Elective use of high frequency oscillatory ventilation with transcutaneous carbon dioxide monitoring during thoracoscopic diaphragmatic hernia repair

Thoracoscopy, a minimally invasive technique, for congenital diaphragmatic hernia (CDH) repair has been shown to offer significant advantages versus open procedures. However, positive pressure ventilation during thoracoscopy can be challenging. Minimizing lung movement is important to improve surgical visualization, but one-lung ventilation can be difficult in neonates and infants. Ventilation-perfusion inequalities occur in the lateral decubitus position making it challenging to maintain oxygenation and control hypercarbia from carbon dioxide insufflation. High frequency oscillatory ventilation (HFOV) offers an alternative means of ventilation for such cases. It maintains a constant distending pressure for the alveoli and optimal lung volumes while limiting peak inflating pressures and thus lung over distention. This provides a means of ensuring adequate oxygenation and ventilation with minimal lung movement, allowing adequate intraoperative exposure. During HFOV, continuous monitoring of carbon dioxide (CO2) can be problematic as end-tidal technology is not feasible. As such, we used transcutaneous CO2 (PtcCO2) monitoring in our patient. We present the elective intraoperative institution of HFOV with PtcCO2 monitoring in a 4-day-old infant for thoracoscopic repair of CDH. Previous reports regarding the intraoperative use of HFOV are reviewed and its application in this scenario is discussed. The utility of continuous PtcCO2 monitoring during such cases is presented.