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Published on: September 11, 2021
Clinical features and outcomes associated with tracheostomy in congenital diaphragmatic hernia
Sahar Al Baroudi1, Joseph M Collaco1, Pamela A Lally2
1Pediatric Pulmonology, Johns Hopkins University, Baltimore, Maryland.
Insights
Infants with congenital diaphragmatic hernia (CDH) requiring tracheostomy have significant mortality. Clinical factors like male sex, birth weight, and cardiac issues increase tracheostomy likelihood, suggesting a need for standardized care protocols.
Area of Science:
- Pediatric Surgery
- Neonatology
- Critical Care Medicine
Background:
- Congenital diaphragmatic hernia (CDH) is a severe condition requiring complex management.
- Tracheostomy is a critical intervention for infants with CDH needing prolonged mechanical ventilation.
- Understanding factors influencing tracheostomy use and outcomes is vital for improving infant care.
Purpose of the Study:
- To investigate clinical features and outcomes associated with tracheostomy in infants diagnosed with congenital diaphragmatic hernia (CDH).
Main Methods:
- Analysis of liveborn infants from the CDH Study Group registry (2007-2017).
- Identification of subjects with tracheostomy based on discharge or transfer status with tracheostomy and/or mechanical ventilation.
- Utilization of multivariate mixed models to analyze clinical features and outcomes.
Main Results:
- Out of 5434 infants, 230 (4.2%) underwent tracheostomy. The overall survival rate was 70.5%.
- The mortality rate for infants with tracheostomy was 32.8%, with a median of 37 days between placement and death.
- Factors associated with increased odds of tracheostomy included male sex, higher birth weight, lower 5-minute APGAR score, larger defect size, liver herniation, ECMO use, cardiac abnormalities, other congenital anomalies, pulmonary hypertension, and feeding tube use.
Conclusions:
- Several clinical features are linked to a higher probability of tracheostomy placement in infants with CDH.
- The majority of deaths in tracheostomized infants occurred beyond the immediate postoperative phase.
- A standardized protocol for tracheostomy in infants with CDH warrants consideration to optimize patient management and outcomes.
Introduction:
The purpose of this study was to examine the clinical features/outcomes associated with tracheostomy in infants with congenital diaphragmatic hernia (CDH).
Methods:
The study population consisted of liveborn infants reported to the CDH Study Group registry between 2007 and 2017. Subjects were identified as having a tracheostomy if they were discharged or transferred to another hospital with tracheostomy and/or on mechanical ventilation. Multivariate mixed models were used for analyses.
Results:
The registry population consisted of 5434 subjects, of whom 230 (4.2%) underwent tracheostomy placement. Only 3830 (70.5%) infants survived until discharge/transfer. The median age of tracheostomy placement was 3.3 months (range, 1.3-13.4 when known; n = 58 out of 154 survivors). The mortality rate among subjects with tracheostomy was 32.8% with a median of 37 days (range, 8-189 when known; n = 32 out of 75 deceased) ensuing between tracheostomy placement and death. The clinical features found to be associated with increased odds ratio of tracheostomy placement included male sex, birth weight, 5-minute APGAR score, defect size, liver in chest, ECMO use, cardiac abnormality, other congenital abnormalities, pulmonary hypertension, and the presence of a feeding tube. There was center variation in the rate of tracheostomy placement, which may be partially accounted for by disease severity, but not center size.
Conclusion:
There are several clinical features that are associated with increased likelihood of tracheostomy placement. Most deaths in subjects with tracheostomies occurred outside the immediate postoperative period. The utility of a standardized protocol for tracheostomy in infants with CDH should be considered.
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