Non-invasive neurally adjusted ventilatory assist in preterm infants with RDS: effect of changing NAVA levels

Julie Lefevere, Brenda Van Delft, Michel Vervoort, Wilfried Cools, Filip Cools, Julie Lefevere, Brenda Van Delft, Michel Vervoort, Wilfried Cools, Filip Cools

Abstract

We aimed to examine the effect of changing levels of support (NAVA level) during non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm infants with respiratory distress syndrome (RDS) on electrical diaphragm activity. This is a prospective, single-centre, interventional, exploratory study in a convenience sample. Clinically stable preterm infants supported with NIV-NAVA for RDS were eligible. Patients were recruited in the first 24 h after the start of NIV-NAVA. Following a predefined titration protocol, NAVA levels were progressively increased starting from a level of 0.5 cmH2O/µV and with increments of 0.5 cmH2O/µV every 3 min, up to a maximum level of 4.0 cmH2O/µV. We measured the evolution of peak inspiratory pressure and the electrical signal of the diaphragm (Edi) during NAVA level titration. Twelve infants with a mean (SD) gestational age at birth of 30.6 (3.5) weeks and birth weight of 1454 (667) g were enrolled. For all patients a breakpoint could be identified during the titration study. The breakpoint was on average (SD) at a level of 2.33 (0.58) cmH2O/µV. With increasing NAVA levels, the respiratory rate decreased significantly. No severe complications occurred.Conclusions: Preterm neonates with RDS supported with NIV-NAVA display a biphasic response to changing NAVA levels with an identifiable breakpoint. This breakpoint was at a higher NAVA level than commonly used in this clinical situation. Immature neural feedback mechanisms warrant careful monitoring of preterm infants when supported with NIV-NAVA.Trial registration: clinicaltrials.gov NCT03780842. Date of registration December 12, 2018. What is Known: • Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is a safe, feasible and effective way to support respiration in preterm infants. • Intact neural feedback mechanisms are needed to protect the lung from overdistension in neurally adjusted ventilatory assist. What is New: • Preterm infants with acute RDS have a similar pattern of respiratory unloading as previously described. • Neural feedback mechanisms seem to be immature with the risk of insufficient support and lung injury due to overdistension of the lung.

Keywords: Artificial; Diaphragm; Infant; Intensive care units; Interactive ventilatory support; Neonatal; Newborn; Premature; Respiration; Respiratory distress syndrome.

Conflict of interest statement

The authors declare no competing interests.

© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.

Figures

Fig. 1
Fig. 1
Combined data of effect of changes in neurally adjusted ventilatory assist levels on peak inspiratory pressure (PIP in cmH2O, solid line) and change in electrical activity of the diaphragm (dEdi in µV, dashed line) for all patients on non-invasive neurally adjusted ventilatory assist. Values are given as average values with standard deviation At NAVA levels below the breakpoint (BrP-2 to BrP-0.5) PIP increases with increasing NAVA level. After the breakpoint (BrP) is reached, there is no further increase in PIP with increases in NAVA level (BrP+0.5 to BrP+1). With even higher NAVA levels (BrP+1.5 and BrP+2) a small secondary rise in PIP is noticed. At NAVA levels below the breakpoint the dEdi remained constant, then decreased slightly as the NAVA level was increased beyond the breakpoint. At the highest NAVA levels (BrP+1.5 and BrP+2) no further decrease in dEdi was seen. *p < 0.05 between a 0.5 cmH2O/µV change in the NAVA levels

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