Kitano Yoshihiro, Nakagawa Satoshi, Kuroda Tatsuo, Honna Toshiro, Itoh Yushi, Nakamura Tomoo, Morikawa Nobuyuki, Shimizu Naoki, Kashima Kyoko, Hayashi Satoshi, Sago Haruhiko
Division of General Surgery, National Center for Child Health and Development, Tokyo 157-8535, Japan.
J Pediatr Surg. 2005 Dec;40(12):1827-32. doi: 10.1016/j.jpedsurg.2005.08.020.
BACKGROUND/PURPOSE: The aims of this study were to analyze the outcomes of fetuses with congenital diaphragmatic hernia (CDH) treated by a lung-protective strategy using high-frequency oscillatory ventilation (HFOV) in a single center with a perinatology service and extracorporeal membrane oxygenation (ECMO) capability and to define the natural history of CDH in the era of lung-protective ventilation.
A retrospective chart review of 30 neonates with CDH seen between April 2002 and October 2004 was conducted. All fetuses with a prenatal diagnosis were evaluated by fetal magnetic resonance imaging to define the liver position, and those with a significant volume of the liver in the chest were regarded as liver-up. Patients were managed by a lung-protective strategy using pressure-limited (maximum mean airway pressure [MAP], 18 cm H(2)O) HFOV. The patients were initially placed on HFOV with a fraction of inspired oxygen (Fio(2)) of 1.0 and a MAP of 12 cm H(2)O. Hypercapnea and preductal saturation as low as 85% were accepted. Inhaled nitric oxide and ECMO were introduced when the baby could not be oxygenated with a MAP of 18 cm H(2)O.
Twenty-six neonates (22 inborns with prenatal diagnosis and 4 outborns) were treated with this protocol. Four cases were not treated or died in utero because of severe associated anomalies. Thirteen of the 14 liver-down cases survived without ECMO and were discharged home (93% survival). On the contrary, 4 of 12 liver-up cases survived (33% survival). ECMO was required for initial stabilization in 5 cases with 1 survivor.
Liver-down CDH babies have a good chance for survival without ECMO by a planned delivery and the lung-protective strategy using HFOV. Liver herniation demonstrated by prenatal magnetic resonance imaging retains a poor prognostic value even with this approach.
背景/目的：本研究的目的是分析在一个具备围产医学服务和体外膜肺氧合（ECMO）能力的单一中心，采用高频振荡通气（HFOV）的肺保护策略治疗先天性膈疝（CDH）胎儿的结局，并确定肺保护通气时代CDH的自然病史。
对2002年4月至2004年10月间收治的30例CDH新生儿进行回顾性病历审查。所有产前诊断的胎儿均通过胎儿磁共振成像评估肝脏位置，肝脏大量位于胸腔内的胎儿被视为肝脏上移。患者采用压力限制（最大平均气道压[MAP]，18 cm H₂O）的HFOV肺保护策略进行管理。患者最初接受HFOV治疗，吸入氧分数（Fio₂）为1.0，MAP为12 cm H₂O。允许出现高碳酸血症和导管前饱和度低至85%的情况。当婴儿在MAP为18 cm H₂O时无法实现氧合时，引入吸入一氧化氮和ECMO。
26例新生儿（22例产前诊断的足月儿和4例早产儿）按照该方案接受治疗。4例因严重合并畸形未接受治疗或死于宫内。14例肝脏下移的病例中有13例未使用ECMO存活并出院（存活率93%）。相反，12例肝脏上移的病例中有4例存活（存活率33 %）。5例患者最初需要ECMO稳定病情，其中1例存活。
通过计划分娩和采用HFOV的肺保护策略，肝脏下移的CDH婴儿有很大机会在不使用ECMO的情况下存活。即使采用这种方法，产前磁共振成像显示的肝脏疝出预后仍然较差。
