Dr. Gautam Ghosh NEO-PULMONOLOGY Evidence – 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 IssuesRecom. 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 IssuesRecomen. Prophylactic theophylline in pretermsNR 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 Neonates IssuesRecomen. Usefulness in RDS, Apnea of prematurityI 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 / pneumoniaNR / ID

Dr. Gautam Ghosh Mechanical Ventilation(MV) IssuesRecomme. IV Midiazolam as sedative in MVNR /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 Disease IssuesRecommen. 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 use IssuesRecomm. 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 Miscellaneous IssuesRecomm. 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