoperative to preoperative with no change in total survival. HFOV did not alter the overall surv ival. Results of autopsies performed (70%) showed significant pulmonar y hypoplasia and barotrauma as the primary causes of death. The surviv al was 54.7%, Conclusion: Conventional ventilation with HFOV produced equal survival to conventional ventilation with ECMO in two comparable series. Pulmonary hypoplasia was the principle cause of death. This c ontinued high mortality at both centers suggests that new therapies ar e required to improve outcomes. Copyright (C) 1997 by W.B. Saunders Co mpany.