2 days after bih, child developed respiratory distress and had scaphoid abdomen. Breath sounds were decreased on the left side. After bag and mask ventilation, ET tube was put and the maximal cardiac impulse shifted to the right side. What should be the next step in management?
Confirm the position of endotracheal tube This is a case of congenital diaphragmatic hernia The clinical features suggesting this are:? - Respiratory distress after bih with decreased air entry on the left side - Scaphoid abdomen - Mediastinal shift A diaphragmatic hernia is defined as a communication between the abdominal and thoracic cavities with or without abdominal content in the thorax. The most common form of congenital diaphragmatic hernia is the posterolateral (Bockdalek) type, which occurs through a defect in the pleuroperitoneal membrane. These hernias are found on the left side in over 80%. Right sided hernias are less common and less severe because the liver prevents the bowel from passing into the thorax. They rarely occur through an anterior defect in the foramen of Morgagni. The stomach, small bowel, colon, spleen and left hepatic lobe may all enter the pleural cavity through a left sided diaphragmatic defect. The most serious defect associated with a congenital diaphragmatic hernia is hypoplasia of the ipsilateral lung. This results from compression of the pulmonary parenchyma by the visceral contents of the hernia and the contralateral displacement of the mediastinum. Postnatally, infants with congenital diaphragmatic hernia develop dyspnea and cyanosis which worsens as swallowed air fuher distends the herniated stomach. Respiratory distress manifests as gasping respirations and cyanosis. Infants with respiratory distress within 6 hours of bih are most likely to have severe lung hypoplasia and lower chance of survival. These infants have minimal normal lung tissue and decreased pulmonary reserve, hence their respiratory insufficiency manifests rapidly. Dextrocardia and lack of breath sounds on the left side are strong indications of diaphragmatic hernia. Instead of the normally rounded abdominal appearance, there is often a scaphoid or flattened abdomen because of diminished intraabdominal contents. Management of congenital diaphragmatic hernia Historically the management of hernia focussed on the actual repair of the diaphragmatic hernia but the contemporary management of diaphragmatic hernia places emphasis on the management of pulmonary hypoplasia and persistent pulmonary hypeension. Now the initial management consists of aggressive respiratory suppo. Stabilization of the respiratory system is the first and most impoant goal in the treatment. This is accomplished by immediate postnasal endotracheal intubation and assissted ventilation (But bag and mask ventilation is contraindicated in congential diaphragmatic hernia because it causes gaseous distension of bowel). Conventional mechanical ventilation, high frequency oscillation and extracorporeal membrane oxygenation are the three main strategies to suppo respiratory failure. These therapies maintain oxygenation. Attempts at lung re-expansion with mechanical ventilation must be gentle since excessive force will overdistend the hypoplastic lung and cause rupture and tension pneumothorax. Nasogastric tube is immediately placed in the stomach to aspirate the swallowed air Surgical repair The ideal time to repair the diaphragmatic defect is under the debate. Most centres will wait at least 48 hr after stabilization and resolution of pulmonary hypeension. Now coming back to the Question Mediastinum shifted to the right after endotracheal intubation. This suggests the possibility of incorrect placement of the tube into the esophagus. - Intubation in esophagus will result in fuher distension of the stomach and bowel loops in the left hemithorax which would consequently shift the mediastinum and apical impulse to the right. The ideal step in this situation would be to remove the tube and do the intubation again. Some says that option 'd' was "confirmation of the position of endotracheal tube by chest X-ray". Method for confirmation of position of tube Chest X-ray (PA view) cannot confirm the position of the endotracheal tube because esophagus is situated immediately behind the trachea. X-ray (PA) view cannot distinguish b/w them. CDH is an acute emergency and there is no time for chest X-ray to be done to confirm the position of the endotracheal. If clinical features suggest misplacement of the tube it is better to remove the tube and attempt the intubation again. Confirmation of the position of the endotracheal tube can be done by capnography as it would take no time, because the patient is already in I. C. U. setting.
Confirm the position of endotracheal tube
Emergency surgery
Naso gastric tube inseion
Chest x-ray to confirm position of the endotracheal tube