Neurally adjusted ventilatory assist (NAVA) allows patient-ventilator synchrony during pediatric noninvasive ventilation: a crossover physiological study

Laurence Ducharme-Crevier, Jennifer Beck, Sandrine Essouri, Philippe Jouvet, Guillaume Emeriaud, Laurence Ducharme-Crevier, Jennifer Beck, Sandrine Essouri, Philippe Jouvet, Guillaume Emeriaud

Abstract

Introduction: The need for intubation after a noninvasive ventilation (NIV) failure is frequent in the pediatric intensive care unit (PICU). One reason is patient-ventilator asynchrony during NIV. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation controlled by the patient's neural respiratory drive. The aim of this study was to assess the feasibility and tolerance of NIV-NAVA in children and to evaluate its impact on synchrony and respiratory effort.

Methods: This prospective, physiologic, crossover study included 13 patients requiring NIV in the PICU of Sainte-Justine's Hospital from October 2011 to May 2013. Patients were successively ventilated in conventional NIV as prescribed by the physician in charge (30 minutes), in NIV-NAVA (60 minutes), and again in conventional NIV (30 minutes). Electrical activity of the diaphragm (EAdi) and airway pressure were simultaneously recorded to assess patient-ventilator synchrony.

Results: NIV-NAVA was feasible and well tolerated in all patients. One patient asked to stop the study because of anxiety related to the leak-free facial mask. Inspiratory trigger dys-synchrony and cycling-off dys-synchrony were significantly shorter in NIV-NAVA versus initial and final conventional NIV periods (both P <0.05). Wasted efforts were also decreased in NIV-NAVA (all values expressed as median and interquartile values) (0 (0 to 0) versus 12% (4 to 20) and 6% (2 to 22), respectively; P <0.01). As a whole, total time spent in asynchrony was reduced to 8% (6 to 10) in NIV-NAVA, versus 27% (19 to 56) and 32% (21 to 38) in conventional NIV before and after NIV-NAVA, respectively (P =0.05).

Conclusion: NIV-NAVA is feasible and well tolerated in PICU patients and allows improved patient-ventilator synchronization. Larger controlled studies are warranted to evaluate the clinical impact of these findings.

Trial registration: ClinicalTrials.gov NCT02163382. Registered 9 June 2014.

Figures

Figure 1
Figure 1
Patients’ flow charts.
Figure 2
Figure 2
Example of synchronization between ventilator pressure (PVENT) and electrical activity of the diaphragm (EAdi) in two children under NIV. (A) a 1-month-old infant admitted for bronchiolitis on noninvasive Pressure Support Ventilation (PSV) and in NIV-NAVA. (B) A 12-year-old postoperative patient with scoliosis on noninvasive Pressure Control (PC) and in NIV-NAVA. We can observe inspiratory and cycling-off asynchrony and autotriggered breaths during conventional NIV.
Figure 3
Figure 3
Inspiratory dys-synchrony (ms), cycling-off dys-synchrony (ms), ineffective efforts (%) and autotriggered breaths (%) in initial conventional NIV, NIV-NAVA, and final conventional NIV. CPAP periods (n = 3) were not included in synchrony evaluation of conventional NIV periods (they could be considered as 100% wasted efforts). *P ≤ 0.05 and ┼P < 0.01.
Figure 4
Figure 4
Comparison of mean EAdi during conventional and NAVA NIV. (A) Individual mean EAdi during conventional NIV and NIV-NAVA periods. (B) The change in mean EAdi observed from conventional NIV to NIV-NAVA period, according to initial EAdi.

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