Neurally adjusted ventilatory assist in children: An observational study

Bengtsson, Jan A.; Edberg, Karl Erik

doi:10.1097/pcc.0b013e3181b0655e

Cited by 72 publications

(67 citation statements)

References 15 publications

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“…These results are in line with studies in adults that all reported similar synchrony improvement with NAVA (5,11,12,20,21). In the pediatric population, no study has yet quantified the trigger delays and cycling-off delays during conventional ventilation and during NAVA, although two feasibility studies have demonstrated that during NAVA, at least two-thirds of assisted breaths were triggered by the neural signal (17,18). A recent study in a heterogeneous pediatric population showed, similar to our findings, that the inspiratory and expiratory phases of the ventilator match the neural phases of the patient better during NAVA (91% of the time was synchronous) as compared with PCV or pressure-regulated volume-control mode (66% of the time was synchronous) (19).…”

Section: Nava In Infantssupporting

confidence: 75%

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Neurally adjusted ventilatory assist improves patient–ventilator interaction in infants as compared with conventional ventilation

et al. 2012

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Background: Neurally adjusted ventilatory assist (NaVa) is a mode of ventilation controlled by the electrical activity of the diaphragm (edi). The aim was to evaluate patient-ventilator interaction in infants during NaVa as compared with conventional ventilation. Methods: Infants were successively ventilated with NaVa, pressure control ventilation (PcV), and pressure support ventilation (PsV). edi and ventilator pressure (Pvent) waveforms were compared and their variability was assessed by coefficients of variation. results: Ten patients (mean age 4.3 ± 2.4 mo and weight 5.9 ± 2.2 kg) were studied. In PcV and PsV, 4 ± 4.6% and 6.5 ± 7.7% of the neural efforts failed to trigger the ventilator. This did not occur during NaVa. Trigger delays were shorter with NaVa as compared with PcV and PsV (93 ± 20 ms vs. 193 ± 87 ms and 135 ± 29 ms). During PcV and PsV, the ventilator cycled off before the end of neural inspiration in 12 ± 13% and 21 ± 19% of the breaths (0 ± 0% during NaVa). During PcV and PsV, 24 ± 11% and 25 ± 9% of the neural breath cycle was asynchronous with the ventilator as compared with 11 ± 3% with NaVa. a large variability was observed for edi in all modes, which was transmitted into Pvent during NaVa (coefficient of variation: 24 ± 8%) and not in PcV (coefficient of variation 2 ± 1%) or PsV (2 ± 2%). conclusion: NaVa improves patient-ventilator interaction and delivers adequate ventilation with variable pressure in infants.c onventional modes of mechanical ventilation are clearly limited in their ability to provide synchrony between the patient and the assist delivered, as demonstrated repeatedly in adults (1,2) and more recently in children (3). Patientventilator asynchrony has been associated with poor clinical outcome (1,2,4). Despite the attempt to improve synchrony with "patient-triggered" modes such as pressure control ventilation (PCV) or pressure support ventilation (PSV), 25% of adult patients show more than 10% asynchrony with the ventilator (1,2,5). In pediatric patients, synchrony is particularly difficult to achieve because of the small tidal volumes, high respiratory rates, and weak airway flows and pressures. Ironically, during synchronized intermittent mandatory ventilation, more than half of the patient's breathing cycle is spent in asynchrony (3) with the ventilator.Besides the poor timing between the patient and the ventilator, patient-ventilator asynchrony also includes the inability of the ventilator to respond to patient demand and the natural breath-to-breath variability. Respiratory variability is a sign of a well functioning respiratory system (6). By definition, PCV and PSV deliver fixed levels of assist, thereby offering no possibility to respond to the patient's respiratory demand and variability.Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation that delivers assist in time and in proportion to the electrical activity of the diaphragm (Edi) on a breath-by-breath basis (7). Numerous studies have shown that NAVA efficiently unloads the respirat...

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Section: Nava In Infantssupporting

confidence: 75%

“…In the pediatric population, NAVA has been shown to be feasible (17,18) and to be more in phase with the patient's breathing (19). In none of these studies was a specific evaluation performed on the timing differences between the patient and the ventilator on a breath-by-breath basis.…”

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confidence: 99%

Neurally adjusted ventilatory assist improves patient–ventilator interaction in infants as compared with conventional ventilation

et al. 2012

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“…30,31 Observational data from small populations suggest that NAVA in these patients is feasible and seems well tolerated. 32,33 …”

Section: Titration Of the Peep Level And Tonic Diaphragm Activitymentioning

confidence: 99%

Neurally Adjusted Ventilatory Assist: A Ventilation Tool or a Ventilation Toy?

Verbrugghe

Jorens

2011

Respir Care

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Mechanical ventilation has, since its introduction into clinical practice, undergone a major evolution from controlled ventilation to various modes of assisted ventilation. Neurally adjusted ventilatory assist (NAVA) is the newest development. The implementation of NAVA requires the introduction of a catheter to measure the electrical activity of the diaphragm (EA di ). NAVA relies, opposite to conventional assisted ventilation modes, on the EA di to trigger the ventilator breath and to adjust the ventilatory assist to the neural drive. The amplitude of the ventilator assist is determined by the instantaneous EA di and the NAVA level set by the clinician. The NAVA level amplifies the EA di signal and determines instantaneous ventilator assist on a breath-to-breath basis. Experimental and clinical data suggest superior patient-ventilator synchrony with NAVA. Patient-ventilator asynchrony is present in 25% of mechanically ventilated patients in the intensive care unit and may contribute to patient discomfort, sleep fragmentation, higher use of sedation, development of delirium, ventilator-induced lung injury, prolonged mechanical ventilation, and ultimately mortality. With NAVA, the reliance on the EA di signal, together with an intact ventilatory drive and intact breathing reflexes, allows integration of the ventilator in the neuro-ventilatory coupling on a higher level than conventional ventilation modes. The simple monitoring of the EA di signal alone may provide the clinician with important information to guide ventilator management, especially during the weaning process. Although, until now, little evidence proves the superiority of NAVA on clinically relevant end points, it seems evident that patient populations (eg, COPD and small children) with major patient-ventilator asynchrony may benefit from this new ventilatory tool.

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“…The advantages of NAVA in this regard have been demonstrated in several studies in children [52,55,57]. A prospective crossover study in which NAVA (neural trigger) was compared to pressure support ventilation (pneumatic trigger) demonstrated reduced peak airway pressures with the NAVA mode and elements for a lung protective effect [52].…”

Section: Improving Patient-ventilator Synchronymentioning

confidence: 99%

Ventilating the Lungs Safely: What’s New for Infants and Children?

Corbelli

Habre

2013

Curr Anesthesiol Rep

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The concept of lung protection ventilation is based on a multimodal approach aimed at preventing the occurrence of ventilator-induced lung injury (VILI). The strategies used include (i) alveolar recruitment maneuvers in order to open up the closed lung units, (ii) application of optimal positive end-expiratory pressure adapted to the expiratory limb of the pressure-volume curve to prevent airway closure at small tidal volume ventilation, (iii) the use of small tidal volume ventilation to avoid overdistending alveoli and/or alveolar shear stress injury by the cyclical opening and closing of lung units, and lastly, (iv) the application of new ventilation modes that take into account the physiological concept of respiratory variability and in particular, neurally-adjusted ventilatory assist, which enhances both patient-ventilator synchrony and lung protective strategy.

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Neurally adjusted ventilatory assist in children: An observational study

Abstract: We feel that neurally adjusted ventilatory assist would be safe and potentially efficacious to ventilate infants and children. It has the potential for improved patient-ventilator synchrony, decreasing airway pressures, and it might lead to earlier extubation.

Cited by 72 publications

References 15 publications

Neurally adjusted ventilatory assist improves patient–ventilator interaction in infants as compared with conventional ventilation

Neurally adjusted ventilatory assist improves patient–ventilator interaction in infants as compared with conventional ventilation

Neurally Adjusted Ventilatory Assist: A Ventilation Tool or a Ventilation Toy?

Ventilating the Lungs Safely: What’s New for Infants and Children?

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