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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