(9) CDH Ventilator Management Before and After Implementation of a Clinical Practice Guideline

Katrin Lichtsinn, UPMC Childrens Hospital of Pittsburgh, PITTSBURGH, PA, United States; Joseph T. Church, UPMC Childrens Hospital of Pittsburgh, United States; Abeer Azzuqa, UPMC Children’s Hospital of Pittsburgh, United States; Paul Waltz, Childrens Hospital Pittsburgh, PA, United States; Jacqueline Graham, Children's Hospital of PIttsburgh, Pittsburgh, PA, United States; Jennifer Troutman, Children’s Hospital of Pittsburgh, United States; Burhan Mahmood, UPMC Children's Hospital of Pittsburgh, PA, United States

Background: Lung hypoplasia and pulmonary hypertension contribute to the morbidity and mortality of infants with congenital diaphragmatic hernia (CDH), but respiratory management that minimizes lung injury can improve outcomes. Our NICU implemented a standardized clinical practice guideline (CPG) to manage infants with CDH in January 2012 emphasizing a consistent, gentle respiratory management approach. In a prior study we found that infants managed with the CPG had significantly less need for ECMO and improved clinical outcomes and survival than those with unstandardized management.

Objectives: Characterize ventilator management strategies before and after implementation of the CPG. Our hypothesis was that infants managed after implementation of the CPG spent more time in optimal ventilator parameters than those managed before the CPG.

Design/Methods: Retrospective chart review of infants with CDH admitted to our NICU from January 2007 to July 2021, divided into Cohort 1 (January 2007 - December 2011, management not standardized), and Cohort 2 (January 2012 to July 2021, after CPG implementation). Infants intubated for < 24 hours, cannulated to ECMO < 24 hours of admission or intubated for the first time at >14 days of life were excluded. Hourly ventilator settings for the first 7 days (168 hours) of mechanical ventilation or until cannulation to ECMO were collected and the cohorts were compared with descriptive statistics in terms of percentage time spent in low, optimal and high parameters for each ventilator variable (Table 1).

Results: 104 infants met inclusion criteria; 41 in Cohort 1 and 63 in Cohort 2. Conventional mechanical ventilator (CMV) use increased (59% to 87.4%) and high frequency oscillatory ventilator (HFOV) use decreased (48.2% to 12.6%) in Cohort 2 compared to Cohort 1. Infants in Cohort 2 had a significantly higher median percentage for CMV-MAP within the optimal range compared to Cohort 1 (Table 2). The distributions of median percentage of time in different ranges for PIP, PEEP, Rate, CMV-MAP, and FiO2 were also significantly different between the cohorts (Table 3, Figure 1). Infants in Cohort 1 had more exposure to higher FiO2 while those in Cohort 2 were mostly managed at optimal to higher PEEP and lower ventilator rates.

Conclusion: Consistent ventilation support for infants with CDH that reduces MAP, optimizes PEEP and minimizes oxygen toxicity may reduce ECMO utilization and improve outcomes. Further assessment of ventilator settings specifically in response to gas exchange will elucidate a better understanding of the nuances of respiratory management in infants with CDH.