New setting of neurally adjusted ventilatory assist for noninvasive ventilation by facial mask: a physiologic study

Federico Longhini, Chun Pan, Jianfeng Xie, Gianmaria Cammarota, Andrea Bruni, Eugenio Garofalo, Yi Yang, Paolo Navalesi, Haibo Qiu, Federico Longhini, Chun Pan, Jianfeng Xie, Gianmaria Cammarota, Andrea Bruni, Eugenio Garofalo, Yi Yang, Paolo Navalesi, Haibo Qiu

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.

Keywords: Neurally adjusted ventilatory assist; Noninvasive ventilation; Patient-ventilator asynchrony; Patient-ventilator interaction; Pressure support ventilation; Ventilator performance.

Conflict of interest statement

Competing interests

PN contributed to the development of the helmet, Next (Castar Next, Intersurgical, Mirandola, Italy), whose license for the patent belongs to Intersurgical S.P.A., and received royalties for that invention. PN’s research laboratory has received equipment and/or grants from Maquet Critical Care (Solna, Sweden), Intersurgical S.p.A. (Mirandola, Italy), Draeger Medical GmbH (Corsico, Italy), Biotest (Trezzano sul Naviglio, Italy) and Hillrom (Bussigny, Switzerland). PN received honoraria/speaking fees from Maquet Critical Care (Solna, Sweden), Covidien AG (Segrate, Italy), Draeger Medical GmbH (Corsico, Italy), Breas (Mölnlycke, Sweden), Hillrom (Chicago, IL, USA), Resmed (Vimercate MB, Italy) and Linde AG (Munich, Germany). All other authors declare that they have no competing interests.

Consent for publication

All patients gave consent for data publication according to national regulations.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Enrolment of the study participants. The flow of patient assessment and inclusion in the protocol is shown. A total of 54 patients were considered eligible for the study, having met all inclusion criteria: 40 patients were excluded from the study because they met one or more of the exclusion criteria. Therefore, 14 patients were included in the study. No protocol discontinuations were recorded. EAdi diaphragm electrical activity
Fig. 2
Fig. 2
Comfort score. Individual values (open circles), median and interquartile range (solid lines) of the comfort score during pneumatically triggered pressure support (PSP), neurally adjusted ventilatory assist (NAVA) and neurally controlled pressure support (PSN) are depicted from left to right
Fig. 3
Fig. 3
Examples of tracings from one representative patient. From top to bottom, airway pressure (Paw), flow and electrical activity of the diaphragm (EAdi) tracings of a representative patient are shown during pneumatically triggered pressure support (PSP), neurally adjusted ventilatory assist (NAVA) and neurally controlled pressure support (PSN). The arrow indicates an ineffective effort during PSP
Fig. 4
Fig. 4
Pressure airway profiles. Airway pressure (Paw) profile of single breaths during pneumatically triggered pressure support (solid line), neurally adjusted ventilatory assist (dotted line) and neurally controlled pressure support (dashed line) from another patient. The arrow indicates the beginning of the patient’s effort. See main text for additional explanation

References

    1. Esteban A, Frutos-Vivar F, Muriel A, Ferguson ND, Penuelas O, Abraira V, Raymondos K, Rios F, Nin N, Apezteguia C, et al. Evolution of mortality over time in patients receiving mechanical ventilation. Am J Respir Crit Care Med. 2013;188(2):220–30. doi: 10.1164/rccm.201212-2169OC.
    1. Nava S, Navalesi P, Carlucci A. Non-invasive ventilation. Minerva Anestesiol. 2009;75(1-2):31–6.
    1. Crimi C, Noto A, Princi P, Nava S. Survey of non-invasive ventilation practices: a snapshot of Italian practice. Minerva Anestesiol. 2011;77(10):971–8.
    1. Cammarota G, Longhini F, Perucca R, Ronco C, Colombo D, Messina A, Vaschetto R, Navalesi P. New setting of neurally adjusted ventilatory assist during noninvasive ventilation through a helmet. Anesthesiology. 2016;125(6):1181–9. doi: 10.1097/ALN.0000000000001354.
    1. Antonelli M, Conti G, Pelosi P, Gregoretti C, Pennisi MA, Costa R, Severgnini P, Chiaranda M, Proietti R. New treatment of acute hypoxemic respiratory failure: noninvasive pressure support ventilation delivered by helmet–a pilot controlled trial. Crit Care Med. 2002;30(3):602–8. doi: 10.1097/00003246-200203000-00019.
    1. Calderini E, Confalonieri M, Puccio PG, Francavilla N, Stella L, Gregoretti C. Patient-ventilator asynchrony during noninvasive ventilation: the role of expiratory trigger. Intensive Care Med. 1999;25(7):662–7. doi: 10.1007/s001340050927.
    1. Vignaux L, Vargas F, Roeseler J, Tassaux D, Thille AW, Kossowsky MP, Brochard L, Jolliet P. Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med. 2009;35(5):840–6. doi: 10.1007/s00134-009-1416-5.
    1. Navalesi P, Longhini F. Neurally adjusted ventilatory assist. Curr Opin Crit Care. 2015;21(1):58–64. doi: 10.1097/MCC.0000000000000167.
    1. Colombo D, Cammarota G, Bergamaschi V, De Lucia M, Corte FD, Navalesi P. Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure. Intensive Care Med. 2008;34(11):2010–8. doi: 10.1007/s00134-008-1208-3.
    1. Vaschetto R, Cammarota G, Colombo D, Longhini F, Grossi F, Giovanniello A, Della Corte F, Navalesi P. Effects of propofol on patient-ventilator synchrony and interaction during pressure support ventilation and neurally adjusted ventilatory assist*. Crit Care Med. 2014;42(1):74–82. doi: 10.1097/CCM.0b013e31829e53dc.
    1. Schmidt M, Dres M, Raux M, Deslandes-Boutmy E, Kindler F, Mayaux J, Similowski T, Demoule A. Neurally adjusted ventilatory assist improves patient-ventilator interaction during postextubation prophylactic noninvasive ventilation. Crit Care Med. 2012;40(6):1738–44. doi: 10.1097/CCM.0b013e3182451f77.
    1. Bertrand PM, Futier E, Coisel Y, Matecki S, Jaber S, Constantin JM. Neurally adjusted ventilatory assist vs pressure support ventilation for noninvasive ventilation during acute respiratory failure: a crossover physiologic study. Chest. 2013;143(1):30–6. doi: 10.1378/chest.12-0424.
    1. Piquilloud L, Tassaux D, Bialais E, Lambermont B, Sottiaux T, Roeseler J, Laterre PF, Jolliet P, Revelly JP. Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator interaction during non-invasive ventilation delivered by face mask. Intensive Care Med. 2012;38(10):1624–31. doi: 10.1007/s00134-012-2626-9.
    1. Doorduin J, Sinderby CA, Beck J, van der Hoeven JG, Heunks L. Automated patient-ventilator interaction analysis during neurally adjusted non-invasive ventilation and pressure support ventilation in chronic obstructive pulmonary disease. Crit Care. 2014;18(5):550. doi: 10.1186/s13054-014-0550-9.
    1. Cammarota G, Olivieri C, Costa R, Vaschetto R, Colombo D, Turucz E, Longhini F, Della Corte F, Conti G, Navalesi P. Noninvasive ventilation through a helmet in postextubation hypoxemic patients: physiologic comparison between neurally adjusted ventilatory assist and pressure support ventilation. Intensive Care Med. 2011;37(12):1943–50. doi: 10.1007/s00134-011-2382-2.
    1. Liu L, Xia F, Yang Y, Longhini F, Navalesi P, Beck J, Sinderby C, Qiu H. Neural versus pneumatic control of pressure support in patients with chronic obstructive pulmonary diseases at different levels of positive end expiratory pressure: a physiological study. Crit Care. 2015;19:244. doi: 10.1186/s13054-015-0971-0.
    1. Altman DG, Schulz KF, Moher D, Egger M, Davidoff F, Elbourne D, Gotzsche PC, Lang T. The revised CONSORT statement for reporting randomized trials: explanation and elaboration. Ann Intern Med. 2001;134(8):663–94. doi: 10.7326/0003-4819-134-8-200104170-00012.
    1. Navalesi P, Frigerio P, Moretti MP, Sommariva M, Vesconi S, Baiardi P, Levati A. Rate of reintubation in mechanically ventilated neurosurgical and neurologic patients: evaluation of a systematic approach to weaning and extubation. Crit Care Med. 2008;36(11):2986–92. doi: 10.1097/CCM.0b013e31818b35f2.
    1. Nava S, Gregoretti C, Fanfulla F, Squadrone E, Grassi M, Carlucci A, Beltrame F, Navalesi P. Noninvasive ventilation to prevent respiratory failure after extubation in high-risk patients. Crit Care Med. 2005;33(11):2465–70. doi: 10.1097/01.CCM.0000186416.44752.72.
    1. Ferrer M, Sellares J, Valencia M, Carrillo A, Gonzalez G, Badia JR, Nicolas JM, Torres A. Non-invasive ventilation after extubation in hypercapnic patients with chronic respiratory disorders: randomised controlled trial. Lancet. 2009;374(9695):1082–8. doi: 10.1016/S0140-6736(09)61038-2.
    1. SERVO-i VENTILATOR SYSTEM V6.0, User’s Manual, Rev 14 English edn: Maquet Critical Care AB; 2011.
    1. Chooi CS, White AM, Tan SG, Dowling K, Cyna AM. Pain vs comfort scores after Caesarean section: a randomized trial. Br J Anaesth. 2013;110(5):780–7. doi: 10.1093/bja/aes517.
    1. Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, Montini L, De Gaetano A, Navalesi P, Antonelli M. Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med. 2014;190(3):282–8. doi: 10.1164/rccm.201402-0364OC.
    1. Olivieri C, Longhini F, Cena T, Cammarota G, Vaschetto R, Messina A, Berni P, Magnani C, Della Corte F, Navalesi P. New versus conventional helmet for delivering noninvasive ventilation: a physiologic, crossover randomized study in critically ill patients. Anesthesiology. 2016;124(1):101–8. doi: 10.1097/ALN.0000000000000910.
    1. Navalesi P, Hernandez P, Wongsa A, Laporta D, Goldberg P, Gottfried SB. Proportional assist ventilation in acute respiratory failure: effects on breathing pattern and inspiratory effort. Am J Respir Crit Care Med. 1996;154(5):1330–8. doi: 10.1164/ajrccm.154.5.8912744.
    1. Bellani G, Mauri T, Coppadoro A, Grasselli G, Patroniti N, Spadaro S, Sala V, Foti G, Pesenti A. Estimation of patient’s inspiratory effort from the electrical activity of the diaphragm. Crit Care Med. 2013;41(6):1483–91. doi: 10.1097/CCM.0b013e31827caba0.
    1. Olivieri C, Costa R, Conti G, Navalesi P. Bench studies evaluating devices for non-invasive ventilation: critical analysis and future perspectives. Intensive Care Med. 2012;38(1):160–7. doi: 10.1007/s00134-011-2416-9.
    1. Olivieri C, Costa R, Spinazzola G, Ferrone G, Longhini F, Cammarota G, Conti G, Navalesi P. Bench comparative evaluation of a new generation and standard helmet for delivering non-invasive ventilation. Intensive Care Med. 2013;39(4):734–8. doi: 10.1007/s00134-012-2765-z.
    1. Costa R, Navalesi P, Antonelli M, Cavaliere F, Craba A, Proietti R, Conti G. Physiologic evaluation of different levels of assistance during noninvasive ventilation delivered through a helmet. Chest. 2005;128(4):2984–90. doi: 10.1378/chest.128.4.2984.
    1. Moerer O, Beck J, Brander L, Costa R, Quintel M, Slutsky AS, Brunet F, Sinderby C. Subject-ventilator synchrony during neural versus pneumatically triggered non-invasive helmet ventilation. Intensive Care Med. 2008;34(9):1615–23. doi: 10.1007/s00134-008-1163-z.
    1. Costa R, Navalesi P, Spinazzola G, Ferrone G, Pellegrini A, Cavaliere F, Proietti R, Antonelli M, Conti G. Influence of ventilator settings on patient-ventilator synchrony during pressure support ventilation with different interfaces. Intensive Care Med. 2010;36(8):1363–70. doi: 10.1007/s00134-010-1915-4.
    1. Lemyze M, Mallat J, Nigeon O, Barrailler S, Pepy F, Gasan G, Vangrunderbeeck N, Grosset P, Tronchon L, Thevenin D. Rescue therapy by switching to total face mask after failure of face mask-delivered noninvasive ventilation in do-not-intubate patients in acute respiratory failure. Crit Care Med. 2013;41(2):481–8. doi: 10.1097/CCM.0b013e31826ab4af.
    1. Bonmarchand G, Chevron V, Chopin C, Jusserand D, Girault C, Moritz F, Leroy J, Pasquis P. Increased initial flow rate reduces inspiratory work of breathing during pressure support ventilation in patients with exacerbation of chronic obstructive pulmonary disease. Intensive Care Med. 1996;22(11):1147–54. doi: 10.1007/BF01709328.
    1. Bonmarchand G, Chevron V, Menard JF, Girault C, Moritz-Berthelot F, Pasquis P, Leroy J. Effects of pressure ramp slope values on the work of breathing during pressure support ventilation in restrictive patients. Crit Care Med. 1999;27(4):715–22. doi: 10.1097/00003246-199904000-00023.
    1. Chiumello D, Pelosi P, Taccone P, Slutsky A, Gattinoni L. Effect of different inspiratory rise time and cycling off criteria during pressure support ventilation in patients recovering from acute lung injury. Crit Care Med. 2003;31(11):2604–10. doi: 10.1097/01.CCM.0000089939.11032.36.
    1. Prinianakis G, Delmastro M, Carlucci A, Ceriana P, Nava S. Effect of varying the pressurisation rate during noninvasive pressure support ventilation. Eur Respir J. 2004;23(2):314–20. doi: 10.1183/09031936.03.00010203.
    1. Chiumello D, Pelosi P, Croci M, Bigatello LM, Gattinoni L. The effects of pressurization rate on breathing pattern, work of breathing, gas exchange and patient comfort in pressure support ventilation. Eur Respir J. 2001;18(1):107–14. doi: 10.1183/09031936.01.00083901.
    1. Vargas F, Thille A, Lyazidi A, Campo FR, Brochard L. Helmet with specific settings versus facemask for noninvasive ventilation. Crit Care Med. 2009;37(6):1921–8. doi: 10.1097/CCM.0b013e31819fff93.
    1. Gerbershagen HJ, Rothaug J, Kalkman CJ, Meissner W. Determination of moderate-to-severe postoperative pain on the numeric rating scale: a cut-off point analysis applying four different methods. Br J Anaesth. 2011;107(4):619–26. doi: 10.1093/bja/aer195.
    1. Gagliese L, Weizblit N, Ellis W, Chan VW. The measurement of postoperative pain: a comparison of intensity scales in younger and older surgical patients. Pain. 2005;117(3):412–20. doi: 10.1016/j.pain.2005.07.004.
    1. Gift AG, Narsavage G. Validity of the numeric rating scale as a measure of dyspnea. Am J Crit Care. 1998;7(3):200–4.

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