University of Michigan Medical School, Ann Arbor, MI 48109, USA.
J Pediatr Surg. 2013 Jun;48(6):1190-7. doi: 10.1016/j.jpedsurg.2013.03.033.
A major determinant of survival in patients with congenital diaphragmatic hernia (CDH) is severity of pulmonary hypoplasia. This study addresses the comparative effectiveness of prenatal methods of lung assessment in predicting mortality, extracorporeal membrane oxygenation (ECMO), and ventilator dependency.
We retrospectively reviewed all patients born with isolated CDH between 2004 and 2008. Lung-to-head ratio (LHR) and observed-to-expected LHR (OELHR) were obtained from prenatal ultrasounds. Percent-predicted lung volume (PPLV) was obtained from fetal MRI (fMRI). Postnatal data included in-hospital mortality, need for ECMO, and ventilator dependency at day-of-life 30.
Thirty-seven patients underwent 81 prenatal ultrasounds, while 26 of this sub-cohort underwent fMRI. Gestational age during imaging study was associated with LHR (p=0.02), but not OELHR (p=0.12) or PPLV (p=0.72). PPLV, min-LHR, and min-OELHR were each associated with mortality (p=0.03, p=0.02, p=0.01), ECMO (p<0.01, p<0.01, p=0.03), and ventilator dependency (p<0.01, p<0.01, p=0.02). For each outcome, PPLV was a more discriminative measure, based on Akaike's information criterion. Using longitudinal analysis techniques for patients with multiple ultrasounds, OELHR remained associated with mortality (p=0.04), ECMO (p=0.03), and ventilator dependency (p=0.02), while LHR was associated with ECMO (p=0.01) and ventilator dependency (p=0.02) but not mortality (p=0.06).
When assessing fetuses with CDH, OELHR and PPLV may be most helpful for counseling regarding postnatal outcomes.
在先天性膈疝（CDH）患者中，生存的一个主要决定因素是肺发育不全的严重程度。本研究旨在比较产前肺评估方法在预测死亡率、体外膜肺氧合（ECMO）和呼吸机依赖方面的有效性。
我们回顾性分析了 2004 年至 2008 年间出生的所有孤立性 CDH 患者。从产前超声中获得肺与头比（LHR）和观察到的与预期的 LHR（OELHR）。从胎儿磁共振成像（fMRI）中获得预测肺体积百分比（PPLV）。围生期数据包括院内死亡率、ECMO 需求和生后 30 天的呼吸机依赖。
37 例患者行 81 次产前超声检查，其中 26 例亚组患者行 fMRI。成像研究时的胎龄与 LHR 相关（p=0.02），但与 OELHR 无关（p=0.12）或 PPLV 无关（p=0.72）。PPLV、最小 LHR 和最小 OELHR 均与死亡率相关（p=0.03、p=0.02、p=0.01）、ECMO（p<0.01、p<0.01、p=0.03）和呼吸机依赖（p<0.01、p<0.01、p=0.02）。对于每种结果，基于赤池信息量准则，PPLV 是更具判别力的指标。对于有多次超声检查的患者，采用纵向分析技术，OELHR 与死亡率（p=0.04）、ECMO（p=0.03）和呼吸机依赖（p=0.02）相关，而 LHR 与 ECMO（p=0.01）和呼吸机依赖（p=0.02）相关，但与死亡率无关（p=0.06）。
在评估患有 CDH 的胎儿时，OELHR 和 PPLV 可能对预测围生期结局的咨询最有帮助。
