Fig. 3

Optional guidelines for “optimal” management of a neonate with congenital diaphragmatic hernia in the preoperative period. A nasogastric or orogastric suction tube is placed to decompress the stomach in the delivery room. Respiratory management includes intubation and positive pressure ventilation with care to avoid high PIP. The target of respiratory management is to maintain preductal oxygen saturations in the 85–95% range and PaCO₂ between 45 and 70 mmHg with a pH > 7.20. If PaCO₂ of ≤70 mmHg cannot be achieved with conventional ventilation (maximum PIP of 28 cm H₂O and a maximum rate of 60/min), high frequency ventilation (high frequency oscillator – HFOV or jet ventilator – HFJV) may be required. Blood pressure is maintained to achieve adequate perfusion and avoid lactic acidosis and oliguria. Monitoring chest X-rays to maintain contralateral lung expansion to 8 to 9 ribs may avoid baro/volutrama. A trial of inhaled NO may be considered when oxygenation index exceeds 15 with clinical or echocardiographic evidence of pulmonary hypertension. CMV – conventional mechanical ventilation. Modified from Chandrasekharan et al. [48]