Which of the following ventilation strategies is the best initial approach for a neonate with a left congenital diaphragmatic hernia and the following post ductal arterial blood gases: PaO2 50 mm Hg, PaCO2 60 mm Hg, pH 7.35?

b. Permissive hypercapnia with convential pressure controlled ventilation

Contemporary congenital diaphragmatic hernia management emphasizes permissive hypercapnia using any necessary mode of respiratory support. Ordinarily, pressure controlled ventilation is the initial mode of support. The purpose is to reduce the iatrogenic lung injury associated with high-pressure mechanical ventilation. It is this latter problem, barotrauma-induced lung injury, which has reduced enthusiasm for induced respiratory alkalosis. Although alkalosis can sometimes be achieved, the price is often prohibitive mean and peak airway pressures. High-frequency jet ventilation, ECMO and inhaled nitric oxide are all evolving strategies which must be considered developmental and are reserved for use after the initial strategy is unsuccessful.