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Physiological effects of invasive ventilation with neurally adjusted ventilatory assist (NAVA) in a crossover study.

ABSTRACT: 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.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.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?

SUBMITTER: Liet JM

PROVIDER: S-EPMC5100099 | biostudies-literature | 2016 Nov

REPOSITORIES: biostudies-literature

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Physiological effects of invasive ventilation with neurally adjusted ventilatory assist (NAVA) in a crossover study.

Liet Jean-Michel JM Barrière François F Gaillard-Le Roux Bénédicte B Bourgoin Pierre P Legrand Arnaud A Joram Nicolas N

BMC pediatrics 20161108 1

<h4>Background</h4>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.<h4>Methods</h4>After a baseline period, infants received NAV ...[more]

PMID: 27821162

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Project description:Neurally Adjusted Ventilatory Assist (NAVA) is a proportional ventilatory mode that uses the electrical activity of the diaphragm (EAdi) to offer ventilatory assistance in proportion to patient effort. NAVA has been increasingly used for critically ill patients, but it has not been evaluated during spontaneous breathing trials (SBT). We designed a pilot trial to assess the feasibility of using NAVA during SBTs, and to compare the breathing pattern and patient-ventilator asynchrony of NAVA with Pressure Support (PSV) during SBTs.We conducted a crossover trial in the ICU of a university hospital in Brazil and included mechanically ventilated patients considered ready to undergo an SBT on the day of the study. Patients underwent two SBTs in randomized order: 30 min in PSV of 5 cmH2O or NAVA titrated to generate equivalent peak airway pressure (Paw), with a positive end-expiratory pressure of 5 cmH2O. The ICU team, blinded to ventilatory mode, evaluated whether patients passed each SBT. We captured flow, Paw and electrical activity of the diaphragm (EAdi) from the ventilator and used it to calculate respiratory rate (RR), tidal volume (VT), and EAdi. Detection of asynchrony events used waveform analysis and we calculated the asynchrony index as the number of asynchrony events divided by the number of neural cycles.We included 20 patients in the study. All patients passed the SBT in PSV, and three failed the SBT in NAVA. Five patients were reintubated and the extubation failure rate was 25% (95% CI 9-49%). Respiratory parameters were similar in the two modes: VT = 6.1 (5.5-6.5) mL/Kg in NAVA vs. 5.5 (4.8-6.1) mL/Kg in PSV (p = 0.076) and RR = 27 (17-30) rpm in NAVA vs. 26 (20-30) rpm in PSV, p = 0.55. NAVA reduced AI, with a median of 11.5% (4.2-19.7) compared to 24.3% (6.3-34.3) in PSV (p = 0.033).NAVA reduces patient-ventilator asynchrony index and generates a respiratory pattern similar to PSV during SBTs. Patients considered ready for mechanical ventilation liberation may be submitted to an SBT in NAVA using the same objective criteria used for SBTs in PSV.ClinicalTrials.gov ( NCT01337271 ), registered April 12, 2011.

Project description:We aimed to examine the effect of changing levels of support (NAVA level) during non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm infants with respiratory distress syndrome (RDS) on electrical diaphragm activity. This is a prospective, single-centre, interventional, exploratory study in a convenience sample. Clinically stable preterm infants supported with NIV-NAVA for RDS were eligible. Patients were recruited in the first 24 h after the start of NIV-NAVA. Following a predefined titration protocol, NAVA levels were progressively increased starting from a level of 0.5 cmH2O/µV and with increments of 0.5 cmH2O/µV every 3 min, up to a maximum level of 4.0 cmH2O/µV. We measured the evolution of peak inspiratory pressure and the electrical signal of the diaphragm (Edi) during NAVA level titration. Twelve infants with a mean (SD) gestational age at birth of 30.6 (3.5) weeks and birth weight of 1454 (667) g were enrolled. For all patients a breakpoint could be identified during the titration study. The breakpoint was on average (SD) at a level of 2.33 (0.58) cmH2O/µV. With increasing NAVA levels, the respiratory rate decreased significantly. No severe complications occurred.Conclusions: Preterm neonates with RDS supported with NIV-NAVA display a biphasic response to changing NAVA levels with an identifiable breakpoint. This breakpoint was at a higher NAVA level than commonly used in this clinical situation. Immature neural feedback mechanisms warrant careful monitoring of preterm infants when supported with NIV-NAVA.Trial registration: clinicaltrials.gov NCT03780842. Date of registration December 12, 2018. What is Known: • Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is a safe, feasible and effective way to support respiration in preterm infants. • Intact neural feedback mechanisms are needed to protect the lung from overdistension in neurally adjusted ventilatory assist. What is New: • Preterm infants with acute RDS have a similar pattern of respiratory unloading as previously described. • Neural feedback mechanisms seem to be immature with the risk of insufficient support and lung injury due to overdistension of the lung.

Project description:NIV-NAVA mode for respiratory support in preterm infants is not well-studied. This study aimed to describe the diaphragmatic function, diaphragmatic excursion (DE), and thickness fraction (DTF), in preterm infants < 30 weeks' gestation supported by NIV-NAVA compared to NIPPV using bedside ultrasonography. In this consecutive prospective study, DE, diaphragmatic thickness at end of expiration (DTexp), end of inspiration (DTins), and DTF were assessed using bedside ultrasound. Lung aeration evaluation using lung ultrasound score (LUS) was performed for the two groups. Diaphragmatic measurements and LUS were compared for the 2 groups (NIV-NAVA group versus NIPPV group). Statistical analyses were conducted using the SPSS software version 22. Out of 70 infants evaluated, 40 were enrolled. Twenty infants were on NIV-NAVA and 20 infants on NIPPV with a mean [SD] study age of 25.7 [0.9] weeks and 25.1 [1.4] weeks respectively (p = 0.15). Baseline characteristics and respiratory parameters at the time of the scan showed no significant difference between groups. DE was significantly higher in NIV-NAVA with a mean SD of 4.7 (1.5) mm versus 3.5 (0.9) mm in NIPPV, p = 0.007. Additionally, the mean (SD) of DTF for the NIV-NAVA group was 81.6 (30) % vs 78.2 (27) % for the NIPPV group [p = 0.71]. Both groups showed relatively high LUS but no significant difference between groups [12.8 (2.6) vs 12.6 (2.6), p = 0.8]. Conclusion: Preterm infants managed with NIV-NAVA showed significantly higher DE compared to those managed on NIPPV. This study raises the hypothesis that NIV-NAVA could potentially improve diaphragmatic function due to its synchronization with patients' own breathing. Longitudinal studies to assess diaphragmatic function over time are needed. Trial registry: Clinicaltrials.gov (NCT05079412). Date of registration September 30, 2021. What is Known: • NIV-NAVA utilizes diaphragmatic electrical activity to provide synchronized breathing support. • Evidence for the effect of NIV-NAVA on diaphragmatic thickness fraction (DTF) and excursion (DE) is limited. What is New: • Ultrasonographic assessment of diaphragmatic function (DTF and DE) is feasible. • In preterm infants, DE was significantly higher in infants supported with NIV-NAVA compared to those supported with NIPPV.

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Physiological effects of invasive ventilation with neurally adjusted ventilatory assist (NAVA) in a crossover study.

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Physiological effects of invasive ventilation with neurally adjusted ventilatory assist (NAVA) in a crossover study.

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