Transcript NEO-PULMONOLOGY Evidence – Based –Med.

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
Issues
Recom.
Room-air as good as 100% O2 for
resuscitation of neonates
Ib/B
Restricted O2 prevents morbidity (ROP
&BPD) in pre-terms /VLBW neonate
Ib/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
Doxapram use in clinical practice
including long term outcome
Kinesthetic stimulation in preventing
& treating apnea visa-vis theophylline
II a /B
Dr. Gautam Ghosh
NR(ID)
NR (ID)
CPAP in Neonates
Issues
Recomen.
Usefulness in RDS, Apnea of prematurity
I a /A
Early therapeutic(<2 hrs.) use gives
better result than late use
Prophylactic CPAP prevents morbidity in
pre terms.
Non-invasive CPAP gives better outcome
specially in long term than invasive ones
Usefulness in MAS / pneumonia
Dr. Gautam Ghosh
I a /A
IV / NR
Ia/A
NR / ID
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
IV Dexamethasone gives better result during
extubation in prolonged (>2 weeks) and
repeated IPPV
Nebulized Epi. before extubation after
prolonged IPPV
Routine use of neuromuscular blocking
agents during neonatal ventilation
Ib/B
Dr. Gautam Ghosh
Ia/A
NR /ID
NR / ID
Chronic lung Disease
Issues
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
II a / B
(No long term outcome result was demonstrated)
Delayed (>21 d) steroids use to
prevent CLD in Ventilated neonates.
III a/ C
(Adverse neuro-developmental effects may be seen)
Aerosolized furosemide in pre-terms
> 3 weeks to prevent CLD
Dr. Gautam Ghosh
NR / ID
Surfactant use
Issues
Prophylactic use in preterms & RDS
Recomm.
Ia/A
( PDA & Pulmonary hemmorhage chance greater)
Early therapeutic use (INSURE) in
RDS
Multiple use in developed RDS shows
better outcome than single use.
Natural drug may give better results
than the synthetic ones.
I a /A
Ib/A
II b / B
( Though natural ones may increase risk of IVH)
Therapeutic use in MAS may reduce
Dr. Gautam Ghosh
complications and need
for ECMO
II a / B
Miscellaneous
Issues
Recomm.
Tracheal suction in resuscitation of all
meconium-stained newborn
IV Furosemide to mother/ IV, oral or
aerosolized use in neonate for TTN
Inhaled NO for PPHN in term neonates
without diaphragmatic hernia
Early( < 24 hrs) repair of diaphragmatic
hernia better than late correction after
stabilisation
Inositol / Digoxin in treatment /prevention
of RDS
NR
Dr. Gautam Ghosh
NR
II a / C
NR /ID
NR /ID
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
Dr. Gautam Ghosh
Thank You