Neurally adjusted ventilatory assist vs. pressure support ventilation in critically ill patients: an observational study

Barwing, Jürgen; Linden, N. Hoogerbrugge-van der; Ambold, M.; Quintel, Michael; Moerer, Onnen

doi:10.1111/j.1399-6576.2011.02522.x

Cited by 20 publications

(15 citation statements)

References 36 publications

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“…15 Several patient studies demonstrated plateaus in Vt, Pvent, or transpulmonary pressure during increasing NAVA levels associated with EAdi suppression. 7,9,10,16,17,33,34 Our observation of a more favourable distribution of aeration with less atelectatic regions after ALI compared to normal lungs (i.e. HCL induced lung injury improved pattern of lung aeration in cNAVA ventilated rabbits) agree with findings that HCL-induced ALI induces heterogeneous injury and de-recruitment of the lungs.…”

Section: Protection From Lung Over-distensionsupporting

confidence: 87%

Neural control of ventilation prevents both over-distension and de-recruitment of experimentally injured lungs

Brander

Moerer

Hedenstierna

et al. 2017

Respiratory Physiology & Neurobiology

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HighlightsScientific Knowledge on the Subject:The Hering-Breuer inflation and deflation reflexes, discovered over 140 years ago, limit the volume of inspiration (so called Hering-Breuer inflation reflex) and prevent de-recruitment of the lung during exhalation (Hering-Breuer deflation reflex). We reasoned that if these vagallymediated reflexes were permitted to guide mechanical ventilation by adjusting the positive airway pressure delivered during in-and expiration using a neurally driven pressure delivery device (i.e. continuous neurally adjusted ventilatory assist, cNAVA), their functional impact on lung recruitment and volume delivery could be studied.What This Study Adds to the Field: When using cNAVA in early experimental lung injury, vagally mediated reflexes a) inhibit the neural inspiratory activity of the diaphragm (i.e. the signal controlling both, the respiratory muscles and the ventilator) such that lung-distending pressure is limited during inspiration, and b) increase the neural activity of the diaphragm during exhalation such that lung de-recruitment is prevented. This study presents the first in situ and in vivo model to clarify neurally mediated lung protective mechanisms during application of mechanical ventilation before and after ALI and highlights the importance of functioning vagal lung reflexes and spontaneous breathing during mechanical ventilation.

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Section: Protection From Lung Over-distensionsupporting

confidence: 87%

Neural control of ventilation prevents both over-distension and de-recruitment of experimentally injured lungs

Brander

Moerer

Hedenstierna

et al. 2017

Respiratory Physiology & Neurobiology

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“…During a recent observational study, transferring patients to NAVA was uneventful and the NAVA level contributed to adjustments of the preset NAVA level [80]. Interpretation of several interacting physiological parameters might be difficult in cases in which there is no marked decrease in EAdi during NAVA titration [80]. An automated approach enabled faster identification of the best NAVA level with a good accuracy [81].…”

Section: How Can the Optimal Nava Level Be Determined?mentioning

confidence: 99%

Clinical review: Update on neurally adjusted ventilatory assist - report of a round-table conference

et al. 2012

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Conventional mechanical ventilators rely on pneumatic pressure and flow sensors and controllers to detect breaths. New modes of mechanical ventilation have been developed to better match the assistance delivered by the ventilator to the patient's needs. Among these modes, neurally adjusted ventilatory assist (NAVA) delivers a pressure that is directly proportional to the integral of the electrical activity of the diaphragm recorded continuously through an esophageal probe. In clinical settings, NAVA has been chiefly compared with pressure-support ventilation, one of the most popular modes used during the weaning phase, which delivers a constant pressure from breath to breath. Comparisons with proportional-assist ventilation, which has numerous similarities, are lacking. Because of the constant level of assistance, pressure-support ventilation reduces the natural variability of the breathing pattern and can be associated with asynchrony and/or overinflation. The ability of NAVA to circumvent these limitations has been addressed in clinical studies and is discussed in this report. Although the underlying concept is fascinating, several important questions regarding the clinical applications of NAVA remain unanswered. Among these questions, determining the optimal NAVA settings according to the patient's ventilatory needs and/or acceptable level of work of breathing is a key issue. In this report, based on an investigator-initiated round table, we review the most recent literature on this topic and discuss the theoretical advantages and disadvantages of NAVA compared with other modes, as well as the risks and limitations of NAVA.

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“…12,17 However, reported experience with NAVA is limited to small case study which emphasizes brief physiologic trials. 31,[49][50][51][52][53][54] Finally, any patient requiring substantial sedation or having hemodynamic compromise would not be appropriate for PAV or NAVA. 55 …”

Section: Assisted Ventilation: Conclusionmentioning

confidence: 99%

Assisted Ventilation

Dries

2016

Journal of Burn Care & Research

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Controlled Mechanical Ventilation may be essential in the setting of severe respiratory failure but consequences to the patient including increased use of sedation and neuromuscular blockade may contribute to delirium, atelectasis, and diaphragm dysfunction. Assisted ventilation allows spontaneous breathing activity to restore physiological displacement of the diaphragm and recruit better perfused lung regions. Pressure Support Ventilation is the most frequently used mode of assisted mechanical ventilation. However, this mode continues to provide a monotonous pattern of support for respiration which is normally a dynamic process. Noisy Pressure Support Ventilation where tidal volume is varied randomly by the ventilator may improve ventilation and perfusion matching but the degree of support is still determined by the ventilator. Two more recent modes of ventilation, Proportional Assist Ventilation and Neurally Adjusted Ventilatory Assist (NAVA), allow patient determination of the pattern and depth of ventilation. Proposed advantages of Proportional Assist Ventilation and NAVA include decrease in patient ventilator asynchrony and improved adaptation of ventilator support to changing patient demand. Work of breathing can be normalized with these modes as well. To date, however, a clear pattern of clinical benefit has not been demonstrated. Existing challenges for both of the newer assist modes include monitoring patients with dynamic hyperinflation (auto-positive end expiratory pressure), obstructive lung disease, and air leaks in the ventilator system. NAVA is dependent on consistent transduction of diaphragm activity by an electrode system placed in the esophagus. Longevity of effective support with this technique is unclear.

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Neurally adjusted ventilatory assist vs. pressure support ventilation in critically ill patients: an observational study

Cited by 20 publications

References 36 publications

Neural control of ventilation prevents both over-distension and de-recruitment of experimentally injured lungs

Neural control of ventilation prevents both over-distension and de-recruitment of experimentally injured lungs

Clinical review: Update on neurally adjusted ventilatory assist - report of a round-table conference

Assisted Ventilation

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