Congenital diaphragmatic hernia: Impact of preoperative stabilization. A prospective pilot study in 13 patients

Hazebroek, F. W. J.; Tibboel, Dick; Bos, Albert P.; Pattenier, Annemieke W.; Madern, Gerard C.; Bergmeijer, J.H.; Molenaar, Jan C.

doi:10.1016/s0022-3468(88)80330-0

Cited by 81 publications

(19 citation statements)

References 23 publications

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“…There is supporting evidence proving not all children having identical and severe hypoplasia of the lungs succumb to a delay in surgery [12]. Moreover, recent experiences documented in Toronto, Canada [5,13], Rotterdam, The Netherlands [14], and Nottingham, UK [6] have shown that: (a) emergency surgical repair is often followed by deterioration rather than improvement, which has been our experience as well; (b) there is a distinct possibility that unsatisfactory respiratory parameters may improve with appropriate resuscitative measures; (c) by delaying surgery, time is available in which to detect and treat such situations as persistent fetal circulation (PFC); and (d) poor hemodynamic and ventilatory status on admission which does not respond to appropriate resuscitation and usually fails to improve with surgery.…”

Section: Discussionmentioning

confidence: 97%

Congenital Diaphragmatic Hernia: Update on Regional Experience

et al. 1991

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A consecutive series of 34 patients with congenital diaphragmatic hernia are reported from a tertiary neonatal care unit in the Eastern Province. All the patients presented within the first 24 hours of life with left-sided defect. The overall mortality (56%) and postoperative mortality (44%) are comparable with reports from other centers. The outcome of treatment correlated well with the age on presentation, the size of the defect, and preoperative blood gas results. Our approach to management has been modified lately, in the light of recent experience from other centers. The surgery is delayed until the neonate is stabilized with biochemical values of PaCO 2 = 45 torr or less; pH = 7.2 or higher; and PaO 2 = 50 torr or more. This management policy did not adversely affect overall survival. The problems encountered with patient transfer and the need for continued improvement in the organization of regionalized care are highlighted.

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Section: Discussionmentioning

confidence: 97%

Congenital Diaphragmatic Hernia: Update on Regional Experience

et al. 1991

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“…Surgical correction of the diaphragmatic defect does not improve oxygenation (1), and mechanical ventilatory support with high concentrations of inspired oxygen is usually required (2). Infants with this condition surviving the immediate neonatal period have a higher prevalence of airway obstruction (3).…”

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confidence: 99%

Airway Smooth Muscle Changes in the Nitrofen-Induced Congenital Diaphragmatic Hernia Rat Model

et al. 2003

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In the fetal rat, nitrofen induces congenital diaphragmatic hernia (CDH) and pulmonary vascular remodeling similar to what is observed in the human condition. Airway hyperactivity is common in infants with CDH and attributed to the ventilatorinduced airway damage. The purpose of this study was to test the hypothesis that airway smooth muscle mechanical properties are altered in the nitrofen-induced CDH rat model. Lungs from nitrofen-exposed fetuses with hernias (CDH) or intact diaphragm (nitrofen) and untreated fetuses (control) were studied on gestation d 21. The left intrapulmonary artery and bronchi were removed and mounted on a wire myograph, and lung expression, content, and immunolocalization of cyclooxygenases COX-1 and COX-2 were evaluated. Pulmonary artery muscle in the CDH group had significantly (p Ͻ 0.01) lower force generation compared with control and nitrofen groups. In contrast, the same generation bronchial smooth muscle of the CDH and nitrofen groups developed higher force compared with control. Whereas no differences were found in endothelium-dependent pulmonary vascular muscle tone, the epithelium-dependent airway muscle relaxation was significantly decreased (p Ͻ 0.01) in the CDH and nitrofen groups. The lung mRNA levels of COX-1 and COX-2 were increased in the CDH and nitrofen groups. COX-1 vascular and airway immunostaining, as well as COX-1 and COX-2 lung protein content, were increased in the CDH group. This is the first report of airway smooth muscle abnormalities in the nitrofen-induced fetal rat model of CDH. We speculate that congenital airway muscle changes may be present in the human form of this disease. Persistent pulmonary hypertension is commonly associated with CDH. Surgical correction of the diaphragmatic defect does not improve oxygenation (1), and mechanical ventilatory support with high concentrations of inspired oxygen is usually required (2). Infants with this condition surviving the immediate neonatal period have a higher prevalence of airway obstruction (3). This has been attributed to the mechanical ventilatorand oxygen-induced lung injury (4).Nitrofen exposure during gestation results in CDH in the fetal rat (5, 6). Pulmonary vascular smooth muscle of fetuses with nitrofen-induced CDH is known to be less responsive to pharmacologic stimulation and shows abnormal relaxation potential (7). Lung hypoplasia (8) and pulmonary airway branching abnormalities (9) are seen early in gestation in nitrofenexposed rats, suggesting that morphogenetic changes precede the diaphragmatic failure to close. However, little is known about functional changes occurring in the airway smooth muscle of this model.The purpose of the present study was to test the hypothesis that the nitrofen-induced fetal rat model of CDH exhibits abnormal airway smooth muscle contraction and relaxation properties. Our initial studies confirmed the hypothesis and thus we sought to determine the factors responsible for enhanced bronchial smooth muscle contraction. Specifically, we tested the hypothesis that COX ...

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“…Reports started appearing in the mid-1980s suggesting that survival may be improved if surgery was delayed until preoperative stabilization was achieved, recognizing the impact of persistent pulmonary hypertension on survival [17,18] . However, the major paradigm shift in the management of CDH of delay in operative repair until hemodynamic stability was not widely adopted until the early 1990s [15,19,20] .…”

Section: Timing Of Surgerymentioning

confidence: 99%

Surgical Management of the Newborn with Congenital Diaphragmatic Hernia

Tsao

Lally

2010

Fetal Diagn Ther

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Despite advances in the surgical treatment and medical management over the last 20 years, neonates with congenital diaphragmatic hernia (CDH) remain one of the most challenging patient groups for all clinicians. Treatment strategies have shifted from emergent surgical repair and maximum ventilatory support to delayed repair and preoperative hemodynamic stabilization with lung-sparing ventilation strategies and extracorporeal membrane oxygenation. Subsequently, overall survival has improved to as high as 80% in some centers. However, specific treatment criteria are vague and highly variable amongst centers. This lack of consensus of these treatment modalities remains elusive due to the heterogeneity in disease severity as well as heterogeneity in patient care amongst centers. As a result of the rare incidence of disease and limited experience of individual centers, the evidence for CDH is typically reported as a homogenous disease largely supported by case series and networked-based studies. To better evaluate the data and compare treatment strategies, a classification and stratification of disease and centers is needed.

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Congenital diaphragmatic hernia: Impact of preoperative stabilization. A prospective pilot study in 13 patients

Cited by 81 publications

References 23 publications

Congenital Diaphragmatic Hernia: Update on Regional Experience

Congenital Diaphragmatic Hernia: Update on Regional Experience

Airway Smooth Muscle Changes in the Nitrofen-Induced Congenital Diaphragmatic Hernia Rat Model

Surgical Management of the Newborn with Congenital Diaphragmatic Hernia

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