The ipsilateral lung is small. It's not as big as the pleural space. That's how God made this lung. So you're not going to, it's a mistake to think you're going to inflate that lung to fill the chest.
The ipsilateral lung is small. It's not as big as the pleural space. That's how God made this lung. So you're not going to, it's a mistake to think you're going to inflate that lung to fill the chest.
The problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest.
The problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest.
Congenital Diaphragmatic Hernia with Dr. Charlie Stolar
▶Ep 1 · 2:13
quoteThe most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach.↗
▶Ep 1 · 3:11
quoteThe discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends.↗
▶Ep 1 · 3:37
clinicalCDH diagnosis is usually made at about 20 weeks gestation with routine anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart↗
▶Ep 1 · 4:14
clinicalCDH should be discussed as a growth arrest of both lungs with the ipsilateral side more severely affected than the contralateral side↗
▶Ep 1 · 4:23
clinicalThe lungs are affected at birth by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation↗
▶Ep 1 · 5:00
quoteThis is not a surgical emergency, it's a medical physiologic emergency but not a surgical emergency.↗
▶Ep 1 · 5:00
clinicalCDH is not a surgical emergency but a medical physiologic emergency↗
▶Ep 1 · 5:24
guidelineDiagnosis of CDH alone is not an indication for cesarean section; recommend elective spontaneous vaginal delivery assuming no obstetric issues↗
▶Ep 1 · 6:35
opinionAntenatal interventions for CDH are no better than investigational and experimental at best↗
▶Ep 1 · 7:23
guidelineBabies with CDH should be born at a full service children's facility with availability of ECMO, as maybe 10-15% will benefit from ECMO↗
▶Ep 1 · 8:31
clinicalIn single center experiences, presence of liver in chest or stomach in chest is of no prognostic value↗
▶Ep 1 · 8:42
clinicalLung to head ratio is of no better than limited value except when very low (less than 0.8), where prognosis is concerning↗
▶Ep 1 · 9:07
clinicalAssociated congenital heart disease and central nervous system abnormalities augur for poor prognosis↗
▶Ep 1 · 10:13
quoteIf you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them.↗
▶Ep 1 · 10:13
epidemiologicalIf shown 100 children with CDH, 80-85% will survive to become teenagers↗
▶Ep 1 · 10:37
clinicalSteroids have tremendous value for preterm labor under 35 weeks but role in near-term babies (37-39 weeks) with CDH is arguable↗
▶Ep 1 · 12:06
opinionExit to ECMO for CDH is nonsense except potentially for investigational protocol using liquid ventilation with perfluorocarbons as trophic agent to provoke lung growth↗
▶Ep 1 · 15:12
guidelineRespiratory care strategy requires babies to be breathing spontaneously with no paralysis and minimal sedation↗
▶Ep 1 · 17:52
guidelineECMO indication is not meeting tissue oxygen requirements despite best medical management, commonly using oxygenation index greater than 40 for 4 hours or more↗
▶Ep 1 · 19:06
guidelineAll therapy is guided by preductal oximetry, not postductal, because guiding by postductal will lead to premature and precipitous interventions↗
▶Ep 1 · 19:32
clinicalIf preductal saturation is 90% (PAO2 of 65 torr), the brain is doing fine because this is fetal hemoglobin↗
▶Ep 1 · 21:38
quoteIf you ever wanted to find out if somebody tried to invent a neonatal ventilator today, they would throw it out as a lethal device because they will trash in the lungs in a heartbeat.↗
▶Ep 1 · 22:49
clinicalMost babies with CDH don't tolerate conventional ventilator settings and require unconventional mode with 100 breaths per minute, peak pressure turned down to zero, and high gas flow rate↗
▶Ep 1 · 24:30
quoteWhen people say, how do you know when to set up an ECMO circuit with a diaphragmatic hernia, it's when they get out the oscillator.↗
▶Ep 1 · 25:45
opinionNitric oxide is a waste of money for CDH babies; it's terrific for premature babies with immature lung disease but of no value in CDH↗
quoteThe best drug for diaphragmatic hernia is oxygen.↗
▶Ep 1 · 26:22
clinicalECMO gestational age limit has been pushed from 36 weeks down to 35 or 34 weeks, with reports as low as 32 weeks, but intracranial hemorrhage rate increases significantly below 34 weeks↗
▶Ep 1 · 28:45
guidelineThe real issue for ECMO candidacy is whether you have a reversible condition - don't start something you can't finish↗
clinicalVV ECMO is terrific if the heart works, but in CDH the heart function is often depressed and it's hard to get the cannula in with mediastinum shifted↗
clinicalVA bypass is basically dial in a PAO2, while VV has mixing issues and canal position concerns making it much more annoying for unstable CDH patients↗
▶Ep 1 · 32:17
clinicalEcho guidance during ECMO cannulation is really helpful to avoid driving arterial cannula out subclavian artery or venous cannula into innominate vein↗
▶Ep 1 · 32:40
quoteIf you can have echo guidance as you advance your cannule, it's really, really helpful.↗
▶Ep 1 · 35:10
clinicalGoal ECMO flow on VA is about 100-125 cc/kg/min, which is about 80% of cardiac output assuming open duct↗
▶Ep 1 · 39:20
quoteThe problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest.↗
▶Ep 1 · 1:06:47
quoteThe ipsilateral lung is small. It's not as big as the pleural space. That's how God made this lung. So you're not going to, it's a mistake to think you're going to inflate that lung to fill the chest.↗
▶Ep 1 · 1:09:00
clinicalTypical stable CDH patient will be crummy for about 1 day postoperatively then get better and be extubated in 4-5 days↗
▶Ep 1 · 1:09:39
clinicalCDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz, causing disordered motility throughout↗
▶Ep 1 · 1:09:55
clinicalGI series in CDH patients shows very dilated, ectatic, abnormal looking esophagus with abnormal motility, gastric motility, and gastric emptying↗
▶Ep 1 · 1:10:09
quoteThis business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture.↗
▶Ep 1 · 1:10:09
opinionThe foregut dysmotility is not really reflux, and calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture↗
▶Ep 1 · 1:10:28
clinicalCDH patients do well with continuous feedings slowly condensed to bolus; unusual to need surgical intervention↗
▶Ep 1 · 1:10:43
opinionNissen fundoplication is a poor operation for CDH patients because it's fully competent on an esophagus with abnormal motility↗
▶Ep 1 · 1:12:18
clinicalCDH patients followed in multidisciplinary clinic have issues with heart, lungs, foregut, nutrition, neurodevelopmental outcome, and axial skeleton that emerge over time↗
▶Ep 1 · 1:13:18
clinicalFour CDH teenagers developed Barrett's esophagitis, leading to recommendation for lifelong proton pump inhibitors and regular endoscopy↗
▶Ep 1 · 1:13:57
epidemiologicalCDH patients have increased incidence of attention deficit disorders and autism, requiring early intervention for neuropsychiatric issues↗
▶Ep 1 · 1:14:09
clinicalAs field defect, CDH causes asymmetric chest growth leading to pectus-like deformities requiring Nuss operation and breast implants in girls with no breast development on hernia side↗
▶Ep 1 · 1:14:34
clinicalCDH patients develop thoracolumbar scoliosis (not idiopathic), mostly in boys, requiring early bracing program↗
▶Ep 1 · 1:17:55
clinicalIn right-sided CDH, hepatic veins not infrequently enter directly into right atrium rather than suprahepatic cava, and attempting to reduce liver when attached to heart will cause trouble↗
▶Ep 1 · 1:18:36
clinicalHepatopulmonary fusion exists in CDH where liver and lung are fused and cannot be separated surgically; most patients don't survive and often have severe congenital heart disease and IVC discontinuation↗
clinicalEchocardiographic guidance during ECMO cannulation is helpful to ensure proper cannula position↗
▶Ep 20 · 35:10
clinicalTarget ECMO flow for VA support is 100-125 cc/kg/min, which is about 80% of cardiac output↗
▶Ep 20 · 39:20
quoteThe problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs.↗
▶Ep 20 · 40:52
clinicalA platelet thrombus has a lifespan of 48-72 hours, so there is a 2-3 day window after surgery on ECMO before bleeding risk increases↗
▶Ep 20 · 45:42
guidelineOptimal timing for CDH repair is when stable on minimal ventilator settings, typically 3-4 days after birth↗
▶Ep 20 · 46:07
guidelineInfant ventilators should be used intraoperatively instead of anesthesia machines to continue respiratory care strategy↗
▶Ep 20 · 48:32
quoteThe thoracoscopic approach is gorgeous. It is just a gorgeous view.↗
▶Ep 20 · 49:46
clinicalThoracoscopic CDH repair has a recurrence rate of approximately 25% within one year↗
▶Ep 20 · 55:02
quoteThis is not the time to do a little incision, get two fingers in.↗
▶Ep 20 · 56:28
quoteNobody cares about the phrenic nerve. It's irrelevant on that side.↗
▶Ep 20 · 56:33
clinicalWhen no diaphragm tissue is available medially, an upside-down U-shaped pericardial flap can be rotated down to begin the repair↗
▶Ep 20 · 57:21
opinionMonofilament suture (like PDS) is preferred because it does not saw through tissue when pulled↗
▶Ep 20 · 58:52
clinicalPatches should have some redundancy to allow ballooning and prevent suture pull-through↗
▶Ep 20 · 1:06:35
quoteNeonatal nurses, they pee around their isolate to mark their territory.↗
▶Ep 20 · 1:06:50
clinicalThe pneumothorax after CDH repair is ex vacuo (not under pressure) because the ipsilateral lung is small and cannot fill the pleural space↗
▶Ep 20 · 1:07:13
quoteIt's not a pneumothorax like there's air under pressure. It's a pneumothorax ex vacuo.↗
▶Ep 20 · 1:07:30
guidelineChest tubes are not indicated after CDH repair unless there is active air leak or anticipated bleeding (such as repair on ECMO)↗
▶Ep 20 · 1:09:39
clinicalCDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz↗
▶Ep 20 · 1:10:23
opinionForegut dysmotility in CDH is not true reflux and fundoplication should be approached as palliation, not cure↗
▶Ep 20 · 1:13:32
guidelineCDH patients should be on proton pump inhibitors for life due to risk of Barrett's esophagitis↗
▶Ep 20 · 1:17:55
clinicalFor right-sided CDH, hepatic veins may drain directly into the right atrium rather than the suprahepatic IVC↗
▶Ep 20 · 1:18:36
clinicalHepatopulmonary fusion exists in some right-sided CDH cases and cannot be surgically separated↗
▶Ep 20 · 1:19:50
guidelineRight-sided CDH should be approached with preparation for both thoracic and abdominal incisions↗
Congenital Diaphragmatic Hernia with Dr. Charlie Stolar
▶Ep 32 · 2:13
quoteThe most important understanding of the word doctor means to teach. It has nothing to do with healing, means to teach.↗
▶Ep 32 · 3:11
quoteThe discussion begins with telling parents that the chances are they're going to raise an obnoxious teenager. That's sort of how this story usually ends.↗
▶Ep 32 · 3:37
clinicalCDH diagnosis is usually made at about 20 weeks gestation with routine anatomy scan when ultrasonographers see the stomach in the same cross-sectional plane as the heart↗
▶Ep 32 · 4:14
clinicalCDH should be discussed as a growth arrest of both lungs with the ipsilateral side more severely affected than the contralateral side↗
▶Ep 32 · 4:23
clinicalThe lungs are affected at birth by a mix of pulmonary hypoplasia and altered pulmonary vascular resistance with altered transitional circulation↗
▶Ep 32 · 5:00
clinicalCDH is not a surgical emergency but a medical physiologic emergency↗
▶Ep 32 · 5:00
quoteThis is not a surgical emergency, it's a medical physiologic emergency but not a surgical emergency.↗
▶Ep 32 · 5:24
guidelineDiagnosis of CDH alone is not an indication for cesarean section; recommend elective spontaneous vaginal delivery assuming no obstetric issues↗
▶Ep 32 · 6:35
opinionAntenatal interventions for CDH are no better than investigational and experimental at best↗
▶Ep 32 · 7:23
guidelineBabies with CDH should be born at a full service children's facility with availability of ECMO, as maybe 10-15% will benefit from ECMO↗
▶Ep 32 · 8:31
clinicalIn single center experiences, presence of liver in chest or stomach in chest is of no prognostic value↗
▶Ep 32 · 8:42
clinicalLung to head ratio is of no better than limited value except when very low (less than 0.8), where prognosis is concerning↗
▶Ep 32 · 9:07
clinicalAssociated congenital heart disease and central nervous system abnormalities augur for poor prognosis↗
▶Ep 32 · 10:13
quoteIf you show me 100 children with diaphragmatic hernia, 80 to 85% are going to turn into obnoxious teenagers, and that's what I tell them.↗
▶Ep 32 · 10:13
epidemiologicalIf shown 100 children with CDH, 80-85% will survive to become teenagers↗
▶Ep 32 · 10:37
clinicalSteroids have tremendous value for preterm labor under 35 weeks but role in near-term babies (37-39 weeks) with CDH is arguable↗
▶Ep 32 · 12:06
opinionExit to ECMO for CDH is nonsense except potentially for investigational protocol using liquid ventilation with perfluorocarbons as trophic agent to provoke lung growth↗
▶Ep 32 · 15:12
guidelineRespiratory care strategy requires babies to be breathing spontaneously with no paralysis and minimal sedation↗
▶Ep 32 · 17:52
guidelineECMO indication is not meeting tissue oxygen requirements despite best medical management, commonly using oxygenation index greater than 40 for 4 hours or more↗
▶Ep 32 · 19:06
guidelineAll therapy is guided by preductal oximetry, not postductal, because guiding by postductal will lead to premature and precipitous interventions↗
▶Ep 32 · 19:32
clinicalIf preductal saturation is 90% (PAO2 of 65 torr), the brain is doing fine because this is fetal hemoglobin↗
▶Ep 32 · 21:38
quoteIf you ever wanted to find out if somebody tried to invent a neonatal ventilator today, they would throw it out as a lethal device because they will trash in the lungs in a heartbeat.↗
▶Ep 32 · 22:49
clinicalMost babies with CDH don't tolerate conventional ventilator settings and require unconventional mode with 100 breaths per minute, peak pressure turned down to zero, and high gas flow rate↗
▶Ep 32 · 24:30
quoteWhen people say, how do you know when to set up an ECMO circuit with a diaphragmatic hernia, it's when they get out the oscillator.↗
▶Ep 32 · 25:45
opinionNitric oxide is a waste of money for CDH babies; it's terrific for premature babies with immature lung disease but of no value in CDH↗
▶Ep 32 · 26:07
quoteThe best drug for diaphragmatic hernia is oxygen.↗
clinicalECMO gestational age limit has been pushed from 36 weeks down to 35 or 34 weeks, with reports as low as 32 weeks, but intracranial hemorrhage rate increases significantly below 34 weeks↗
▶Ep 32 · 28:45
guidelineThe real issue for ECMO candidacy is whether you have a reversible condition - don't start something you can't finish↗
clinicalVV ECMO is terrific if the heart works, but in CDH the heart function is often depressed and it's hard to get the cannula in with mediastinum shifted↗
clinicalVA bypass is basically dial in a PAO2, while VV has mixing issues and canal position concerns making it much more annoying for unstable CDH patients↗
▶Ep 32 · 32:17
clinicalEcho guidance during ECMO cannulation is really helpful to avoid driving arterial cannula out subclavian artery or venous cannula into innominate vein↗
▶Ep 32 · 32:40
quoteIf you can have echo guidance as you advance your cannule, it's really, really helpful.↗
▶Ep 32 · 35:10
clinicalGoal ECMO flow on VA is about 100-125 cc/kg/min, which is about 80% of cardiac output assuming open duct↗
▶Ep 32 · 39:20
quoteThe problem is not that the bowel is up in the chest. The problem is that there's been a growth arrest of the lungs. And just there's nothing miraculous about getting the bowel out of the chest.↗
▶Ep 32 · 1:06:47
quoteThe ipsilateral lung is small. It's not as big as the pleural space. That's how God made this lung. So you're not going to, it's a mistake to think you're going to inflate that lung to fill the chest.↗
▶Ep 32 · 1:09:00
clinicalTypical stable CDH patient will be crummy for about 1 day postoperatively then get better and be extubated in 4-5 days↗
▶Ep 32 · 1:09:39
clinicalCDH is a field defect affecting the entire foregut from pharynx to ligament of Treitz, causing disordered motility throughout↗
▶Ep 32 · 1:09:55
clinicalGI series in CDH patients shows very dilated, ectatic, abnormal looking esophagus with abnormal motility, gastric motility, and gastric emptying↗
▶Ep 32 · 1:10:09
quoteThis business about calling it reflux has suckered all kinds of surgeons into doing fundoplications and pyloroplasties and all kinds of stuff in these kids that basically is torture.↗
▶Ep 32 · 1:10:09
opinionThe foregut dysmotility is not really reflux, and calling it reflux has suckered surgeons into doing fundoplications and pyloroplasties that are basically torture↗
▶Ep 32 · 1:10:28
clinicalCDH patients do well with continuous feedings slowly condensed to bolus; unusual to need surgical intervention↗
▶Ep 32 · 1:10:43
opinionNissen fundoplication is a poor operation for CDH patients because it's fully competent on an esophagus with abnormal motility↗
▶Ep 32 · 1:12:18
clinicalCDH patients followed in multidisciplinary clinic have issues with heart, lungs, foregut, nutrition, neurodevelopmental outcome, and axial skeleton that emerge over time↗
▶Ep 32 · 1:13:18
clinicalFour CDH teenagers developed Barrett's esophagitis, leading to recommendation for lifelong proton pump inhibitors and regular endoscopy↗
▶Ep 32 · 1:13:57
epidemiologicalCDH patients have increased incidence of attention deficit disorders and autism, requiring early intervention for neuropsychiatric issues↗
▶Ep 32 · 1:14:09
clinicalAs field defect, CDH causes asymmetric chest growth leading to pectus-like deformities requiring Nuss operation and breast implants in girls with no breast development on hernia side↗
▶Ep 32 · 1:14:34
clinicalCDH patients develop thoracolumbar scoliosis (not idiopathic), mostly in boys, requiring early bracing program↗
▶Ep 32 · 1:17:55
clinicalIn right-sided CDH, hepatic veins not infrequently enter directly into right atrium rather than suprahepatic cava, and attempting to reduce liver when attached to heart will cause trouble↗
▶Ep 32 · 1:18:36
clinicalHepatopulmonary fusion exists in CDH where liver and lung are fused and cannot be separated surgically; most patients don't survive and often have severe congenital heart disease and IVC discontinuation↗
