Rehabilitation Care for Diaphragmatic Hernia
Rehabilitation for diaphragmatic hernia focuses on respiratory muscle training and pulmonary rehabilitation to improve lung function, exercise capacity, and quality of life, particularly in postoperative patients who experience persistent respiratory compromise. The evidence demonstrates that structured respiratory interventions can significantly improve outcomes in these patients 1.
Postoperative Respiratory Management
Immediate Post-Repair Period
Place a nasogastric or orogastric tube immediately to decompress the herniated stomach and reduce pulmonary compression, which can dramatically improve respiratory mechanics 2.
Minimize peak inspiratory pressure and avoid large tidal volumes to reduce ventilator-associated acute lung injury in infants with congenital diaphragmatic hernia (CDH) 3.
High-frequency oscillatory ventilation is a reasonable alternative mode when poor lung compliance, low volumes, and poor gas exchange complicate the clinical course 3.
Monitoring Diaphragmatic Function
Transthoracic ultrasound should be used to assess diaphragm motion after CDH repair, measuring craniocaudal diaphragmatic excursion bilaterally during routine breathing 4.
A diaphragmatic excursion ratio (repaired vs. unrepaired side) below 0.54 is associated with longer hospital stays, more ventilator days, increased oxygen requirements at discharge, and greater likelihood of gastrostomy tube dependence 4.
Serial echocardiograms are recommended to monitor for pulmonary hypertension and response to therapy 3.
Structured Respiratory Rehabilitation Program
Core Components
Respiratory muscle training combined with incentive spirometry should be implemented as the primary rehabilitation intervention for school-aged children with postoperative CDH, conducted three times weekly for at least twelve consecutive weeks 1.
This combination produces significant improvements in:
Incentive spirometry alone without inspiratory muscle training does not produce significant improvements in these outcomes 1.
Long-Term Follow-Up Considerations
Pulmonary Function Trajectory
Airflow obstruction and diffusion capacity deteriorate mildly from childhood into adulthood in CDH survivors, requiring ongoing monitoring 5.
Midexpiratory flows (FEF25-75) progressively decline from childhood to young adulthood in CDH patients 5.
Diffusion capacity (DLCO) decreases significantly in both CDH patients and those who underwent similar neonatal intensive care 5.
The prevalence of asthma is higher than in the normal population (approximately 28-30%), necessitating appropriate screening and management 5.
Nutritional Support
Percutaneous endoscopic gastrostomy (PEG), gastrostomy, or jejunostomy are suggested in patients with oral intake difficulties 3.
Patients with decreased diaphragmatic excursion ratios are less likely to achieve exclusive oral feeding at 1-year post-surgery and more likely to require gastrostomy tube placement 4.
Risk Stratification for Rehabilitation Intensity
High-Risk Indicators Requiring Intensive Rehabilitation
- Diaphragmatic excursion ratio < 0.54 on ultrasound 4
- Non-primary repair (internal oblique muscle flap or mesh patch) 4
- Prolonged ventilator dependence (>16 days) 4
- Oxygen requirement at discharge 4
- Persistent pulmonary hypertension requiring treatment 3
Management of Pulmonary Hypertension During Rehabilitation
Supplemental oxygen therapy should maintain O2 saturations between 92-95% to avoid episodic or sustained hypoxemia 3.
Inhaled nitric oxide (iNO) therapy can be used to improve oxygenation in infants with CDH and severe pulmonary hypertension, but should be used cautiously in subjects with suspected left ventricular dysfunction 3.
PAH-targeted therapy can be useful for patients with CDH and pulmonary hypertension on optimal treatment of underlying respiratory and cardiac disease 3.
Common Pitfalls to Avoid
Do not delay rehabilitation until complete resolution of respiratory symptoms, as early intervention produces better outcomes 1.
Do not rely solely on passive respiratory exercises (incentive spirometry alone); active inspiratory muscle training is essential for meaningful improvement 1.
Do not assume normal lung function based on static measurements alone; diffusion capacity and exercise tolerance require specific assessment 5.
Do not overlook the need for long-term follow-up, as pulmonary function continues to deteriorate into adulthood even in survivors 5.