The effect of gentle ventilation on survival in congenital diaphragmatic hernia.

In the September 2003 issue of Pediatrics, Stege et al1 discuss the effect of new therapies for congenital diaphragmatic hernia (CDH) on survival. They point out that studies reporting improved survival using high-frequency ventilation, extracorporeal membrane oxygenation, inhaled nitric oxide, and delayed surgery are flawed by selection bias and conclude, after assessing 185 cases of CDH from a regional database, that survival is determined principally by the rate of antenatal termination and incidence of associated anomalies. Literature supporting a very promising approach to CDH, gentle ventilation, spearheaded by Wung et al,2 was not presented. In a study reporting 89 consecutive patients with CDH at a single institution, patients treated with gentle ventilation had a 78% overall survival (89% of treated infants survived), compared with 15% and 44% survival during earlier eras in which paralysis, hyperventilation, alkalinization, and extracorporeal membrane oxygenation were used in the absence of gentle ventilation.3 This study minimizes the selection bias reported by Stege et al, with all CDH patients born during the time of data collection included for analysis. Because prenatal diagnosis did not effect survival in this cohort, it is unlikely that the improved survival was due to prenatal termination rate. Most recently, an 85% survival is reported with gentle ventilation in CDH.4,5 Given the low cost, low potential morbidity, and ease of initiating this promising therapy, gentle ventilation should be assessed aggressively and critically for efficacy in improving survival in CDH.