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Matlock DN, Ratcliffe SJ, Courtney SE, Kirpalani H, Firestone K, Stein H, Dysart K, Warren K, Goldstein MR, Lund KC, Natarajan A, Demissie E, Foglia EE. The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation. Trials 2024; 25:201. [PMID: 38509583 PMCID: PMC10953115 DOI: 10.1186/s13063-024-08038-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/06/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation. METHODS This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer. DISCUSSION The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites. TRIAL REGISTRATION www. CLINICALTRIALS gov , trial identifier NCT05446272 , registered July 6, 2022.
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Affiliation(s)
- David N Matlock
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 512-5B, Little Rock, AR, 72205, USA.
- University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | | | | | - Haresh Kirpalani
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- McMaster University, Hamilton, ON, Canada
| | | | | | - Kevin Dysart
- Nemours Children's Health Wilmington, Philadelphia, PA, USA
| | - Karen Warren
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Aruna Natarajan
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ejigayehu Demissie
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth E Foglia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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McKinney RL, Wallström L, Courtney SE, Sindelar R. Novel forms of ventilation in neonates: Neurally adjusted ventilatory assist and proportional assist ventilation. Semin Perinatol 2024; 48:151889. [PMID: 38565434 DOI: 10.1016/j.semperi.2024.151889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Patient-triggered modes of ventilation are currently the standard of practice in the care of term and preterm infants. Maintaining spontaneous breathing during mechanical ventilation promotes earlier weaning and possibly reduces ventilator-induced diaphragmatic dysfunction. A further development of assisted ventilation provides support in proportion to the respiratory effort and enables the patient to have full control of their ventilatory cycle. In this paper we will review the literature on two of these modes of ventilation: neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation (PAV), propose future studies and suggest clinical applications of these modes.
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Affiliation(s)
- R L McKinney
- Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02906, United States.
| | - L Wallström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - S E Courtney
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - R Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Poole G, Harris C, Shetty S, Dassios T, Jenkinson A, Greenough A. Study protocol for a randomised cross-over trial of Neurally adjusted ventilatory Assist for Neonates with Congenital diaphragmatic hernias: the NAN-C study. Trials 2024; 25:72. [PMID: 38245741 PMCID: PMC10800044 DOI: 10.1186/s13063-023-07874-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation that delivers oxygen pressures in proportion to electrical signals of the diaphragm. The proportional assistance can be adjusted by the clinician to reduce the patient's work of breathing. Several case series of infants with congenital diaphragmatic hernias (CDH) have shown that NAVA may reduce oxygenation index and mean airway pressures. To date, no clinical trial has compared NAVA to standard methods of mechanical ventilation for babies with CDH. METHODS The aim of this dual-centre randomised cross-over trial is to compare post-operative NAVA with assist control ventilation (ACV) for infants with CDH. If eligible, infants will be enrolled for a ventilatory support tolerance trial (VSTT) to assess their suitability for randomisation. If clinically stable during the VSTT, infants will be randomised to receive either NAVA or ACV first in a 1:1 ratio for a 4-h period. The oxygenation index, respiratory severity score and cumulative sedative medication use will be measured. DISCUSSION Retrospective studies comparing NAVA to ACV in neonates with congenital diaphragmatic hernia have shown the ventilatory mode may improve respiratory parameters and benefit neonates. To our knowledge, this is the first prospective cross-over trial comparing NAVA to ACV. TRIAL REGISTRATION NAN-C was prospectively registered on ClinicalTrials.gov NCT05839340 Registered on May 2023.
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Affiliation(s)
- Grace Poole
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK.
| | - Christopher Harris
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Sandeep Shetty
- Neonatal Intensive Care Unit, St. George's University NHS Foundation Trust, London, UK
| | - Theodore Dassios
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Allan Jenkinson
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
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Protain A, Firestone K, Hussain S, Lubarsky D, Stein H. Evaluation of NAVA-PAP in premature neonates with apnea of prematurity: minimal backup ventilation and clinically significant events. Front Pediatr 2023; 11:1234964. [PMID: 37868266 PMCID: PMC10587435 DOI: 10.3389/fped.2023.1234964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Background Neonates with apnea of prematurity (AOP) clinically deteriorate because continuous positive airway pressure (CPAP) provides inadequate support during apnea. Neurally adjusted ventilatory assist (NAVA) provides proportional ventilator support from the electrical activity of the diaphragm. When the NAVA level is 0 cmH2O/mcV (NAVA-PAP), patients receive CPAP when breathing and backup ventilation when apneic. This study evaluates NAVA-PAP and time spent in backup ventilation. Methods This was a prospective, two-center, observational study of preterm neonates on NAVA-PAP for AOP. Ventilator data were downloaded after 24 h. The number of clinically significant events (CSEs) was collected. A paired t-test was used to perform statistical analysis. Results The study was conducted on 28 patients with a gestational age of 25 ± 1.8 weeks and a study age of 28 ± 23 days. The number of CSEs was 4 ± 4.39/24 h. The patients were on NAVA-PAP for approximately 90%/min, switched to backup mode 2.5 ± 1.1 times/min, and spent 10.6 ± 7.2% in backup. Conclusion Preterm neonates on NAVA-PAP had few CSEs with minimal time in backup ventilation.
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Affiliation(s)
- Alison Protain
- Pediatrix Medical Group Akron Ohio, Akron Children’s Hospital, Akron, OH, United States
| | - Kimberly Firestone
- Department of Neonatology, Akron Children’s Hospital, Akron, OH, United States
| | - Saima Hussain
- Department of Pediatrics, ProMedica Russell J. Ebeid Children’s Hospital, Toledo, OH, United States
| | - Daniel Lubarsky
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, United States
| | - Howard Stein
- Northwest Ohio Neonatal Associates, ProMedica Russell J. Ebeid Children’s Hospital, Toledo, OH, United States
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Sahni M, Bhandari V. Invasive and non-invasive ventilatory strategies for early and evolving bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151815. [PMID: 37775369 DOI: 10.1016/j.semperi.2023.151815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
In the age of surfactant and antenatal steroids, neonatal care has improved outcomes of preterm infants dramatically. Since the early 2000's neonatologists have strived to decrease bronchopulmonary dysplasia (BPD) by decreasing ventilator-associated lung injury and utilizing many novel modes of non-invasive respiratory support. After the initial success with nasal continuous positive airway pressure, it was established that discontinuing invasive ventilation early in favor of non-invasive respiratory support is the most effective way to reduce the incidence of BPD. In this review, we discuss the management of the preterm lung from the time of delivery, through the phases of respiratory distress syndrome (early BPD) and then evolving BPD. The goal remains to optimize respiratory support of the preterm lung while minimizing ventilator-associated lung injury and oxygen toxicity. A multidisciplinary approach involving the medical team and family is quintessential in reaching this goal and involves adequate respiratory support, optimizing nutrition and fluid balance as well as preventing infections.
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Affiliation(s)
- Mitali Sahni
- Pediatrix Medical Group, Sunrise Children's Hospital, Las Vegas, NV, United States; University of Nevada, Las Vegas, NV, United States
| | - Vineet Bhandari
- Neonatology Research Laboratory (Room #206), Education and Research Building, Cooper University Hospital, Camden, NJ, United States; The Children's Regional Hospital at Cooper, Cooper Medical School of Rowan University, Camden, NJ, United States.
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Khan KS, Jawaid S, Memon UA, Perera T, Khan U, Farwa UE, Jindal U, Afzal MS, Razzaq W, Abdin ZU, Khawaja UA. Management of Chronic Obstructive Pulmonary Disease (COPD) Exacerbations in Hospitalized Patients From Admission to Discharge: A Comprehensive Review of Therapeutic Interventions. Cureus 2023; 15:e43694. [PMID: 37724212 PMCID: PMC10505355 DOI: 10.7759/cureus.43694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 08/18/2023] [Indexed: 09/20/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a common and debilitating condition that often necessitates hospitalization for exacerbations. Since COPD exacerbations can cause significant morbidity and mortality, managing them is crucial for patient care. Effective management of COPD exacerbations is essential to prevent complications, as COPD exacerbations are associated with increased healthcare costs and decreased quality of life. This review aims to comprehensively discuss the management of COPD exacerbations, covering various pharmacologic and non-pharmacologic strategies. These include inhaled bronchodilators, systemic steroids, antibiotics, invasive and non-invasive ventilation, oxygen therapy, smoking cessation, immunization with pneumococcal vaccine, inhalers at discharge, pulmonary rehabilitation, long-term oxygen therapy (LTOT), ambulatory oxygen therapy, short-burst oxygen therapy, extracorporeal membrane oxygenation (ECMO), lung volume reduction surgery (LVRS), endobronchial procedures, and lung transplant. It is drawn upon various sources, including clinical studies, systemic reviews, and observational studies, to provide a comprehensive overview of current practices and identify areas for future research and innovation in managing COPD exacerbations. Addressing these areas of interest can improve patient outcomes and quality of life.
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Affiliation(s)
- Khizar S Khan
- Basic Sciences, Foundation University Medical College, Islamabad, PAK
| | - Sanyah Jawaid
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Unaib Ahmed Memon
- Internal Medicine, Liaquat University of Medical and Health Sciences, Hyderabad, PAK
| | - Tharindu Perera
- General Medicine, Grodno State Medical University, Grodno, BLR
| | - Usman Khan
- General Practice, Akhtar Saeed Medical and Dental College, Lahore, PAK
| | - Umm E Farwa
- Emergency Medicine, Jinnah Sindh Medical University, Karachi, PAK
| | - Urmi Jindal
- Internal Medicine, KJ Somaiya Medical College, Mumbai, IND
| | | | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarter Hospital, Faisalabad, PAK
| | - Uzzam Ahmed Khawaja
- Pulmonary and Critical Care Medicine, Jinnah Medical and Dental College, Karachi, PAK
- Clinical and Translational Research, Dr Ferrer BioPharma, South Miami, USA
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Dreyfus L, Butin M, Plaisant F, Claris O, Baudin F. Respiratory physiology during NAVA ventilation in neonates born with a congenital diaphragmatic hernia: The "NAVA-diaph" pilot study. Pediatr Pulmonol 2023; 58:1542-1550. [PMID: 36807570 DOI: 10.1002/ppul.26357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 02/07/2023] [Accepted: 02/13/2023] [Indexed: 02/20/2023]
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that delivers synchronized ventilation, proportional to the electrical activity of the diaphragm (EAdi). Although it has been proposed in infants with a congenital diaphragmatic hernia (CDH), the diaphragmatic defect and the surgical repair could alter the physiology of the diaphragm. AIM To evaluate, in a pilot study, the relationship between the respiratory drive (EAdi) and the respiratory effort in neonates with CDH during the postsurgical period under either NAVA ventilation or conventional ventilation (CV). METHODS This prospective physiological study included eight neonates admitted to a neonatal intensive care unit with a diagnosis of CDH. EAdi, esophageal, gastric, and transdiaphragmatic pressure, as well as clinical parameters, were recorded during NAVA and CV (synchronized intermittent mandatory pressure ventilation) in the postsurgical period. RESULTS EAdi was detectable and there was a correlation between the ΔEAdi (maximal - minimal values) and the transdiaphragmatic pressure (r = 0.26, 95% confidence interval [CI] [0.222; 0.299]). There was no significant difference in terms of clinical or physiological parameters during NAVA compared to CV, including work of breathing. CONCLUSION Respiratory drive and effort were correlated in infants with CDH and therefore NAVA is a suitable proportional mode in this population. EAdi can also be used to monitor the diaphragm for individualized support.
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Affiliation(s)
- Lélia Dreyfus
- Service de Néonatologie et Réanimation Néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Marine Butin
- Service de Néonatologie et Réanimation Néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
- Centre International de Recherche en infectiologie (CIRI), Team "Pathogénie des Staphylocoques", CNRS, UMR5308, ENS de Lyon, Inserm, U1111, Université Claude Bernard Lyon 1, Lyon, France
| | - Frank Plaisant
- Service de Néonatologie et Réanimation Néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
| | - Olivier Claris
- Service de Néonatologie et Réanimation Néonatale, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
- EA 419, Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Florent Baudin
- Service de réanimation pédiatrique, Hospices Civils de Lyon, Hôpital Femme Mère Enfant, Bron, France
- Unité APCSe (UP 2021, A101), Universités de Lyon, VetAgro Sup, Marcy l'Etoile, France
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Harris C, Greenough A. The prevention and management strategies for neonatal chronic lung disease. Expert Rev Respir Med 2023; 17:143-154. [PMID: 36813477 DOI: 10.1080/17476348.2023.2183842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Survival from even very premature birth is improving, but long-term respiratory morbidity following neonatal chronic lung disease (bronchopulmonary dysplasia (BPD)) has not reduced. Affected infants may require supplementary oxygen at home, because they have more hospital admissions particularly due to viral infections and frequent, troublesome respiratory symptoms requiring treatment. Furthermore, adolescents and adults who had BPD have poorer lung function and exercise capacity. AREAS COVERED Antenatal and postnatal preventative strategies and management of infants with BPD. A literature review was undertaken using PubMed and Web of Science. EXPERT OPINION There are effective preventative strategies which include caffeine, postnatal corticosteroids, vitamin A, and volume guarantee ventilation. Side-effects, however, have appropriately caused clinicians to reduce use of systemically administered corticosteroids to infants only at risk of severe BPD. Promising preventative strategies which need further research are surfactant with budesonide, less invasive surfactant administration (LISA), neurally adjusted ventilatory assist (NAVA) and stem cells. The management of infants with established BPD is under-researched and should include identifying the optimum form of respiratory support on the neonatal unit and at home and which infants will most benefit in the long term from pulmonary vasodilators, diuretics, and bronchodilators.
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Affiliation(s)
- Christopher Harris
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, UK
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Greenough A, Milner AD. Early origins of respiratory disease. J Perinat Med 2023; 51:11-19. [PMID: 35786507 DOI: 10.1515/jpm-2022-0257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 01/20/2023]
Abstract
Chronic respiratory morbidity is unfortunately common in childhood, particularly in those born very prematurely or with congenital anomalies affecting pulmonary development and those with sickle cell disease. Our research group, therefore, has focused on the early origins of chronic respiratory disease. This has included assessing antenatal diagnostic techniques and potentially therapeutic interventions in infants with congenital diaphragmatic hernia. Undertaking physiological studies, we have increased the understanding of the premature baby's response to resuscitation and evaluated interventions in the delivery suite. Mechanical ventilation modes have been optimised and randomised controlled trials (RCTs) with short- and long-term outcomes undertaken. Our studies highlighted respiratory syncytial virus lower respiratory tract infections (LRTIs) and other respiratory viral LRTIs had an adverse impact on respiratory outcomes of prematurely born infants, who we demonstrated have a functional and genetic predisposition to respiratory viral LRTIs. We have described the long-term respiratory outcomes for children with sickle cell disease and importantly identified influencing factors. In conclusion, it is essential to undertake long term follow up of infants at high risk of chronic respiratory morbidity if effective preventative strategies are to be developed.
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Affiliation(s)
- Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anthony David Milner
- NIHR Biomedical Research Centre Based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Piątek K, Lehtonen L, Parikka V, Setänen S, Soukka H. Implementation of neurally adjusted ventilatory assist and high flow nasal cannula in very preterm infants in a tertiary level NICU. Pediatr Pulmonol 2022; 57:1293-1302. [PMID: 35243818 PMCID: PMC9314087 DOI: 10.1002/ppul.25879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 01/26/2022] [Accepted: 02/27/2022] [Indexed: 11/11/2022]
Abstract
Preterm infants treated with invasive ventilation are often affected by bronchopulmonary dysplasia, brain structure alterations, and later neurodevelopmental impairment. We studied the implementation of neurally adjusted ventilatory assist (NAVA) and high flow nasal cannula (HFNC) in a level III neonatal unit, and its effects on pulmonary and central nervous system outcomes. This retrospective cohort study included 193 surviving infants born below 32 weeks of gestation in preimplementation (2007-2008) and postimplementation (2016-2017) periods in a single study center in Finland. The proportion of infants requiring invasive ventilation decreased from 67% in the pre- to 48% in the postimplementation period (p = 0.009). Among infants treated with invasive ventilation, 68% were treated with NAVA after its implementation. At the same time, the duration of invasive ventilation of infants born at or below 28 weeks increased threefold compared with the preimplementation period (p = 0.042). The postimplementation period was characterized by a gradual replacement of nasal continuous positive airway pressure (nCPAP) with HFNC, earlier discontinuation of nCPAP, but a longer duration of positive pressure support. The proportion of normal magnetic resonance imaging (MRI) findings at term corrected age increased from 62% to 84% (p = 0.018). Cognitive outcome improved by one standard score between the study periods (p = 0.019). NAVA was used as the primary mode of ventilation in the postimplementation period. During this period, invasive ventilation time was significantly prolonged. HFNC led to a decrease in the use of nCPAP. The change in the respiratory support might have contributed to the improvement in brain MRI findings and cognitive outcomes.
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Affiliation(s)
- Katarzyna Piątek
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Liisa Lehtonen
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Vilhelmiina Parikka
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Sirkku Setänen
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
- Department of Pediatric NeurologyTurku University HospitalTurkuFinland
| | - Hanna Soukka
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
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Abstract
Extremely preterm infants who must suddenly support their own gas exchange with lungs that are incompletely developed and lacking adequate amount of surfactant and antioxidant defenses are susceptible to lung injury. The decades-long quest to prevent bronchopulmonary dysplasia has had limited success, in part because of increasing survival of more immature infants. The process must begin in the delivery room with gentle assistance in establishing and maintaining adequate lung aeration, followed by noninvasive support and less invasive surfactant administration. Various modalities of invasive and noninvasive support have been used with varying degree of effect and are reviewed in this article.
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Dassios T, Vervenioti A, Dimitriou G. Respiratory muscle function in the newborn: a narrative review. Pediatr Res 2022; 91:795-803. [PMID: 33875805 PMCID: PMC8053897 DOI: 10.1038/s41390-021-01529-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 03/24/2021] [Accepted: 03/29/2021] [Indexed: 02/02/2023]
Abstract
Our aim was to summarise the current evidence and methods used to assess respiratory muscle function in the newborn, focusing on current and future potential clinical applications. The respiratory muscles undertake the work of breathing and consist mainly of the diaphragm, which in the newborn is prone to dysfunction due to lower muscle mass, flattened shape and decreased content of fatigue-resistant muscle fibres. Premature infants are prone to diaphragmatic dysfunction due to limited reserves and limited capacity to generate force and avoid fatigue. Methods to assess the respiratory muscles in the newborn include electromyography, maximal respiratory pressures, assessment for thoraco-abdominal asynchrony and composite indices, such as the pressure-time product and the tension time index. Recently, there has been significant interest and a growing body of research in assessing respiratory muscle function using bedside ultrasonography. Neurally adjusted ventilator assist is a novel ventilation mode, where the level of the respiratory support is determined by the diaphragmatic electrical activity. Prolonged mechanical ventilation, hypercapnia and hypoxia, congenital anomalies and systemic or respiratory infection can negatively impact respiratory muscle function in the newborn, while caffeine and synchronised or volume-targeted ventilation have a positive effect on respiratory muscle function compared to conventional, non-triggered or pressure-limited ventilation, respectively. IMPACT: Respiratory muscle function is impaired in prematurely born neonates and infants with congenital anomalies, such as congenital diaphragmatic hernia. Respiratory muscle function is negatively affected by prolonged ventilation and infection and positively affected by caffeine and synchronised compared to non-synchronised ventilation modes. Point-of-care diaphragmatic ultrasound and neurally adjusted ventilator assist are recent diagnostic and therapeutic technological developments with significant clinical applicability.
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Affiliation(s)
- Theodore Dassios
- Department of Women and Children's Health, King's College London, London, UK. .,Department of Paediatrics, University of Patras, Patras, Greece.
| | - Aggeliki Vervenioti
- grid.11047.330000 0004 0576 5395Department of Paediatrics, University of Patras, Patras, Greece
| | - Gabriel Dimitriou
- grid.11047.330000 0004 0576 5395Department of Paediatrics, University of Patras, Patras, Greece
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Owen LS, Manley BJ, Hodgson KA, Roberts CT. Impact of early respiratory care for extremely preterm infants. Semin Perinatol 2021; 45:151478. [PMID: 34474939 DOI: 10.1016/j.semperi.2021.151478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Despite advances in neonatal intensive care, more than half of surviving infants born extremely preterm (EP; < 28 weeks' gestation) develop bronchopulmonary dysplasia (BPD). Prevention of BPD is critical because of its associated mortality and morbidity, including adverse neurodevelopmental outcomes and respiratory health in later childhood and beyond. The respiratory care of EP infants begins before birth, then continues in the delivery room and throughout the primary hospitalization. This chapter will review the evidence for interventions after birth that might improve outcomes for infants born EP, including the timing of umbilical cord clamping, strategies to avoid or minimize exposure to mechanical ventilation, modes of mechanical ventilation and non-invasive respiratory support, oxygen saturation targets, postnatal corticosteroids and other adjunct therapies.
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Affiliation(s)
- Louise S Owen
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia.
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kate A Hodgson
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, Australia; Newborn Research Centre, The Royal Women's Hospital, Flemington Road, Parkville, Melbourne, VIC 3052, Australia
| | - Calum T Roberts
- Monash Newborn, Monash Children's Hospital, Monash University, Clayton, VIC, Australia; Department of Paediatrics, Monash University, Clayton, VIC, Australia; The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
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14
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Abstract
Respiratory care of premature neonates has witnessed substantial advances in the last two decades and has played a crucial role in decreasing early mortality in this population. This review outlines advances in techniques of synchronization and modes of synchronized invasive mechanical ventilation in neonates. The use of synchronized ventilation in the neonatal population was delayed as compared to adults, mainly because of technical reasons. Coordinating the infant's respiratory effort and the onset of mechanical ventilation in the neonatal population has requested high sensitivity instruments.
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Affiliation(s)
- Ilia Bresesti
- Division of Neonatology, "V.Buzzi" Children's Hospital, ASST-FBF-Sacco, Via Castelvetro 32, Milan 20154, Italy; Division of Neonatology, "F. Del Ponte" Hospital, Woman and Child Department, University of Insubria, Varese, Italy
| | - Massimo Agosti
- Division of Neonatology, "F. Del Ponte" Hospital, Woman and Child Department, University of Insubria, Varese, Italy
| | | | - Gianluca Lista
- Division of Neonatology, "V.Buzzi" Children's Hospital, ASST-FBF-Sacco, Via Castelvetro 32, Milan 20154, Italy.
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15
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Abstract
Patient-ventilator asynchrony is very common in newborns. Achieving synchrony is quite challenging because of small tidal volumes, high respiratory rates, and the presence of leaks. Leaks also cause unreliable monitoring of respiratory metrics. In addition, ventilator adjustment must take into account that infants have strong vagal reflexes and demonstrate central apnea and periodic breathing, with a high variability in breathing pattern. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation whereby the timing and amount of ventilatory assist is controlled by the patient's own neural respiratory drive. As NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized assist, both invasively and noninvasively (NIV-NAVA), to follow the variability in breathing pattern, and to monitor patient respiratory drive, independent of leaks. This article provides an updated review of the physiology and the scientific literature pertaining to the use of NAVA in children (neonatal and pediatric age groups). Both the invasive NAVA and NIV-NAVA publications since 2016 are summarized, as well as the use of Edi monitoring. Overall, the use of NAVA and Edi monitoring is feasible and safe. Compared with conventional ventilation, NAVA improves patient-ventilator interaction, provides lower peak inspiratory pressure, and lowers oxygen requirements. Evidence from several studies suggests improved comfort, less sedation requirements, less apnea, and some trends toward reduced length of stay and more successful extubation.
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Affiliation(s)
- Jennifer Beck
- Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B1W8, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada.
| | - Christer Sinderby
- Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B1W8, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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16
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Oda A, Parikka V, Lehtonen L, Azimi S, Porres I, Soukka H. Neurally adjusted ventilatory assist in ventilated very preterm infants: A crossover study. Pediatr Pulmonol 2021; 56:3857-3862. [PMID: 34437773 DOI: 10.1002/ppul.25639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/03/2021] [Accepted: 08/19/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To assess the effects of neurally adjusted ventilatory assist (NAVA) ventilation on oxygenation and respiratory parameters in preterm infants. STUDY DESIGN An observational crossover study with a convenience sample of 19 infants born before 30 gestational weeks. Study parameters were recorded during 3-h periods of both NAVA and conventional ventilation. The proportion of time peripheral oxygen saturation (SpO2 ) and cerebral regional oxygen saturation (cRSO2 ) were within their target ranges, plus the number and severity of desaturation episodes were analyzed. In addition, electrical activity of the diaphragm (Edi), neural respiratory rates, and peak inspiratory pressures (PIPs) were recorded. RESULTS Infants were born at a median age of 264/7 gestational weeks (range: 230/7 -293/7 ); the study was performed at a median age of 20 days (range: 1-82). The proportion of time SpO2 was within the target range, the number of peripheral desaturations or cRSO2 did not differ between the modes. However, the desaturation severity index was lower (131 vs. 152; p = .03) and fewer manual supplemental oxygen adjustments (1.3 vs. 2.2/h; p = .006) were needed during the period of NAVA ventilation following conventional ventilation. The mean Edi (8.1 vs. 11.4 µV; p < .006) and PIP values (14.9 vs. 19.1; p < .001) were lower during the NAVA mode. CONCLUSIONS Although NAVA ventilation did not increase the proportion of time with optimal saturation, it was associated with decreased diaphragmatic activity, lower PIPs, less severe hypoxemic events, and fewer manual oxygen adjustments in very preterm infants.
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Affiliation(s)
- Arata Oda
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Vilhelmiina Parikka
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland.,Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Liisa Lehtonen
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland.,Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Sepinoud Azimi
- Department of Information Technology, Faculty of Natural Sciences and Technology, Åbo Akademi University, Turku, Finland
| | - Ivan Porres
- Department of Information Technology, Faculty of Natural Sciences and Technology, Åbo Akademi University, Turku, Finland
| | - Hanna Soukka
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland.,Department of Clinical Medicine, University of Turku, Turku, Finland
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17
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Asai H, Okamoto T, Nii M, Nohara F, Nagaya K. Neurally adjusted ventilatory assist in an infant with tracheobronchomalacia. Pediatr Int 2021; 63:1396-1398. [PMID: 34355466 DOI: 10.1111/ped.14625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 01/15/2021] [Accepted: 01/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Hiroko Asai
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan.,Department of Pediatrics, Hokkaido Ryoikuen, Asahikawa, Japan
| | - Toshio Okamoto
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan
| | - Mitsumaro Nii
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan
| | - Fumikatsu Nohara
- Department of Pediatrics, Asahikawa Kosei Hospital, Hokkaido, Japan
| | - Ken Nagaya
- Division of Neonatology, Center for Maternity and Infant Care, Asahikawa Medical University Hospital, Hokkaido, Japan
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18
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Pavlek LR, Rivera BK, Smith CV, Randle J, Hanlon C, Small K, Bell EF, Rysavy MA, Conroy S, Backes CH. Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review. J Pediatr 2021; 235:63-74.e12. [PMID: 33894262 PMCID: PMC9348995 DOI: 10.1016/j.jpeds.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation). STUDY DESIGN PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale. RESULTS Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation. CONCLUSIONS The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.
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Affiliation(s)
- Leeann R. Pavlek
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Brian K. Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital
| | - Charles V. Smith
- Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
| | - Joanie Randle
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Cory Hanlon
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Kristi Small
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Edward F. Bell
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Matthew A. Rysavy
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Sara Conroy
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University,Biostatistics Resource at Nationwide Children’s Hospital
| | - Carl H. Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH,Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH,Obstetrics and Gynecology, The Ohio State University Wexner Medical Center,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
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19
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McKinney RL, Keszler M, Truog WE, Norberg M, Sindelar R, Wallström L, Schulman B, Gien J, Abman SH. Multicenter Experience with Neurally Adjusted Ventilatory Assist in Infants with Severe Bronchopulmonary Dysplasia. Am J Perinatol 2021; 38:e162-e166. [PMID: 32208500 DOI: 10.1055/s-0040-1708559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study is to determine patterns of neurally adjusted ventilatory assist (NAVA) use in ventilator-dependent preterm infants with evolving or established severe bronchopulmonary dysplasia (sBPD) among centers of the BPD Collaborative, including indications for its initiation, discontinuation, and outcomes. STUDY DESIGN Retrospective review of infants with developing or established sBPD who were placed on NAVA after ≥4 weeks of mechanical ventilation and were ≥ 30 weeks of postmenstrual age (PMA). RESULTS Among the 13 sites of the BPD collaborative, only four centers (31%) used NAVA in the management of infants with evolving or established BPD. A total of 112 patients met inclusion criteria from these four centers. PMA, weight at the start of NAVA and median number of days on NAVA, were different among the four centers. The impact of NAVA therapy was assessed as being successful in 67% of infants, as defined by the ability to achieve respiratory stability at a lower level of ventilator support, including extubation to noninvasive positive pressure ventilation or support with a home ventilator. In total 87% (range: 78-100%) of patients survived until discharge. CONCLUSION We conclude that NAVA can be used safely and effectively in selective infants with sBPD. Indications and current strategies for the application of NAVA in infants with evolving or established BPD, however, are highly variable between centers. Although this pilot study suggests that NAVA may be successfully used for the management of infants with BPD, sufficient experience and well-designed clinical studies are needed to establish standards of care for defining the role of NAVA in the care of infants with sBPD.
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Affiliation(s)
- Robin L McKinney
- Department of Pediatric Critical Care Medicine, Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, Rhode Island
| | - Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island
| | - William E Truog
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Michael Norberg
- Department of Neonatology, Children's Mercy Hospital, Kansas City, Missouri
| | - Richard Sindelar
- Division of Neonatology, Department of Women's and Children's Health Uppsala University Children's Hospital, Uppsala, Sweden
| | - Linda Wallström
- Division of Neonatology, Department of Women's and Children's Health Uppsala University Children's Hospital, Uppsala, Sweden
| | - Bruce Schulman
- Department of Neonatology, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Jason Gien
- Department of Pediatrics, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
| | - Steven H Abman
- Department of Pediatrics, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
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20
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Sindelar R, McKinney RL, Wallström L, Keszler M. Proportional assist and neurally adjusted ventilation: Clinical knowledge and future trials in newborn infants. Pediatr Pulmonol 2021; 56:1841-1849. [PMID: 33721418 DOI: 10.1002/ppul.25354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/16/2021] [Accepted: 03/02/2021] [Indexed: 11/07/2022]
Abstract
Different types of patient triggered ventilator modes have become the mainstay of ventilation in term and preterm newborn infants. Maintaining spontaneous breathing has allowed for earlier weaning and the additive effects of respiratory efforts combined with pre-set mechanical inflations have reduced mean airway pressures, both of which are important components in trying to avoid lung injury and promote normal lung development. New sophisticated modes of assisted ventilation have been developed during the last decades where the control of ventilator support is turned over to the patient. The ventilator detects the respiratory effort and adjusts ventilatory assistance proportionally to each phase of the respiratory cycle, thus enabling the patient to have full control of the start, the duration and the amount of ventilatory assistance. In this paper we will review the literature on the ventilatory modes of proportional assist ventilation and neurally adjusted ventilatory assistance, examine the different ways the signals are analyzed, propose future studies, and suggest ways to apply these modes in the clinical environment.
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Affiliation(s)
- Richard Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Robin L McKinney
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Linda Wallström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
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21
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Chakkarapani AA, Adappa R, Mohammad Ali SK, Gupta S, Soni NB, Chicoine L, Hummler HD. "Current concepts in assisted mechanical ventilation in the neonate" - Part 2: Understanding various modes of mechanical ventilation and recommendations for individualized disease-based approach in neonates. Int J Pediatr Adolesc Med 2020; 7:201-208. [PMID: 33319021 PMCID: PMC7729247 DOI: 10.1016/j.ijpam.2020.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/08/2020] [Indexed: 06/12/2023]
Abstract
Mechanical ventilation is a lifesaving intervention in critically ill preterm and term neonates. However, it has the potential to cause significant damage to the lungs resulting in long-term complications. Understanding the pathophysiological process and having a good grasp of the basic concepts of conventional and high-frequency ventilation is essential for any medical or allied healthcare practitioner involved in the neonates' respiratory management. This review aims to describe the various types and modes of ventilation usually available in neonatal units. It also describes recommendations of an individualized disease-based approach to mechanical ventilation strategies implemented in the authors' institutions.
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Affiliation(s)
- Aravanan Anbu Chakkarapani
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Roshan Adappa
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
| | | | - Samir Gupta
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
- Durham University, United Kingdom
| | - Naharmal B. Soni
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
| | - Louis Chicoine
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
| | - Helmut D. Hummler
- Division of Neonatology, Department of Paediatrics, Sidra Medicine, Doha, Qatar
- Weill Cornell Medicine-Qatar, Doha, Qatar
- University of Ulm, Germany
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22
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Rong X, Liang F, Li YJ, Liang H, Zhao XP, Zou HM, Lu WN, Shi H, Zhang JH, Guan RL, Sun Y, Zhang H. Application of Neurally Adjusted Ventilatory Assist in Premature Neonates Less Than 1,500 Grams With Established or Evolving Bronchopulmonary Dysplasia. Front Pediatr 2020; 8:110. [PMID: 32266188 PMCID: PMC7105827 DOI: 10.3389/fped.2020.00110] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/03/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Very low birth weight premature (VLBW) infants with bronchopulmonary dysplasia (BPD) often need prolonged respiratory support, which is associated with worse outcomes. The application of neurally adjusted ventilatory assist ventilation (NAVA) in infants with BPD has rarely been reported. This study investigated whether NAVA is safe and can reduce the duration respiratory support in VLBW premature infants with established or evolving BPD. Methods: This retrospective matched-cohort study included patients admitted to our NICU between April 2017 to April 2019 who were born at <32 weeks' gestation with birthweight of <1,500 g. The study groups (NAVA group) were infants who received NAVA ventilation as a sequel mode of ventilation after at least 2 weeks of traditional respiratory support after birth. The control group were preterm infants who required traditional respiratory support beyond first 2 weeks of life and were closely matched to the NAVA patients by gestational age and birthweight. The primary outcome was to compare the total duration of respiratory support between the NAVA group and the control group. The secondary outcomes were comparisons of duration of invasive and non-invasive support, oxygen therapy, length of stay, severity of BPD, weight gain and sedation need between the groups. Results: There were no significant differences between NAVA group and control group in the primary and most of the secondary outcomes (all P > 0.05). However, NAVA was well tolerated and there was a decrease in the need of sedation (p = 0.012) after switching to NAVA. Conclusion: NAVA, when used as a sequel mode of ventilation, in premature neonates <1,500 g with evolving or established BPD showed a similar effect compared to conventional ventilation in respiratory outcomes. NAVA can be safely used in this patient population and potentially can decrease the need of sedation.
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Affiliation(s)
- Xiao Rong
- Division of Neonatology, Guangzhou Women and Children's Medical Center Affiliated With Jinan University, Guanghzou, China
| | - Feng Liang
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Yuan-Jing Li
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Hong Liang
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Xiao-Peng Zhao
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Hong-Mei Zou
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Wei-Neng Lu
- Division of Neonatology, Guangzhou Women and Children's Medical Center Affiliated With Jinan University, Guanghzou, China
| | - Hui Shi
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Jing-Hua Zhang
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Rui-Lian Guan
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Yi Sun
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Huayan Zhang
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China.,Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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23
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Proportional assist ventilation (PAV) versus neurally adjusted ventilator assist (NAVA): effect on oxygenation in infants with evolving or established bronchopulmonary dysplasia. Eur J Pediatr 2020; 179:901-908. [PMID: 31980954 PMCID: PMC7220976 DOI: 10.1007/s00431-020-03584-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 01/13/2020] [Accepted: 01/15/2020] [Indexed: 11/11/2022]
Abstract
Both proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) provide pressure support synchronised throughout the respiratory cycle proportional to the patient's respiratory demand. Our aim was to compare the effect of these two modes on oxygenation in infants with evolving or established bronchopulmonary dysplasia. Two-hour periods of PAV and NAVA were delivered in random order to 18 infants born less than 32 weeks of gestation. Quasi oxygenation indices ("OI") and alveolar-arterial ("A-a") oxygen gradients at the end of each period on PAV, NAVA and baseline ventilation were calculated using capillary blood samples. The mean "OI" was not significantly different on PAV compared to NAVA (7.8 (standard deviation (SD) 3.2) versus 8.1 (SD 3.4), respectively, p = 0.70, but lower on both than on baseline ventilation (mean baseline "OI" 11.0 (SD 5.0)), p = 0.002, 0.004, respectively). The "A-a" oxygen gradient was higher on PAV and baseline ventilation than on NAVA (20.8 (SD 12.3) and 22.9 (SD 11.8) versus 18.5 (SD 10.8) kPa, p = 0.015, < 0.001, respectively).Conclusion: Both NAVA and PAV improved oxygenation compared to conventional ventilation. There was no significant difference in the mean "OI" between the two modes, but the mean "A-a" gradient was better on NAVA.What is Known:• Proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) can improve the oxygenation index (OI) in prematurely born infants.• Both PAV and NAVA can provide support proportional to respiratory drive or demand throughout the respiratory cycle.What is New:• In infants with evolving or established BPD, using capillary blood samples, both PAV and NAVA compared to baseline ventilation resulted in improvement in the "OI", but there was no significant difference in the "OI" on PAV compared to NAVA.• The "alveolar-arterial" oxygen gradient was better on NAVA compared to PAV.
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24
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Ventilation strategies in transition from neonatal respiratory distress to chronic lung disease. Semin Fetal Neonatal Med 2019; 24:101035. [PMID: 31759915 DOI: 10.1016/j.siny.2019.101035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the advance in neonatal care over the past few decades, preventing preterm infants with respiratory distress syndrome progress to bronchopulmonary dysplasia remained challenging. In this review, we will discuss the respiratory support strategies in preterm infants with RDS evolving into BPD based on the changes in pulmonary mechanics and pathophysiology as well as currently available evidence.
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25
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Abstract
Introduction: Bronchopulmonary dysplasia (BPD) is a common long-term adverse complication of very premature delivery. Affected infants can suffer chronic respiratory morbidities including lung function abnormalities and reduced exercise capacity even as young adults. Many studies have investigated possible preventative strategies; however, it is equally important to identify optimum management strategies for infants with evolving or established BPD. Areas covered: Respiratory support modalities and established and novel pharmacological treatments. Expert opinion: Respiratory support modalities including proportional assist ventilation and neurally adjusted ventilatory assist are associated with short term improvements in oxygenation indices. Such modalities need to be investigated in appropriate RCTs. Many pharmacological treatments are routinely used with a limited evidence base, for example diuretics. Stem cell therapies in small case series are associated with promising results. More research is required before it is possible to determine if such therapies should be investigated in large RCTs with long-term outcomes.
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Affiliation(s)
- Emma Williams
- a Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , UK.,b The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London , UK
| | - Anne Greenough
- a Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , UK.,c NIHR Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London , London , UK
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26
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Charles E, Hunt KA, Rafferty GF, Peacock JL, Greenough A. Work of breathing during HHHFN and synchronised NIPPV following extubation Eur J Pediatr 2019;178:105-110, doi: 10.1007/s00431-018-3254-3. Response to: How can we provide true synchronization in synchronized NIPPV. Corresponding Author: Kadir Şerafettin Tekgündüz; doi: 10.1007/s00431-019-03353-4. Eur J Pediatr 2019; 178:781-782. [PMID: 30903307 DOI: 10.1007/s00431-019-03354-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 02/19/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Elinor Charles
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Katie A Hunt
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Gerrard F Rafferty
- Centre for Human and Aerospace Physiological Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Janet L Peacock
- School of Population Health and Environmental Sciences, King's College London, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Anne Greenough
- The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.
- NICU, 4th Floor Golden Jubilee Wing, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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Liu G, Wu H, Li Z. Current views of complications associated with neonatal ventilation. Minerva Pediatr 2018; 72:60-64. [PMID: 29479941 DOI: 10.23736/s0026-4946.18.04822-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Infants born prematurely require external respiratory support device like ventilation for the purpose of life saving. However, these ventilation machines have complications that sometimes unfortunately result in morbidity. New ventilation techniques have been developed to prevent morbidity, but have yet to be fully evaluated. The present review article would discuss current aspects of this life saving gear especially for pediatric patients in clinical setting. Besides basic ventilation apparatus, advancements in the filed like proportional assist ventilation, volume targeted ventilation would be discussed.
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Affiliation(s)
- Gang Liu
- Department of Neonatology, Xunzhou Children's Hospital, Xuzhou, China
| | - Hongwei Wu
- Department of Neonatology, Xunzhou Children's Hospital, Xuzhou, China
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Rossor TE, Hunt KA, Shetty S, Greenough A. Neurally adjusted ventilatory assist compared to other forms of triggered ventilation for neonatal respiratory support. Cochrane Database Syst Rev 2017; 10:CD012251. [PMID: 29077984 PMCID: PMC6485908 DOI: 10.1002/14651858.cd012251.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Effective synchronisation of infant respiratory effort with mechanical ventilation may allow adequate gas exchange to occur at lower peak airway pressures, potentially reducing barotrauma and volutrauma and development of air leaks and bronchopulmonary dysplasia. During neurally adjusted ventilatory assist ventilation (NAVA), respiratory support is initiated upon detection of an electrical signal from the diaphragm muscle, and pressure is provided in proportion to and synchronous with electrical activity of the diaphragm (EADi). Compared to other modes of triggered ventilation, this may provide advantages in improving synchrony. OBJECTIVES Primary• To determine whether NAVA, when used as a primary or rescue mode of ventilation, results in reduced rates of bronchopulmonary dysplasia (BPD) or death among term and preterm newborn infants compared to other forms of triggered ventilation• To assess the safety of NAVA by determining whether it leads to greater risk of intraventricular haemorrhage (IVH), periventricular leukomalacia, or air leaks when compared to other forms of triggered ventilation Secondary• To determine whether benefits of NAVA differ by gestational age (term or preterm)• To determine whether outcomes of cross-over trials performed during the first two weeks of life include peak pressure requirements, episodes of hypocarbia or hypercarbia, oxygenation index, and the work of breathing SEARCH METHODS: We performed searches of the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cohrane Library; MEDLINE via Ovid SP (January 1966 to March 2017); Embase via Ovid SP (January 1980 to March 2017); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to March 2017); and the Web of Science (1985 to 2017). We searched abstracts from annual meetings of the Pediatric Academic Societies (PAS) (2000 to 2016); meetings of the European Society of Pediatric Research (published in Pediatric Research); and meetings of the Perinatal Society of Australia and New Zealand (PSANZ) (2005 to 2016). We also searched clinical trials databases to March 2017. SELECTION CRITERIA We included randomised and quasi-randomised clinical trials including cross-over trials comparing NAVA with other modes of triggered ventilation (assist control ventilation (ACV),synchronous intermittent mandatory ventilation plus pressure support (SIMV ± PS), pressure support ventilation (PSV), or proportional assist ventilation (PAV)) used in neonates. DATA COLLECTION AND ANALYSIS Primary outcomes of interest from randomised controlled trials were all-cause mortality, bronchopulmonary dysplasia (BPD; defined as oxygen requirement at 28 days), and a combined outcome of all-cause mortality or BPD. Secondary outcomes were duration of mechanical ventilation, incidence of air leak, incidence of IVH or periventricular leukomalacia, and survival with an oxygen requirement at 36 weeks' postmenstrual age.Outcomes of interest from cross-over trials were maximum fraction of inspired oxygen, mean peak inspiratory pressure, episodes of hypocarbia, and episodes of hypercarbia measured across the time period of each arm of the cross-over. We planned to assess work of breathing; oxygenation index, and thoraco-abdominal asynchrony at the end of the time period of each arm of the cross-over study. MAIN RESULTS We included one randomised controlled study comparing NAVA versus patient-triggered time-cycled pressure-limited ventilation. This study found no significant difference in duration of mechanical ventilation, nor in rates of BPD, pneumothorax, or IVH. AUTHORS' CONCLUSIONS Risks and benefits of NAVA compared to other forms of ventilation for neonates are uncertain. Well-designed trials are required to evaluate this new form of triggered ventilation.
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Affiliation(s)
- Thomas E Rossor
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
| | | | - Sandeep Shetty
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
| | - Anne Greenough
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
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