Desfrere L, Jarreau P H, Dommergues M, Brunhes A, Hubert P, Nihoul-Fekete C, Mussat P, Moriette G
Services de Médicine Néonatale, UFR Cochin-Port Royal, Paris, France.
Intensive Care Med. 2000 Jul;26(7):934-41. doi: 10.1007/s001340051284.
a) To analyze the influence of a new management strategy on the outcome of neonates with antenatally diagnosed congenital diaphragmatic hernia (CDH); b) to determine early prognosis respiratory factors with the new strategy.
Retrospective study.
Level III perinatal center.
Between 1985 and 1997, 51 consecutive neonates with antenatally diagnosed CDH were admitted to our level III neonatal intensive care unit. Before 1992 (period 1; n = 19), we used conventional mechanical ventilation and early surgery requiring transfer. Since 1992 (period 2; n = 32), we prospectively tested a new approach including (a) systematically use of high-frequency oscillatory ventilation (HFOV) regardless of the initial clinical severity, (b) delayed surgery following stabilization requiring transfer to a different surgical unit, but (c) no transfer of unstable patients with surgery under HFOV in our neonatal intensive care unit (n = 10). The two cohorts were comparable in terms of potential ante and postnatal prognostic indicators.
Survival was improved with the new strategy: 21/32 (66%) vs. 5/19 (26%); P < 0.02. This improvement between periods 1 and 2 was due to a decrease in both preoperative and postoperative deaths in the later period. The better survival during period 2 was associated with the appearance of very late deaths, frequent pleural effusions, and the survival of more severe forms having evolved to a chronic respiratory insufficiency. Survivors were ventilated for longer time with longer duration of oxygen supplementation. The best oxygenation index (OI), alveolar arterial difference and oscillation amplitude (P/P) during the first 24 h, but not the best PaCO2, were the most reliable prognostic indicators during period 2. An OI < or = 10 with a P/P < or = 55 cmH2O was associated with a very good prognosis (94% survival).
The prognosis of antenatally diagnosed CDH was improved by systematic HFOV on admission, no systematic transfer, and delayed surgery. This improvement is associated with modification of postnatal outcome.
a）分析一种新的管理策略对产前诊断为先天性膈疝（CDH）新生儿结局的影响；b）确定该新策略下早期预后的呼吸因素。
回顾性研究。
三级围产期中心。
1985年至1997年期间，51例产前诊断为CDH的新生儿连续入住我们的三级新生儿重症监护病房。1992年以前（第1阶段；n = 19），我们采用传统机械通气和早期手术，且需要转运。自1992年起（第2阶段；n = 32），我们前瞻性地测试了一种新方法，包括（a）无论初始临床严重程度如何，系统地使用高频振荡通气（HFOV）；（b）在病情稳定后延迟手术，需要转至不同的外科单位，但（c）在我们的新生儿重症监护病房中，对不稳定患者不进行HFOV下的手术（n = 10）。两组在潜在的产前和产后预后指标方面具有可比性。
新策略使生存率提高：21/32（66%）对5/19（26%）；P < 0.02。第1阶段和第2阶段之间的这种改善是由于后期术前和术后死亡人数均减少。第2阶段更好的生存率与极晚期死亡的出现、频繁的胸腔积液以及更严重类型演变为慢性呼吸功能不全后的存活有关。幸存者通气时间更长，吸氧时间更长。第2阶段中，最初24小时内最佳氧合指数（OI）、肺泡动脉氧分压差和振荡幅度（P/P），而非最佳PaCO2，是最可靠的预后指标。OI≤10且P/P≤55 cmH2O与非常好的预后（94%存活）相关。
入院时系统使用HFOV、不进行系统转运以及延迟手术可改善产前诊断为CDH的预后。这种改善与出生后结局的改变相关。
