NIV-NAVA Versus Nasal Continuous Positive Airway Pressure (nCPAP) or Non Synchronized NIPPV (Bio-NAVA)

Non-invasive Neurally Adjusted Ventilatory Assist Versus nCPAP or Non Synchronized NIPPV in Preterm Infants Under 32 Weeks Gestational Age: A Randomized Clinical Trial

Mechanical respiratory support of preterm neonates with respiratory distress syndrome (RDS) and/or apnoea of prematurity (AOP) might be associated with adverse effects due to positive pressure (barotrauma), excessive gas delivery (volutrauma) or inadequate volume (atelectrauma). Asynchrony between patient efforts and ventilator support increases patient discomfort, favouring "fighting" the machine, and increases the risk of air trapping and lung overdistension even in patients with non-invasive ventilation (NIV).

Recently, a new modality of synchronization has been available for pediatric and neonatal use: the neurally adjusted ventilatory assist (NAVA), which uses the diaphragmatic electrical activity (Edi) as a signal to start the rise in pressure of the ventilator, and to adjust the tidal volume and the inspiratory time (cycling off) to the patient needs, breath by breath.

The aims of this study are to know whether NIV-NAVA compared to unsynchronized modalities (nCPAP/nIPPV), in infants born < 32 weeks GA with respiratory distress syndrome or requiring prophylactic NIV (immaturity, apnoea) reduces systemic inflammation, measured by serum cytokines concentration, reduces the need for oxygen and respiratory support, and if it increases the probabilities of survival without bronchopulmonary dysplasia (BPD).

Study Overview

• Status: Completed
• Conditions: Respiratory Distress Syndrome, Newborn; Apnea of Prematurity
• Intervention / Treatment: Device: NIV-NAVA; Device: Conventional

Detailed Description

Introduction. Mechanical respiratory support of preterm neonates with respiratory distress syndrome (RDS) and/or apnoea of prematurity (AOP) might be associated with adverse effects as a consequence of positive pressure use (barotrauma), excessive gas delivery (volutrauma) or inadequate volume (atelectrauma). All these factors could give rise to an increase in the alveolo-capillary membrane permeability, alveoli oedema, hyaline membrane formation and epithelial cells desquamation. These phenomena eventually could lead to activation of inflammatory mediators (biotrauma) with local and systemic noxious effects.

During assisted ventilation, the lack of synchrony between patient efforts and ventilator support increases patient discomfort, favouring "fighting" the machine, and increases the risk of air trapping and lung overdistension. Even in patients with non-invasive ventilation (NIV), uneasiness and respiratory distress would cause air hunger, developing intrapleural negative pressure with risk of lung overinflation despite using low airway positive pressures. The use of neuromuscular blockade in adults with acute respiratory distress syndrome (ARDS) has been associated with a decrease in serum cytokine levels and 90 days adjusted mortality.

NAVA uses the diaphragmatic electrical activity (Edi) as a signal to start the rise in pressure of the ventilator. Likewise, it allows automatic adjustment of peak inspiratory pressure (PIP) to the patient's effort, providing variable tidal volume according to his/her needs. Finally, the system allows the inspiratory cycling off with Edi decline (normally set at 70% of Edi Peak), that is, with diaphragmatic relaxation. NAVA has shown a faster response time and a better level of synchronization than traditional flow or pressure systems, achieving greater comfort levels in adults and paediatric patients. Some paediatric and neonatal studies have shown a reduction in PIP, without changes in mean airway pressure (MAP), and a reduction in oxygen requirement (FiO2). These changes were not associated with major complications (intraventricular haemorrhage, pneumothorax, or necrotizing enterocolitis).

A relevant target in neonatal ventilatory support is to minimize the aggression to the lungs and respiratory system using NIV whenever possible, and/or extubating patients as soon as possible. For this reason, profound sedation, analgesia, or neuromuscular blockade are rarely indicated in the newborn period. NAVA synchronization might improve patient comfort, preventing patient-ventilator fighting, and lung overinflation episodes (volutrauma), ultimately reducing biotrauma. To the knowledge of the investigators, studies evaluating this new ventilatory modality (NAVA) in the newborn period are still scarce, and its potential to reduce inflammation has not been tested.

Objectives.

To determine if NIV-NAVA compared to unsynchronized modalities (nCPAP/nIPPV), in infants born < 32 weeks GA with respiratory distress syndrome or requiring prophylactic NIV (immaturity, apnoea):

1. Reduces systemic inflammation, measured by serum cytokines concentration.
2. Reduces the need for oxygen and respiratory support.
3. Increases the probabilities of survival without bronchopulmonary dysplasia (BPD).

Design. Single centre, prospective and controlled randomized clinical trial.

Setting. Tertiary Hospital with near 6000 births per year and a Neonatal Intensive Care Unit (NICU) with 15 beds and approximately 250 admissions per year.

Methods. Informed consent (IC) will be obtained before birth, during mothers' admission with threatened preterm labour. Once the IC is obtained and after the infant's birth, patients will be randomized by a random numbers table, kept in sealed envelops, to "Group A" (NAVA) or "Group B" (conventional strategies).

In all cases meeting inclusion criteria, a cord blood sample will be collected to determine the level of cytokines: Tumour necrosis factor alpha (TNF - α), interleukin (IL) 1 beta (IL-1ß), IL-6, and IL-8.

The decision to intubate in delivery room or to provide NIV will be carried out by the attending neonatologist at time of birth based on clinical criteria. In our unit, standard care is intubation and prophylactic surfactant administration in delivery room in neonates < 25 weeks GA, or older babies that did not received antenatal steroid and need intubation during resuscitation. Neonates 26 - 29 weeks GA with adequate respiratory effort are resuscitated and transferred to NICU with NIV (Neo-puff ®). Preterm babies > 29 weeks GA receive respiratory support (invasive or NIV) only when clinically indicated.

After admission to NICU, patients requiring invasive mechanical ventilation will be supported according to theirs needs and the criteria of the attending neonatologist. In our unit, modes with volume guarantee (VG) or volume control are currently used: Assist/Control+VG, Synchronized - Intermittent Mandatory Ventilation (S-IMV)+VG, and Pressure Regulated Volume Control (PRVC). After extubation and in patients supported non-invasively since the beginning, NIV will be provided according to randomization group:

Group A: With the ventilator SERVO-n (Maquet, Solna, Sweden), in NIV-NAVA mode. The ventilation parameters (PEEP, FiO2, NAVA level, etc.) will be established and adjusted by the attending clinician according to the patient's needs.

Group B: With the Infant Flow device (CareFusion) in nCPAP or non-synchronised Biphasic mode. The ventilation parameters (Flow, PEEP, FiO2, PIP level, etc.) will be established and adjusted by the attending clinician according to the patient's needs.

Surfactant (Curosurf ®, 100 mg/kg) will be administered according to clinical indications following the Unit's protocol. In general, if the patient did not receive it in delivery room, it is administered as soon as possible in the NICU when the patient needs FiO2 >0.3. Intubated patients will receive surfactant through a double lumen tube, and those with NIV by a minimally invasive method, or by the Insure (intubate, surfactant, and extubated) method.

Quantitative cytokine determination will be carried out simultaneously in all samples by X-MAP technology using the Bioplex cytometer (Biorad) which allows the simultaneous measure of multiple analytes.

• Study Type: Interventional
• Enrollment (Actual): 56
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Spain
  • Las Palmas
    • Las Palmas de Gran Canaria, Las Palmas, Spain, 35016
      • Complejo Hospitalario Universitario Insular Materno Infantil

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Child; Adult; Older Adult
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

1. Newborns < 32 weeks GA with neonatal respiratory distress syndrome, diagnosed by clinical and radiological findings who need invasive or non-invasive mechanical ventilation.
2. Newborns < 29 weeks of gestation (GA) with non-invasive mechanical ventilation at admission indicated as per protocol.
3. Previous parent or legal guardian authorization (informed consent).

Exclusion Criteria:

1. Major congenital malformation or chromosomal abnormality.
2. Absence of informed consent.
3. Outborn patients.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: NIV-NAVA; Patients allocated to non-invasive NAVA	Device: NIV-NAVA; Non-invasive ventilatory support by means of neurally adjusted ventilatory assist (SERVO-n, Maquet, Solna, Sweden)
Active Comparator: Conventional; Patients allocated to nasal CPAP or non-synchronized nasal IPPV	Device: Conventional; Non-invasive ventilatory support by means of nCPAP or non-synchronized nIPPV (Infant Flow, CareFusion)

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Survival without moderate or severe bronchopulmonary dysplasia (BPD)	Moderate or severe BPD: dependency on supplemental oxygen and/or ventilatory support at 36 weeks postmenstrual age (PMA) or at hospital discharge (what happens first).	From admission to first discharge from hospital, assessed up to 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Blood level of cytokines: Tumor necrosis factor alpha (TNF-α), interleukin (IL) 1 beta (IL-1ß), IL-6, and IL-8.	Level of the different cytokines in blood	T-0: cord blood or immediately after admission; T-1: 48 to 72 h.; T-2: 5th to 7th day of life; and T-3: 28th day of life.
Total time of ventilatory support (in days)	Number of days with invasive and/or non-invasive ventilatory support	From admission to first discharge from hospital, assessed up to 1 year
Intervention failure	Need for intubation	From admission to first discharge from hospital, assessed up to 1 year
Total time of oxygen therapy (in days)	Numer of days with supplementary oxygen	From admission to first discharge from hospital, assessed up to 1 year
Length of stay (in days)	Number of days in hospital until first discharge	From admission to first discharge from hospital, assessed up to 1 year

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Intraventricular haemorrhage (IVH) and grade	According to Papile's classification	From admission to first discharge from hospital, assessed up to 1 year
Periventricular leukomalacia (PVL)	Cysts or hyperecogenicities for more tan 14 days	From admission to first discharge from hospital, assessed up to 1 year
Retinopathy of Prematurity (ROP) stage and need for laser therapy	Grade 3 or higher (International classification).	From admission to first discharge from hospital, assessed up to 1 year
Necrotizing Enterocolitis (NEC) and stage	Grade 2 or greater of Bell's classification	From admission to first discharge from hospital, assessed up to 1 year

Collaborators and Investigators

• Sponsor: Complejo Hospitalario Universitario Insular Materno Infantil
• Investigators: Principal Investigator: Fermín García-Muñoz Rodrigo, Ph.D, Head of Neonatal Unit

Publications and helpful links

General Publications

• Slutsky AS, Ranieri VM. Ventilator-induced lung injury. N Engl J Med. 2013 Nov 28;369(22):2126-36. doi: 10.1056/NEJMra1208707. No abstract available. Erratum In: N Engl J Med. 2014 Apr 24;370(17):1668-9.
• Stein H, Firestone K, Rimensberger PC. Synchronized mechanical ventilation using electrical activity of the diaphragm in neonates. Clin Perinatol. 2012 Sep;39(3):525-42. doi: 10.1016/j.clp.2012.06.004.
• Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, Jaber S, Arnal JM, Perez D, Seghboyan JM, Constantin JM, Courant P, Lefrant JY, Guerin C, Prat G, Morange S, Roch A; ACURASYS Study Investigators. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010 Sep 16;363(12):1107-16. doi: 10.1056/NEJMoa1005372.
• Tremblay LN, Slutsky AS. Ventilator-induced injury: from barotrauma to biotrauma. Proc Assoc Am Physicians. 1998 Nov-Dec;110(6):482-8.
• Forel JM, Roch A, Marin V, Michelet P, Demory D, Blache JL, Perrin G, Gainnier M, Bongrand P, Papazian L. Neuromuscular blocking agents decrease inflammatory response in patients presenting with acute respiratory distress syndrome. Crit Care Med. 2006 Nov;34(11):2749-57. doi: 10.1097/01.CCM.0000239435.87433.0D.
• de la Oliva P, Schuffelmann C, Gomez-Zamora A, Villar J, Kacmarek RM. Asynchrony, neural drive, ventilatory variability and COMFORT: NAVA versus pressure support in pediatric patients. A non-randomized cross-over trial. Intensive Care Med. 2012 May;38(5):838-46. doi: 10.1007/s00134-012-2535-y. Epub 2012 Apr 6.
• Breatnach C, Conlon NP, Stack M, Healy M, O'Hare BP. A prospective crossover comparison of neurally adjusted ventilatory assist and pressure-support ventilation in a pediatric and neonatal intensive care unit population. Pediatr Crit Care Med. 2010 Jan;11(1):7-11. doi: 10.1097/PCC.0b013e3181b0630f.
• Stein H, Howard D. Neurally adjusted ventilatory assist in neonates weighing <1500 grams: a retrospective analysis. J Pediatr. 2012 May;160(5):786-9.e1. doi: 10.1016/j.jpeds.2011.10.014. Epub 2011 Dec 3.

Study record dates

Study Major Dates

• Study Start (Actual): August 1, 2016
• Primary Completion (Actual): November 30, 2017
• Study Completion (Actual): December 1, 2017

Study Registration Dates

• First Submitted: August 2, 2016
• First Submitted That Met QC Criteria: August 8, 2016
• First Posted (Estimate): August 9, 2016

Study Record Updates

• Last Update Posted (Actual): December 20, 2017
• Last Update Submitted That Met QC Criteria: December 19, 2017
• Last Verified: December 1, 2017

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Respiratory Tract Diseases; Respiration Disorders; Lung Diseases; Infant, Newborn, Diseases; Infant, Premature, Diseases; Respiratory Distress Syndrome; Respiratory Distress Syndrome, Newborn
• Other Study ID Numbers: CEIC-CHUIMI-2014/761

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided