Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

Users Online : 266726

AbstractMaterial and MethodsResultsDiscussionConclusionReferences
Article in PDF How to Cite Citation Manager Readers' Comments (0) Audio Visual Article Statistics Link to PUBMED Print this Article Send to a Friend
Advertisers Access Statistics Resources

Dr Mohan Z Mani

"Thank you very much for having published my article in record time.I would like to compliment you and your entire staff for your promptness, courtesy, and willingness to be customer friendly, which is quite unusual.I was given your reference by a colleague in pathology,and was able to directly phone your editorial office for clarifications.I would particularly like to thank the publication managers and the Assistant Editor who were following up my article. I would also like to thank you for adjusting the money I paid initially into payment for my modified article,and refunding the balance.
I wish all success to your journal and look forward to sending you any suitable similar article in future"



Dr Mohan Z Mani,
Professor & Head,
Department of Dermatolgy,
Believers Church Medical College,
Thiruvalla, Kerala
On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



Dr Kalyani R
Professor and Head
Department of Pathology
Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
As an experienced dentist and an academician, I proudly recommend this journal to the dental fraternity as a good quality open access platform for rapid communication of their cutting-edge research progress and discovery.
I wish JCDR a great success and I hope that journal will soar higher with the passing time."



Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




Dr. Arunava Biswas

"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2007 | Month : December | Volume : 1 | Issue : 6 | Page : 460 - 466 Full Version

Inhaled Nitric Oxide in Hypoxic Respiratory Failure in Preterms: Audit of Ten Years of Practice


Published: December 1, 2007 | DOI: https://doi.org/10.7860/JCDR/2007/.146
SEHGAL A*, CALLANDER I**, STACK J**, JAIN H**, STERLING-LEVIS K***

*Department of Newborn Services, Monash Medical Centre, Clayton, Victoria, Australia,**Department of Newborn Care, Liverpool Hospital, Liverpool, New South Wales, Australia,***Department of Biostatistics, Sydney Children’s Hospital, Randwick, New South Wales, Australia

Correspondence Address :
Dr. Arvind Sehgal. Department of Newborn Services, Monash Medical Centre, 246, Clayton Road, Clayton, VIC 3168, Australia.E-mail: sehgalarvind@yahoo.ca

Abstract

Objective: We set out to ascertain the patient profile and practice pattern regarding use of inhaled Nitric Oxide (iNO) in preterm population with oxygenation failure in last ten years. Furthermore, we aim to identify characteristics of patients who respond to iNO.

Study Design and Setting: Retrospective chart review in a tertiary teaching referral hospital.

Subjects and Intervention: All preterm babies less than 34 weeks gestation with oxygenation failure who were treated with iNO were assessed for inclusion. Response to iNO therapy was defined as decline in oxygenation index by 50% 4 hours after start of iNO.

Results: iNO was administered to 26 preterm babies during the study period. Of these, 23 (88.5%) met the inclusion criteria. Total of 13 (56%) infants survived. The iNO responders had a higher gestation age (29 weeks Vs 26.5 weeks), birth weight (1279g Vs 999g), lower initial oxygenation index (38.7 Vs 58), earlier initiation of therapy (20 hours Vs 41.4 hours) and less mortality (25% Vs 86%) when compared to non-responders.

Conclusions: Although the infants were at a higher end of spectrum for severity of respiratory illness, nitric administration was successful in improving oxygenation. Characteristics of responders might help in better patient selection and optimize timing of intervention, in case use of Nitric Oxide therapy is being considered.

Keywords

Nitric Oxide, oxygen index, preterm, respiratory failure

Introduction

Premature infants in hypoxic respiratory failure can have dramatic improvements after treatment with exogenous surfactant. However, a subset of premature infants has suboptimal responses to surfactant therapy and echocardiographic studies have shown that pulmonary hypertension frequently complicates the course of severe cases (1). Physiologically, inhaled Nitric Oxide (iNO) may be of help in selectively dilating pulmonary vascular bed. Early introduction in the course of the disease is expected to reverse pulmonary vasoconstriction and improve ventilation-perfusion mismatch, thereby decreasing barotrauma and toxic effects of oxygen, especially on immature lungs (2). While efficacious in term babies, iNO is a controversial treatment for premature babies and is considered a very contentious area in neonatal medicine. While it has been demonstrated to improve oxygenation in the short term, there is lack of consensus on its impact on decrease in mortality and/or chronic lung disease. The evidence from multicentric clinical trials published so far does not support the use of iNO to reduce mortality and risk of chronic lung disease in preterm infants (3),(4).

This study describes the practice pattern of use of iNO in last ten years in the preterm population with severe oxygenation failure. Secondly, it also highlights important characteristics of babies who responded to therapy which might give future guidance towards selection of population and optimal timing of intervention, leading to potential refinement of approach. We hypothesized that inhaled nitric oxide for oxygenation failure in preterm babies would be more effective in improving oxygenation if initiated early. Furthermore, we hypothesized that maximum response is seen in relatively mature infants. Audits of practice also serve as excellent learning tools with a potential to optimize protocols and guidelines.

Material and Methods

The study was designed as a retrospective chart review of practice at the Department of Newborn Care, Liverpool Hospital, Sydney, NSW, Australia, a tertiary level teaching hospital. About 3000 deliveries take place annually and the unit also serves as the referral center for high risk deliveries in South Western Sydney. Nitric Oxide has been in use in the unit for past ten years (since 1996). Neonatal audit database and medical records were reviewed for all preterm babies who received iNO therapy. For this review, preterm infants were defined as those born at less than 34 weeks gestation. Babies with congenital heart disease other than Patent Ductus Arteriosus (PDA) and those greater than two weeks at intervention were excluded. Demographic and clinical information like gestation, birth weight, mode of delivery, Apgar score, gender and underlying diagnosis was collected and details of concurrent modalities of treatment, arterial blood gas values, baseline ventilator & iNO parameters and response to therapy were recorded. The oxygenation index (OI) was calculated as 100 Ă— the Fraction of Inspired Oxygen (FiO2) Ă— the Mean Airway Pressure (MAP) (in cm of water) Ă· the Partial Pressure of Arterial Oxygen (post ductal PaO2) (in mm of Hg). In terms of improvement in oxygenation, responders were defined as decline in OI by 50% when assessed after 4 hours of iNO therapy. Safety profile in terms of biochemical and cranial ultrasound (US) findings was also recorded. Data is presented as median and interquartile with p value < 0.05 taken as significant. Fisher Exact tests were used for testing significance of comparative data.

Results

A total of 26 preterm babies less than 34 weeks gestation were administered iNO during the study period. Two neonates with Total Anomalous Pulmonary Venous Connection and one greater than two weeks at intervention were excluded from analysis. Data from remaining 23 babies was analyzed. The mean gestation age was 28.4 weeks (range 23 to 33.6 weeks) and mean birth weight was 1247g (range 630g to 2000g). (Table/Fig 1) describes the demographic characteristics and underlying diagnosis in the study population. Survival in the study population was 56% (13/23). Concurrent modalities of treatment like surfactant, muscle relaxation, sedation, volume expansion, inotropic support, and sodium bicarbonate were used prior to administration of iNO. Relevant findings on echocardiographic analysis were tricuspid regurgitation and bidirectional PDA. Seven out of 23 babies had blood culture proven sepsis, while risk factors for sepsis like maternal fever and prolong rupture of membranes were present in two others.

Infants were on a high MAP and FiO2 at the time of initiation of iNO, still resulting in poor oxygenation as reflected by low PaO2 and high mean OI of 47.2. The mean age at which iNO was started was 45.6 hours. Details of baseline ventilator and iNO parameters are mentioned in (Table/Fig 2). When assessed 4 hours after start of intervention, significant improvement in oxygenation in terms of increase of PaO2 and a decline in OI (Table/Fig 3) & (Table/Fig 4) was observed. Eight babies had documented intracranial hemorrhages on cranial US after therapy, mainly grade I-II, while two infants had severe hemorrhages (grade III-IV) with no periventricular leucomalacias. iNO was well tolerated in terms of NO2 and methaemoglobin levels and dose reduction was not required in any case. (Table/Fig 5) shows the characteristics of responders (16/23) and non- responders (7/23). Responders had a higher gestational age & birth weight, much lower OI, were started on iNO relatively early in disease process and had lower mortality. The incidence of culture proven sepsis was higher in the responders group, while the dose and duration of iNO in both groups were comparable.

Discussion

The use of inhaled Nitric Oxide in management of oxygenation failure in preterm infants is a contentious issue. Although considered controversial, it is still used in many centers after concurrent modalities of treatment fail to improve oxygenation. Many of these infants may have underlying persistent pulmonary hypertension. With increasing use of antenatal steroids and surfactant, the pattern of preterm lung disease has undergone a transformation, with a small minority of them developing severe acute respiratory failure. Nitric Oxide may benefit such infants by selectively dilating pulmonary vasculature, improving ventilation-perfusion matching, and decreasing the pulmonary inflammatory response (5),(6),(7). Trials of iNO were previously focused on those preterm infants who continued to have major respiratory problems despite antenatal steroids and surfactant, i.e. the sickest and smallest infants. These individual trials (3),(8),(9) each reported that iNO produced statistically significant short-term improvements in oxygenation, but none showed a statistically significant impact on any medium- or longer-term outcome measure. A recent retrospective audit (10) showed an 83% response to iNO in preterm babies ranging from 29 to 34 weeks.

In the current review, the predominant underlying clinical diagnosis was Respiratory Distress Syndrome (RDS) associated with preterm lung disease. A high incidence (30%) of culture proven sepsis was also noted. Multiple factors can contribute to high pulmonary vascular resistance (PVR) which includes hypoxia, acidosis, low lung volumes or sepsis and iNO may have additional benefits in reducing pulmonary edema and lung neutrophil accumulation in severe experimental hyaline membrane disease (11). Subsequent work in animals found that inhaled Nitric Oxide reduces lung inflammation (12), improves surfactant function (13), attenuates hyperoxic lung injury (14) and promotes lung growth. Another recent study has shown that sepsis, preterm prolonged rupture of membranes, chorioamnionitis and pulmonary hypoplasia significantly predisposed to pulmonary hypertension (10). The survival in preterm infants receiving iNO was significantly less as compared to near term & term babies which suggests that the underlying pathophysiology as well as potential risks differ substantially in the two groups and response to therapy may depend on the etiopathogenesis. It is plausible that anatomic differences in vascular smooth muscle as well as molecular level differences in preterm babies as compared to term babies play a part in reduced responsiveness to iNO in the former (10). Data from animal studies has shown that the pulmonary vasodilator response to oxygen (mediated by iNO) improves with advancing age (15). It is important to appreciate that babies in this review were towards the more severe spectrum of oxygenation failure, as manifest by poor oxygenation in presence of optimal ventilation and use of concurrent modalities of treatment. OI is a sensitive indicator of hypoxia and if greater than 25, correlates with 50% risk (80% if greater than 40) of mortality and need for ECMO (16), an option which is not feasible for small preterm babies. In many cases iNO was started after disease process had been quite progressed. Within limitations of this being a retrospective audit, a possible explanation could be individual staff preference to not to initiate iNO in view of earlier reports of lack of impact on survival and concerns regarding its safety profile in preterm infants. The unit has no protocol for initiation of

Conclusion

To conclude, this study addresses a very controversial and contentious aspect of neonatal practice. While consensus eludes, we know from practice and experience, that there exists a subset of neonates, who have refractory hypoxemia and underlying PPHN, which responds to iNO therapy. Although the infants were at a higher end of spectrum for severity of respiratory illness, nitric administration was successful in improving oxygenation. The real challenge is to sub-select a population, in which an impact on mortality and long term neurological & pulmonary morbidity could be demonstrated.

References

1.
Walther FJ, Benders MJ, Leighton, JO. Persistent pulmonary hypertension in premature neonates with severe respiratory distress syndrome. Pediatrics 1992; 90:899-904.
2.
Mercier JC, Thebaud B, Onody P, Storme L, van Overmeire B, Breart G. Early compared with delayed inhaled nitric oxide in moderately hypoxemic neonates with respiratory failure: a randomized controlled trial. Lancet 1999; 354:1066.
3.
Kinsella JP, Walsh WF, Bose CL, Gerstmann DR, Labella JJ, Sardesai S. Inhaled nitric oxide in premature neonates with severe hypoxic respiratory failure: a randomized controlled trial. Lancet 1999; 354:1061-1065.
4.
Van Meurs KP, Wright LL, Ehrenkranz RA, Lemons JA, Ball MB, Poole WK et al. Inhaled nitric oxide for premature infants with severe respiratory failure. N Eng J Med 2005; 335: 13-22.
5.
Frostell C, Fratacci M-D, Wain JC, Jones R, Zapol WM. Inhaled nitric oxide: a selective pulmonary vasodilator reversing hypoxic pulmonary vasoconstriction. Circulation 1991; 23: 2038-47.
6.
Rossaint R, Falke KJ, Lopex F, Salma K, Pison U, Zalpol WM. Inhaled nitric oxide for the adult respiratory syndrome. N Eng J Med 1993; 328:399-405.
7.
Kinsella JP, Parker TA, Galan H, Sheridan BC, Halbower AC, Abman SH. Effect of inhaled nitric oxide on pulmonary edema and lung neutrophil accumulation in severe experimental hyaline membrane disease. Pediatr Res 1997; 41:457-63.
8.
The Franco-Belgium Collaborative NO Trial Group. Early compared with delayed inhaled nitric oxide in moderately hypoxemic neonates with respiratory failure: a randomized controlled trial. Lancet 1999; 354:1066-71.
9.
Subhedar NV, Ryan SW, Shaw NJ. Open randomized controlled trial of inhaled nitric oxide and early dexamethasone in high risk premature infants. Arch Dis Child fetal neonatal Ed 1997; 77:F185-F190.
10.
Kumar VH, Hutchinson AA, Lakshminrusimha S, Morin III FC, Wynn RJ, Ryan RM. Characteristics of pulmonary hypertension in preterm neonates. J Perinatol 2007; 27: 214-219.
11.
Kinsella JP, Truog WP, Walsh WF, Goldberg RN, Bancalari E, Clark RH et al. Randomized multicentre trial of inhaled NO and high frequency oscillatory ventilation in severe persistent pulmonary hypertension of the newborn. J Pediatr. 1997 Jul;131(1 Pt 1)

JCDR is now Monthly and more widely Indexed .
  • Emerging Sources Citation Index (Web of Science, thomsonreuters)
  • Index Copernicus ICV 2017: 134.54
  • Academic Search Complete Database
  • Directory of Open Access Journals (DOAJ)
  • Embase
  • EBSCOhost
  • Google Scholar
  • HINARI Access to Research in Health Programme
  • Indian Science Abstracts (ISA)
  • Journal seek Database
  • Google
  • Popline (reproductive health literature)
  • www.omnimedicalsearch.com