Infants affected with congenital diaphragmatic hernias (CDH) suffer from some degree of respiratory insufficiency arising from a combination of pulmonary hypoplasia and pulmonary hypertension. Respiratory care strategies to optimize blood gasses lead to significant barotrauma, increased morbidity, and overuse of extracorporeal membrane oxygenation (ECMO). Newer permissive hypercapnia/spontaneous ventilation protocols geared to accept moderate hypercapnia at lower peak airway pressures have led to improved outcomes. High-frequency oscillatory ventilation can be used in infants who continue to have persistent respiratory distress despite conventional ventilation. ECMO can be used successfully as a resuscitative strategy to minimize further barotrauma in carefully selected patients.
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