Neurally Adjusted Ventilatory Assist (NAVA) or Pressure Support Ventilation (PSV) during spontaneous breathing trials in critically ill patients: a crossover trial

Juliana C Ferreira, Fabia Diniz-Silva, Henrique T Moriya, Adriano M Alencar, Marcelo B P Amato, Carlos R R Carvalho, Juliana C Ferreira, Fabia Diniz-Silva, Henrique T Moriya, Adriano M Alencar, Marcelo B P Amato, Carlos R R Carvalho

Abstract

Background: Neurally Adjusted Ventilatory Assist (NAVA) is a proportional ventilatory mode that uses the electrical activity of the diaphragm (EAdi) to offer ventilatory assistance in proportion to patient effort. NAVA has been increasingly used for critically ill patients, but it has not been evaluated during spontaneous breathing trials (SBT). We designed a pilot trial to assess the feasibility of using NAVA during SBTs, and to compare the breathing pattern and patient-ventilator asynchrony of NAVA with Pressure Support (PSV) during SBTs.

Methods: We conducted a crossover trial in the ICU of a university hospital in Brazil and included mechanically ventilated patients considered ready to undergo an SBT on the day of the study. Patients underwent two SBTs in randomized order: 30 min in PSV of 5 cmH2O or NAVA titrated to generate equivalent peak airway pressure (Paw), with a positive end-expiratory pressure of 5 cmH2O. The ICU team, blinded to ventilatory mode, evaluated whether patients passed each SBT. We captured flow, Paw and electrical activity of the diaphragm (EAdi) from the ventilator and used it to calculate respiratory rate (RR), tidal volume (VT), and EAdi. Detection of asynchrony events used waveform analysis and we calculated the asynchrony index as the number of asynchrony events divided by the number of neural cycles.

Results: We included 20 patients in the study. All patients passed the SBT in PSV, and three failed the SBT in NAVA. Five patients were reintubated and the extubation failure rate was 25% (95% CI 9-49%). Respiratory parameters were similar in the two modes: VT = 6.1 (5.5-6.5) mL/Kg in NAVA vs. 5.5 (4.8-6.1) mL/Kg in PSV (p = 0.076) and RR = 27 (17-30) rpm in NAVA vs. 26 (20-30) rpm in PSV, p = 0.55. NAVA reduced AI, with a median of 11.5% (4.2-19.7) compared to 24.3% (6.3-34.3) in PSV (p = 0.033).

Conclusions: NAVA reduces patient-ventilator asynchrony index and generates a respiratory pattern similar to PSV during SBTs. Patients considered ready for mechanical ventilation liberation may be submitted to an SBT in NAVA using the same objective criteria used for SBTs in PSV.

Trial registration: ClinicalTrials.gov ( NCT01337271 ), registered April 12, 2011.

Keywords: Continuous positive airway pressure; Positive-pressure respiration; Respiration, artificial; Ventilator weaning.

Conflict of interest statement

Ethics approval and consent to participate

This trial was approved by our institution’s ethics committee, CAPpesq (University of Sao Paulo Medical School Ethics’ committee - ID 0336/10) and a family member of each participant provided informed consent before inclusion. The study was registered at ClinicalTrials.gov (NCT01337271).

Consent for publication

Not applicable.

Competing interests

Maquet do Brasil provided the NAVA catheters for this study but had no participation in study design, data analysis or interpretation, or in manuscript writing. Dr. Juliana Ferreira received fees for lecturing from Medtronics in 2016 and 2017. Dr. Marcelo B. P. Amato reports that his research laboratory has received grants in the last 5 years from the following companies: Covidien (2012–2015; for experimental studies related to ventilator synchrony), Dixtal Biomedica, and Timpel S.A. (2010–2015; for studies related to mechanical ventilation and Electrical Impedance Tomography). The authors FDS, HTM, AML, and CRRC have no conflicts of interest to disclose related to the contents of the manuscript.

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Figures

Fig. 1
Fig. 1
Outcomes of the Spontaneous Breathing Trials (SBT) in Pressure Support Ventilation (PSV) and Neurally Adjusted Ventilatory Assist (NAVA) and extubation outcomes for the patients included in the trial
Fig. 2
Fig. 2
Prevalence of each type of asynchrony in Pressure Support Ventilation (PSV) and Neurally Adjusted Ventilatory Assist (NAVA) for each patient as well as the total asynchrony index. a Ineffective effort index; b Auto triggering index; c Double triggering index; d Triggering delay index; e Cycling delay index; f Asynchrony index
Fig. 3
Fig. 3
Tracings for Airway Pressure, Flow, and Electric Activity of the Diaphragm (EAdi) showing double-triggering in Neurally Adjusted Ventilatory Assist (NAVA) and Pressure Support Ventilation (PSV). a double triggering in NAVA; notice that despite the elevation of airway pressure on the second breath during the double triggering event, no flow is delivered to the patient, therefore no extra tidal volume was delivered in this second breath. b double triggering in PSV; the second breath during the double triggering event elevated the airway pressure and caused a positive inspiratory flow, therefore delivering a second tidal volume

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