CDH involves herniation of abdominal viscera into the thoracic cavity, causing severe ipsilateral and contralateral pulmonary hypoplasia and pulmonary hypertension.
Key Physiological Equations & Formulas
- CDH Ventilation Goals (EURO-CDH Protocol): $$P_{insp} < 25\text{ cmH}_2\text{O}, \quad PEEP = 3-5\text{ cmH}_2\text{O}, \quad SpO_2 \ge 85-95\%, \quad PaCO_2 = 45-65\text{ mmHg}$$ Strict gentle ventilation to prevent barotrauma in hypoplastic lungs.
Practical Clinical Pearls & Bedside Rules
- Avoid Bag-Mask Ventilation: Never bag-mask ventilate a suspected CDH infant in the delivery room; bag-masking distends the intrathoracic stomach and compresses the heart and lungs. Intubate immediately.
- Nasogastric Decompression: Place large bore (8-10 Fr) double-lumen Replogle suction catheter to continuous low suction immediately at birth.
Initial Settings & Clinical Titration Protocol
| Parameter | Recommended Initial Setting | Titration Goal / Safety Threshold |
|---|---|---|
| Mode | Conventional PC-CMV or HFOV | Strictly limit peak inspiratory pressure (PIP <= 25 cmH2O). |
| ECMO Indications | Pre-ductal SpO2 < 85% or OI > 40 despite HFOV and iNO | Bridge to surgery and lung recovery. |
Bedside Troubleshooting & Red Flags
Warning
Contralateral Pneumothorax: Iatrogenic rupture of the 'good' lung carries near 100% mortality. Maintain low peak pressures at all times.
Key Takeaways & Summary
- Always evaluate patient synchrony and physiological response before changing ventilator parameters.
- Maintain lung-protective strategies to minimize driving pressure ($\Delta P$) and mechanical power.
- Continuously reassess liberation and extubation readiness on daily morning rounds.