Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA versus PSV

Rosa Di Mussi, Savino Spadaro, Lucia Mirabella, Carlo Alberto Volta, Gabriella Serio, Francesco Staffieri, Michele Dambrosio, Gilda Cinnella, Francesco Bruno, Salvatore Grasso, Rosa Di Mussi, Savino Spadaro, Lucia Mirabella, Carlo Alberto Volta, Gabriella Serio, Francesco Staffieri, Michele Dambrosio, Gilda Cinnella, Francesco Bruno, Salvatore Grasso

Abstract

Background: Prolonged controlled mechanical ventilation depresses diaphragmatic efficiency. Assisted modes of ventilation should improve it. We assessed the impact of pressure support ventilation versus neurally adjusted ventilator assist on diaphragmatic efficiency.

Method: Patients previously ventilated with controlled mechanical ventilation for 72 hours or more were randomized to be ventilated for 48 hours with pressure support ventilation (n =12) or neurally adjusted ventilatory assist (n = 13). Neuro-ventilatory efficiency (tidal volume/diaphragmatic electrical activity) and neuro-mechanical efficiency (pressure generated against the occluded airways/diaphragmatic electrical activity) were measured during three spontaneous breathing trials (0, 24 and 48 hours). Breathing pattern, diaphragmatic electrical activity and pressure time product of the diaphragm were assessed every 4 hours.

Results: In patients randomized to neurally adjusted ventilator assist, neuro-ventilatory efficiency increased from 27 ± 19 ml/μV at baseline to 62 ± 30 ml/μV at 48 hours (p <0.0001) and neuro-mechanical efficiency increased from 1 ± 0.6 to 2.6 ± 1.1 cmH2O/μV (p = 0.033). In patients randomized to pressure support ventilation, these did not change. Electrical activity of the diaphragm, neural inspiratory time, pressure time product of the diaphragm and variability of the breathing pattern were significantly higher in patients ventilated with neurally adjusted ventilatory assist. The asynchrony index was 9.48 [6.38- 21.73] in patients ventilated with pressure support ventilation and 5.39 [3.78- 8.36] in patients ventilated with neurally adjusted ventilatory assist (p = 0.04).

Conclusion: After prolonged controlled mechanical ventilation, neurally adjusted ventilator assist improves diaphragm efficiency whereas pressure support ventilation does not.

Trial registration: ClinicalTrials.gov study registration: NCT02473172, 06/11/2015.

Figures

Fig. 1
Fig. 1
Flow diagram of patient enrollment. NG naso-gastric; SBT spontaneous breathing trial, CMV controlled mechanical ventilation, NAVA adjusted ventilatory assist, EAdi diaphragm electrical activity, PSV pressure support ventilation, RR respiratory rate
Fig. 2
Fig. 2
Neuro-ventilatory efficiency (NVE) and neuro-muscular efficiency (NME) recorded during the spontaneous breathing trial at 0, 24 and 48 hours in the two groups of patients, i.e., randomized to be ventilated in neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV). The NVE and NME trends were significantly different (analysis of variance model; F = 15.32; p <0,0001 for NVE and F = 5,15; p = 0.033 for NME). *Significant difference compared to 0 hours (within-group post-hoc comparison). #Significant difference compared to 24 hours (within-group post-hoc comparison). §Significant difference compared to the same time (between-groups post-hoc comparison)
Fig. 3
Fig. 3
Main breathing pattern and diaphragm electrical activity (EAdi) parameters recorded each 4 hours in the two groups of patients, ventilated in neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV). The neural inspiratory time (TiNEUR) was significantly lower in the PSV than in the NAVA group (F = 9.85; p = 0,007). The peak diaphragm electrical activity (EAdiPEAK) was significantly higher in the NAVA than in the PSV group (F = 4.83; p = 0,045). *Significant difference between PSV and NAVA (analysis of variance model). ΔPAO assistance level (peak airway pressure – positive end-expiratory airway pressure), VT tidal volume, PBW predicted body weight, RRMECH mechanical respiratory rate, TiMECH mechanical inspiratory time
Fig. 4
Fig. 4
Inspiratory pressure–time product of the diaphragm (PTPDI) per breath (PTPDI/b) and per minute (PTPDI/min) in the two groups of patients, ventilated in neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV). Black bars denote PTPDI/b and PTPDI/minute measured during the three spontaneous breathing trials (SBT) (0, 24 and 48 hours). White bars denote PTPDI/b and PTPDI/min measured each 4 hours during assisted ventilation. During the assisted ventilation period both the PMUSC/b and the PMUSC/min were constantly higher in the NAVA than in the PSV group (analysis of variance model: for PDI/b, F = 32.64; p <0,001; for PMUSC/min, F = 39.15; p <0.001)
Fig. 5
Fig. 5
Inspiratory pressure–time product of the diaphragm per minute (PTPDI/min) in the two groups of patients, ventilated in neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV). White bars denote the PTPDI/min recorded each 4 hours during NAVA; black bars denote the PTPDI/min recorded each 4 hours during PSV. Dotted red lines denote the physiological PTPDI/min range according to a previous publication [42]

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