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Congenital diaphragmatic hernia: are improvements in ECMO & survival sustainable over time?
Michelle J Yang1,2, Ryan J Carpenter3,4,5, Christian C Yost3,4,6
1Department of Pediatrics/Neonatology, Intermountain Health, Salt Lake City, UT, USA. michelle.yang@hsc.utah.edu.
Insights
New guidelines for congenital diaphragmatic hernia (CDH) care have sustained improved survival rates and significantly reduced the need for extracorporeal membrane oxygenation (ECMO) in infants. These positive outcomes demonstrate the long-term effectiveness of the updated CDH management protocols.
Area of Science:
- Neonatal Surgery
- Pediatric Critical Care
- Congenital Anomalies
Background:
- Infants with congenital diaphragmatic hernia (CDH) face high risks of mortality and requiring extracorporeal membrane oxygenation (ECMO).
- Previous implementation of new CDH care guidelines showed initial outcome improvements.
- This study aimed to verify if these improvements in ECMO rates and survival persisted over time.
Purpose of the Study:
- To reassess ECMO utilization and survival rates in neonatal CDH patients following the implementation of updated care guidelines.
- To evaluate the long-term adherence to and impact of CDH care guidelines on patient outcomes.
- To determine if the previously observed improvements in survival and reduced ECMO dependence were sustained.
Main Methods:
- A retrospective review of neonatal CDH cases was conducted at a single center.
- Data were analyzed for a pre-guideline period (2003-2015) and two post-guideline epochs (2016-2019 and 2020-2024).
- Key outcome measures included ECMO rates, survival without ECMO, and overall survival.
Main Results:
- Survival without ECMO significantly improved from 53% pre-guideline to 74% in the first post-guideline period and 82% in the second (p < 0.001).
- Overall survival also increased from 72% to 83% and 86% respectively (p = 0.006).
- ECMO use decreased substantially from 31% pre-guideline to 14% and 6% in the post-guideline periods (p < 0.001), with reduced use of inhaled nitric oxide and vasoactive medications.
Conclusions:
- The updated CDH care guidelines have led to sustained improvements in survival rates and a significant reduction in ECMO use.
- Key elements of the guideline changes include minimal stimulation, gentle ventilation, delayed transfer, pre-ductal saturation monitoring, and limited vasoactive therapy.
- These findings underscore the long-term benefits of standardized, evidence-based care protocols for neonatal CDH.
Background:
Infants with congenital diaphragmatic hernia (CDH) remain at high risk for ECMO and mortality. We previously reported improved outcomes after implementing new CDH care guidelines. This study reassesses ECMO rates, survival, and guideline adherence to determine if improvements persisted.
Methods:
Retrospective review of all neonatal CDH cases at a single center during pre-guideline (2003-2015, n = 229) and post-guideline (2016-2024, n = 160) periods, with post-guideline subdivided into two epochs: post-1 (2016-2019, n = 70) and post-2 (2020-2024, n = 90).
Results:
Survival without ECMO improved (pre-53%; post-1 74%; post-2 82%; p < 0.001), as did overall survival (72% vs. 83% vs. 86%; p = 0.006). ECMO use decreased (31% vs. 14% vs. 6%; p < 0.001). Inhaled nitric oxide use remained low, and vasoactive medication use dropped significantly in post-2.
Conclusion:
Sustained survival improvement and reduced ECMO use followed guideline changes emphasizing minimal stimulation, gentle ventilation, delayed transfer, pre-ductal saturation monitoring, and limited vasoactive therapy.
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