Spontaneous breathing approach in mild congenital diaphragmatic hernia: A resuscitation algorithm

Emily J J Horn-Oudshoorn; Ronny Knol; Suzan C M Cochius-den Otter; Arjan B Te Pas; Stuart B Hooper; Calum T Roberts; Neysan Rafat; Thomas Schaible; Willem P de Boode; Robin van der Lee; Anne Debeer; Florian Kipfmueller; Charles C Roehr; Irwin K M Reiss; Philip L J DeKoninck

doi:10.3389/fped.2022.945090

Spontaneous breathing approach in mild congenital diaphragmatic hernia: A resuscitation algorithm

Front Pediatr. 2022 Jul 18:10:945090. doi: 10.3389/fped.2022.945090. eCollection 2022.

Authors

Emily J J Horn-Oudshoorn¹, Ronny Knol¹, Suzan C M Cochius-den Otter², Arjan B Te Pas³, Stuart B Hooper⁴, Calum T Roberts^{4

5}, Neysan Rafat⁶, Thomas Schaible⁶, Willem P de Boode⁷, Robin van der Lee⁷, Anne Debeer⁸, Florian Kipfmueller⁹, Charles C Roehr^{10

11

12}, Irwin K M Reiss¹, Philip L J DeKoninck^{4

13}

Affiliations

¹ Division of Neonatology, Department of Paediatrics, Erasmus MC University Medical Center, Rotterdam, Netherlands.
² Intensive Care and Department of Paediatric Surgery, Erasmus MC University Medical Center, Rotterdam, Netherlands.
³ Division of Neonatology, Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands.
⁴ The Ritchie Centre, Hudson Institute for Medical Research, Monash University, Melbourne, VIC, Australia.
⁵ Department of Paediatrics, Monash University, Melbourne, VIC, Australia.
⁶ Department of Neonatology, University Medical Center Mannheim, Mannheim, Germany.
⁷ Division of Neonatology, Department of Paediatrics, Radboud Institute for Health Sciences, Radboudumc Amalia Children's Hospital, Nijmegen, Netherlands.
⁸ Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.
⁹ Department of Neonatology and Paediatric Critical Care Medicine, University of Bonn Children's Hospital, Bonn, Germany.
¹⁰ National Perinatal Epidemiology Unit, Medical Sciences Division, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
¹¹ Newborn Services Southmead Hospital, North Bristol Trust, Bristol, United Kingdom.
¹² Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom.
¹³ Division of Obstetrics and Fetal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC University Medical Center, Rotterdam, Netherlands.

Abstract

Background: Infants with a congenital diaphragmatic hernia (CDH) and expected mild pulmonary hypoplasia have an estimated survival rate of 90%. Current guidelines for delivery room management do not consider the individual patient's disease severity, but an individualized approach with spontaneous breathing instead of routine mechanical ventilation could be beneficial for the mildest cases. We developed a resuscitation algorithm for this individualized approach serving two purposes: improving the success rate by structuring the approach and providing a guideline for other centers.

Methods: An initial algorithm was discussed with all local stakeholders. Afterwards, the resulting algorithm was refined using input from international experts.

Results: Eligible CDH infants: left-sided defect, observed to expected lung-to-head ratio ≥50%, gestational age at birth ≥37.0 weeks, and no major associated structural or genetic abnormalities. To facilitate fetal-to-neonatal transition, we propose to start stabilization with non-invasive respiratory support and to adjust this individually.

Conclusions: Infants with mild CDH might benefit from an individualized approach for neonatal resuscitation. Herein, we present an algorithm that could serve as guidance for centers implementing this.

Keywords: birth; congenital diaphragmatic hernia; intubation; neonatal resuscitation; spontaneous breathing approach.