Dr. Gautam Ghosh

NEO-PULMONOLOGYEvidence – Based –Med.

Dr. Gautam Ghosh

IAP Resarch Fellow

Ped. Pulmonology

Dr. Gautam Ghosh

Category of Evidence• I a : Evidence from meta-analysis of

randomised controlled trials

• I b: Evidence from at least 1 randomised controlled trial

• II a : Evidence from at least 1 controlled study without randomization

• II b : Evidence from at least 1 other type of quasi-experimental study

• III : Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies and case-control studies

• IV : Evidence from expert committee reports or clinical experience of respected authors or both.

Dr. Gautam Ghosh

Strength of Recommendation

• A :Directly based on category I evidence • B : Directly based on category II evidence

or extrapolated recommendation from category I evidence

• C :Directly based on category III evidence or extrapolated recommendation from category I or II evidence

• D :Directly based on category IV evidence or extrapolated recommendation from I, II or III evidence.

• NR : Not rated

Dr. Gautam Ghosh

Oxygen Therapy

Issues Recom.

Room-air as good as 100% O2 for resuscitation of neonates

I b / B

Restricted O2 prevents morbidity (ROP &BPD) in pre-terms /VLBW neonate

I b / B

Late discontinuation of O2shows better outcome in pre-terms/ LBW neonates

NR

Gradual weaning of O2 is better than abrupt weaning in pre-terms / LBW

neonates.

NR

Dr. Gautam Ghosh

Apnea in neonates

Issues Recomen.

Prophylactic theophylline in preterms NR

Caffeine better than theophylline except in long term outcome

II a /B

Doxapram use in clinical practice including long term outcome

NR(ID)

Kinesthetic stimulation in preventing & treating apnea visa-vis theophylline

NR (ID)

Dr. Gautam Ghosh

CPAP in NeonatesIssues Recomen.

Usefulness in RDS, Apnea of prematurity I a /A

Early therapeutic(<2 hrs.) use gives better result than late use

I a /A

Prophylactic CPAP prevents morbidity in pre terms.

IV / NR

Non-invasive CPAP gives better outcome specially in long term than invasive ones

I a / A

Usefulness in MAS / pneumonia NR / ID

Dr. Gautam Ghosh

Mechanical Ventilation(MV)

Issues Recomme.

IV Midiazolam as sedative in MV NR /ID

Trial of ETT CPAP is not mandatory in pre terms before extubation

I b / B

IV Dexamethasone gives better result during extubation in prolonged (>2 weeks) and

repeated IPPV

I a / A

Nebulized Epi. before extubation after prolonged IPPV

NR /ID

Routine use of neuromuscular blocking agents during neonatal ventilation

NR / ID

Dr. Gautam Ghosh

Chronic lung DiseaseIssues Recommen.

Early (<7d) steroid use to prevent CLD in Ventilated neonates

NR / ID

Mod. Early (7 –14 d) steroid use to prevent CLD in Ventilated neonates

(No long term outcome result was demonstrated)

II a / B

Delayed (>21 d) steroids use to prevent CLD in Ventilated neonates.

(Adverse neuro-developmental effects may be seen)

III a/ C

Aerosolized furosemide in pre-terms > 3 weeks to prevent CLD

NR / ID

Dr. Gautam Ghosh

Surfactant useIssues Recomm.

Prophylactic use in preterms & RDS( PDA & Pulmonary hemmorhage chance greater)

I a / A

Early therapeutic use (INSURE) in RDS

I a /A

Multiple use in developed RDS shows better outcome than single use.

I b / A

Natural drug may give better results than the synthetic ones.

( Though natural ones may increase risk of IVH)

II b / B

Therapeutic use in MAS may reduce complications and need for ECMO

II a / B

Dr. Gautam Ghosh

MiscellaneousIssues Recomm.

Tracheal suction in resuscitation of all meconium-stained newborn

NR

IV Furosemide to mother/ IV, oral or aerosolized use in neonate for TTN

NR

Inhaled NO for PPHN in term neonates without diaphragmatic hernia

II a / C

Early( < 24 hrs) repair of diaphragmatic hernia better than late correction after

stabilisation

NR /ID

Inositol / Digoxin in treatment /prevention of RDS

NR /ID

Dr. Gautam Ghosh

Conclusion

• Changing attitudes and practice utilizing key evidences based messages ensures best care for the neonates.

• Future neonatal researches should be planned to address these important and practice oriented issues.

• If we have not changed a major clinical decision in last few years, let us check our pulse!! Is it running!!!

Dr. Gautam Ghosh Thank You