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Lin HZ, Lin YF, Zheng YR. Comparison of neurally adjusted ventilatory assist and synchronized intermittent mandatory ventilation in preterm infants after patent ductus arteriosus ligation: a retrospective study. BMC Pediatr 2024; 24:277. [PMID: 38678190 PMCID: PMC11055325 DOI: 10.1186/s12887-024-04727-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/27/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVE This study aimed to compare the efficacy of neurally adjusted ventilatory assist (NAVA) to synchronized intermittent mandatory ventilation (SIMV) in preterm infants requiring mechanical ventilation after patent ductus arteriosus (PDA) ligation. METHODS A retrospective analysis was conducted on intubated preterm infants who underwent PDA ligation at our hospital from July 2021 to January 2023. Infants were divided into NAVA or SIMV groups based on the ventilation mode after surgery. RESULTS Fifty preterm infants were included. During treatment, peak inspiratory pressure (PIP) and mean airway pressure (MAP) were lower with NAVA compared to SIMV (PIP: 19.1 ± 2.9 vs. 22.4 ± 3.6 cmH2O, P < 0.001; MAP: 9.1 ± 1.8 vs. 10.9 ± 2.7 cmH2O, P = 0.002). PaO2 and PaO2/FiO2 were higher with NAVA (PaO2: 94.0 ± 11.7 vs. 84.8 ± 15.8 mmHg, P = 0.031; PaO2/FiO2: 267 [220-322] vs. 232 [186-290] mmHg, P = 0.025). Less sedation was required with NAVA (midazolam: 1.5 ± 0.5 vs. 1.1 ± 0.3 μg/kg/min, P < 0.001). CONCLUSION Compared to SIMV, early use of NAVA post PDA ligation in preterm infants was associated with decreased PIP and MAP. Early NAVA was also associated with reduced sedation needs and improved oxygenation. However, further studies are warranted to quantify the benefits of NAVA ventilation.
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Affiliation(s)
- Hui-Zi Lin
- Department of Neonatology, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China
| | - Yun-Feng Lin
- Department of Neonatology, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China.
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China.
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China.
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China.
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Mohamed MSA, Moerer O, Harnisch LO. Recording of a left ventricle assist device electrical current with a neurally adjusted ventilation assist (NAVA) catheter: a small case series. J Clin Monit Comput 2023; 37:1635-1639. [PMID: 37458915 DOI: 10.1007/s10877-023-01055-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/27/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Neurally Adjusted Ventilatory Assist (NAVA) is an adaptive ventilation mode that recognizes electromyographic diaphragmatic activation as a sensory input to control the ventilator. NAVA may be of interest in prolonged mechanical ventilation and weaning, as it provides effort-adapted support, improves patient-ventilator synchronization, and allows additional monitoring of neuromuscular function and drive. Ventricular assist devices (VAD), especially for the left ventricle (LVAD), are increasingly entering clinical practice, and intensivists are faced with distinct challenges such as the interaction between the system and other measures of organ support. CASE PRESENTATION We present two cases in which a NAVA mode was intended to support ventilator weaning in patients with recent LVAD implantation (HeartMate III®). However, in these patients, the electrical activity of the diaphragm (Edi) could not be used to control the ventilator, because the LVAD current detected by the catheter superposed the Edi current, making usage of this mode impossible. DISCUSSION/CONCLUSIONS An implanted LVAD can render the NAVA signal unusable for ventilatory support because the LVAD signal can interfere with the recording of electromyographic activation of the diaphragm. Therefore, patients with implanted LVAD may need other modes of ventilation than NAVA for advanced weaning strategies.
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Affiliation(s)
- M Salaheldin Atta Mohamed
- Department of Anaesthesiology, University Medical Center of Göttingen, Robert-Koch-Str. 40, D-37075, Göttingen, Germany
| | - O Moerer
- Department of Anaesthesiology, University Medical Center of Göttingen, Robert-Koch-Str. 40, D-37075, Göttingen, Germany
| | - L O Harnisch
- Department of Anaesthesiology, University Medical Center of Göttingen, Robert-Koch-Str. 40, D-37075, Göttingen, Germany.
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Liu L, Li HL, Lu C, Patel P, Wang D, Beck J, Sinderby C. Estimation of transpulmonary driving pressure during synchronized mechanical ventilation using a single lower assist maneuver (LAM) in rabbits: a comparison to measurements made with an esophageal balloon. Crit Care 2023; 27:325. [PMID: 37626372 PMCID: PMC10463600 DOI: 10.1186/s13054-023-04607-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Mechanical ventilation is applied to unload the respiratory muscles, but knowledge about transpulmonary driving pressure (ΔPL) is important to minimize lung injury. We propose a method to estimate ΔPL during neurally synchronized assisted ventilation, with a simple intervention of lowering the assist for one breath ("lower assist maneuver", LAM). METHODS In 24 rabbits breathing spontaneously with imposed loads, titrations of increasing assist were performed, with two neurally synchronized modes: neurally adjusted ventilatory assist (NAVA) and neurally triggered pressure support (NPS). Two single LAM breaths (not sequentially, but independently) were performed at each level of assist by acutely setting the assist to zero cm H2O (NPS) or NAVA level 0 cm H2O/uV (NAVA) for one breath. NPS and NAVA titrations were followed by titrations in controlled-modes (volume control, VC and pressure control, PC), under neuro-muscular blockade. Breaths from the NAVA/NPS titrations were matched (for flow and volume) to VC or PC. Throughout all runs, we measured diaphragm electrical activity (Edi) and esophageal pressure (PES). We measured ΔPL during the spontaneous modes (PL_PES) and controlled mechanical ventilation (CMV) modes (PL_CMV) with the esophageal balloon. From the LAMs, we derived an estimation of ΔPL ("PL_LAM") using a correction factor (ratio of volume during the LAM and volume during assist) and compared it to measured ΔPL during passive (VC or PC) and spontaneous breathing (NAVA or NPS). A requirement for the LAM was similar Edi to the assisted breath. RESULTS All animals successfully underwent titrations and LAMs for NPS/NAVA. One thousand seven-hundred ninety-two (1792) breaths were matched to passive ventilation titrations (matched Vt, r = 0.99). PL_LAM demonstrated strong correlation with PL_CMV (r = 0.83), and PL_PES (r = 0.77). Bland-Altman analysis revealed little difference between the predicted PL_LAM and measured PL_CMV (Bias = 0.49 cm H2O and 1.96SD = 3.09 cm H2O). For PL_PES, the bias was 2.2 cm H2O and 1.96SD was 3.4 cm H2O. Analysis of Edi and PES at peak Edi showed progressively increasing uncoupling with increasing assist. CONCLUSION During synchronized mechanical ventilation, a LAM breath allows for estimations of transpulmonary driving pressure, without measuring PES, and follows a mathematical transfer function to describe respiratory muscle unloading during synchronized assist.
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Affiliation(s)
- Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Cong Lu
- Institute of Medical Science, University of Toronto, Toronto, Canada
- Department of Critical Care, St. Michael's Hospital, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - Purab Patel
- Department of Critical Care, St. Michael's Hospital, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
| | - Danqiong Wang
- Department of Critical Care Medicine, The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Quzhou, 324000, China
| | - Jennifer Beck
- Department of Critical Care, St. Michael's Hospital, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.
- Department of Pediatrics, University of Toronto, Toronto, Canada.
- Member, 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, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada
- Member, 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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Pinto CB, Leite D, Brandão M, Nedel W. Clinical outcomes in patients undergoing invasive mechanical ventilation using NAVA and other ventilation modes - A systematic review and meta-analysis. J Crit Care 2023; 76:154287. [PMID: 36958129 DOI: 10.1016/j.jcrc.2023.154287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 03/03/2023] [Accepted: 03/05/2023] [Indexed: 03/25/2023]
Abstract
PURPOSE Neurally adjusted ventilatory assist mode (NAVA) benefit in mechanical ventilation (MV) patients with regard to clinically outcomes is still uncertain. Recent randomized clinical trials (RCTs) have addressed this issue, making it important to assess the real impact of NAVA in relation to these outcomes. MATERIALS AND METHODS We performed a systematic review and meta-analysis of RCTs comparing NAVA ventilation mode versus the standard ventilation mode in critically ill adult patients admitted to the ICU with invasive MV. The main outcome was 28-days ventilatory free-days (VFD). Secondary outcomes were weaning failure, mortality, ICU and hospital length of stay and need for tracheostomy. RESULTS We included 5 RCTs (643 patients). The patients in the NAVA group had increased VFDs compared to the control group: mean difference (MD) 3.42 (95% CI 1.21 to 5.62, I2 = 0%). NAVA and control groups did not differ in ICU mortality [OR 0.58 (95% CI 0.33 to 1.03), I2 = 41%]. NAVA mode was associated with a reduced incidence of weaning failure [OR 0.51 (95% CI 0.29 to 0.88), I2 = 0%]. NAVA and control groups did not differ in the number of MV days: MD -1.9 days (95% CI -4.2 to 0.3, I2 = 0%). CONCLUSIONS NAVA mode has a modest impact on MV-free days and weaning success, with no association with improvements in other relevant clinical outcomes.
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Affiliation(s)
- Clarissa Both Pinto
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Debora Leite
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Mariana Brandão
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Wagner Nedel
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brazil; Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre, Brazil; Brazilian Research in Intensive Care Network, BRICNet, Brazil.
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Weiyun T, Linli S, Liuzhao C. Neurally-Adjusted Ventilatory Assist Versus Pressure Support Ventilation During Noninvasive Ventilation. Respir Care 2022; 67:879-888. [PMID: 35177538 PMCID: PMC9994081 DOI: 10.4187/respcare.09881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Noninvasive ventilation (NIV) is increasingly used during ventilatory support. Neurally-adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation that can improve patient-ventilator interaction. We conducted a meta-analysis to compare patient-ventilator interaction and clinical outcomes between NAVA and pressure support ventilation (PSV) in adult subjects during NIV. METHODS The PubMed, Cochrane Library, Web of Science, OpenGrey, and Embase databases were searched for appropriate clinical trials comparing NIV-NAVA with NIV-PSV for adult subjects. Comparisons of asynchrony index (AI), types of asynchrony, and clinical outcomes were pooled. RESULTS Fifteen studies were included involving 615 subjects. AI was significantly lower in NAVA than PSV group (mean difference [MD] -14.70 [95% CI -23.20 to -6.19], P < .001). Subgroup analysis grouped by exacerbation of COPD or non-COPD showed that the AI of NAVA was lower than PSV in COPD exacerbation (MD -14.56 [95% CI -21.04 to -8.09], P < .001) and non-COPD (MD -3.02 [95% CI -4.44 to -1.61], P < .001). Severe asynchrony was significantly lower in NAVA than in PSV (odds ratio 0.06 [95% CI 0.03-0.11], P < .001). Inspiratory trigger delay in NAVA was significantly lower than PSV (MD -129.60 [95% CI -148.43 to -110.78], P < .001). NAVA had longer ICU length of stay than PSV (MD 1.22 [95% CI 0.44-2.00], P = .002). Level of discomfort was significantly higher in NAVA group than PSV group (MD 0.62 [95% CI 0.02-1.21], P = .040). CONCLUSIONS NAVA has advantages in ventilator-patient interaction compared to PSV in NIV. Further research is needed in order to estimate effects on clinical outcomes.
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Affiliation(s)
- Teng Weiyun
- Department of Respiratory and Critical Care Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, People's Republic of China
| | - Sang Linli
- Department of Respiratory and Critical Care Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, People's Republic of China
| | - Cao Liuzhao
- Department of Respiratory and Critical Care Medicine, Northern Jiangsu People's Hospital Affiliated to Yangzhou University, Yangzhou, Jiangsu, People's Republic of China.
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Benn K, De Rooy L, Cornuaud P, Kulkarni A, Shetty S. Improved nutritional outcomes with neurally adjusted ventilatory assist (NAVA) in premature infants: a single tertiary neonatal unit's experience. Eur J Pediatr 2022; 181:2155-9. [PMID: 35194652 DOI: 10.1007/s00431-022-04411-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/13/2022] [Accepted: 02/06/2022] [Indexed: 11/25/2022]
Abstract
During neurally adjusted ventilatory assist (NAVA)/non-invasive (NIV) NAVA, a modified nasogastric feeding tube with electrodes, monitors the electrical activity of the diaphragm (Edi). The Edi waveform determines the delivered pressure from the ventilator. Infant breathing is in synchrony with the ventilator and therefore is more comfortable with less work of breathing. Our aim was to determine if infants on NAVA had improved nutritional outcomes compared to infants managed on conventional respiratory support. A retrospective study was undertaken. Infants on NAVA were matched with two conventionally ventilated controls by gestational age, birth weight, sex, antenatal steroid exposure, and whether inborn or transferred ex utero. NAVA/NIV-NAVA was delivered by the SERVO-n® Maquet Getinge group ventilator. Conventional ventilation included pressure and volume control ventilation, and non-invasive ventilation included nasal intermittent positive pressure ventilation, triggered biphasic positive airway pressure, continuous positive airway pressure and heated humidified high flow oxygen. The measured outcome was discharge weight z scores. Eighteen "NAVA" infants with median gestational age (GA) of 25.3 (23.6-27.1) weeks and birth weight (BW) of 765 (580-1060) grams were compared with 36 controls with GA 25.2 (23.4-28) weeks (p = 0.727) and BW 743 (560-1050) grams (p = 0.727). There was no significant difference in the rates of postnatal steroids (61% versus 36% p = 0.093), necrotising enterocolitis (22% versus 11% p = 0.279) in the NAVA/NIV NAVA compared to the control group. There were slightly more infants who were breastfed at discharge in the NAVA/NIV NAVA group compared to controls: breast feeds (77.8% versus 58.3%), formula feeds (11.1% versus 30.6%), and mixed feeds (11.1% versus 11.1%), but this difference was not significant (p = 0.275). There was no significant difference in the birth z scores 0.235 (-1.56 to 1.71) versus -0.05 (-1.51 to -1.02) (p = 0.248) between the groups. However, the discharge z score was significantly in favour of the NAVA/NIV-NAVA group: -1.22 (-2.66 to -0.12) versus -2.17 (-3.79 to -0.24) in the control group (p = 0.033).Conclusion: The combination of NAVA/NIV-NAVA compared to conventional invasive and non-invasive modes may contribute to improved nutritional outcomes in premature infants.
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Kampolis CF, Mermiri M, Mavrovounis G, Koutsoukou A, Loukeri AA, Pantazopoulos I. Comparison of advanced closed-loop ventilation modes with pressure support ventilation for weaning from mechanical ventilation in adults: A systematic review and meta-analysis. J Crit Care 2021; 68:1-9. [PMID: 34839229 DOI: 10.1016/j.jcrc.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 10/26/2021] [Accepted: 11/14/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE To compare neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), adaptive support ventilation (ASV) and Smartcare pressure support (Smartcare/PS) with standard pressure support ventilation (PSV) regarding their effectiveness for weaning critically ill adults from invasive mechanical ventilation (IMV). METHODS Electronic databases were searched to identify parallel-group randomized controlled trials (RCTs) comparing NAVA, PAV, ASV, or Smartcare/PS with PSV, in adult patients under IMV through July 28, 2021. Primary outcome was weaning success. Secondary outcomes included weaning time, total MV duration, reintubation or use of non-invasive MV (NIMV) within 48 h after extubation, in-hospital and intensive care unit (ICU) mortality, in-hospital and ICU length of stay (LOS) (PROSPERO registration No:CRD42021270299). RESULTS Twenty RCTs were finally included. Compared to PSV, NAVA was associated with significantly lower risk for in-hospital and ICU death and lower requirements for post-extubation NIMV. Moreover, PAV showed significant advantage over PSV in terms of weaning rates, MV duration and ICU LOS. No significant differences were found between ASV or Smart care/PS and PSV. CONCLUSIONS Moderate certainty evidence suggest that PAV increases weaning success rates, shortens MV duration and ICU LOS compared to PSV. It is also noteworthy that NAVA seems to improve in-hospital and ICU survival.
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Affiliation(s)
- Christos F Kampolis
- Department of Emergency Medicine, "Hippokration" General Hospital of Athens, Athens, Greece.
| | - Maria Mermiri
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, General University Hospital of Larissa, Mezourlo 41110, Larissa, Greece
| | - Georgios Mavrovounis
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, General University Hospital of Larissa, Mezourlo 41110, Larissa, Greece
| | - Antonia Koutsoukou
- Intensive Care Unit, 1st Department of Respiratory Medicine, "Sotiria" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Ioannis Pantazopoulos
- Department of Emergency Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, General University Hospital of Larissa, Mezourlo 41110, Larissa, Greece
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Yuan X, Lu X, Chao Y, Beck J, Sinderby C, Xie J, Yang Y, Qiu H, Liu L. Neurally adjusted ventilatory assist as a weaning mode for adults with invasive mechanical ventilation: a systematic review and meta-analysis. Crit Care 2021; 25:222. [PMID: 34187528 PMCID: PMC8240429 DOI: 10.1186/s13054-021-03644-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
Background Prolonged ventilatory support is associated with poor clinical outcomes. Partial support modes, especially pressure support ventilation, are frequently used in clinical practice but are associated with patient–ventilation asynchrony and deliver fixed levels of assist. Neurally adjusted ventilatory assist (NAVA), a mode of partial ventilatory assist that reduces patient–ventilator asynchrony, may be an alternative for weaning. However, the effects of NAVA on weaning outcomes in clinical practice are unclear. Methods We searched PubMed, Embase, Medline, and Cochrane Library from 2007 to December 2020. Randomized controlled trials and crossover trials that compared NAVA and other modes were identified in this study. The primary outcome was weaning success which was defined as the absence of ventilatory support for more than 48 h. Summary estimates of effect using odds ratio (OR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with accompanying 95% confidence interval (CI) were expressed. Results Seven studies (n = 693 patients) were included. Regarding the primary outcome, patients weaned with NAVA had a higher success rate compared with other partial support modes (OR = 1.93; 95% CI 1.12 to 3.32; P = 0.02). For the secondary outcomes, NAVA may reduce duration of mechanical ventilation (MD = − 2.63; 95% CI − 4.22 to − 1.03; P = 0.001) and hospital mortality (OR = 0.58; 95% CI 0.40 to 0.84; P = 0.004) and prolongs ventilator-free days (MD = 3.48; 95% CI 0.97 to 6.00; P = 0.007) when compared with other modes. Conclusions Our study suggests that the NAVA mode may improve the rate of weaning success compared with other partial support modes for difficult to wean patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03644-z.
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Affiliation(s)
- Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Xinxing Lu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yali Chao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Canada.,Department of Critical Care, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
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Kato Y, Takemoto A, Oumi C, Hisaichi T, Shimaji Y, Takaoka M, Moriyama H, Hirata K, Wada K. Effects of skin-to-skin care on electrical activity of the diaphragm in preterm infants during neurally adjusted ventilatory assist. Early Hum Dev 2021; 157:105379. [PMID: 33962362 DOI: 10.1016/j.earlhumdev.2021.105379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Skin-to-skin care (SSC) reduces neonatal mortality and morbidity and is widely implemented in the neonatal intensive care unit. However, changes in respiratory effort during SSC in ventilated preterm infants remain unclear. AIMS To evaluate the effect of SSC on electrical activity of the diaphragm (Edi) and vital signs in premature infants who are intubated and under neurally adjusted ventilatory assist ventilation. STUDY DESIGN We performed an observational cross-over study. Data were measured in three periods: before (pre-SSC period), during (SSC period), and after (post-SSC period) SSC. Stable 30-min data in each period were extracted. SUBJECTS Thirty-four SSC procedures were performed in 14 preterm infants with a median gestational age of 25.3 weeks (interquartile range, 24, 26.4) and a birth weight of 659 g (566, 694). The median postnatal age was 41 days (31, 53) at the study with a median postmenstrual age of 31.3 weeks (30.4, 32.5). OUTCOME MEASURES Median values of Edi peak, Edi minimum, respiratory rate, SpO2, and heart rate were measured in each condition. The Kruskal-Wallis test with Bonferroni multiple comparisons was used to compare each parameter in each period. RESULTS Median Edi peak and Edi minimum values were significantly lower during SSC compared with pre- and post-SSC, without any change in respiratory rate, SpO2, or heart rate. CONCLUSIONS Respiratory efforts as evaluated by Edi are significantly reduced during SSC in ventilated preterm infants.
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Affiliation(s)
- Yuta Kato
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Ayumi Takemoto
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Chiyo Oumi
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Tomomi Hisaichi
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Yuki Shimaji
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Misa Takaoka
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Hiroko Moriyama
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Katsuya Hirata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
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Cammarota G, Verdina F, De Vita N, Boniolo E, Tarquini R, Messina A, Zanoni M, Navalesi P, Vetrugno L, Bignami E, Corte FD, De Robertis E, Santangelo E, Vaschetto R. Effects of Varying Levels of Inspiratory Assistance with Pressure Support Ventilation and Neurally Adjusted Ventilatory Assist on Driving Pressure in Patients Recovering from Hypoxemic Respiratory Failure. J Clin Monit Comput 2021; 36:419-427. [PMID: 33559864 PMCID: PMC7871131 DOI: 10.1007/s10877-021-00668-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/28/2021] [Indexed: 12/29/2022]
Abstract
Background Driving pressure can be readily measured during assisted modes of ventilation such as pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA). The present prospective randomized crossover study aimed to assess the changes in driving pressure in response to variations in the level of assistance delivered by PSV vs NAVA. Methods 16 intubated adult patients, recovering from hypoxemic acute respiratory failure (ARF) and undergoing assisted ventilation, were randomly subjected to six 30-min-lasting trials. At baseline, PSV (PSV100) was set with the same regulation present at patient enrollment. The corresponding level of NAVA (NAVA100) was set to match the same inspiratory peak of airway pressure obtained in PSV100. Therefore, the level of assistance was reduced and increased by 50% in both ventilatory modes (PSV50, NAVA50; PSV150, NAVA150). At the end of each trial, driving pressure obtained in response to four short (2–3 s) end-expiratory and end-inspiratory occlusions was analyzed. Results Driving pressure at PSV50 (6.6 [6.1–7.8] cmH2O) was lower than that recorded at PSV100 (7.9 [7.2–9.1] cmH2O, P = 0.005) and PSV150 (9.9 [9.1–13.2] cmH2O, P < 0.0001). In NAVA, driving pressure at NAVA50 was reduced compared to NAVA150 (7.7 [5.1–8.1] cmH2O vs 8.3 [6.4–11.4] cmH2O, P = 0.013), whereas there were no changes between baseline and NAVA150 (8.5 [6.3–9.8] cmH2O vs 8.3 [6.4–11.4] cmH2O, P = 0.331, respectively). Driving pressure at PSV150 was higher than that observed in NAVA150 (P = 0.011). Conclusions NAVA delivers better lung-protective ventilation compared to PSV in hypoxemic ARF patients. Trial registration number and date of registration The present trial was prospectively registered at www.clinicatrials.gov (NCT03719365) on 24 October 2018
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Affiliation(s)
- Gianmaria Cammarota
- Anesthesia and General Intensive Care, "Maggiore Della Carità" University Hospital, Novara, Italy. .,Department of Medicine and Surgery, Università Degli Studi Di Perugia, Perugia, Italy.
| | - Federico Verdina
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Nello De Vita
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Ester Boniolo
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Riccardo Tarquini
- Anesthesia and General Intensive Care, "Maggiore Della Carità" University Hospital, Novara, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Marta Zanoni
- Anesthesia and General Intensive Care, "Maggiore Della Carità" University Hospital, Novara, Italy
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padova, Italy
| | - Luigi Vetrugno
- Department of Medicine, Anesthesia and Intensive Care Clinic, Università Di Udine, Udine, Italy
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Francesco Della Corte
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Edoardo De Robertis
- Department of Medicine and Surgery, Università Degli Studi Di Perugia, Perugia, Italy
| | - Erminio Santangelo
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Rosanna Vaschetto
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
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12
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Meinen RD, Alali YI, Al-Subu A, Wilhelm M, Wraight CL, McAdams RM, Limjoco JJ, McCulley DJ. Neurally-Adjusted Ventilatory Assist Can Facilitate Extubation in Neonates With Congenital Diaphragmatic Hernia. Respir Care 2021; 66:41-49. [PMID: 32753531 PMCID: PMC9993818 DOI: 10.4187/respcare.07681] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia is associated with a high risk of neonatal mortality and long-term morbidity due to lung hypoplasia, pulmonary hypertension, and prolonged exposure to positive-pressure ventilation. Ventilator-associated lung injury may be reduced by using approaches that facilitate the transition from invasive ventilation to noninvasive ventilation (NIV), such as with neurally-adjusted ventilatory assist (NAVA). We reported our use of NAVA in neonatal patients with congenital diaphragmatic hernia during the transition from invasive ventilation to NIV. METHODS A retrospective analysis of neonatal subjects with congenital diaphragmatic hernia admitted to a tertiary care children's hospital between December 2015 and May 2018 was conducted. Subject data and factors that affected the use of NAVA were analyzed. RESULTS Ten neonatal subjects with congenital diaphragmatic hernia were placed on NAVA, and 6 were successfully transitioned, after surgery, from pressure control synchronized intermittent mandatory ventilation to invasive ventilation with NAVA and then to NIV with NAVA without the need for re-intubation. The transition from pressure control synchronized intermittent mandatory ventilation to invasive ventilation with NAVA resulted in a decrease in peak inspiratory pressure, mean airway pressure, and [Formula: see text]. Barriers to the use of NAVA included symptomatic pleural effusion or chylothorax and pulmonary sequestration. CONCLUSIONS Both invasive ventilation with NAVA and NIV with NAVA were used successfully in subjects with congenital diaphragmatic hernia during the transition from invasive ventilation to NIV. The transition to NAVA was associated with a decrease in peak inspiratory pressure, mean airway pressure, and the need for supplemental oxygen. A prospective trial is needed to determine the short- and long-term impacts of this mode of ventilation in neonates with congenital diaphragmatic hernia.
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Affiliation(s)
- Ryan D Meinen
- Division of Neonatology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Yousef I Alali
- Division of Respiratory Therapy, University of Wisconsin-Madison, Madison, Wisconsin
| | - Awni Al-Subu
- Division of Critical Care Medicine, Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Michael Wilhelm
- Division of Critical Care Medicine, Department of Pediatrics, University of Wisconsin-Madison, Madison, Wisconsin
| | - Catherine L Wraight
- Division of Neonatology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Ryan M McAdams
- Division of Neonatology, University of Wisconsin-Madison, Madison, Wisconsin
| | - Jamie J Limjoco
- Division of Neonatology, University of Wisconsin-Madison, Madison, Wisconsin
| | - David J McCulley
- Division of Neonatology, University of Wisconsin-Madison, Madison, Wisconsin.
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Kacmarek RM, Villar J, Parrilla D, Alba F, Solano R, Liu S, Montiel R, Rico-Feijoo J, Vidal A, Ferrando C, Murcia I, Corpas R, González-Higueras E, Sun Q, Pinedo CE, Pestaña D, Martínez D, Aldecoa C, Añón JM, Soro M, González-Martín JM, Fernández C, Fernández RL; NAVa In Acute respiraTORy failure (NAVIATOR) Network. Neurally adjusted ventilatory assist in acute respiratory failure: a randomized controlled trial. Intensive Care Med 2020; 46:2327-37. [PMID: 32893313 DOI: 10.1007/s00134-020-06181-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/11/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE We hypothesized that neurally adjusted ventilatory assist (NAVA) compared to conventional lung-protective mechanical ventilation (MV) decreases duration of MV and mortality in patients with acute respiratory failure (ARF). METHODS We carried out a multicenter, randomized, controlled trial in patients with ARF from several etiologies. Intubated patients ventilated for ≤ 5 days expected to require MV for ≥ 72 h and able to breathe spontaneously were eligible for enrollment. Eligible patients were randomly assigned based on balanced treatment assignments with a computerized randomization allocation sequence to two ventilatory strategies: (1) lung-protective MV (control group), and (2) lung-protective MV with NAVA (NAVA group). Allocation concealment was maintained at all sites during the trial. Primary outcome was the number of ventilator-free days (VFDs) at 28 days. Secondary outcome was all-cause hospital mortality. All analyses were done according to the intention-to-treat principle. RESULTS Between March 2014 and October 2019, we enrolled 306 patients and randomly assigned 153 patients to the NAVA group and 153 to the control group. Median VFDs were higher in the NAVA than in the control group (22 vs. 18 days; between-group difference 4 days; 95% confidence interval [CI] 0 to 8 days; p = 0.016). At hospital discharge, 39 (25.5%) patients in the NAVA group and 47 (30.7%) patients in the control group had died (between-group difference - 5.2%, 95% CI - 15.2 to 4.8, p = 0.31). Other clinical, physiological or safety outcomes did not differ significantly between the trial groups. CONCLUSION NAVA decreased duration of MV although it did not improve survival in ventilated patients with ARF.
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14
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Yu T, Wu R, Yao L, Wang K, Wang G, Fan Z, Wu N, Fang X. Neurally adjusted ventilatory assist after surgical treatment of intracerebral hemorrhage: a randomized crossover study. J Int Med Res 2020; 48:300060520939837. [PMID: 32720550 PMCID: PMC7388128 DOI: 10.1177/0300060520939837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We assessed the neuromechanical efficiency (NME), neuroventilatory efficiency (NVE), and diaphragmatic function effects between pressure support ventilation (PSV) and neutrally adjusted ventilatory assist (NAVA). METHODS Fifteen patients who had undergone surgical treatment of intracerebral hemorrhage were enrolled in this randomized crossover study. The patients were assigned to PSV for the first 24 hours and then to NAVA for the following 24 hours or vice versa. The monitored ventilatory parameters under the two ventilation models were compared. NME, NVE, and diaphragmatic function were compared between the two ventilation models. RESULTS One patient's illness worsened during the study. The study was stopped for this patient, and intact data were obtained from the other 14 patients and analyzed. The monitored tidal volume was significantly higher with PSV than NAVA (487 [443-615] vs. 440 [400-480] mL, respectively). NME, NVE, diaphragmatic function, and the partial pressures of arterial carbon dioxide and oxygen were not significantly different between the two ventilation models. CONCLUSION The tidal volume was lower with NAVA than PSV; however, the patients' selected respiratory pattern during NAVA did not change the NME, NVE, or diaphragmatic function.Clinical trial registration no. ChiCTR1900022861.
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Affiliation(s)
- Tao Yu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Rongrong Wu
- Department of Education, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Lin Yao
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Kui Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Guiliang Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Zhen Fan
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Nianlong Wu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Xinggen Fang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
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15
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Spinazzola G, Costa R, De Luca D, Chidini G, Ferrone G, Piastra M, Conti G. Pressure Support Ventilation (PSV) versus Neurally Adjusted Ventilatory Assist (NAVA) in difficult to wean pediatric ARDS patients: a physiologic crossover study. BMC Pediatr 2020; 20:334. [PMID: 32631305 PMCID: PMC7338290 DOI: 10.1186/s12887-020-02227-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is an innovative mode for assisted ventilation that improves patient-ventilator interaction in children. The aim of this study was to assess the effects of patient-ventilator interaction comparing NAVA with pressure support ventilation (PSV) in patients difficult to wean from mechanical ventilation after moderate pediatric acute respiratory distress syndrome (PARDS). METHODS In this physiological crossover study, 12 patients admitted in the Pediatric Intensive Care Unit (PICU) with moderate PARDS failing up to 3 spontaneous breathing trials in less than 7 days, were enrolled. Patients underwent three study conditions lasting 1 h each: PSV1, NAVA and PSV2. RESULTS The Asynchrony Index (AI) was significantly reduced during the NAVA trial compared to both the PSV1 and PSV2 trials (p = 0.001). During the NAVA trial, the inspiratory and expiratory trigger delays were significantly shorter compared to those obtained during PSV1 and PSV2 trials (Delaytrinspp < 0.001, Delaytrexpp = 0.013). These results explain the significantly longer Timesync observed during the NAVA trial (p < 0.001). In terms of gas exchanges, PaO2 value significantly improved in the NAVA trial with respect to the PSV trials (p < 0.02). The PaO2/FiO2 ratio showed a significant improvement during the NAVA trial compared to both the PSV1 and PSV2 trials (p = 0.004). CONCLUSIONS In this specific PICU population, presenting difficulty in weaning after PARDS, NAVA was associated with a reduction of the AI and a significant improvement in oxygenation compared to PSV mode. TRIAL REGISTRATION ClinicalTrial.gov Identifier: NCT04360590 "Retrospectively registered".
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Affiliation(s)
- Giorgia Spinazzola
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy.
| | - Roberta Costa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy
| | - Daniele De Luca
- Division of Pediatric and Neonatal Critical Care, South Paris University Hospital, Medical Centers "A. Beclere" Assistance Publique-Hopitaux de Paris (APHP), Paris, France
| | - Giovanna Chidini
- Pediatric Intensive Care Unit, Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuliano Ferrone
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy
| | - Marco Piastra
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy
| | - Giorgio Conti
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy.,Division of Pediatric and Neonatal Critical Care, South Paris University Hospital, Medical Centers "A. Beclere" Assistance Publique-Hopitaux de Paris (APHP), Paris, France.,Pediatric Intensive Care Unit, Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
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16
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Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR, Ferreira JC. Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial. Ann Intensive Care 2020; 10:18. [PMID: 32040785 PMCID: PMC7010869 DOI: 10.1186/s13613-020-0638-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/02/2020] [Indexed: 01/06/2023] Open
Abstract
Background Protective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient–ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (VT) at protective levels with NAVA and PSV in patients with ARDS. Methods We conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and VT. Asynchrony events detection was based on waveform analysis. Results We randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain VT below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, VT was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH2O) than in PSV (19 ± 3 cmH2O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0–2.7) in PSV and 0% (0–2.2) in NAVA (p = 0.6835). Conclusions It was feasible to keep VT in protective levels with NAVA and PSV for 75% of the patients. NAVA resulted in similar VT, RR and Paw compared to PSV. Our findings suggest that partial ventilatory assistance with NAVA and PSV is feasible as a protective ventilation strategy in selected ARDS patients under continuous sedation. Trial registration ClinicalTrials.gov (NCT01519258). Registered 26 January 2012, https://clinicaltrials.gov/ct2/show/NCT01519258
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Affiliation(s)
- Fabia Diniz-Silva
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Escola Politécnica da USP, Av. Prof. Luciano Gualberto, trav. 3, 158, Cidade Universitária, São Paulo, SP, CEP 05586-0600, Brazil
| | - Adriano M Alencar
- Instituto de Física, Universidade de São Paulo, Caixa Postal 66318, São Paulo, SP, CEP 05314-970, Brazil
| | - Marcelo B P Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil.
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17
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Shimatani T, Shime N, Nakamura T, Ohshimo S, Hotz J, Khemani RG. Neurally adjusted ventilatory assist mitigates ventilator-induced diaphragm injury in rabbits. Respir Res 2019; 20:293. [PMID: 31870367 PMCID: PMC6929282 DOI: 10.1186/s12931-019-1265-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022] Open
Abstract
Background Ventilator-induced diaphragmatic dysfunction is a serious complication associated with higher ICU mortality, prolonged mechanical ventilation, and unsuccessful withdrawal from mechanical ventilation. Although neurally adjusted ventilatory assist (NAVA) could be associated with lower patient-ventilator asynchrony compared with conventional ventilation, its effects on diaphragmatic dysfunction have not yet been well elucidated. Methods Twenty Japanese white rabbits were randomly divided into four groups, (1) no ventilation, (2) controlled mechanical ventilation (CMV) with continuous neuromuscular blockade, (3) NAVA, and (4) pressure support ventilation (PSV). Ventilated rabbits had lung injury induced, and mechanical ventilation was continued for 12 h. Respiratory waveforms were continuously recorded, and the asynchronous events measured. Subsequently, the animals were euthanized, and diaphragm and lung tissue were removed, and stained with Hematoxylin-Eosin to evaluate the extent of lung injury. The myofiber cross-sectional area of the diaphragm was evaluated under the adenosine triphosphatase staining, sarcomere disruptions by electron microscopy, apoptotic cell numbers by the TUNEL method, and quantitative analysis of Caspase-3 mRNA expression by real-time polymerase chain reaction. Results Physiological index, respiratory parameters, and histologic lung injury were not significantly different among the CMV, NAVA, and PSV. NAVA had lower asynchronous events than PSV (median [interquartile range], NAVA, 1.1 [0–2.2], PSV, 6.8 [3.8–10.0], p = 0.023). No differences were seen in the cross-sectional areas of myofibers between NAVA and PSV, but those of Type 1, 2A, and 2B fibers were lower in CMV compared with NAVA. The area fraction of sarcomere disruptions was lower in NAVA than PSV (NAVA vs PSV; 1.6 [1.5–2.8] vs 3.6 [2.7–4.3], p < 0.001). The proportion of apoptotic cells was lower in NAVA group than in PSV (NAVA vs PSV; 3.5 [2.5–6.4] vs 12.1 [8.9–18.1], p < 0.001). There was a tendency in the decreased expression levels of Caspase-3 mRNA in NAVA groups. Asynchrony Index was a mediator in the relationship between NAVA and sarcomere disruptions. Conclusions Preservation of spontaneous breathing using either PSV or NAVA can preserve the cross sectional area of the diaphragm to prevent atrophy. However, NAVA may be superior to PSV in preventing sarcomere injury and apoptosis of myofibrotic cells of the diaphragm, and this effect may be mediated by patient-ventilator asynchrony.
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Affiliation(s)
- Tatsutoshi Shimatani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Tomohiko Nakamura
- Division of Neonatology, Nagano Children's Hospital, 3100 Toyoshina, Azumino City, Nagano, 399-8288, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Justin Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, United States
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, United States.,Department of Pediatrics, University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA, 90033, United States
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18
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Abstract
Non-invasive ventilation is currently the preferred respiratory support for premature infants with respiratory distress. The lung-protective effects of non-invasive ventilation should however not prompt disregard for the possible pain and discomfort it can generate. Non-pharmacological interventions should be used in all premature infants, regardless of their respiratory support, and are not detailed in this review. This review includes currently available evidence and gaps in knowledge regarding three aspects of pain management in premature infants receiving non-invasive ventilation: optimisation of non-invasive ventilation especially through the choice of positive pressure source, appropriate interface and synchronisation; sedative or analgesic drug use for strategies aiming at administering surfactant with reduction or avoidance of tracheal ventilation; risks and benefits of some analgesic and/or sedative drugs used to treat or prevent prolonged pain and discomfort during non-invasive ventilation. In spite of limited robust evidence, this overview should trigger caregivers' reflections on their daily practice.
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19
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Karagiannidis C, Strassmann S, Schwarz S, Merten M, Fan E, Beck J, Sinderby C, Windisch W. Control of respiratory drive by extracorporeal CO 2 removal in acute exacerbation of COPD breathing on non-invasive NAVA. Crit Care 2019; 23:135. [PMID: 31014366 PMCID: PMC6480839 DOI: 10.1186/s13054-019-2404-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/21/2019] [Indexed: 01/19/2023]
Abstract
Background Veno-venous extracorporeal CO2 removal (vv-ECCO2R) and non-invasive neurally adjusted ventilator assist (NIV-NAVA) are two promising techniques which may prevent complications related to prolonged invasive mechanical ventilation in patients with acute exacerbation of COPD. Methods A physiological study of the electrical activity of the diaphragm (Edi) response was conducted with varying degrees of extracorporeal CO2 removal to control the respiratory drive in patients with severe acute exacerbation of COPD breathing on NIV-NAVA. Results Twenty COPD patients (SAPS II 37 ± 5.6, age 57 ± 9 years) treated with vv-ECCO2R and supported by NIV-NAVA were studied during stepwise weaning of vv-ECCO2R. Based on dyspnea, tolerance, and blood gases, weaning from vv-ECCO2R was successful in 12 and failed in eight patients. Respiratory drive (measured via the Edi) increased to 19 ± 10 μV vs. 56 ± 20 μV in the successful and unsuccessful weaning groups, respectively, resulting in all patients keeping their CO2 and pH values stable. Edi was the best predictor for vv-ECCO2R weaning failure (ROC analysis AUC 0.95), whereas respiratory rate, rapid shallow breathing index, and tidal volume had lower predictive values. Eventually, 19 patients were discharged home, while one patient died. Mortality at 90 days and 180 days was 15 and 25%, respectively. Conclusions This study demonstrates for the first time the usefulness of the Edi signal to monitor and guide patients with severe acute exacerbation of COPD on vv-ECCO2R and NIV-NAVA. The Edi during vv-ECCO2R weaning was found to be the best predictor of tolerance to removing vv-ECCO2R. Electronic supplementary material The online version of this article (10.1186/s13054-019-2404-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany.
| | - Stephan Strassmann
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Sarah Schwarz
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Michaela Merten
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Extracorporeal Life Support Program, Toronto General Hospital, Toronto, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Wolfram Windisch
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln gGmbH, Witten/Herdecke University Hospital, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
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20
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Baez Hernandez N, Milad A, Li Y, Van Bergen AH. Utilization of Neurally Adjusted Ventilatory Assist (NAVA) Mode in Infants and Children Undergoing Congenital Heart Surgery: A Retrospective Review. Pediatr Cardiol 2019; 40:563-569. [PMID: 30600371 DOI: 10.1007/s00246-018-2027-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/29/2018] [Indexed: 01/15/2023]
Abstract
We assessed the feasibility and the impact of NAVA compared to conventional modes of mechanical ventilation in ventilatory and gas exchange parameters in post-operative children with congenital heart disease. Infants and children (age < 18 years) that underwent congenital heart surgery were enrolled. Patients were ventilated with conventional synchronized intermittent mechanical ventilation (SIMV) and subsequently transitioned to NAVA during their cardiovascular intensive care unit (CVICU) stay. The ventilatory and gas exchange parameters for the 24 h pre- and post-transition to NAVA were compared. Additional parameters assessed included pain scores and sedation requirements. Eighty-one patients met inclusion criteria with a median age of 21 days (interquartile range 13 days-2 months). The majority of patients enrolled (75.3%) had complex congenital heart disease with high surgical severity scores. The transition to NAVA was tolerated by all patients without complications. The mean peak inspiratory pressure (PIP) was 1.8 cm H2O lower (p < 0.001) and mean airway pressure (Paw) was 0.5 cm H2O lower (p = 0.009) on NAVA compared to conventional modes of mechanical ventilation. There was no significant difference in patients' respiratory rate, tidal volume, arterial pH, pCO2, and lactate levels between the two modes of ventilation. There was a decreased sedation requirement during the time of NAVA ventilation. Comfort scores did not differ significantly with ventilator mode change. We concluded that NAVA is safe and well-tolerated mode of mechanical ventilation for our cohort of patients after congenital heart surgery. Compared to conventional ventilation there was a statistically significant decrease in PIP and Paw on NAVA.
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Affiliation(s)
- Nathanya Baez Hernandez
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Abdulhamid Milad
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Yi Li
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Andrew H Van Bergen
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA.
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21
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Oda A, Parikka V, Lehtonen L, Porres I, Soukka H. Nasal high-flow therapy decreased electrical activity of the diaphragm in preterm infants during the weaning phase. Acta Paediatr 2019; 108:253-257. [PMID: 29959864 DOI: 10.1111/apa.14485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/19/2018] [Accepted: 06/27/2018] [Indexed: 11/28/2022]
Abstract
AIM We evaluated whether nasal high-flow therapy was better than no respiratory support during the weaning phase in preterm infants. METHODS The study was conducted in the neonatal intensive care unit of the Turku University Hospital between September 2014 and August 2015. Preterm infants who were alternating between nasal high-flow therapy and unassisted breathing were enrolled. Electrical activity of the diaphragm (EAdi) was recorded and compared during three-hour time periods for each option. RESULTS We studied eight infants at a median gestational age of 31 weeks. The EAdi peak was lower during nasal high-flow therapy when compared to no respiratory support (6.1 μV vs 7.1 μV, p = 0.02), but the EAdi minimum was similar with and without respiratory support. Neural respiratory rate (62 vs 68 per minute, p = 0.02) and the frequency of sighs (27.8 vs 37.9 per hour, p = 0.03) were lower during nasal high-flow therapy than no respiratory support. CONCLUSION Nasal high-flow therapy reduced diaphragm activation in our cohort when compared to no respiratory support, as indicated by the lower Edi peak. An increase in the respiratory rate and the sigh frequency without respiratory support also suggests that nasal high-flow therapy provided support during the weaning phase.
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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
- The University of Turku; Turku Finland
| | - Liisa Lehtonen
- Department of Pediatrics and Adolescent Medicine; Turku University Hospital; Turku Finland
- The University of Turku; Turku Finland
| | - Ivan Porres
- Faculty of Natural Sciences and Technology; Åbo Akademi University; Turku Finland
| | - Hanna Soukka
- Department of Pediatrics and Adolescent Medicine; Turku University Hospital; Turku Finland
- The University of Turku; Turku Finland
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22
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Xu XT, Sun Q, Xie JF, Pan C, Yang Y, Qiu HB, Liu L. [Effect of neurally adjusted ventilatory assist on trigger of mechanical ventilation in acute exacerbation of chronic obstructive pulmonary disease patients with intrinsic positive end-expiratory pressure]. Zhonghua Nei Ke Za Zhi 2019; 58:43-48. [PMID: 30605950 DOI: 10.3760/cma.j.issn.0578-1426.2019.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To compare the trigger delay and work of trigger between neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients with intrinsic positive end-expiratory pressure (PEEP) during mechanical ventilation. Methods: AECOPD patients with intrinsic PEEP (PEEPi) greater than or equal to 3 cmH(2)O (1 cmH(2)O=0.098 kPa) were enrolled during invasive mechanical ventilation. Subjects were ventilated with low, medium and high pressure under either NAVA or PSV mode. Servo Tracker software continuously recorded the waveform of ventilator and respiratory mechanics indexes (including respiratory frequency, inspiratory tidal volume (Vti), minute ventilation volume (VE), peak airway pressure (PIP), inspiratory time), and calculated trigger and expiratory conversion delay time, work of trigger and total work of breath. Results: A total of 14 AECOPD patients were enrolled with the average PEEPi (4.3±1.3) cmH(2)O. PSV inspiratory trigger delay time was positively correlated with PEEPi (r=0.913, P<0.05). Compared with PSV, NAVA significantly decreased trigger delay time in low, medium and high pressure level groups [(48±17) ms vs. (167±86) ms, (63±65) ms vs. (247±240) ms, (63±49) ms vs. (342±192) ms,respectively all P<0.05]. Similar results were shown as to work of trigger [(0.92±0.36) μV∙s vs. (1.22±0.70) μV∙s, (1.08±0.51) μV∙s vs. (1.62±1.25) μV∙s, (1.20±0.96) μV∙s vs. (2.29±1.02) μV∙s, all P<0.05]. Trigger delay time increased according to the increase of pressure level in PSV mode. Conclusion: The presence of PEEPi in AECOPD patients leads to obvious trigger delay under PSV mode, which is positively correlated with PEEPi level. NAVA significantly reduces trigger delay time and work of trigger compared with PSV mode.
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Affiliation(s)
- X T Xu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, Nanjing 210009, China
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23
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Lamouret O, Crognier L, Vardon Bounes F, Conil JM, Dilasser C, Raimondi T, Ruiz S, Rouget A, Delmas C, Seguin T, Minville V, Georges B. Neurally adjusted ventilatory assist (NAVA) versus pressure support ventilation: patient-ventilator interaction during invasive ventilation delivered by tracheostomy. Crit Care 2019; 23:2. [PMID: 30616669 PMCID: PMC6323755 DOI: 10.1186/s13054-018-2288-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged weaning is a major issue in intensive care patients and tracheostomy is one of the last resort options. Optimized patient-ventilator interaction is essential to weaning. The purpose of this study was to compare patient-ventilator synchrony between pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA) in a selected population of tracheostomised patients. METHODS We performed a prospective, sequential, non-randomized and single-centre study. Two recording periods of 60 min of airway pressure, flow, and electrical activity of the diaphragm during PSV and NAVA were recorded in a random assignment and eight periods of 1 min were analysed for each mode. We searched for macro-asynchronies (ineffective, double, and auto-triggering) and micro-asynchronies (inspiratory trigger delay, premature, and late cycling). The number and type of asynchrony events per minute and asynchrony index (AI) were determined. The two respiratory phases were compared using the non-parametric Wilcoxon test after testing the equality of the two variances (F-Test). RESULTS Among the 61 patients analysed, the total AI was lower in NAVA than in PSV mode: 2.1% vs 14% (p < 0.0001). This was mainly due to a decrease in the micro-asynchronies index: 0.35% vs 9.8% (p < 0.0001). The occurrence of macro-asynchronies was similar in both ventilator modes except for double triggering, which increased in NAVA. The tidal volume (ml/kg) was lower in NAVA than in PSV (5.8 vs 6.2, p < 0.001), and the respiratory rate was higher in NAVA than in PSV (28 vs 26, p < 0.05). CONCLUSION NAVA appears to be a promising ventilator mode in tracheotomised patients, especially for those requiring prolonged weaning due to the decrease in asynchronies.
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Affiliation(s)
- Olivier Lamouret
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France. .,Department of Anaesthesiology and Critical Care Unit, University Hospital of Toulouse, 31059, Toulouse Cedex 9, France.
| | - Laure Crognier
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Fanny Vardon Bounes
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Jean-Marie Conil
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Caroline Dilasser
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thibaut Raimondi
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Stephanie Ruiz
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Antoine Rouget
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Clément Delmas
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thierry Seguin
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Vincent Minville
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Bernard Georges
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
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24
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Kallio M, Mahlman M, Koskela U, Aikio O, Suo-Palosaari M, Pokka T, Saarela T, Hallman M. NIV NAVA versus Nasal CPAP in Premature Infants: A Randomized Clinical Trial. Neonatology 2019; 116:380-384. [PMID: 31487718 DOI: 10.1159/000502341] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 07/24/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Noninvasive ventilation is recommended for neonatal respiratory distress to avoid adverse effects of invasive ventilation. OBJECTIVE The aim of this study was to compare the feasibility of noninvasive neurally adjusted ventilatory assist (NIV NAVA) and continuous positive airway pressure (CPAP) in preterm newborn infants. METHODS Forty preterm infants (gestational age 28+0 to 36+6 weeks) requiring CPAP and supplemental oxygen (FiO2 >0.23) for respiratory distress at <48 h of postnatal age were randomized to NIV NAVA or CPAP. The primary endpoint was the inspired oxygen concentration 12 h after study inclusion. Secondary endpoints were the duration of oxygen treatment, total duration of respiratory support, parenteral nutrition, blood gas values, patient comfort, need for invasive ventilation, and treatment complications. RESULTS The mean FiO2 at the time of study inclusion was 0.29 in both groups. After 12 h of treatment, FiO2 was 0.26 ± 0.07 and 0.26 ± 0.04 in the NIV NAVA and CPAP groups, respectively (difference 0.006, 95% CI -0.4 to 0.5), with no difference between the groups during the course of noninvasive ventilation (p = 0.80). Seven patients (35%) in the NIV NAVA group and 10 (50%) in the control group required intubation (difference 15%, 95% CI -15.5 to 4.3, p = 0.36). Time to intubation, gas exchange, vital parameters, pain scale, treatment complications, and neonatal outcome did not differ between the groups. CONCLUSIONS In the present trial, NIV NAVA had no statistically significant effect on oxygen requirements or the need for invasive ventilation in preterm newborn infants.
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Affiliation(s)
- Merja Kallio
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, Oulu, Finland, .,Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland,
| | - Mari Mahlman
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland.,Children's Hospital, Pediatric Research Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Ulla Koskela
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Outi Aikio
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Maria Suo-Palosaari
- Research Unit of Medical Imaging, Physics and Technology, Department of Diagnostic Radiology, Faculty of Medicine, University of Oulu, Oulu, Finland.,Medical Research Center, Oulu University Hospital, University of Oulu, Oulu, Finland
| | - Tytti Pokka
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Timo Saarela
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
| | - Mikko Hallman
- PEDEGO Research Unit, Medical Research Center Oulu, University of Oulu, Oulu, Finland.,Department of Children and Adolescents, Oulu University Hospital, Oulu, Finland
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25
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Oda A, Parikka V, Lehtonen L, Soukka H. Rapid respiratory transition at birth as evaluated by electrical activity of the diaphragm in very preterm infants supported by nasal CPAP. Respir Physiol Neurobiol 2018; 258:1-4. [PMID: 30273719 DOI: 10.1016/j.resp.2018.09.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Revised: 09/06/2018] [Accepted: 09/25/2018] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To investigate breathing patterns during respiratory adaptation in preterm infants using the electrical activity of the diaphragm (EAdi) signal. PATIENTS Infants born between 28 + 0 and 31 + 6 gestational weeks and supported by early nasal continuous positive airway pressure (nCPAP) were studied. The EAdi signal was recorded for 120 min after birth. RESULTS Eight preterm infants were evaluated. The median EAdi peak value of 19.2 μV (lower quartile 13.1; upper quartile 22.2) at 20 min after birth decreased to 11.4 μV (9.5-14.7) at 55 min of age. The median EAdi minimum value of 4.5 μV (2.2-5.5) at 25 min after birth decreased to 1.6 μV (1.2-2.7) at 85 min of age. CONCLUSION EAdi was high right after birth. This indicates that preterm infants are capable of generating sufficient respiratory drive and diaphragm tone during expiration to establish and maintain functional residual capacity. Diaphragm activity decreased within the first 90 min, suggesting that early adaptation was accomplished by 90 min of age.
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26
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Trapp O, Fiedler M, Hartwich M, Schorl M, Kalenka A. Monitoring of Electrical Activity of the Diaphragm Shows Failure of T-Piece Trial Earlier than Protocol-Based Parameters in Prolonged Weaning in Non-communicative Neurological Patients. Neurocrit Care 2018; 27:35-43. [PMID: 28063121 DOI: 10.1007/s12028-016-0360-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The weaning target in tracheotomised patients is not extubation, but spontaneous breathing without the support of a ventilator. Overloading the respiratory pump during such spontaneous breathing trials is unfavorable, prolongs weaning time, and increases morbidity and mortality. The goal of this study was to evaluate the electrical activity of the diaphragm during a t-piece trial in non-communicative neurological patients and the comparison to clinical parameters of exhaustion. METHODS During multiple t-piece trials, the electrical activity of the diaphragm was obtained before, during and after the end of the trial. T-piece trials were grouped based on the reason for stopping the trial (exhaustion or allotted time period). RESULTS Twenty-nine tracheotomised patients in prolonged weaning (29 ± 22 days ventilated at the start of the study) were included in a prospective observational study. T-piece trials (n = 152; 5 ± 2 per patient) were grouped based on the reason for stopping the trial (n = 91 because of exhaustion; n = 61 because of the allotted time period). We found that the electrical activity of the diaphragm exhibits an earlier increase than protocol-based clinical parameters in patients who failed the trial due to exhaustion. The electrical activity of the diaphragm shows no relevant difference during the t-piece trial in patients in whom the trial was stopped due to the allotted time period per protocol. CONCLUSIONS Monitoring the electrical activity of the diaphragm in non-communicative neurological patients in prolonged weaning allows earlier detection of exhaustion than protocol-based parameters.
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Affiliation(s)
- Oliver Trapp
- Asklepios Schlossberg Clinic, Bad König, Germany
| | - Mascha Fiedler
- Clinic for Anaesthesiology and Operative Intensive Care Medicine, University Medical Centre Mannheim, Mannheim, Germany
| | | | - Martin Schorl
- Passauer Wolf Rehabilitation Center, Neurology, Bad Gögging, Germany
| | - Armin Kalenka
- Department of Anaesthesiology and Intensive Care Medicine, Hospital Bergstrasse, Heppenheim, Germany. .,Medical Faculty Heidelberg, Heidelberg, Germany.
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27
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Iyer NP, Dickson J, Ruiz ME, Chatburn R, Beck J, Sinderby C, Rodriguez RJ. Neural breathing pattern in newborn infants pre- and postextubation. Acta Paediatr 2017; 106:1928-1933. [PMID: 28833570 DOI: 10.1111/apa.14040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/29/2017] [Accepted: 08/17/2017] [Indexed: 12/24/2022]
Abstract
AIM To describe the neural breathing pattern before and after extubation in newborn infants. METHODS Prospective, observational study. In infants deemed ready for extubation, the diaphragm electrical activity (EAdi) was continuously recorded from 30 minute before to two hours after extubation. RESULTS Total of 25 neonates underwent 29 extubations; 10 extubations resulted in re-intubation within 72 hours. Postextubation, there was an increase in peak EAdi (EAdi-max) and EAdi-delta (peak minus minimum EAdi) in both groups. The pre- to postextubation change in EAdi-max (8.9-11.1 μv) and EAdi-delta (6-8 μv) was less in the failure group in comparison with the change in EAdi-max (10.2-13.4 μv) and EAdi-delta (6.3-10.6 μv) in the success group, (p = 0.02 and 0.01, respectively). CONCLUSION In our neonatal cohort, extubation failure was associated with a smaller increase in peak and delta EAdi after extubation. If confirmed, these findings indicate an important cause of extubation failure in preterm infants.
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Affiliation(s)
- Narayan P. Iyer
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
| | - John Dickson
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
| | - Michelle E. Ruiz
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
| | - Robert Chatburn
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
| | - Jennifer Beck
- Department of Critical Care; Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Department of Pediatrics; University of Toronto; Toronto ON Canada
| | - Chister Sinderby
- Department of Critical Care; Keenan Research Centre for Biomedical Science of St. Michael's Hospital; Toronto ON Canada
- Department of Pediatrics; University of Toronto; Toronto ON Canada
- Department of Medicine and Interdepartmental Division of Critical Care Medicine; University of Toronto; Toronto ON Canada
| | - Ricardo J. Rodriguez
- Department of Neonatology; Cleveland Clinic Children's Hospital; Cleveland OH USA
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Longhini F, Pan C, Xie J, Cammarota G, Bruni A, Garofalo E, Yang Y, Navalesi P, Qiu H. New setting of neurally adjusted ventilatory assist for noninvasive ventilation by facial mask: a physiologic study. Crit Care 2017; 21:170. [PMID: 28683763 PMCID: PMC5501553 DOI: 10.1186/s13054-017-1761-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/19/2017] [Indexed: 11/10/2022] Open
Abstract
Background Noninvasive ventilation (NIV) is generally delivered using pneumatically-triggered and cycled-off pressure support (PSP) through a mask. Neurally adjusted ventilatory assist (NAVA) is the only ventilatory mode that uses a non-pneumatic signal, i.e., diaphragm electrical activity (EAdi), to trigger and drive ventilator assistance. A specific setting to generate neurally controlled pressure support (PSN) was recently proposed for delivering NIV by helmet. We compared PSN with PSP and NAVA during NIV using a facial mask, with respect to patient comfort, gas exchange, and patient-ventilator interaction and synchrony. Methods Three 30-minute trials of NIV were randomly delivered to 14 patients immediately after extubation to prevent post-extubation respiratory failure: (1) PSP, with an inspiratory support ≥8 cmH2O; (2) NAVA, adjusting the NAVA level to achieve a comparable peak EAdi (EAdipeak) as during PSP; and (3) PSN, setting the NAVA level at 15 cmH2O/μV with an upper airway pressure (Paw) limit to obtain the same overall Paw applied during PSP. We assessed patient comfort, peak inspiratory flow (PIF), time to reach PIF (PIFtime), EAdipeak, arterial blood gases, pressure-time product of the first 300 ms (PTP300-index) and 500 ms (PTP500-index) after initiation of patient effort, inspiratory trigger delay (DelayTR-insp), and rate of asynchrony, determined as asynchrony index (AI%). The categorical variables were compared using the McNemar test, and continuous variables by the Friedman test followed by the Wilcoxon test with Bonferroni correction for multiple comparisons (p < 0.017). Results PSN significantly improved patient comfort, compared to both PSP (p = 0.001) and NAVA (p = 0.002), without differences between the two latter (p = 0.08). PIF (p = 0.109), EAdipeak (p = 0.931) and gas exchange were similar between modes. Compared to PSP and NAVA, PSN reduced PIFtime (p < 0.001), and increased PTP300-index (p = 0.004) and PTP500-index (p = 0.001). NAVA and PSN significantly reduced DelayTR-insp, as opposed to PSP (p < 0.001). During both NAVA and PSN, AI% was <10% in all patients, while AI% was ≥10% in 7 patients (50%) with PSP (p = 0.023 compared with both NAVA and PSN). Conclusions Compared to both PSP and NAVA, PSN improved comfort and patient-ventilator interaction during NIV by facial mask. PSN also improved synchrony, as opposed to PSP only. Trial registration ClinicalTrials.gov, NCT03041402. Registered (retrospectively) on 2 February 2017.
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Affiliation(s)
- Federico Longhini
- Anesthesia and Intensive Care, Sant'Andrea Hospital, ASL VC, Vercelli, Italy
| | - Chun Pan
- Department of Critical Care Medicine, Nanjing Zhong-Da Hospital, Southeast University School of Medicine, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Jianfeng Xie
- Department of Critical Care Medicine, Nanjing Zhong-Da Hospital, Southeast University School of Medicine, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Gianmaria Cammarota
- Anesthesia and Intensive Care, "Maggiore della Carità" Hospital, Novara, Italy
| | - Andrea Bruni
- Intensive Care Unit, University Hospital Mater Domini, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, University Hospital Mater Domini, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Yi Yang
- Department of Critical Care Medicine, Nanjing Zhong-Da Hospital, Southeast University School of Medicine, 87 Dingjiaqiao Road, Nanjing, 210009, China
| | - Paolo Navalesi
- Intensive Care Unit, University Hospital Mater Domini, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing Zhong-Da Hospital, Southeast University School of Medicine, 87 Dingjiaqiao Road, Nanjing, 210009, China.
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Shetty S, Hunt K, Peacock J, Ali K, Greenough A. Crossover study of assist control ventilation and neurally adjusted ventilatory assist. Eur J Pediatr 2017; 176:509-513. [PMID: 28180985 DOI: 10.1007/s00431-017-2866-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/22/2017] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
UNLABELLED Some studies of infants with acute respiratory distress have demonstrated that neurally adjusted ventilator assist (NAVA) had better short-term results compared to non-triggered or other triggered models. We determined if very prematurely born infants with evolving or established bronchopulmonary dysplasia (BPD) had a lower oxygenation index (OI) on NAVA compared to assist control ventilation (ACV). Infants were studied for 1 h each on each mode. At the end of each hour, blood gas analysis was performed and the OI calculated. The inspired oxygen concentration (FiO2), the peak inflation (PIP) and mean airway pressures (MAP) and compliance were averaged from the last 5 min on each mode. Nine infants, median gestational age of 25 (range 22-27) weeks, were studied at a median postnatal age of 20 (range 8-84) days. The mean OI after 1 h on NAVA was 7.9 compared to 11.1 on ACV (p = 0.0007). The FiO2 (0.36 versus 0.45, p = 0.007), PIP (16.7 versus 20.1 cm H2O, p = 0.017) and MAP (9.2 versus 10.5 cm H2O, p = 0.004) were lower on NAVA. Compliance was higher on NAVA (0.62 versus 0.50 ml/cmH2O/kg, p = 0.005). CONCLUSION NAVA compared to ACV improved oxygenation in prematurely born infants with evolving or established BPD. What is Known: • Neurally assist ventilator adjust (NAVA) uses the electrical activity of the diaphragm to servo control the applied pressure. • In infants with acute RDS, use of NAVA was associated with lower peak inflation pressures and higher tidal volumes. What is New: • This study uniquely reports infants with evolving or established BPD, and their results were compared on 1 h each of NAVA and assist controlled ventilation. • On NAVA, infants had superior (lower) oxygen indices, lower inspired oxygen concentrations and peak and mean airway pressures and higher compliance.
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Affiliation(s)
- Sandeep Shetty
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Katie Hunt
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Janet Peacock
- Division of Health and Social Care Research, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Kamal Ali
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK. .,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK. .,Neonatal Intensive Care Unit, 4th Floor Golden Jubilee Wing, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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Beloncle F, Piquilloud L, Rittayamai N, Sinderby C, Rozé H, Brochard L. A diaphragmatic electrical activity-based optimization strategy during pressure support ventilation improves synchronization but does not impact work of breathing. Crit Care 2017; 21:21. [PMID: 28137269 PMCID: PMC5282691 DOI: 10.1186/s13054-017-1599-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 01/04/2017] [Indexed: 12/14/2022]
Abstract
Background Poor patient-ventilator synchronization is often observed during pressure support ventilation (PSV) and has been associated with prolonged duration of mechanical ventilation and poor outcome. Diaphragmatic electrical activity (Eadi) recorded using specialized nasogastric tubes is a surrogate of respiratory brain stem output. This study aimed at testing whether adapting ventilator settings during PSV using a protocolized Eadi-based optimization strategy, or Eadi-triggered and -cycled assisted pressure ventilation (or PSVN) could (1) improve patient-ventilator interaction and (2) reduce or normalize patient respiratory effort as estimated by the work of breathing (WOB) and the pressure time product (PTP). Methods This was a prospective cross-over study. Patients with a known chronic pulmonary obstructive or restrictive disease, asynchronies or suspected intrinsic positive end-expiratory pressure (PEEP) who were ventilated using PSV were enrolled in the study. Four different ventilator settings were sequentially applied for 15 minutes (step 1: baseline PSV as set by the clinician, step 2: Eadi-optimized PSV to adjust PS level, inspiratory trigger, and cycling settings, step 3: step 2 + PEEP adjustment, step 4: PSVN). The same settings as step 3 were applied again after step 4 to rule out a potential effect of time. Breathing pattern, trigger delay (Td), inspiratory time in excess (Tiex), pressure-time product (PTP), and work of breathing (WOB) were measured at the end of each step. Results Eleven patients were enrolled in the study. Eadi-optimized PSV reduced Td without altering Tiex in comparison with baseline PSV. PSVN reduced Td and Tiex in comparison with baseline and Eadi-optimized PSV. Respiratory pattern did not change during the four steps. The improvement in patient-ventilator interaction did not lead to changes in WOB or PTP. Conclusions Eadi-optimized PSV allows improving patient ventilator interaction but does not alter patient effort in patients with mild asynchrony. Trial registration Clinicaltrials.gov identifier: NCT 02067403. Registered 7 February 2014. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1599-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Francois Beloncle
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Medical Intensive Care Unit, Hospital of Angers, University of Angers, Angers, France
| | - Lise Piquilloud
- Medical Intensive Care Unit, Hospital of Angers, University of Angers, Angers, France.,Adult Intensive Care and Burn Unit, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Nuttapol Rittayamai
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Division of Respiratory Diseases and Tuberculosis, Department of Medicine, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Christer Sinderby
- Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - Hadrien Rozé
- CHU de Bordeaux, Service d'Anesthesie-Reanimation 2, Pessac, 33600, France
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada. .,Keenan Research Centre and Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
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Liet JM, Barrière F, Gaillard-Le Roux B, Bourgoin P, Legrand A, Joram N. Physiological effects of invasive ventilation with neurally adjusted ventilatory assist (NAVA) in a crossover study. BMC Pediatr 2016; 16:180. [PMID: 27821162 PMCID: PMC5100099 DOI: 10.1186/s12887-016-0717-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 10/25/2016] [Indexed: 12/19/2022] Open
Abstract
Background Neurally Adjusted Ventilatory Assist (NAVA) is a mode of assisted mechanical ventilation that delivers inspiratory pressure proportionally to the electrical activity of the diaphragm. To date, no pediatric study has focused on the effects of NAVA on hemodynamic parameters. This physiologic study with a randomized cross-over design compared hemodynamic parameters when NAVA or conventional ventilation (CV) was applied. Methods After a baseline period, infants received NAVA and CV in a randomized order during two consecutive 30-min periods. During the last 10 min of each period, respiratory and hemodynamic parameters were collected. No changes in PEEP, FiO2, sedation or inotropic doses were allowed during these two periods. The challenge was to keep minute volumes constant, with no changes in blood CO2 levels and in pH that may affect the results. Results Six infants who had undergone cardiac surgery (mean age 7.8 ± 4.1 months) were studied after parental consent. Four of them had low central venous oxygen saturation (ScvO2 < 65 %). The ventilatory settings resulted in similar minute volumes (1.7 ± 0.4 vs. 1.6 ± 0.6 ml/kg, P = 0.67) and in similar tidal volumes respectively with NAVA and with CV. There were no statistically significant differences on blood pH levels between the two modes of ventilation (7.32 ± 0.02 vs. 7.32 ± 0.04, P = 0.34). Ventilation with NAVA delivered lower peak inspiratory pressures than with CV: -32.7 % (95 % CI: -48.2 to –17.1 %, P = 0.04). With regard to hemodynamics, systolic arterial pressures were higher using NAVA: +8.4 % (95 % CI: +3.3 to +13.6 %, P = 0.03). There were no statistically significant differences on cardiac index between the two modes of ventilation. However, all children with a low baseline ScvO2 (<65 %) tended to increase their cardiac index with NAVA compared to CV: 2.03 ± 0.30 vs. 1.91 ± 0.39 L/min.m2 (median ± interquartile, P = 0.07). Conclusions This pilot study raises the hypothesis that NAVA could have beneficial effects on hemodynamics in children when compared to a conventional ventilatory mode that delivered identical PEEP and similar minute volumes. Trial registration ClinicalTrials.gov Identifier: NCT01490710. Date of registration: December 7, 2011.
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Affiliation(s)
- Jean-Michel Liet
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France.
| | - François Barrière
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Bénédicte Gaillard-Le Roux
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Arnaud Legrand
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France.,CIC-INSERM 1413, University of Nantes, Nantes, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
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32
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Villar J, Belda J, Blanco J, Suarez-Sipmann F, Añón JM, Pérez-Méndez L, Ferrando C, Parrilla D, Montiel R, Corpas R, González-Higueras E, Pestaña D, Martínez D, Fernández L, Soro M, García-Bello MA, Fernández RL, Kacmarek RM. Neurally adjusted ventilatory assist in patients with acute respiratory failure: study protocol for a randomized controlled trial. Trials 2016; 17:500. [PMID: 27737690 PMCID: PMC5064782 DOI: 10.1186/s13063-016-1625-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/25/2016] [Indexed: 12/25/2022] Open
Abstract
Background Patient-ventilator asynchrony is a common problem in mechanically ventilated patients with acute respiratory failure. It is assumed that asynchronies worsen lung function and prolong the duration of mechanical ventilation (MV). Neurally Adjusted Ventilatory Assist (NAVA) is a novel approach to MV based on neural respiratory center output that is able to trigger, cycle, and regulate the ventilatory cycle. We hypothesized that the use of NAVA compared to conventional lung-protective MV will result in a reduction of the duration of MV. It is further hypothesized that NAVA compared to conventional lung-protective MV will result in a decrease in the length of ICU and hospital stay, and mortality. Methods/design This is a prospective, multicenter, randomized controlled trial in 306 mechanically ventilated patients with acute respiratory failure from several etiologies. Only patients ventilated for less than 5 days, and who are expected to require prolonged MV for an additional 72 h or more and are able to breathe spontaneously, will be considered for enrollment. Eligible patients will be randomly allocated to two ventilatory arms: (1) conventional lung-protective MV (n = 153) and conventional lung-protective MV with NAVA (n = 153). Primary outcome is the number of ventilator-free days, defined as days alive and free from MV at day 28 after endotracheal intubation. Secondary outcomes are total length of MV, and ICU and hospital mortality. Discussion This is the first randomized clinical trial examining, on a multicenter scale, the beneficial effects of NAVA in reducing the dependency on MV of patients with acute respiratory failure. Trial registration ClinicalTrials.gov website (NCT01730794). Registered on 15 November 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1625-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain. .,Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 4th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain. .,Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
| | - Javier Belda
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Jesús Blanco
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Intensive Care Unit, Hospital Universitario Río Hortega, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Fernando Suarez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University Hospital, Akademiska Sjukhuset, Ing 40, Tr 3, SE-75185, Uppsala, Sweden
| | - José Manuel Añón
- Intensive Care Unit, Hospital Virgen de La Luz, Hermandad de Donantes de Sangre s/n, 16002, Cuenca, Spain
| | - Lina Pérez-Méndez
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Division of Clinical Epidemiology and Biostatistics, Research Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Carlos Ferrando
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Dácil Parrilla
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Raquel Montiel
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Ruth Corpas
- Intensive Care Unit, Hospital General NS del Prado, Carretera de Madrid, Km. 114, 45600, Talavera de la Reina, Toledo, Spain
| | - Elena González-Higueras
- Intensive Care Unit, Hospital Virgen de La Luz, Hermandad de Donantes de Sangre s/n, 16002, Cuenca, Spain
| | - David Pestaña
- Department of Anesthesiology, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo, Km. 9,100, 28034, Madrid, Spain
| | - Domingo Martínez
- Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Carretera Madrid-Cartagena s/n, 30120, El Palmar, Murcia, Spain
| | - Lorena Fernández
- Intensive Care Unit, Hospital Universitario Río Hortega, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Marina Soro
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Miguel Angel García-Bello
- Division of Biostatistics, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 35019, Las Palmas de Gran Canaria, Spain
| | - Rosa Lidia Fernández
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 4th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Department of Anesthesiology, Harvard University, 55 Fruit Street Gray-Bigelow 444, Boston, MA, 02144, USA
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Demoule A, Clavel M, Rolland-Debord C, Perbet S, Terzi N, Kouatchet A, Wallet F, Roze H, Vargas F, Guerin C, Dellamonica J, Jaber S, Brochard L, Similowski T. Neurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults: a French multicentre randomized trial. Intensive Care Med 2016; 42:1723-1732. [PMID: 27686347 DOI: 10.1007/s00134-016-4447-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/05/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that tailors the level of assistance delivered by the ventilator to the electromyographic activity of the diaphragm. The objective of this study was to compare NAVA and pressure support ventilation (PSV) in the early phase of weaning from mechanical ventilation. METHODS A multicentre randomized controlled trial of 128 intubated adults recovering from acute respiratory failure was conducted in 11 intensive care units. Patients were randomly assigned to NAVA or PSV. The primary outcome was the probability of remaining in a partial ventilatory mode (either NAVA or PSV) throughout the first 48 h without any return to assist-control ventilation. Secondary outcomes included asynchrony index, ventilator-free days and mortality. RESULTS In the NAVA and PSV groups respectively, the proportion of patients remaining in partial ventilatory mode throughout the first 48 h was 67.2 vs. 63.3 % (P = 0.66), the asynchrony index was 14.7 vs. 26.7 % (P < 0.001), the ventilator-free days at day 7 were 1.0 day [1.0-4.0] vs. 0.0 days [0.0-1.0] (P < 0.01), the ventilator-free days at day 28 were 21 days [4-25] vs. 17 days [0-23] (P = 0.12), the day-28 mortality rate was 15.0 vs. 22.7 % (P = 0.21) and the rate of use of post-extubation noninvasive mechanical ventilation was 43.5 vs. 66.6 % (P < 0.01). CONCLUSIONS NAVA is safe and feasible over a prolonged period of time but does not increase the probability of remaining in a partial ventilatory mode. However, NAVA decreases patient-ventilator asynchrony and is associated with less frequent application of post-extubation noninvasive mechanical ventilation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02018666.
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Affiliation(s)
- A Demoule
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013, Paris, France.
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.
| | - M Clavel
- Réanimation Polyvalente, Hôpital Dupuytren, Limoges, France
| | - C Rolland-Debord
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - S Perbet
- Réanimation Médico-Chirurgicale, CHU de Clermont-Ferrand, Clermont-Ferrand, France
- R2D2 EA-7281, Université d'Auvergne, Clermont-Ferrand, France
| | - N Terzi
- INSERM U1042, Université Grenoble-Alpes, HP2, 38000, Grenoble, France
- Service de Réanimation Médicale, CHU Grenoble Alpes, 38000, Grenoble, France
| | - A Kouatchet
- Service de Réanimation Médicale et Médecine Hyperbare, CHU d'Angers, Angers, Angers, France
| | - F Wallet
- Réanimation Médicale et Chirurgicale, Centre Hospitalier Lyon-Sud, Lyon, France
- Laboratoire des Pathogènes Emergents, Centre International de Recherche en Infectiologie, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| | - H Roze
- Anesthésie et Réanimation, CHU de Bordeaux, Pessac, France
| | - F Vargas
- Réanimation Médicale, Hôpital Pellegrin-Tripode, Bordeaux, France
| | - C Guerin
- Réanimation Médicale, Hôpital de la Croix Rousse, Lyon, France
| | - J Dellamonica
- Réanimation Médicale, Hôpital de l'Archet, Centre Hospitalier Universitaire de Nice, Nice, France
- INSERM 1065 Team 3 C3 M, Nice, France
| | - S Jaber
- Anesthésie et Réanimation, Hôpital Saint-Eloi, Montpellier, France
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - L Brochard
- Keenan Research Centre and Li Ka Shing Institute, Saint-Michael's Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - T Similowski
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
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Zhu L, Xu Z, Gong X, Zheng J, Sun Y, Liu L, Han L, Zhang H, Xu Z, Liu J, Rimensberger PC. Mechanical Ventilation After Bidirectional Superior Cavopulmonary Anastomosis for Single-Ventricle Physiology: A Comparison of Pressure Support Ventilation and Neurally Adjusted Ventilatory Assist. Pediatr Cardiol 2016; 37:1064-71. [PMID: 27090649 DOI: 10.1007/s00246-016-1392-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 04/05/2016] [Indexed: 11/29/2022]
Abstract
We evaluated the effects of different respiratory assist modes on cerebral blood flow (CBF) and arterial oxygenation in single-ventricle patients after bidirectional superior cavopulmonary anastomosis (BCPA). We hypothesized that preserved auto-regulation of respiration during neurally adjusted ventilatory assist (NAVA) may have potential advantages for CBF and pulmonary blood flow regulation after the BCPA procedure. We enrolled 23 patients scheduled for BCPA, who underwent pressure-controlled ventilation (PCV), pressure support ventilation (PSV), and NAVA at two assist levels for all modes in a randomized order. PCV targeting large V T (15 mL × kg(-1)) resulted in lower CBF and oxygenation compared to targeting low V T (10 mL × kg(-1)). During PSV and NAVA, ventilation assist levels were titrated to reduce EAdi from baseline by 75 % (high assist) and 50 % (low assist). High assist levels during PSV (PSVhigh) were associated with lower PaCO2, PaO2, and O2SAT, lower CBF, and higher pulsatility index compared with those during NAVAhigh. There were no differences in parameters when using low assist levels, except for slightly greater oxygenation in the NAVAlow group. Modifying assist levels during NAVA did not influence hemodynamics, cerebral perfusion, or gas exchange. Targeting the larger V T during PCV resulted in hyperventilation, did not improve oxygenation, and was accompanied by reduced CBF. Similarly, high assist levels during PSV led to mild hyperventilation, resulting in reduced CBF. NAVA's results were independent of the assist level chosen, causing normalized PaCO2, improved oxygenation, and better CBF than did any other mode, with the exception of PSV at low assist levels.
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Affiliation(s)
- Limin Zhu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China.
| | - Zhuoming Xu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Xiaolei Gong
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Jinghao Zheng
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Yanjun Sun
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Liping Liu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Lu Han
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Haibo Zhang
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Zhiwei Xu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Jinfen Liu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Peter C Rimensberger
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
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Abstract
Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation in which both the timing and degree of ventilatory assist are controlled by the patient. Since NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized non-invasive NAVA (NIV-NAVA) regardless of leaks and to monitor continuously patient respiratory pattern and drive. Advantages of NIV-NAVA over conventional modes include improved patient-ventilator interaction, reliable respiratory monitoring and self-regulation of respiratory support. In theory, these characteristics make NIV-NAVA an ideal mode to provide effective, appropriate non-invasive support to newborns with respiratory insufficiency. NIV-NAVA has been successfully used clinically in neonates as a mode of ventilation to prevent intubation, to allow early extubation, and as a novel way to deliver nasal continuous positive airway pressure. The use of NAVA in neonates is described with an emphasis on studies and clinical experience with NIV-NAVA.
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Affiliation(s)
- Howard Stein
- Neonatal Intensive Care Unit, Promedica Toledo Children's Hospital, Toledo, OH, USA; University of Toledo, Toledo, OH, USA
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St Michael's Hospital, Toronto, Ontario, Canada; Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada
| | - Michael Dunn
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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Goto Y, Katayama S, Shono A, Mori Y, Miyazaki Y, Sato Y, Ozaki M, Kotani T. Roles of neurally adjusted ventilatory assist in improving gas exchange in a severe acute respiratory distress syndrome patient after weaning from extracorporeal membrane oxygenation: a case report. J Intensive Care 2016; 4:26. [PMID: 27057312 PMCID: PMC4823850 DOI: 10.1186/s40560-016-0153-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 03/31/2016] [Indexed: 02/06/2023] Open
Abstract
Background Patient-ventilator asynchrony is a major cause of difficult weaning from mechanical ventilation. Neurally adjusted ventilatory assist (NAVA) is reported useful to improve the synchrony in patients with sustained low lung compliance. However, the role of NAVA has not been fully investigated. Case presentation The patient was a 63-year-old Japanese man with acute respiratory distress syndrome secondary to respiratory infection. He was treated with extracorporeal membrane oxygenation for 7 days and survived. Dynamic compliance at withdrawal of extracorporeal membrane oxygenation decreased to 20 ml/cmH2O or less, but gas exchange was maintained by full support with assist/control mode. However, weaning from mechanical ventilation using a flow trigger failed repeatedly because of patient-ventilator asynchrony with hypercapnic acidosis during partial ventilator support despite using different types of ventilators and different trigger levels. Weaning using NAVA restored the regular respiration and stable and normal acid-base balance. Electromyographic analysis of the diaphragm clearly showed improved triggering of both the start and the end of spontaneous inspiration. Regional ventilation monitoring using electrical impedance tomography showed an increase in tidal volume and a ventilation shift to the dorsal regions during NAVA, indicating that NAVA could deliver gas flow to the dorsal regions to adjust for the magnitude of diaphragmatic excursion. NAVA was applied for 31 days, followed by partial ventilatory support with a conventional flow trigger. The patient was discharged from the intensive care unit on day 110 and has recovered enough to be able to live without a ventilatory support for 5 h per day. Conclusion Our experience showed that NAVA improved not only patient-ventilator synchrony but also regional ventilation distribution in an acute respiratory distress patient with sustained low lung compliance.
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Affiliation(s)
- Yuya Goto
- Department of Anesthesiology and Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, 162-8666 Japan
| | - Shinshu Katayama
- Department of Anesthesiology and Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, 162-8666 Japan
| | - Atsuko Shono
- Department of Anesthesiology, Shimane University, Shimane, 693-8501 Japan
| | - Yosuke Mori
- Department of Anesthesiology and Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, 162-8666 Japan
| | - Yuya Miyazaki
- Department of Anesthesiology and Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, 162-8666 Japan
| | - Yoko Sato
- Department of Anesthesiology and Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, 162-8666 Japan
| | - Makoto Ozaki
- Department of Anesthesiology and Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, 162-8666 Japan
| | - Toru Kotani
- Department of Anesthesiology and Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, 162-8666 Japan
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Abstract
Neurally adjusted ventilatory assist (NAVA) uses the electrical activity of the diaphragm (Edi) as a neural trigger to synchronize mechanical ventilatory breaths with the patient's neural respiratory drive. Using this signal enables the ventilator to proportionally support the patient's instantaneous drive on a breath-by-breath basis. Synchrony can be achieved even in the presence of significant air leaks, which make this an attractive choice for invasive and non-invasive ventilation of the neonate. This paper describes the Edi signal, neuroventilatory coupling, and patient-ventilator synchrony including the functional concept of NAVA. Safety features, NAVA terminology, and clinical application of NAVA to unload respiratory musculature are presented. The use of the Edi signal as a respiratory vital sign for conventional ventilation is discussed. The results of animal and adult studies are briefly summarized and detailed descriptions of all NAVA-related research in pediatric and neonatal patients are provided. Further studies are needed to determine whether NAVA will have significant impact on the overall outcomes of neonates.
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Bein T, Osborn E, Hofmann HS, Zimmermann M, Philipp A, Schlitt HJ, Graf BM. Successful treatment of a severely injured soldier from Afghanistan with pumpless extracorporeal lung assist and neurally adjusted ventilatory support. Int J Emerg Med 2010; 3:177-9. [PMID: 21031042 PMCID: PMC2926866 DOI: 10.1007/s12245-010-0192-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 04/22/2010] [Indexed: 11/30/2022] Open
Abstract
Background Life-threatening acute lung injury due to combat and/or terror attacks is associated with high mortality. The successful management includes the use of “rescue” extracorporeal lung assist and early transport by aeromedical evacuation teams. Aims Description of the pre-hospital support of a severely injured soldier with a pumpless extracorporeal arterio-venous lung assist in critical hypercapnia/hypoxemia. Method A British soldier suffered from severe gunshot injuries to the chest and abdomen in Afghanistan. After traumatic pneumonectomy, he developed critical hypercapnia/hypoxemia. He was mechanically ventilated and supported with a pumpless interventional extracorporeal lung assist (iLA, Novalung, Talheim, Germany) and transferred to Germany. Results A sufficient CO2 extraction and improvement in oxygenation enabled the safe transportation and lung protective ventilation. Weaning from mechanical ventilation was promoted by the application of a new neurally adjusted ventilatory assist (NAVA). The patient recovered, and he left Germany in stable condition. Conclusion Novel techniques in extracorporeal lung assist and in ventilatory support may help save lives even in disaster medicine.
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Affiliation(s)
- Thomas Bein
- Department of Anaesthesia and Critical Care, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Eric Osborn
- Trauma Surgery/Surgical Critical Care, Landstuhl Regional Medical Center, Landstuhl, Germany
| | - Hans Stefan Hofmann
- Department of Heart and Thoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Markus Zimmermann
- Department of Anaesthesia and Critical Care, University Hospital Regensburg, 93042 Regensburg, Germany
| | - Alois Philipp
- Department of Heart and Thoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Hans J. Schlitt
- Department of General Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Bernhard M. Graf
- Department of Anaesthesia and Critical Care, University Hospital Regensburg, 93042 Regensburg, Germany
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