Radiographic Appearance Can Be Used As a Predictor of Outcome in Diaphragmatic Hernias
Radiographic Appearance Can Be Used As a Predictor of Outcome in Diaphragmatic Hernias
Abstract & commentary
Synopsis: Mortality of neonates with congenital diaphragmatic hernia relates to the degree of pulmonary hypoplasia. A scoring system for evaluation of initial chest radiographs evaluating aeration of the ipsilateral lung and the contralateral lung, mediastinal shift, and stomach in the hernia can be used to predict mortality.
Source: Donnelly LF, et al. Correlation between findings on chest radiography and survival in neonates with congenital diaphragmatic hernia. Am J Roentgenol 1999;173:1589-1593.
Management of neonates with congenital diaphragmatic hernia is undertaken to result in the best survival of those who present early; however, the outcome largely is dependent upon the degree of existing pulmonary hypoplasia. Because of the enormous resources recruited to care for the infants, a reliable predictor of those who will have successful outcomes is required.
A study of 73 neonates with congenital diaphragmatic hernia presenting in the first 24 hours of life was undertaken to review survival outcome in infants with respiratory distress requiring intubation. Radiographs were evaluated for degree of aeration of the ipsilateral lung (< 10%, 10-50%, and > 50%). The percentage of contralateral lung aerated was judged as 50% or less, 50-80%, and more than 80%. Mediastinal shift away from the hernia was evaluated as absent, displaced less than half the width of the hemithorax, displaced more than half the width of the hemithorax but not abutting the chest wall, and abutting the chest wall. The stomach was considered to be in the hernia if the "bubble" was seen in the hernia content or the nasogastric tube tip was present in the thorax. Retrospective analysis of survival of the infants correlated with these four factors significantly. Multiple poor-prognosis factors also correlated with survival; results showed that 88% of patients with none of the parameters survived, 67% of patients with one parameter survived, 47% with two parameters survived, 20% with three parameters survived, and neither of the two patients with four parameters survived.
Donnelly and colleagues suggest that the specified findings on chest radiograph are sufficiently specific as predictors of survival that they may be applied as prognostic factors.
Comment by Beverly P. Wood, MD
This study was undertaken to investigate indicators of irreversible pulmonary disease and survival predictors in neonates with congenital diaphragmatic hernia. While radiologists reviewing the early radiographs of affected infants have usually made a prediction of poor outcome based on one or more of the indicators described, there has not been a large study to interrelate these indicators. It is logical that the poorer the initial aeration, both in the ipsilateral and contralateral lung, the less likely the survival, no matter what therapy is undertaken, as the infant must be able to survive on the pulmonary surface available postoperatively. The stomach in the hernia has been considered a weaker prognostic sign, though still a sign of poor outcome. Correlation of the four prognostic signs on initial radiographs is useful, especially when the use of intensive interventions such as extracorporeal membrane oxygenation (ECMO) is considered for preoperative management. With this information, radiologists may develop a strong prediction of survival in infants whom they review.
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