congenital diaphragmatic hernia multidisciplinary … 7 wung cdh.pdf · congenital diaphragmatic...
TRANSCRIPT
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CONGENITAL DIAPHRAGMATIC HERNIA Multidisciplinary Management
Jen-Tien Wung, MD, FCCMDivision of Neonatology
Morgan Stanley Children’s Hospital of New YorkColumbia University Medical Center
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Congenital Diaphragmatic Hernia (CDH)Embryology
Pleuroperitoneal cavity begins in the fetus as a single compartment
During 5-10th week of gestation, the gut is extruded into the extraembryonic coelom
Development and closure of the diaphragm is usually completed by 9th week of gestation
Left side of diaphragm closes later than the right side. Incidence of left CDH is about 80%
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CDH - Overview
• Idiopathic defect in muscular
diaphragm
• 1 in 2000-5000 live births
• Most are Bochdalek hernias
(posterolateral)
• 85% left, 15% right (worse
prognosis)
• 60% male, 40% female
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Normal Left Lung
CDH Left Lung
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Morbidity and Mortality in CDH• Lung Hypoplasia
– Decreased number of alveoli and terminal bronchioles– Decreased type II pneumocytes and surfactant– Bilateral - more severe on side of CDH
• Pulmonary Vascular Hypertension– Excessive muscularization of pulmonary vessels – Decreased number of pulmonary vessels– Contributes to hypoxia, shunt, and RV Failure
• Iatrogenic– Barotrauma
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Associated Congenital Anomalies
• 25%-50% associated congenital anomalies– Cardiac - PDA, left heart hypoplasia– Renal– Neurologic - myelomeningocele
• May contribute to mortality
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Congenital Diaphragmatic HerniaPrognosis depends on:1. Other congenital anomalies e.g., congenital heart
disease (15%,) renal abnormalities, chromosomal abnormalities, malrotation of the gut, Cantrell’s pentology etc.
2. The degree of hypoplastic lung3. Persistent pulmonary hypertension of neonate
(PPHN)4. Peri-op management
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Antepartum Diagnosis
Vast majority diagnosed by fetal ultrasound
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Antepartum Diagnosis
MRI confirmation
fetal stomach
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Antepartum Diagnosis
Lung-to-head ratio (LHR)• Measures contralateral lung at
24 to 26 weeks gestation
• <1.0 proposed to identify
fetuses at high risk for mortality
Liver herniation• Proposed to identify fetuses at
high risk for mortality
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PREDICTING OUTCOMESProspective Analysis of Lung-to-Head Ratio Predicts
Survival for Patients With Prenatally Diagnosed Congenital Diaphragmatic Hernia. J Ped Surg 1997; 32(11): 1634-1636. Lipshutz GS, et al.
• 15 patients with Lt. CDH, fetal lung-to-head ratio (LHR) was determined by sonography between 24-26 weeks
• Overall survival rate was 47% with pulmonary insufficiency responsible for all mortality.
• All fetuses with a LHR of less than 1.0 died and all fetuses with a LHR greater than 1.4 survived.
• ECMO was needed for all patients with a LHR < 1.0, 75% of patients with a LHR between 1.0 and 1.4, but only one of four patients with LHR > 1.4.
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• Tracheal occlusion does not improve survival or morbidity in this cohort of fetuses with CDH
• Open fetal repairs no longer performed
Antepartum Diagnosis and Management – Fetal Surgery?
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Intra-Partum• CDH alone is not an indication for Caesarian
section• Vaginal delivery preferred if labor/delivery
tolerated• “elective” induction on a weekday morning
– about 38 weeks– minimal maternal sedation– consider epidural anesthesia
CDH – Initial Management
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• Immediate/early operation within 48 hours
• Mask or endotracheal anesthesia using cyclopropane or ether plus oxygen
• “vest-over-pants” diaphragm repair• Aspiration of the ipsilateral chest to
“expand” the “compressed” lung• SURVIVAL POOR – 50% OR LESS
CDH – Surgical Management“The Past”
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• Delay surgical repair while waiting for pulmonary vascular resistance to fall. It takes around 100 hours on an average. Treat the physiology, not the anatomy!
• minimize barotrauma/oxygen toxicity• permissive hypercapnea/spontaneous
respiration• no muscle paralysis/alkalosis• ECMO only for very specific criteria
CDH – Medical / Surgical Management“The Present”
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CDHWhat is the conventional wisdom regarding
delayed surgical repair?
• allows time for remodeling pulmonary vasculature
• delays compliance changes associated with surgery
• salvages infants “too sick” for surgery• allows ECMO for pre-operative resuscitation• minimizes need for ECMO
– Moffitt, 1991– Sakai, 1991– West, 1992– Stolar, 1989,1995, 2002
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Pre-operative Management - 11) Endotracheal intubation (preferably naso-tracheal intubation for patient comfort and security of tube position.) No “bag and mask.”2) Gastric tube (double lumen) on continuously low suction. Frequent aspiration of the tube to keep it patent at all times.3) Umbilical arterial catheterization for blood pressure monitoring and blood sampling. 4) Temperature control, usual supportive treatments5) Monitoring BP, EKG, Pre- & post-ductal pulse oximetry. Follow pre-ductal O2 saturation (> 90%) to adjust FiO2
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Persistence of fetal circulation
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Pre-operative Management - 2
6) I.V. fluids: D/W10% + calcium to run 4 ml/kg/hr for maintenance Replacement for gastric tube loss7) Laboratory work-up: • Echocardiography if no fetal echocardiogram was
done• Radiograph of chest and abdomen• ABG’s, CBC, chem 7, blood type & X-match, etc.
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Respiratory management:Mechanical ventilation (gentler & kinder).
1) Start with IMV or SIMV, rate 40/min, PIP 20 cmH2O, Ti 0.5 seconds, PEEP 5cmH2O and FiO2 to keep pre-ductal O2 saturation around 90%. 2) Switch to SIMV + PS, or A/C for tachypnea. If rate is not enough to decrease PaCO2, then change to HFPPV. 3) Try HFPPV for excessive labored spontaneous breathings or high PaCO2, with rate 100, P 20/1, Ti 0.3 seconds. 4) Try HFO if all 3 above failed. (for pre-ductal O2saturation<90% or persistent PaCO2>60) * Most of survivable CDH infants just need (1), (2) or (3).
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• Journal Pediatric Surgery, 2002
• 120 newborns with CDH (1992-
2000)
• Permissive hypercapnea, gentle
ventilation, delayed repair, no
prophylactive chest tube
• 84% survival to discharge
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Pre-operative Management - 3
9) No muscle relaxant. To preserve spontaneous breathing and keep respirator settings low. Mild sedation if needed 10) Positioning patient on ipsilateral side, stabilization, minimal handling, follow ABG’s and correct acidosis11) Delay surgical repair while waiting for pulmonary vascular resistance to fall (confirmed by echocardiogram, minimal discrepancy between pre- & post-ductal O2 saturation and high oxygen saturation on low FiO2.) It takes around 100 hours on an average.
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0n left: Liver, small intestines and colon in left chest, Stomach and spleen herniated to right chest via retro-peritoneal defect On right : Liver, small intestines and colon in left chest, Stomach shifts after evacuation of air and positioning on left side
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Pre-operative Management - 4
12) Vasodilator therapy for severe PPHN (for pre-ductal O2 saturation < 90%, •Inhaled nitric oxide•Inhaled iloprost (Ventavis, using Aeroneb)13) Surfactant for the premature infant with RDS and CDH14) ECMO as a last resort. Surgical repair during or after ECMO
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CDH and ECMO - When is it needed?
• evidence of sufficient lung parenchyma– preductal SaO2>90%
• when tissue oxygen requirements are not being met by biologic organs and “conventional” care– usually manifest by progressive deterioration
of oxygenation, metabolic acidosis, and multiple organ failure
• When barotrauma prevents recovery
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Intra-operative Management -11) Temperature control: heating blanket, Bair Huggar, covers head with plastic bag2) Monitoring:BP, EKG, end-tidal CO2, ABG’sPre- & post-ductal pulse oximetry
3) Mechanical ventilation using infant ventilator, no attempt to overexpand hypoplastic lung (hyperinflation of hypoplastic lung causees increase of pulmonary vascular resistanc and is detrimental)4) I.V. fluids: 4 ml/kg/hr for maintenance,Lactated
Ringer’s to replace 3rd space loss and evaporation
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Intra-operative Management -25) Anesthetic agents depend on oxygenation and
cardiovascular stability. No N2O a) Narcotic (fentanyl 5 ug/kg I.V. bolus, total dose
25 - 50 ug/kg,) muscle relaxant, O2 or O2 + airb) Low dose inhalation agent, narcotic, muscle
relaxant and O2 or O2 + air• For increase of BP and tachycardia, deepen
anesthesia. • For increase of tachycardia and decrease of BP,
increase I.V. fluid. • For suddenly severe hypotension and bradycardia,
watch obstruction of inferior vena cava from surgeon's retractor.
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Intra-operative Management-(3)
6. No prophylactic chest tube to prevent hyperinflation of hypoplastic lung
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sub-costal incision viscera reduced
CDH – Surgical CorrectionOpen operation - Laparotomy
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primary repair prosthetic repair
CDH – Surgical CorrectionOpen operation - Laparotomy
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CDH – Surgical CorrectionWhat did the lung look like?
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Congenital Diaphragmatic HerniaTime heals all wounds!
39 weeks 4 days old,Pre-op
7 days old,post-op
11 days old
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CDH – Surgical CorrectionMinimally invasive operation - Thoracoscopic
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CDH – Surgical CorrectionMinimally invasive operation - Thoracoscopic
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CDH – Surgical CorrectionMinimally invasive operation - Thoracoscopic
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CDH – Surgical CorrectionMinimally invasive operation - Thoracoscopic
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• Technical learning curve• Feasible and safe • Less pain, less tissue trauma, cosmetically better• Magnified view for surgeons; better for nurses,
trainees and students (except anesthesiologists, PaCO2 >100 during CO2 insufflations)
• Early results similar to open repairs• Long-term follow up needed
CDH – Surgical CorrectionMinimally invasive operation - Thoracoscopic
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CDH – Surgical CorrectionMinimally invasive operation - Thoracoscopic
MIS Open
0 208
MIS Open
11 25
MIS Open
20 9
1990-2005 2006-2007 2008-2009
“pre-thoracoscopic” “ early thoracoscopic” “current thoracoscopic”
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Post-op day 1 Post-op day 60
CDH – Surgical CorrectionMinimally invasive operation - Thoracoscopic
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CDH – Surgical CorrectionMinimally invasive operation - Thoracoscopic
2 weeks 3 months
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Post-operative Management -1
1) Temperature control, usual supportive treatment2) Monitoring: BP, EKGPre- & post-ductal pulse oximetry and/or TcPO2
3) I.V. fluids: maintenance and replacement of gastric tube drainage4) Positioning on ipsilateral side dow5) No muscle relaxant.
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Post-operative Management -26) Mechanical ventilation: IMV, SIMV, Assisted Ventilation, HFPPV or HFVAvoid hyperinflation of lung. HFV (for hypoxia or hypercarbia on conventional respirator.) Aggressive weaning as tolerated7) Vasodilator continued if needed8) Morphine 0.1 mg/kg or fentanyl 2-5 ug/kg prn for pain. If > 25ug/kg fentanyl given in operating room, the infant seldom needs analgesic after operation.
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Post-operative Management -39) Positioning patient on ipsilateral side. Mediastinum should gradually shift to ipsilateral side, otherwise, although it is very rare, watch for:•Pneumothorax on ipsilateral side. Some residual air in ipsilateral pleural cavity after surgical repair is normal. •Too much pleural effusion requiring partial evacuation (about 40 – 60 ml).•Hyperinflation of ipsilateral hypoplastic lung. If contralateral lung is compressed and ventilation is compromised, one lung ventilation by block of ipsilateral bronchus may be needed.10) ECMO is used as last resort.
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We have not seen “honeymoon” and post-op ECMO since stopping prophylactive tubal thoracostomy on the ipsilateral side in August 1992
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Survival in CDH1940-1955
No. Patients Survival (%)
Orr & Neff 1953
Kansas 17 53
Ladd & Gross 1940
Boston 16 56
Donovan 1945
New York 17 76
Gross 1946
Boston 7 100
Harrington 1948
The Mayo Clinic 21 16
Gross 1953
Boston 64 89
Riker 1954
Chicago 31 81
Irish et al. Clinics in Perinatology. December 1996
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Survival in CDH1990s
No. Patients Survival (%)
Reickert1998
Multicenter 411 69
Ssemakula1997
Louisville 98 72
Frenckner1997
StockholmSweden
52 92
Wilson1997
Boston 196 53
Azarow1997
Toronto 223 55
Wung1995
New York 63 82
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Congenital Diaphragmatic HerniaGentle Ventilation & Delayed Surgery
Immediate Surgery
Very Delayed Surgery
Treatable Infants 17 137
ECMO Contraindications
2 6
Non-ECMO Rx’d (%) [survived]
9/15 (60%) [8]
113/131 (86%) [107]
ECMO Rx’d (%) [survived]
6/15 (40%) [5]
18/131(15%) [11]
Overall Survival** 13/17 (76%) 122/131 (93%)
Survival without ECMO
8/17 (47%) 107/131 (82%)
** 4 infants discharged on supplemental oxygen
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C D HConclusionsHow has survival increased?
•Prenatal diagnosis allows transfer and delivery at experienced centers
• Advances in supportive care• Gentle ventilation • Delayed surgery to allow remolding of pulmonary
vasculatures• No prophylactic chest tube to prevent overexpansion
of ipsilateral hypoplastic lung• Sensible and humane use of ECMO
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• 49% of pts had normal PAP, PAP/SAP <0.5, within 3 weeks– 100% survived
• 34% had intermediate reductions in PAP, PAP/SAP= 0.5-1.0– 75% survival rate
• 17% of pts had persistent PAP/SAP > 1.0 (despite conventional treatment)– 100% mortality
Dillon PW et al. J PedSurgery 2004
CDH: Persistent Pulmonary Hypertension
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Secondary to a combination of:– fixed elevation of pulmonary vascular
resistance secondary to underlying pulmonary hypoplasia (decrease number of pulmonary vessels)
– reversible elevation of pulmonary pressure and resistance (excessive muscularization of pulmonary vessels )
CDH: Persistent Pulmonary Hypertension
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• 2 inborn survivors with CDH requiring ECMO had persistent supra-systemic PAP and depressed RV function and were treated with IV prostacyclin
– Echocardiograms showed dramatic improvement in the PAP
– Patients clinically stabilized– 2 patient converted to po sildenafil (Viagra)
and home
• 1 additional patient receiving po sildenafil for moderate elevation of PAP
CDH: Persistent Pulmonary HypertensionColumbia Experience
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CONGENITAL DIAPHRAGMATIC HERNIA
GASTROINTESTINAL• Global foregut dysmotility• Gastroesophageal reflux
– all babies are screened with post-operative pH probe and upper GI series
– fundoplication reserved for failures of medical management
– small bowel feeding (jejunostomy) tubes are occasionally indicated
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Foregut Ectasia
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CONGENITAL DIAPHRAGMATIC HERNIA
Musculoskeletal
scoliosis pectus excavatum
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Long-term management of CDH
• CDH outcomes clinic• Multidisciplinary – surgery, GI, neonatology,
cardiology, pulmonary, and developmental peds, ortho
• Meets once a month• Convenient for patient follow up as well as
outcomes studies
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Congenital Diaphragmatic Hernia is Not Necessarily a Grim Diagnosis!
• CDH is a physiologic, not an anatomic emergency.• Surgical repair can be delayed without fear of
reprisal.• Treat the baby, not the PaO2 and PaCO2.• High airway pressure and FiO2 can ruin the lungs.• Iatrogenic disease can be more prevalent than
intrinsic disease.• Most infants with CDH can be saved with a simple
ventilator, few drugs, and without the latest device or technique.
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The End