RESPIRATORY FAILURE IN CONGENITAL DIAPHRAGMATIC HERNIA: VENTILATION BY HIGH FREQUENCY OSCILLATION

Abstract

Congenital diaphragmatic hernia (CDH) is characterised by immaturity both of alveoli and pulmonary vasculature. In a prospective analysis of 46 infants with CDH presenting within the first 6 hours of life, simultaneous blood gases drawn from umbilical and right radial artery lines identified a group of 23 patients with severe hypoxemia due mainly to preductal rather than ductal shunting. All were treated with paralysis, hyperventilation, and vasodilator therapy. The single consistent feature in this severely affected group was hypercarbia (P_aCO₂>50mmHg) which remained elevated despite manipulations of both ventilator rates and mean airway pressures. All 23 patients in this group died while 21 of 23 patients with ductal shunting only, survived. In ten of the 23 patients in whom we were unable to control P_aCO₂ we changed from conventional ventilation (CMV) to high frequency oscillation (HFO). The mean P_aCO₂ on CMV was 59±15mmHg with mean P_aO₂ in the right radial artery of 36±11mmHg. The mean P_aCO₂ fell to 32±5mmHg with HFO but while there was a temporary improve ment in P_aO₂, this was not sustained. The fact that control of P_aCO₂ was readily achieved by HFO suggests that the hypercarbia and hypoxemia in this group of patients is based on intrapulmonary rather than intracardiac shunting and represents severe bilateral pulmonary hypoplasia, where pulmonary vasodilator therapy will not be of benefit.

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