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 interestsPN 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 publicationAll patients gave consent for data publication according to national regulations.
Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Figures
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