Neurally adjusted ventilatory assist preserves cerebral blood flow velocity in patients recovering from acute brain injury

Gianmaria Cammarota, Federico Verdina, Gianluigi Lauro, Ester Boniolo, Riccardo Tarquini, Antonio Messina, Nello De Vita, Ilaria Sguazzoti, Raffaella Perucca, Francesco Della Corte, Gian Luca Vignazia, Francesca Grossi, Samuele Crudo, Paolo Navalesi, Erminio Santangelo, Rosanna Vaschetto, Gianmaria Cammarota, Federico Verdina, Gianluigi Lauro, Ester Boniolo, Riccardo Tarquini, Antonio Messina, Nello De Vita, Ilaria Sguazzoti, Raffaella Perucca, Francesco Della Corte, Gian Luca Vignazia, Francesca Grossi, Samuele Crudo, Paolo Navalesi, Erminio Santangelo, Rosanna Vaschetto

Abstract

Neurally adjusted ventilatory assist (NAVA) has never been applied in patients recovering from acute brain injury (ABI) because neural respiratory drive could be affected by intracranial disease with detrimental effects on cerebral blood flow (CBF) velocity. Our primary aim was to assess the impact of NAVA and pressure support ventilation (PSV) on CBF velocity. In fifteen adult patients recovering from ABI and undergoing invasive assisted ventilation, PSV and NAVA were applied over 30-min-lasting trials, in the following sequence: PSV1, NAVA, and PSV2. While PSV was set to deliver a tidal volume ranging between 6 and 8 ml kg-1 of predicted body weight, in NAVA the level of assistance was chosen to achieve the same inspiratory peak airway pressure as PSV. At the end of each trial, a sonographic evaluation of CBF mean velocity was bilaterally obtained on the middle cerebral artery and an arterial blood gas sample was taken for analysis. CBF mean velocity was 51.8 [41.9,75.2] cm s-1 at baseline, 51.9 [43.4,71.0] cm s-1 in PSV1, 53.6 [40.7,67.7] cm s-1 in NAVA, and 49.5 [42.1,70.8] cm s-1 in PSV2 (p = 0.0514) on the left and 50.2 [38.0,77.7] cm s-1 at baseline, 47.8 [41.7,68.2] cm s-1 in PSV1, 53.9 [40.1,78.5] cm s-1 in NAVA, and 55.6 [35.9,74.1] cm s-1 in PSV2 (p = 0.8240) on the right side. No differences were detected for pH (p = 0.0551), arterial carbon dioxide tension (p = 0.8142), and oxygenation (p = 0.0928) over the entire study duration. NAVA and PSV preserved CBF velocity in patients recovering from ABI.Trial registration: The present trial was prospectively registered at www.clinicatrials.gov (NCT03721354) on October 18th, 2018.

Keywords: Acute brain injury; Asynchronies; Cerebral blood flow; Mechanical ventilation.

Conflict of interest statement

Dr. Messina reports personal fees and other from Vygon Italia, outside the submitted work. Dr. Navalesi reports personal fees from Getinge, outside the submitted work.

Figures

Fig. 1
Fig. 1
Asynchrony index. The asynchrony index of each patient during all study trials are depicted. PSV1 pressure support ventilation trial 1, NAVA neurally adjusted ventilatory assist ventilation, PSV2 pressure support ventilation trial 2; p-value is referred to Chi-square test among PSV1, NAVA, and PSV2 for asynchrony index ≥ 10%
Fig. 2
Fig. 2
Macroasynchrony events. The total number of macroasynchrony events and the percentages of the specific types of asynchronies are depicted. Light grey, IE ineffective efforts; middle grey, DT double triggers; dark grey, AT auto-triggers. a Pressure support ventilation trial 1; b neurally adjusted ventilatory assist; c pressure support ventilation trial 2

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