Selective use of extracorporeal membrane oxygenation in the management of congenital diaphragmatic hernia

Extracorporeal membrane oxygenation (ECMO) provides lung rest for moribund infants with congenital diaphragmatic hernia (CDH) after deterioration from a "honeymoon" period. This suggests that unstable pulmonary hypertension determines demise more than pulmonary hypoplasia. We avoided treating overwhelming pulmonary hypoplasia by using ECMO only if the premoribund condition had been marked by evidence of adequate lung parenchyma as a best preductal PO₂>100 torr and PCO₂<50 torr with maximal therapy. Twenty-six CDH infants with respiratory distress within 4 hours survived operation. Five were not ECMO candidates, with best PO₂ 33±9, PCO₂ 157±30 torr, and died. Seven honeymoon infants, with best PO₂ 325±80, PCO₂ 27±5, survived without ECMO. Fourteen additional infants had honeymoon 26±13 hours with PO₂ 256±48, PCO₂ 30±8 followed by a-AdO₂ gradients 600 torr×16±4.5 hours despite maximal therapy. All 14 were treated with ECMO for 48 to 210 hours. Arterial blood gas values at initiation were PO₂ 34±6, PCO₂ 59±19, and pH 7.22±0.2. Right-to-left shunting due to pulmonary hypertension was documented by oximetry and two-dimensional echo/Doppler examination. Twelve of 14 (86%) ECMO-treated infants survived with normal arterial blood gas values on room air, no right-to-left shunting, and no gross neurologic sequellae to date. Two of 14 died. Improvement of ECMO was marked by positive hyperoxia response and decreased right-to-left shunting. Post-ECMO ventilator support was 120±32 hours. ECMO candidates had higher best PO₂ (P<.01) and lower best PCO₂ (P<.05) than non-ECMO candidates. Overwhelming pulmonary hypoplasia is not amenable to ECMO but infants who would succumb primarily to pulmonary hypertension can be identified and saved by ECMO.