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DIAPHRAGMATIC HERNIA

DIAPHRAGMATIC HERNIA. Dr Ho Huyen Emergency Department Children’s Hospital 2. 1. OVERVIEW 2. CLINICAL MANIFESTATIONS 3. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS 4. PROGNOSTIC FACTORS 5. OBSTETRICAL MANAGEMENT 6. NEONATAL MANAGEMENT 7. SUMMARY AND RECOMMENDATIONS. OVERVIEW. OVERVIEW.

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DIAPHRAGMATIC HERNIA

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  1. DIAPHRAGMATIC HERNIA Dr Ho Huyen Emergency Department Children’s Hospital 2

  2. 1. OVERVIEW 2. CLINICAL MANIFESTATIONS 3. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS 4. PROGNOSTIC FACTORS 5. OBSTETRICAL MANAGEMENT 6. NEONATAL MANAGEMENT 7. SUMMARY AND RECOMMENDATIONS

  3. OVERVIEW

  4. OVERVIEW • 1:2200 births • Almost occurs on the left (Right-sided: 11%, bilateral herniation: 2%) • Advent of antenatal diagnosis and improvement of neonatal care: survival has improved

  5. CLINICAL MANIFESTATIONS • Respiratory distress • Barrel-shaped chest • Absence of breath sounds on the ipsilateral side • Heartbeat is displaced to the right • Developing persistent pulmonary hypertension

  6. barrel-shaped chest

  7. Left-sided diaphragmatic hernia

  8. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS • Diagnosis: • Suspected in any full term infants with respiratory distress especially in the absence of breath sounds • Antenatal ultrasound • Natal chest radiography • Differential diagnosis: includes other causes of pulmonary hypoplasia (primary or secondary)

  9. PROGNOSTIC FACTORS • Abnormal karyotype • Severe associated anomalies • Right-sided defect • Liver herniation • Fetal lung volume: Lung area to head circumference ratio

  10. OBSTETRICAL MANAGEMENT Suspected CDH on prenatal ultrasound, suggest: • Ultrafast fetal MRI: find abnormalities, liver herniation, estimate lung volumes • Fetal echocardiography • Fetal karyotype

  11. NEONATAL MANAGEMENT Initial treatment: •  In the delivery room: • immediately intubated • blow-by oxygen and/or bag-masking are contraindicated • ventilated with low peak pressure (goal<25 cm H2O) to minimize lung injury • nasogastric tube  Any delay in obtaining an airway can intensify the resultant acidosis and hypoxia, which can increase the risk of pulmonary hypertension.

  12. NEONATAL MANAGEMENT • Ventilation: • PIP: 20 to 25 cm H2O • PEEP: should be maintained at physiologic levels (3 to 5 cm H2O) • Preductal SaO2: > 80% • PaO2 : > 60 mmHg • Treatment: surgery Retrospective review: the survival rate improved in patients whose delay surgery compared to immediate surgical repair

  13. SUMMARY • CDH is a developmental defect in the diaphragm • The morbidity and mortality of CDH is related to the severity of lung hypoplasia, pulmonary hypertension and associated anomalies • Most case often develop respiratory distress in the first few hours or days of life • Diagnosis: prenatal ultrasound, natal X-ray

  14. RECOMMENDATIONS • Immediate endotracheal intubation(Grade 2C). NOT using blow-by oxygen and/or bag-masking (Grade 1C) • Ventilatory support with minimal airway pressure to maintain preductal SaO2 > 80% and PaO2 > 60 mm Hg (Grade 2C). • Other supportive: nasogastric tube, maintenance of the mean arterial blood pressure >50 mm Hg. • Timing of surgical: unclear, dependent on the severity of the respiratory distress

  15. Thank you!

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