314 - Impact of initial mode of ventilation on gas exchange and NICU outcomes for infants with severe CDH

Sunday, April 30, 2023

3:30 PM – 6:00 PM ET

Poster Number: 314
Publication Number: 314.348

K. Taylor Wild, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Leny Mathew, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Anne Ades, The Children's Hospital of Philadelphia, Philadelphia, PA, United States; Natalie Rintoul, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Holly L. Hedrick, Children’s Hospital of Philadelphia, Philadelphia, PA, United States; Leane Soorikian, Childrens Hospital of Philadelphia, chester springs, PA, United States; Kelle J. Matthews, CHOP, Philadelphia, PA, United States; Sura Lee, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; K. Taylor Van Hoose, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Erin Kesler, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Tom Reynolds, Children's Hospital of Philadelphia, Philadelphia, PA, United States; Sabrina Flohr, Childrens Hospital of Philadelphia, Philadelphia, PA, United States; Anna L. Bostwick, Children’s Hospital of Philadelphia, Philadelphia, PA, United States; Elizabeth Foglia, Perelman School of Medicine at the University of Pennsylvania, Swarthmore, PA, United States

Presenting Author(s)

K. Taylor Wild, MD

Fellow Physician
Children's Hospital of Philadelphia
Philadelphia, Pennsylvania, United States

Background: While pulmonary hypoplasia and pulmonary hypertension are the main causes of mortality in infants with congenital diaphragmatic hernia (CDH), ventilator-induced lung injury and oxygen toxicity may result in prolonged oxygen dependency. High frequency oscillatory ventilation (HFOV) may offer improved clearance of carbon dioxide (CO2) with reduced risk of barotrauma. In 2019, the Children’s Hospital of Philadelphia (CHOP) implemented a practice change of initiating ventilatory support with HFOV in the delivery room (DR) for infants with severe CDH (intrathoracic liver or right-sided).

Objective: To determine whether initial mode of ventilation (conventional mechanical ventilation (CMV) vs HFOV) for infants with severe CDH is associated with 1) improved measures of gas exchange and 2) improved neonatal intensive care unit (NICU) outcomes such as ECMO, length of stay, and survival.

Design/Methods: Retrospective cohort study of infants with severe CDH born at CHOP between 2014 and November 2022. Since 2019, all infants with severe CDH, defined as an intrathoracic liver or a right sided CDH, are transitioned to HFOV immediately after intubation. Infants with severe CDH managed with initial CMV were selected as a comparison group to evaluate differences in DR and NICU outcomes. Continuous variables were compared using the Wilcoxon rank-sum test, and the chi-squared test used to evaluate associations between categorical variables and the analysis groups. Fisher’s exact test was used when expected values in cells were less than 5.

Results: There were 75 and 114 infants with severe CDH placed on HFOV and CMV, respectively (Table 1). Of note, infants in the HFOV group had a significantly lower Observed to Expected Lung to Head Ratio [median (IQR), 26.5 (22.0, 34.5); 36.6 (27.2, 47.5), p< 0.001], demonstrating more severe CDH. DR outcomes demonstrated a higher pH [7.16 (6.98, 7.24); 7.05 (6.94, 7.17); p=0.03], and lower first CO2 [64.5 (48.2, 84.5); 85.2 (59.0, 103.0), p=0.005] in infants placed on HFOV (Table 2). There was no difference in age at CDH repair or survival. ECMO utilization (48% vs. 29.9%, p=0.02) and length of stay (days) [85 (63.4, 172); 72 (47.5, 131), p=0.04] were elevated in the HFOV group, although this may reflect more severe disease in this group (Table 3).

Conclusion(s):

HFOV as the initial mode of ventilation in the DR for infants with severe CDH was associated with improved gas exchange immediately after resuscitation, but was not associated with any improvement in NICU outcomes.