Congenital diaphragmatic hernia by Dr. Varsha Atul Shah
1. Dr Varsha Atul Shah
Senior Consultant
Dept of Neonatal and Devt
Medicine, SGH
Visiting Consultant
Dept of Child Devt, KKH
2. Summary of presentation
Overview
- Background
- Path physiology
- Epidemiology
- Mortality and Morbidity
Clinical Presentation
Differential diagnosis
Investigations
Treatment: Medical and surgical
Follow up care
3. Overview
appeared in the medical literature since its first
description in the early 18th century18th century
In 1946, Gross reported the first successful repair of a
neonatal diaphragmatic hernia
In the 1960s, Areechon and Reid observed that the
high mortality rate of CDH was related to the degree
of pulmonary hypoplasia at birth
4. Incidence
1 in 2000-3000 live births1 in 2000-3000 live births
Accounts for 8% of all major congenital anomalies
The risk of recurrence of isolated (ie, nonsyndromic)
in future siblings is approximately 2%
Familial is rare (< 2% of all cases)
Both autosomal recessive and autosomal dominant
patterns of inheritance is reported
5. Genetic anomalies-Syndrome
Associated with genetic anomalies:
Smith-Lemli-Opitz syndrome
DiGeorge syndrome
Chromosome 15,18,13 and 21 anomalies
Fryns syndrome
Pallister-Killian syndrome
6. Pathophysiology and cause
Cause is unknown
Failure of normal closure of the pleuroperitoneal
canal in the developing embryo
Abdominal contents herniate and compress the
ipsilateral developing lung, causing pulmonary
hypoplasia and hypertension
7. Path physiology of CDH
Is associated with variable degree of pulmonary hypoplasiapulmonary hypoplasia
due to decrease in cross-sectional area of the pulmonary
vasculature and alterations of the surfactant systemalterations of the surfactant system
The lungs have a small alveolar capillary membranesmall alveolar capillary membrane for gas
exchange, which may be further decreased by surfactant
dysfunction
There is increased muscularizationincreased muscularization of the intraacinar
pulmonary arteries
In very severe cases, left ventricular hypoplasia is observed.
Pulmonary capillary blood flow is decreasedPulmonary capillary blood flow is decreased because of the
small cross-sectional area of the pulmonary vascular bed, and
flow may be further decreased by abnormal pulmonary
vasoconstriction.
8. Types of congenital diaphragmatic hernia
Bochdalek hernia:Bochdalek hernia: Poster lateral
(occurring at approximately 6 weeks' gestation)
Morgagni hernia:Morgagni hernia: Anteriomedial
The hiatus hernia
9. Left sided of CDH
The left-sided Bochdalek hernia occurs in
approximately 85% of cases85% of cases
Allow herniation of both the small and large bowel
and intra-abdominal solid organs (stomach, liver) into
the thoracic cavity
10. Right sided CDH
Occurs in (13% of cases)
Only the liver and a portion of the large bowel tend
to herniate
Bilateral hernias are uncommon and are usually fatal.
11. Mortality/Morbidity
Mortality has traditionally been difficult to determine
This is partially because of the "hidden mortalityhidden mortality"
for this condition who die in utero or shortly after
birth, prior to transfer to a surgical site
A population-based study from Western Australia
indicated that only 61% of infants with congenital
diaphragmatic hernia are live born
Nearly 33% of pregnancies that involved a fetus were
electively terminated
Mortality is reported to range from 40-62%40-62%
12. Sex
It occurs equallyequally in both sexes
Age
It is usually a disorder of the new-bornnew-born period
10% of patients may present after the new-born
period and even during adulthood
Outcome in patients with late presentation of
congenital diaphragmatic hernia is extremely good,
with low or no mortality
13. Clinical Presentation
History
Is diagnosed based on prenatal ultrasonographyprenatal ultrasonography
findings in approximately one half of affected infants
May have a prenatal history of polyhydramniospolyhydramnios
The most commonly present with respiratory distress
and cyanosis in the first minutes or hours of life
The respiratory distress can be severe and may be
associated with circulatory insufficiency, requiring
aggressive resuscitative measures.
14. Antenatal Diagnosis:
59% antenatal detection with average age 24.2 weeks24.2 weeks
Polyhydramnios
Intrathoracic stomach or liver
Lung-to-head ratio and lung/transverse thorax ratio.
Usually at prenatal ultrasound (15 weeks).(15 weeks).
Recently fetal MRI and fetal echocardiography,
helpful to determine degree of pulmonary hypoplasia.
(MRI lung volumetry, left ventricular mass and
pulmonary artery diameter)
16. Three general presentations
Severe respiratory distressSevere respiratory distress at the time of birth.
( Severe hypoplasia)
Respiratory deterioration hours after delivery
(honeymoon period). Benefit from correction of
hypoxemia and pulmonary hypertension.
Feeding difficulties, chronic respiratory disease,
pneumonia, intestinal obstruction 24h after birth. (10-
20% of patients).Best prognosis
17. Physical Examination
Scaphoid abdomen, barrel-shaped chest,Scaphoid abdomen, barrel-shaped chest, and signs of respiratory
distress (retractions, cyanosis, grunting respirations)
In left-sided posterolateral hernia, auscultation of the lungs reveals
poor air entry on the left, peristalsis heard in chest, with a shift of
cardiac sounds over the right chest
In patients with severe defects, signs of pneumothorax (poor air entry,
poor perfusion) may also be found
Associated anomalies occur in a relatively high percentage of infants
Dysmorphisms such as craniofacial, extremity abnormalities, or spinal
dysraphism may suggest syndromic congenital diaphragmatic hernia
18. Differential Diagnoses
Cystic Adenomatoid Malformation
Bronchopulmonary sequestration
Bronchogenic cyst
Bronchial atresia
Enteric cyst
Teratoma
Disorders of the Thoracic Cavity and Pleura
Pneumothorax
Primary Pulmonary Hypertension of New-born
(PPHN)
19. Imagining study-Chest X-ray
Placement of an orogastric tubePlacement of an orogastric tube prior to the study
helps decompress the stomach and helps determine
whether the tube is positioned above or below the
diaphragm
Typical findings in a left-sided posterolateral congenital
diaphragmatic hernia include
- Air-filled or fluid-filled loops of the bowel in the left
hemithorax
- Shift of the cardiac silhouette to the right
- Look for evidence of pneumothoraxpneumothorax
21. Imagining study-2D Echography
2DE2DE: To exclude Cardiac anomalies (25%) and degree of
PPHN
Assessing myocardial function and determining
whether the left ventricular mass is significantly
decreased
Renal USGRenal USG: Genitourinary anomalies occur in 6-8%
of infants
Cranial USGCranial USG for CNS anomalies
22. Investigations-Lab studies
ABG (pre-right radial and post ductal-left radial or
posterior tibial artery) measurements to assess for pH,
PaCO2, and PaO2
Note the sampling site because persistent pulmonary
hypertension of the newborn (PPHN) with right-to-
left ductal shunting often complicates CDH
The PaO2 is often higher from a preductal (right-
hand) sampling site
Serum lactate may be helpful in assessing for
circulatory insufficiency or severe hypoxemia
associated with tissue hypoxia
23. Medical Care in the delivery room:
( if the infant is known or suspected to have congenital
diaphragmatic hernia)
Immediately place a vented orogastric tube and
connect it to continuous suction to prevent bowel
distension and further lung compression
Avoid mask ventilation and immediately intubate the
trachea
Avoid high peak inspiratory pressures and be alert to
the possibility of early pneumothorax if the infant does
not stabilize
24. Investigations
Serum electrolytes, ionized calcium, and glucose
initially and frequently
Maintaining glucose levels in the reference range and
maintaining calcium homeostasis are particularly
important
25. Pre and Post Pulse Oxymetry
Continuous pulse oximetry is valuable in the
diagnosis and management of PPHN
Place oximeter probes at preductal (right-hand) and
postductal (either foot) sites to assess for a right-to-
left shunt at the ductus arteriosus level
26. Procedures
UAC insertion: For frequent ABG monitoring and BP
monitoring
UVC insertion for infusion of inotropes, Calcium and for
venous access
Venoarterial or venovenous ECMO support is an
adaptation of cardiopulmonary bypass and involves a
surgical team
27. NICU admission/Critically care
Minimal Handling/stimulation, and gentle suctioning
Maintain temperature
Continuous monitoring of oxygenation, transcutaneous
PaO2, PaCO2, blood pressure, and perfusion
Maintain glucose (reflo regime) and ionized calcium
28. Inotropes for BP
Use volume expansion and inotropic support with
dopamine, dobutamine, or milrinone , 2-20 mcg/kg/min
Dobutamine and milrinone may be particularly helpful if
myocardial dysfunction is present
Epinephrine infusions may be necessary in severe cases;
low-dose epinephrine (< 0.2 mcg/kg/min) may help to
promote pulmonary blood flow and improve cardiac
output
29. Maintain PaO2/PaCO2
PaO2 concentrations greater than 50 mm Hg
Permissive mild hypercarbia is allowed
Maintain PH, avoid acidosis
Inhaled INO ( Nitric Oxide) as indicated
Magnesium sulphate loading and infusion if no INO
available
ECMO if available
Sedation is an important adjunctive therapy, but the
use of paralytic agents remains highly controversial
31. Surgical Care- Antenatal
Open fetal surgery:Open fetal surgery: remove the compression of the
abdominal viscera. High risk for fetus and the
mother. No survival advantage. (Harrison et al, J Ped
Surg, 1997)
Fetal tracheal occlusion:Fetal tracheal occlusion: stimulation of lung
growth
with accumulation of fluid. Result in larger but
persistent abnormal lung.
Steroids therapy weekly to improve lung function is
controversial (risk of brain and body development
32. Surgical Care-Time of surgery
Circulatory stability, respiratory mechanics, and gas
exchange deteriorate after surgical repair
The ideal time to repair a congenital diaphragmatic
hernia is unknown
Some suggest that repair 24 hours after24 hours after
stabilizationstabilization is ideal, but delays of up to 7-10 days
are typically well tolerated, and many surgeons now
adopt this approach
Some surgeons prefer to operate on these neonates
when normal pulmonary artery pressure is
maintained for at least 24-48 hours based on
33. Approaches for surgical repair
Abdominal subcostal
Thoracotomy
Laparoscopic vs Thoracoscopic
MIS (Minimal Invasive surgery) ideal for Morgagni hernias but can be
challenging because the peumoperitoneum widens the defect.
Laparoscopy for Bochdalek’s has a high failure rate and is associated
with pCO2 and acidemia↑
Contraindicated if very high pCO2.
Thoracoscopy is better approach for Bochdalek hernias with recurrence
of 14%. Open approach 3-22%.
Small defect can be repaired primarily
Large defect will require abdominal or thoracic muscle
flaps, or prosthetic patch (tension free)
35. Follow up care
GERD
Growth Failure (FTT)
Foregut dysmotility
Chronic lung disease
Scoliosis
Pectus excavatum
Neurodevelopmental delay, Cognitive skills, LD,
seizures,
Hearing loss
36. Further Inpatient Care-Respiratory care
Severely affected infants have chronic lung diseasechronic lung disease
May require prolonged therapy with supplemental
oxygen and diuretics, an approach similar to that for
bronchopulmonary dysplasia
The use of steroids, particularly high doses for
prolonged periods, is controversial and may hinder
appropriate lung and brain development
Late pulmonary hypertensionLate pulmonary hypertension has been
successfully treated with low-dose inhaled nitric oxide
37. Neurologic evaluation
Neurologist or developmental pediatrician perform
an examination that includes an evaluation for CNS
injury using head CT scanning or MRI
The incidence of hearing loss appears to be
particularly high in patients with congenital
diaphragmatic hernia (approximately 40% of infants40% of infants)
An automated hearing test should be performed prior
to discharge
38. Gastroesophageal reflux
(GERD)
GERD is very high in patients who survive congenital
diaphragmatic hernia, and studies document an
incidence of 45-85%.45-85%.
Severe reflux may result in chronic aspiration and is,
therefore, aggressively treated
Although most infants can be medically treated with
H2-blockers or proton pump inhibitors in combination
with a motility agent such as Domperidone, surgical
intervention is sometimes required.
39. Further Outpatient Care- Failure To Thrive
(FTT)
Possible causes include increased caloric
requirements due to chronic lung disease, oral
aversion after prolonged intubation, poor oral feeding
due to neurologic delays, and gastroesophageal reflux.
More than 50% of patients are below the 25th50% of patients are below the 25th
percentilepercentile for height and weight during the first year
of life
In one study, one third of infants required
gastrostomy tube placement to improve caloric intake
40. Developmental Assessment
Because of the risk for CNS insult and sensorineural
hearing loss, infants should be closely monitored for
the first 3 years of life, preferably in a specialty follow-
up clinic
These risks are particularly high in infants who are
discharged home on supplemental oxygen
Reassess hearing at age 6 months (and later if
indicated) because late sensorineural hearing loss
occurs in approximately 40% of patients40% of patients
41. School age
Even if a child has no major neurodevelopmental
delays, he or she should be evaluated prior to entering
school to determine if any subtle deficits may
predispose the child to learning disabilities.
42. Nursing related pointers
Delivery room-Do not bag and Mask, early intubation
Insert nasogastric tube to decompress stomach and
gut
Sat O2 monitor on right palm and left palm(pre and
post)
Thermoregulation maintain temp 36.7-37.3°C by
control of ambient and/or skin temperature
Minimal stimulation/HandlingMinimal stimulation/Handling, XR,suction and
noise
Strict input output
UAC/UVC or IA line monitoring, perfusion chart
43. Nursing related pointers
HFOV, ETT position, mechanical ventilation charting, prevent
nosocomial pneumonia and infection control
Educate use and connection for INO NOXBOX
Avoid hypoxia, hypercarbia, acidosis
Sedation, pain management
Inline suctioning, Chest PT
Developmental care- avoid noise, bright light etc
Feeding, Expressing breast milk, Weight chart, wound care
Positioning and posture:
- Supportive positioning (Position infant with affected side down toPosition infant with affected side down to
aid ventilation of the “good” lung)aid ventilation of the “good” lung)
- Also position infant in a nesting position to decrease agitation
Parent Education and support
44. Parent education
Parents receiving the diagnosis of Congenital
Diaphragmatic Hernia initially experience emotional
distress, which has been shown to impair optimum
learning
Studies of prospective parents of an infant with a fetal
anomaly revealed their inability to assimilate all the
information given to them in one session
Parents have indicated that both visual and auditory
learning is important and have suggested that written
material and drawings would be useful in helping
parents retain and review information.
45. Parent education
Description of Congenital Diaphragmatic Hernia
Explanation of what to expect in the delivery room
Tour of neonatal unit
Explanation of what to expect upon admission to
NICU and first day of life including intubation,
ventilation, antibiotics, umbilical venous/arterial
lines, IV therapy, gastric decompression and cardiac
monitoring.
Education upon admission to NICU:
Reinforce information given prenatally as noted above
Discuss plan of care given to the parents prenatally:
46. Parent Education
Pre-Op: Update parents to plans for surgery and what
to expect post-operatively
Post-operative Education:
Update parents about infant’s status post-operatively
and review any new equipment, medication, or
therapies that have been added to infant’s care.
Discharge Education:
General Infant Care
Car seat Safety
Care for the infant with reflux (as appropriate)
Care for the infant on oxygen therapy (as appropriate)
47. Conclusion
CDH is a congenital anomaly with a high mortality
Usually associated with pulmonary hypoplasia and hypertension
Surgical repair is only treatment
Delayed surgery until the patient is stable is associated with better
outcomes
Congenital cardiac and renal diseases, hypoxemia and hypercapnia
increases mortality
HFOV, ECMO, iNO has improved the survival of CDH
Permissive hypercapnia with acceptable pO2 has shown to improve
survival
Long term follow up is necessary to detect complications
Tracheal occlusion in utero, keeps lung expanded but is a abnormal
lung
Primary repair if small defect, patch if large defect, to prevent tension