Congenital Diaphragmatic Hernia Management A Systematic Review and Care Pathway Description Including Volume-Targeted Ventilation

Background: Although it is well established that standardized treatment protocols improve outcomes for infants with congenital diaphragmatic hernia (CDH), there remains variance between existing protocols. Purpose: The purpose of this article was to review current literature on protocols for CDH management in the preoperative period and to describe a care pathway integrating best practice elements from existing literature with volume-targeted ventilation strategies previously in place at a major tertiary care center in the Pacific Northwestern United States. Methods/Search Strategy: A systematic review of literature was performed according to PRISMA guidelines to identify current publications on CDH protocols and examine them for similarities and differences, particularly regarding ventilation strategies. Findings/Results: Although existing protocols from multiple regions worldwide shared common goals of reducing barotrauma and delaying surgery until a period of clinical stabilization was achieved, their strategies varied. None included volume-targeted ventilation with pressure limitation as a method of avoiding ventilation-induced lung injury (VILI). Implications for Practice: Institutions that routinely manage infants with CDH should have a standardized treatment protocol in place, as this is shown to improve outcomes. This may include volume-targeted ventilation with pressure limitation as a successful VILI-limiting strategy. Implications for Research: While standardized protocols have been shown to increase survival rate for infants with CDH, more research is needed to determine what these protocols should include. Specifically, there is a need for future study on the most appropriate ventilation mode for this population.