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McKinney RL, Wallström L, Courtney SE, Sindelar R. Novel forms of ventilation in neonates: Neurally adjusted ventilatory assist and proportional assist ventilation. Semin Perinatol 2024; 48:151889. [PMID: 38565434 DOI: 10.1016/j.semperi.2024.151889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Patient-triggered modes of ventilation are currently the standard of practice in the care of term and preterm infants. Maintaining spontaneous breathing during mechanical ventilation promotes earlier weaning and possibly reduces ventilator-induced diaphragmatic dysfunction. A further development of assisted ventilation provides support in proportion to the respiratory effort and enables the patient to have full control of their ventilatory cycle. In this paper we will review the literature on two of these modes of ventilation: neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation (PAV), propose future studies and suggest clinical applications of these modes.
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Affiliation(s)
- R L McKinney
- Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02906, United States.
| | - L Wallström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - S E Courtney
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - R Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Chen CM, Chung MY, Kang HY, Ou-Yang MC, Wang TM, Hsu CT. Case Report: Neurally adjusted ventilatory assist as an effective rescue treatment for pulmonary interstitial emphysema in extremely low birth weight infants. Front Pediatr 2024; 12:1332332. [PMID: 38318454 PMCID: PMC10838975 DOI: 10.3389/fped.2024.1332332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/09/2024] [Indexed: 02/07/2024] Open
Abstract
Pulmonary interstitial emphysema (PIE) is a complication observed in extremely low birth weight (ELBW) infants on mechanical ventilation. Despite various proposed therapeutic interventions, the success rates have shown inconsistency. Neurally adjusted ventilatory assist (NAVA) stands out as a novel respiratory support mode, offering lower pressure and tidal volume in comparison to conventional ventilation methods. In this case report, we present five ELBW infants with refractory PIE who were transitioned to NAVA ventilation. Following the switch to NAVA, all cases of PIE gradually resolved. In contrast to traditional modes, NAVA provided respiratory support with significantly lower fraction of inspired oxygen, reduced peak inspiratory pressure, diminished mean airway pressure, and decreased tidal volume within 7 days of NAVA utilization (p = 0.042, 0.043, 0.043, and 0.042, respectively). Consequently, we propose that NAVA could serve as a valuable rescue treatment for ELBW infants with PIE.
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Affiliation(s)
- Chien-Ming Chen
- Section of Neonatology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Mei-Yung Chung
- Section of Neonatology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Department of Respiratory Care, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
- Chang Gung University of Science and Technology, Chiayi Campus, Chiayi, Taiwan
| | - Hong-Ya Kang
- Department of Respiratory Care, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Mei-Chen Ou-Yang
- Section of Neonatology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Teh-Ming Wang
- Children’s Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Chung-Ting Hsu
- Children’s Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan
- Department of Post-Baccalaureate Medicine, College of Medicine, National Chung Hsing University, Taichung, Taiwan
- Department of Biomedical Engineering & Environmental Sciences, National Tsing Hua University, Hsinchu, Taiwan
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Protain A, Firestone K, Hussain S, Lubarsky D, Stein H. Evaluation of NAVA-PAP in premature neonates with apnea of prematurity: minimal backup ventilation and clinically significant events. Front Pediatr 2023; 11:1234964. [PMID: 37868266 PMCID: PMC10587435 DOI: 10.3389/fped.2023.1234964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Background Neonates with apnea of prematurity (AOP) clinically deteriorate because continuous positive airway pressure (CPAP) provides inadequate support during apnea. Neurally adjusted ventilatory assist (NAVA) provides proportional ventilator support from the electrical activity of the diaphragm. When the NAVA level is 0 cmH2O/mcV (NAVA-PAP), patients receive CPAP when breathing and backup ventilation when apneic. This study evaluates NAVA-PAP and time spent in backup ventilation. Methods This was a prospective, two-center, observational study of preterm neonates on NAVA-PAP for AOP. Ventilator data were downloaded after 24 h. The number of clinically significant events (CSEs) was collected. A paired t-test was used to perform statistical analysis. Results The study was conducted on 28 patients with a gestational age of 25 ± 1.8 weeks and a study age of 28 ± 23 days. The number of CSEs was 4 ± 4.39/24 h. The patients were on NAVA-PAP for approximately 90%/min, switched to backup mode 2.5 ± 1.1 times/min, and spent 10.6 ± 7.2% in backup. Conclusion Preterm neonates on NAVA-PAP had few CSEs with minimal time in backup ventilation.
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Affiliation(s)
- Alison Protain
- Pediatrix Medical Group Akron Ohio, Akron Children’s Hospital, Akron, OH, United States
| | - Kimberly Firestone
- Department of Neonatology, Akron Children’s Hospital, Akron, OH, United States
| | - Saima Hussain
- Department of Pediatrics, ProMedica Russell J. Ebeid Children’s Hospital, Toledo, OH, United States
| | - Daniel Lubarsky
- Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, United States
| | - Howard Stein
- Northwest Ohio Neonatal Associates, ProMedica Russell J. Ebeid Children’s Hospital, Toledo, OH, United States
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Brenne H, Follestad T, Bergseng H, Eriksen BH, Søraunet K, Grunewaldt KH. Inter-rater reliability of the Silverman and Andersen index-a measure of respiratory distress in preterm infants. PLoS One 2023; 18:e0286655. [PMID: 37390074 PMCID: PMC10313036 DOI: 10.1371/journal.pone.0286655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/21/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND There are various methods of respiratory support available to optimize respiratory function in preterm infants. Respiratory scoring tools might provide information on which method to choose and the level and duration of support needed. Before implementing a respiratory scoring tool in our clinical practice, we aimed to test the inter- and intra-rater reliability of the Silverman and Andersen index (SA index) among neonatologists and nurses when applied to preterm infants on respiratory support. We also examined the association between the SA index and the electrical activity of the diaphragm (Edi signals). METHODS This was a multicenter study including three newborn intensive care units in Norway. Four neonatologists and 10 nurses applied the SA index when assessing 80 videos of 44 preterm infants on High Flow Nasal Cannula, Continuous Positive Airway Pressure and Neurally Adjusted Ventilatory Assist. The inter- and intra-rater reliability for the sum scores were measured by the intra-class correlation coefficient (ICC), and Kendall's W was used to assess the degree of agreement for each item. We quantified the association between the Edi signals and the SA index scores by the Spearman's correlation coefficient. RESULTS We found poor inter-rater reliability with an ICC for absolute agreement of 0.34 (95% CI: 0.20 to 0.53). There was fair agreement measuring each item separately for upper chest movements (Kendall's W 0.30), and moderate for lower chest movements (0.43) and xiphoid retractions (0.44). Expiratory grunting showed substantial agreement (0.67). The intra-rater reliability was good (ICC for absolute agreement 0.77; 95% CI: 0.68 to 0.84). We found a moderate positive correlation (r = 0.468, p = 0.028) between the maximum inspiratory diaphragm activity (Edi peak) and the mean inspiratory SA index scores. CONCLUSION Our study showed poor inter-rater and good intra-rater reliability of the SA index when nurses and neonatologists assessed videos of preterm infants on various types of respiratory support. Edi peak and SA index had a moderate positive correlation. Formal training might be essential to improve the inter-rater reliability. TRIAL REGISTRATION Registered 26th June 2017, ClinicalTrials.gov Identifier: NCT03199898.
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Affiliation(s)
- Hilde Brenne
- Department of Pediatrics, St. Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Turid Follestad
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
- Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
| | - Håkon Bergseng
- Department of Pediatrics, St. Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Beate Horsberg Eriksen
- Clinical Research Unit, Norwegian University of Science and Technology, Trondheim, Norway
- Department of Pediatrics, Ålesund Hospital, Ålesund, Norway
| | - Karin Søraunet
- Department of Pediatrics, Levanger Hospital, Levanger, Norway
| | - Kristine Hermansen Grunewaldt
- Department of Pediatrics, St. Olavs Hospital Trondheim University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
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Naples R, Fenton AC, Brodlie M, Harigopal S, O'Brien C. Diaphragm electrical activity during weaning of nasal high-flow therapy in preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 108:237-243. [PMID: 36223982 DOI: 10.1136/archdischild-2022-324112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine whether electrical activity of the diaphragm (Edi) changes with weaning nasal high-flow (HF) therapy in preterm infants according to a standardised protocol. DESIGN Prospective observational cohort study. SETTING Neonatal intensive care unit. PATIENTS Preterm infants born at <32 weeks gestation, receiving nasal HF as part of routine clinical care. INTERVENTIONS Infants recruited to the study had their HF weaned according to set clinical criteria. Edi was measured using a modified gastric feeding tube serially from baseline (pre-wean) to 24-hours post-wean. MAIN OUTCOME MEASURES Change in Edi from baseline was measured at four time points up to 24 hours after weaning. Minimum Edi during expiration, maximum Edi during inspiration and amplitude of the Edi signal (Edidelta) were measured. Clinical parameters (heart rate, respiratory rate and fraction of inspired oxygen) were also recorded. RESULTS Forty preterm infants were recruited at a mean corrected gestational age of 31.6 (±2.7) weeks. Data from 156 weaning steps were analysed, 91% of which were successful. Edi did not change significantly from baseline during flow reduction steps, but a significant increase in diaphragm activity was observed when discontinuing HF (median increase in Edidelta immediately post-discontinuation 1.7 µV (95% CI: 0.6 to 3.0)) and at 24 hours 1.9 µV (95% CI: 0.7 to 3.8)). No significant difference in diaphragm activity was observed between successful and unsuccessful weaning steps. CONCLUSIONS A protocolised approach to weaning has a high probability of success. Edi does not change with reducing HF rate, but significantly increases with discontinuation of HF from 2 L/min.
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Affiliation(s)
- Rebecca Naples
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alan C Fenton
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Malcolm Brodlie
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
| | - Sundeep Harigopal
- Newcastle Neonatal Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Chris O'Brien
- Paediatric Respiratory Medicine, Great North Children's Hospital, Newcastle upon Tyne, UK
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Gurumahan V, Thavalingam S, Schindler T, Smyth J, Lui K, Bolisetty S. Reference values for diaphragm electrical activity (Edi) in newborn infants. BMC Pediatr 2022; 22:559. [PMID: 36151518 PMCID: PMC9502911 DOI: 10.1186/s12887-022-03619-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 09/12/2022] [Indexed: 11/10/2022] Open
Abstract
Background Neurally adjusted ventilatory assist is an emerging mode of respiratory support that uses the electrical activity of the diaphragm (Edi) to provide synchronised inspiratory pressure support, proportional to an infant’s changing inspiratory effort. Data on Edi reference values for neonates are limited. The objective of this study was to establish reference Edi values for preterm and term neonates who are not receiving respiratory support. Methods This was a prospective observational study of newborn infants breathing spontaneously in room air. The Edi waveform was monitored by a specialised naso/orogastric feeding tube with embedded electrodes positioned at the level of the diaphragm. Edi minimums and peaks were recorded continuously for 4 h without changes to routine clinical handling. Results Twenty-four newborn infants (16 preterm [< 37 weeks’ gestation]; 8 term) were studied. All infants were breathing comfortably in room air at the time of study. Edi data were successfully captured in all infants. The mean (±SD) Edi minimum was 3.02 (±0.94) μV and the mean Edi peak was 10.13 (±3.50) μV. In preterm infants the mean (±SD) Edi minimum was 3.05 (±0.91) μV and the mean Edi peak was 9.36 (±2.13) μV. In term infants the mean (±SD) Edi minimum was 2.97 (±1.05) μV and the mean Edi peak was 11.66 (±5.14) μV. Conclusion Reference Edi values were established for both preterm and term neonates. These values can be used as a guide when monitoring breathing support and when using diaphragm-triggered modes of respiratory support in newborn infants Supplementary Information The online version contains supplementary material available at 10.1186/s12887-022-03619-1.
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Affiliation(s)
| | - Sriganesh Thavalingam
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia
| | - Tim Schindler
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia.,Department of Newborn Care, Royal Hospital for Women, Newborn Care, Royal Hospital for Women, Barker St, Randwick, Sydney, NSW, 2031, Australia
| | - John Smyth
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia.,Department of Newborn Care, Royal Hospital for Women, Newborn Care, Royal Hospital for Women, Barker St, Randwick, Sydney, NSW, 2031, Australia
| | - Kei Lui
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia.,Department of Newborn Care, Royal Hospital for Women, Newborn Care, Royal Hospital for Women, Barker St, Randwick, Sydney, NSW, 2031, Australia
| | - Srinivas Bolisetty
- School of Women's and Children's Health, University of New South Wales, Sydney, Australia. .,Department of Newborn Care, Royal Hospital for Women, Newborn Care, Royal Hospital for Women, Barker St, Randwick, Sydney, NSW, 2031, Australia.
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Latremouille S, Bhuller M, Shalish W, Sant'Anna G. Cardiorespiratory measures shortly after extubation and extubation outcomes in extremely preterm infants. Pediatr Res 2022; 93:1687-1693. [PMID: 36057645 DOI: 10.1038/s41390-022-02284-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Nasal continuous positive airway pressure, nasal intermittent positive pressure ventilation, and non-invasive neurally adjusted ventilatory assist are modes of non-invasive respiratory support. The objective was to investigate if cardiorespiratory measures performed shortly after extubation are associated with extubation outcomes and predictors of extubation success. METHODS Randomized crossover trial of infants with birth weight (BW) ≤ 1250 g undergoing their first extubation. Shortly after extubation, electrocardiogram and electrical activity of the diaphragm (Edi) were recorded during 40 min on each mode. Measures of heart rate variability (HRV), diaphragmatic activity (Edi area, breath area and amplitude), and respiratory variability (RV) were computed on each mode and compared between infants with extubation success or failure (reintubation ≤ 7 days). RESULTS Twenty-three extremely preterm infants with median [IQR] gestational age 25.9 weeks [25.2-26.4] and BW 760 g [595-900] were included: 14 success and 9 failures. There were significant differences for HRV (very low-frequency power and sample entropy) and RV parameters (breath areas, amplitudes and expiratory times) between groups, with moderate strength (0.75-0.80 areas under ROC curves) in predicting success. Diaphragmatic activity measures were similar between groups. CONCLUSIONS In extremely preterm infants receiving non-invasive respiratory support shortly after extubation, several cardiorespiratory variability parameters were associated with successful extubation with moderate predictive accuracy. IMPACT Measures of cardiorespiratory variability, performed in extremely preterm infants while receiving NCPAP, NIPPV, and NIV-NAVA shortly after extubation, were significantly different between patients that succeeded or failed extubation. Cardiorespiratory variability measures had a moderate predictive accuracy for extubation success and can be potentially used as biomarkers, in recently extubated infants. Future investigations in this population may also consider including cardiorespiratory variability measures when assessing types of post-extubation respiratory support and promote individualized care.
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Affiliation(s)
- Samantha Latremouille
- Division of Experimental Medicine, McGill University Health Center, Montreal, QC, Canada
| | - Monica Bhuller
- Division of Experimental Medicine, McGill University Health Center, Montreal, QC, Canada
| | - Wissam Shalish
- Assistant Professor of Pediatrics, Division of Neonatology, McGill University Health Center, Montreal, QC, Canada
| | - Guilherme Sant'Anna
- Professor of Pediatrics, Division of Neonatology, McGill University Health Center, Montreal, QC, Canada.
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Shin SH, Shin SH, Kim SH, Song IG, Jung YH, Kim EK, Kim HS. Noninvasive Neurally Adjusted Ventilation in Postextubation Stabilization of Preterm Infants: A Randomized Controlled Study. J Pediatr 2022; 247:53-59.e1. [PMID: 35460702 DOI: 10.1016/j.jpeds.2022.04.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/07/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare the effects of noninvasive neurally adjusted ventilatory assist (NIV-NAVA) to nasal continuous positive airway pressure (NCPAP) in achieving successful extubation in preterm infants. STUDY DESIGN This prospective, single-center, randomized controlled trial enrolled preterm infants born at <30 weeks of gestation who received invasive ventilation. Participants were assigned at random to either NIV-NAVA or NCPAP after their first extubation from invasive ventilation. The primary outcome of the study was extubation failure within 72 hours of extubation. Electrical activity of the diaphragm (Edi) values were collected before extubation and at 1, 4, 12, and 24 hours after extubation. RESULTS A total of 78 infants were enrolled, including 35 infants in the NIV-NAVA group and 35 infants in the NCPAP group. Extubation failure within 72 hours of extubation was higher in the NCPAP group than in the NIV-NAVA group (28.6% vs 8.6%; P = .031). The duration of respiratory support and incidence of severe bronchopulmonary dysplasia were similar in the 2 groups. Peak and swing Edi values were comparable before and at 1 hour after extubation, but values at 4, 12, and 24 hours after extubation were lower in the NIV-NAVA group compared with the NCPAP group. CONCLUSIONS In the present trial, NIV-NAVA was more effective than NCPAP in preventing extubation failure in preterm infants. TRIAL REGISTRATION ClinicalTrials.gov: NCT02590757.
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Affiliation(s)
- Seung Han Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Seung Hyun Shin
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seh Hyun Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - In Gyu Song
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Korea University Guro Hospital, Seoul, Republic of Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Seoul National University Bundang Hospital, Sungnam-si, Republic of Korea
| | - Ee-Kyung Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Republic of Korea; Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Republic of Korea.
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Abstract
Patient-ventilator asynchrony is very common in newborns. Achieving synchrony is quite challenging because of small tidal volumes, high respiratory rates, and the presence of leaks. Leaks also cause unreliable monitoring of respiratory metrics. In addition, ventilator adjustment must take into account that infants have strong vagal reflexes and demonstrate central apnea and periodic breathing, with a high variability in breathing pattern. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation whereby the timing and amount of ventilatory assist is controlled by the patient's own neural respiratory drive. As NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized assist, both invasively and noninvasively (NIV-NAVA), to follow the variability in breathing pattern, and to monitor patient respiratory drive, independent of leaks. This article provides an updated review of the physiology and the scientific literature pertaining to the use of NAVA in children (neonatal and pediatric age groups). Both the invasive NAVA and NIV-NAVA publications since 2016 are summarized, as well as the use of Edi monitoring. Overall, the use of NAVA and Edi monitoring is feasible and safe. Compared with conventional ventilation, NAVA improves patient-ventilator interaction, provides lower peak inspiratory pressure, and lowers oxygen requirements. Evidence from several studies suggests improved comfort, less sedation requirements, less apnea, and some trends toward reduced length of stay and more successful extubation.
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Affiliation(s)
- Jennifer Beck
- Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B1W8, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada.
| | - Christer Sinderby
- Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B1W8, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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10
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Latremouille S, Bhuller M, Shalish W, Sant'Anna G. Cardiorespiratory effects of NIV-NAVA, NIPPV, and NCPAP shortly after extubation in extremely preterm infants: A randomized crossover trial. Pediatr Pulmonol 2021; 56:3273-3282. [PMID: 34379891 DOI: 10.1002/ppul.25607] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 07/05/2021] [Accepted: 07/29/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Investigate the cardiorespiratory effects of noninvasive neurally adjusted ventilatory assist (NIV-NAVA), nonsynchronized nasal intermittent positive pressure ventilation (NIPPV), and nasal continuous positive airway pressure (NCPAP) shortly after extubation. HYPOTHESIS Types of noninvasive pressure support and the presence of synchronization may affect cardiorespiratory parameters. STUDY DESIGN Randomized crossover trial. PATIENT-SUBJECT SELECTION Infants with birth weight (BW) 1250 g or under, undergoing their first planned extubation were randomly assigned to all three modes using a computer-generated sequence. METHODOLOGY Electrocardiogram and electrical activity of the diaphragm (Edi) were recorded for 30 min on each mode. Analysis of heart rate variability (HRV), diaphragmatic activity (Edi area, breath area, amplitude, inspiratory and expiratory times), and respiratory variability were compared between modes. RESULTS Twenty-three infants had full data recordings and analysis: Median (IQR) gestational age = 25.9 weeks (25.2-26.4), BW = 760 g (595-900), and postnatal age 7 (4-19) days. There were no differences in HRV between modes. A significantly reduced Edi area and breath amplitude, and increased coefficient of variation (CV) of breath amplitude were observed during NIV-NAVA and NIPPV compared to NCPAP. A higher proportion of assisted breaths (99% vs. 51%; p < .001) provided a higher mean airway pressure (MAP; 9.4 vs. 8.2 cmH2 O; p = .002) with lower peak inflation pressures (PIPs; 14 vs. 16 cmH2 O; p < .001) during NIV-NAVA compared to NIPPV. CONCLUSIONS NIV-NAVA and NIPPV applied shortly after extubation were associated with lower respiratory efforts and higher respiratory variability. These effects were more evident for NIV-NAVA where optimal patient-ventilator synchronization provided a higher MAP with lower PIPs.
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Affiliation(s)
- Samantha Latremouille
- Division of Experimental Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Monica Bhuller
- Division of Experimental Medicine, McGill University Health Center, Montreal, Quebec, Canada
| | - Wissam Shalish
- Division of Neonatology, McGill University Health Center, Montreal, Quebec, Canada
| | - Guilherme Sant'Anna
- Division of Neonatology, McGill University Health Center, Montreal, Quebec, Canada
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11
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Effects of heliox and non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm infants. Sci Rep 2021; 11:15778. [PMID: 34349223 PMCID: PMC8338984 DOI: 10.1038/s41598-021-95444-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/23/2021] [Indexed: 12/02/2022] Open
Abstract
Due to its unique properties, helium–oxygen (heliox) mixtures may provide benefits during non-invasive ventilation, however, knowledge regarding the effects of such therapy in premature infants is limited. This is the first report of heliox non-invasive neurally adjusted ventilatory assist (NIV-NAVA) ventilation applied in neonates born ≤ 32 weeks gestational age. After baseline NIV-NAVA ventilation with a standard mixture of air and oxygen, heliox was introduced for 3 h, followed by 3 h of air-oxygen. Heart rate, peripheral capillary oxygen saturation, cerebral oxygenation, electrical activity of the diaphragm (Edi) and selected ventilatory parameters (e.g., respiratory rate, peak inspiratory pressure) were continuously monitored. We found that application of heliox NIV-NAVA in preterm infants was feasible and associated with a prompt and significant decrease of Edi suggesting reduced respiratory effort, while all other parameters were stable throughout the study, and had similar values during heliox and air-oxygen ventilation. This therapy may potentially enhance the efficacy of non-invasive respiratory support in preterm neonates and reduce the number of infants progressing to ventilatory failure.
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12
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Sindelar R, McKinney RL, Wallström L, Keszler M. Proportional assist and neurally adjusted ventilation: Clinical knowledge and future trials in newborn infants. Pediatr Pulmonol 2021; 56:1841-1849. [PMID: 33721418 DOI: 10.1002/ppul.25354] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 02/16/2021] [Accepted: 03/02/2021] [Indexed: 11/07/2022]
Abstract
Different types of patient triggered ventilator modes have become the mainstay of ventilation in term and preterm newborn infants. Maintaining spontaneous breathing has allowed for earlier weaning and the additive effects of respiratory efforts combined with pre-set mechanical inflations have reduced mean airway pressures, both of which are important components in trying to avoid lung injury and promote normal lung development. New sophisticated modes of assisted ventilation have been developed during the last decades where the control of ventilator support is turned over to the patient. The ventilator detects the respiratory effort and adjusts ventilatory assistance proportionally to each phase of the respiratory cycle, thus enabling the patient to have full control of the start, the duration and the amount of ventilatory assistance. In this paper we will review the literature on the ventilatory modes of proportional assist ventilation and neurally adjusted ventilatory assistance, examine the different ways the signals are analyzed, propose future studies, and suggest ways to apply these modes in the clinical environment.
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Affiliation(s)
- Richard Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Robin L McKinney
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Linda Wallström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Providence, Rhode Island
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Kato Y, Takemoto A, Oumi C, Hisaichi T, Shimaji Y, Takaoka M, Moriyama H, Hirata K, Wada K. Effects of skin-to-skin care on electrical activity of the diaphragm in preterm infants during neurally adjusted ventilatory assist. Early Hum Dev 2021; 157:105379. [PMID: 33962362 DOI: 10.1016/j.earlhumdev.2021.105379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Skin-to-skin care (SSC) reduces neonatal mortality and morbidity and is widely implemented in the neonatal intensive care unit. However, changes in respiratory effort during SSC in ventilated preterm infants remain unclear. AIMS To evaluate the effect of SSC on electrical activity of the diaphragm (Edi) and vital signs in premature infants who are intubated and under neurally adjusted ventilatory assist ventilation. STUDY DESIGN We performed an observational cross-over study. Data were measured in three periods: before (pre-SSC period), during (SSC period), and after (post-SSC period) SSC. Stable 30-min data in each period were extracted. SUBJECTS Thirty-four SSC procedures were performed in 14 preterm infants with a median gestational age of 25.3 weeks (interquartile range, 24, 26.4) and a birth weight of 659 g (566, 694). The median postnatal age was 41 days (31, 53) at the study with a median postmenstrual age of 31.3 weeks (30.4, 32.5). OUTCOME MEASURES Median values of Edi peak, Edi minimum, respiratory rate, SpO2, and heart rate were measured in each condition. The Kruskal-Wallis test with Bonferroni multiple comparisons was used to compare each parameter in each period. RESULTS Median Edi peak and Edi minimum values were significantly lower during SSC compared with pre- and post-SSC, without any change in respiratory rate, SpO2, or heart rate. CONCLUSIONS Respiratory efforts as evaluated by Edi are significantly reduced during SSC in ventilated preterm infants.
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Affiliation(s)
- Yuta Kato
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Ayumi Takemoto
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Chiyo Oumi
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Tomomi Hisaichi
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Yuki Shimaji
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Misa Takaoka
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Hiroko Moriyama
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Katsuya Hirata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
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Diaphragmatic activity and neural breathing variability during a 5-min endotracheal continuous positive airway pressure trial in extremely preterm infants. Pediatr Res 2021; 89:1810-1817. [PMID: 32942291 PMCID: PMC7533985 DOI: 10.1038/s41390-020-01159-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Revised: 07/31/2020] [Accepted: 08/25/2020] [Indexed: 11/13/2022]
Abstract
BACKGROUND Extremely preterm infants are often exposed to endotracheal tube continuous positive airway pressure (ETT-CPAP) trials to assess extubation readiness. The effects of ETT-CPAP trial on their diaphragmatic activity (Edi) and breathing variability is unknown. METHODS Prospective observational study enrolling infants with birth weight ≤1250 g undergoing their first extubation attempt. Diaphragmatic activity, expressed as the absolute minimum (Edi min) and maximum values (Edi max), area under the Edi signal, and breath-by-breath analyses for breath areas, amplitudes, widths, and neural inspiratory and expiratory times, were analyzed during mechanical ventilation (MV) and ETT-CPAP. Neural breathing variability of each of these parameters was also calculated and compared between MV and ETT-CPAP. RESULTS Thirteen infants with median (interquartile range) birth weight of 800 g [610-920] and gestational age of 25.4 weeks [24.4-26.3] were included. Diaphragmatic activity significantly increased during ETT-CPAP when compared to MV:Edi max (44.2 vs. 38.1 μV), breath area (449 vs. 312 μV·s), and amplitude (10.12 vs. 7.46 μV). Neural breathing variability during ETT-CPAP was characterized by increased variability for amplitude and area under the breath, and decreased for breath time and width. CONCLUSIONS A 5-min ETT-CPAP in extremely preterm infants undergoing extubation imposed significant respiratory load with changes in respiratory variability. IMPACT ETT-CPAP trials are often used to assess extubation readiness in extremely preterm infants, but its effects upon their respiratory system are not well known. Diaphragmatic activity analysis demonstrated that these infants are able to mount an important response to a short trial. A 5-min trial imposed a significant respiratory load evidenced by increased diaphragmatic activity and changes in breathing variability. Differences in breathing variability were observed between successful and failed extubations, which should be explored further in extubation readiness investigations. This type of trial cannot be recommended for preterm infants in clinical practice until clear standards and accuracy are established.
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Svanberg EK, Larsson J, Rasmussen M, Larsson M, Leander D, Bergsten S, Bood J, Greisen G, Fellman V. Changes in pulmonary oxygen content are detectable with laser absorption spectroscopy: proof of concept in newborn piglets. Pediatr Res 2021; 89:823-829. [PMID: 32534453 PMCID: PMC7322222 DOI: 10.1038/s41390-020-0971-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/10/2020] [Accepted: 04/14/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND Using an optical method based on tunable diode laser absorption spectroscopy, we previously assessed oxygen (O2) and water vapor (H2O) content in a tissue phantom of the preterm infant lung. Here we applied this method on newborn piglets with induced lung complications. METHODS Five mechanically ventilated piglets were subjected to stepwise increased and decreased fraction of inspired oxygen (FiO2), to atelectasis using a balloon catheter in the right bronchus, and to pneumothorax by injecting air in the pleural cavity. Two diode lasers (764 nm for O2 gas absorption and 820 nm for H2O absorption) were combined in a probe delivering light either externally, on the skin, or internally, through the esophagus. The detector probe was placed dermally. RESULTS Calculated O2 concentrations increased from 20% (IQR 17-23%) when ventilated with room air to 97% (88-108%) at FiO2 1.0. H2O was only detectable with the internal light source. Specific light absorption and transmission patterns were identified in response to atelectasis and pneumothorax, respectively. CONCLUSIONS The optical method detected FiO2 variations and discriminated the two induced lung pathologies, providing a rationale for further development into a minimally invasive device for real-time monitoring gas changes in the lungs of sick newborn infants. IMPACT Optical spectroscopy can detect pulmonary complications in an animal model. Oxygen concentrations can be evaluated in the lungs. Presents a novel minimally invasive method to detect lung oxygenation and complications. Potential to be developed into a lung monitoring method in newborn infants. Potential for bed-side detection of pulmonary complications in newborn infants.
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Affiliation(s)
- Emilie Krite Svanberg
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Anesthesiology and Intensive Care Medicine and Skåne University Hospital, SE-221 85 Lund, Sweden
| | - Jim Larsson
- grid.4514.40000 0001 0930 2361Department of Physics, Lund University, P.O. Box 118, SE-221 00 Lund, Sweden
| | - Martin Rasmussen
- grid.475435.4Department of Neonatology, Copenhagen University Hospital—Rigshospitalet, 2300 Copenhagen, Denmark
| | - Marcus Larsson
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Lund, Sweden ,grid.411843.b0000 0004 0623 9987Pediatrics and Skåne University Hospital, SE-221 85 Lund, Sweden
| | | | - Sara Bergsten
- GPX Medical AB, Maskinvägen 1, SE-227 30 Lund, Sweden
| | - Joakim Bood
- grid.4514.40000 0001 0930 2361Department of Physics, Lund University, P.O. Box 118, SE-221 00 Lund, Sweden
| | - Gorm Greisen
- grid.475435.4Department of Neonatology, Copenhagen University Hospital—Rigshospitalet, 2300 Copenhagen, Denmark
| | - Vineta Fellman
- Department of Clinical Sciences, Lund University, Lund, Sweden. .,Pediatrics and Skåne University Hospital, SE-221 85, Lund, Sweden. .,University of Helsinki, Helsinki University Hospital, Children's Hospital, FI-00014, Helsinki, Finland.
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Iwasaki E, Hirata K, Morikawa K, Nozaki M, Mochizuki N, Hirano S, Wada K. Postnatal physiological changes in electrical activity of the diaphragm in extremely preterm infants. Pediatr Pulmonol 2020; 55:1969-1973. [PMID: 32470214 DOI: 10.1002/ppul.24873] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 05/23/2020] [Accepted: 05/26/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES This study aimed to describe postnatal physiological changes in maximum values of peak electrical activity of the diaphragm (Edi) in extremely preterm infants during the preterm period. WORKING HYPOTHESIS The amplitude and frequency of neural sigh are different at each postmenstrual age in extremely preterm infants. STUDY DESIGN A retrospective, observational study. PATIENT-SUBJECT SELECTION Edi values were evaluated in 14 extremely preterm infants with neurally-adjusted ventilatory assist. METHODOLOGY Data of Edi peak and Edi minimum were collected from a ventilator. Edi-sigh was defined as the Edi peak value that was more than twice as large as the median Edi peak at each postmenstrual week in each patient. The frequency of Edi-sigh, and median values of Edi-sigh, Edi peak, and Edi minimum were evaluated at each postmenstrual week. The Jonckheere-Terpstra test was used to analyze the trend between postmenstrual weeks and Edi values. RESULTS From 26 to 35 postmenstrual weeks, the number of Edi-sighs per hour significantly increased as postmenstrual weeks increased (P < .001). Furthermore, the median values of Edi-sigh significantly increased as postmenstrual weeks increased (16.9 µV at 26 weeks to 25.4 µV at 35 weeks, P < .001). There were no significant changes in the median values of Edi peak and Edi minimum at each week. CONCLUSIONS The amplitude and frequency of neural sigh in extremely preterm infants increase with the number of postmenstrual weeks.
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Affiliation(s)
- Eriko Iwasaki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Katsuya Hirata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kazue Morikawa
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Masatoshi Nozaki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Narutaka Mochizuki
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Shinya Hirano
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, Osaka, Japan
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Brenne H, Grunewaldt KH, Follestad T, Bergseng H. A randomised cross-over study showed no difference in diaphragm activity during weaning from respiratory support. Acta Paediatr 2018; 107:1726-1732. [PMID: 29504671 DOI: 10.1111/apa.14303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 01/18/2018] [Accepted: 02/26/2018] [Indexed: 11/29/2022]
Abstract
AIM We measured electrical activity of the diaphragm (Edi) to compare the breathing effort in preterm infants during weaning from respiratory support with high-flow nasal cannulae (HFNC) or nasal continuous positive airway pressure (nCPAP). METHODS This randomised cross-over study was carried out at St Olav's University Hospital, Trondheim, Norway, from December 2013 to June 2015. We gave 21 preterm infants weighing at least 1000 g HFNC 6 L/minute for four hours and nCPAP 3 cmH2 O for four hours with a one-hour wash-out period. Measurements included diaphragmatic load, Edi, vital signs and a modified Silverman-Andersen Retraction Score. RESULTS We found no differences in HFNC and nCPAP in the median Edi peak (8.0 μV versus 7.8 μV, p = 0.095), median Edi min (1.1 μV versus 1.2 μV in, p = 0.958) or mean heart rate (157 versus 159, p = 0.300) in the 21 infants who took part. The mean respiratory rate was significantly lower during HFNC than nCPAP (47 versus 52, p = 0.012). The modified Silverman-Andersen Retraction Score showed no significant differences. CONCLUSION This study of preterm infants found no difference in the breathing effort measured by Edi between HFNC 6 L/minute and nCPAP 3 cmH2 O. HFNC could replace nCPAP when preterm infants are ready for weaning.
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Affiliation(s)
- Hilde Brenne
- Department of Pediatrics; St. Olav University Hospital; Trondheim Norway
| | - Kristine Hermansen Grunewaldt
- Department of Pediatrics; St. Olav University Hospital; Trondheim Norway
- Department of Laboratory Medicine, Children's and Women's Health; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - Turid Follestad
- Department of Public Health and Nursing; Faculty of Medicine; Norwegian University of Science and Technology (NTNU); Trondheim Norway
| | - Håkon Bergseng
- Department of Pediatrics; St. Olav University Hospital; Trondheim Norway
- Department of Laboratory Medicine, Children's and Women's Health; Norwegian University of Science and Technology (NTNU); Trondheim Norway
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Firestone KS, Beck J, Stein H. Neurally Adjusted Ventilatory Assist for Noninvasive Support in Neonates. Clin Perinatol 2016; 43:707-724. [PMID: 27837754 DOI: 10.1016/j.clp.2016.07.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Noninvasive ventilation (NIV) is frequently used in the NICU to avoid intubation or as postextubation support for spontaneously breathing infants experiencing respiratory distress. Neurally adjusted ventilatory assist (NAVA) is used as a mode of noninvasive support in which both the timing and degree of ventilatory assist are controlled by the patient. NIV-NAVA has been successfully used clinically in neonates as a mode of ventilation to prevent intubation, allow early extubation, and as a novel way to deliver nasal continuous positive airway pressure.
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Affiliation(s)
- Kimberly S Firestone
- Neonatal Respiratory Outreach Clinical Liaison, Neonatal Intensive Care Unit, Neonatology Department, Akron Children's Hospital, One Perkins Square, Akron, OH 44308, USA
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Department of Pediatrics, University of Toronto, 30 Bond Street, Toronto, ON M5B 1W8, Canada; Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St. Michael's Hospital, Department of Chemistry and Biology, 350 Victoria Street, Toronto, ON M5B 2K3, Canada
| | - Howard Stein
- Neonatal Intensive Care Unit, Promedica Toledo Children's Hospital, Department of Pediatrics, 2142 North Cove Boulevard, Toledo, OH 43606, USA; University of Toledo, Department of Pediatrics, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH 43614, USA.
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Impact of feeding method on diaphragm electrical activity and central apnea in preterm infants (FEAdi study). Early Hum Dev 2016; 101:33-7. [PMID: 27405054 DOI: 10.1016/j.earlhumdev.2016.05.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Revised: 04/12/2016] [Accepted: 05/10/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND In preterm infants, it is unknown whether feeding affects neural breathing pattern. OBJECTIVES By measuring the diaphragm electrical activity (Edi) waveform, we evaluated the effect of enteral feeding and compared the effects of feeding methods on neural breathing pattern and central apnea in very low birth weight preterm infants. METHODS In a prospective, randomized, crossover study, ten non-ventilated preterm infants with birth weights<1250g and tolerating full feeds were randomized to either bolus feeding (BF) or slow infusion feeding (SF) over 90min, followed by crossover to the other method at the next feed. Edi was continuously measured by a feeding catheter with miniaturized sensors. Five 15-min epochs were chosen [Baseline (BL), first 15min and 90min after BF/SF started] for breath-by-breath analyses of neural breathing pattern, including Edi peak, Edi min (end-expiratory), neural inspiratory and expiratory times, neural respiratory rate, and central apnea. Primary outcome was change in Edi min with feed. Secondary outcomes include change in Edi peak, frequency and duration of central apnea with feeding. RESULTS Although intrasubject coefficient of variation was not significantly different, individual responses to feeding and feeding method were variable. No significant difference in Edi timing, Edi min, Edi peak, or apnea was observed for the different epochs. CONCLUSIONS In this study cohort, neural breathing pattern does not appear to be consistently affected by enteral feeding or the feeding method. Compared with BF, SF does not appear to reduce the number or duration of apneas.
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Stein H, Beck J, Dunn M. Non-invasive ventilation with neurally adjusted ventilatory assist in newborns. Semin Fetal Neonatal Med 2016; 21:154-61. [PMID: 26899957 DOI: 10.1016/j.siny.2016.01.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation in which both the timing and degree of ventilatory assist are controlled by the patient. Since NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized non-invasive NAVA (NIV-NAVA) regardless of leaks and to monitor continuously patient respiratory pattern and drive. Advantages of NIV-NAVA over conventional modes include improved patient-ventilator interaction, reliable respiratory monitoring and self-regulation of respiratory support. In theory, these characteristics make NIV-NAVA an ideal mode to provide effective, appropriate non-invasive support to newborns with respiratory insufficiency. NIV-NAVA has been successfully used clinically in neonates as a mode of ventilation to prevent intubation, to allow early extubation, and as a novel way to deliver nasal continuous positive airway pressure. The use of NAVA in neonates is described with an emphasis on studies and clinical experience with NIV-NAVA.
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Affiliation(s)
- Howard Stein
- Neonatal Intensive Care Unit, Promedica Toledo Children's Hospital, Toledo, OH, USA; University of Toledo, Toledo, OH, USA
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St Michael's Hospital, Toronto, Ontario, Canada; Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada
| | - Michael Dunn
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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21
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Nasef N, El-Gouhary E, Schurr P, Reilly M, Beck J, Dunn M, Ng E. High-flow nasal cannulae are associated with increased diaphragm activation compared with nasal continuous positive airway pressure in preterm infants. Acta Paediatr 2015; 104:e337-43. [PMID: 25759095 DOI: 10.1111/apa.12998] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Revised: 10/30/2014] [Accepted: 03/09/2015] [Indexed: 11/28/2022]
Abstract
AIM High-flow nasal cannulae (HFNC) are increasingly used for respiratory management of preterm infants. However, their ability to provide support compared to nasal continuous positive airway pressure (CPAP) has been questioned. We compared the effect of HFNC versus nasal CPAP on diaphragm electrical activity (EAdi) in preterm infants. METHODS Preterm infants ≤1500 g were randomised in a crossover design to receive 2 hours of either Infant Flow(®) CPAP (IF-CPAP) at 5-6 cmH2 O or HFNC with the flow rate adjusted to achieve an equivalent pharyngeal pressure. A feeding catheter with miniaturised sensors was inserted for continuous EAdi measurement. RESULTS The study comprised ten infants. Physiologic parameters and oxygen requirements were not different between the two modes. However, seven infants demonstrated a higher EAdi peak and six showed a higher EAdi tonic on HFNC, even though the mean group data showed no difference between HFNC and IF-CPAP. Neural inspiratory time was significantly longer with HFNC than IF-CPAP (0.55 ± 0.11 versus 0.48 ± 0.06 seconds, p = 0.018). CONCLUSION In this cohort of preterm infants, the majority exhibited greater diaphragm activation, as assessed by neural breathing patterns, when supported with HFNC than IF-CPAP, suggesting that nasal CPAP may provide more effective respiratory support.
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Affiliation(s)
- Nehad Nasef
- Women and Babies Program; Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Enas El-Gouhary
- Women and Babies Program; Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Patti Schurr
- Women and Babies Program; Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Maureen Reilly
- Women and Babies Program; Sunnybrook Health Sciences Centre; Toronto ON Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science; Department of Critical Care; St. Michael's Hospital; Toronto ON Canada
| | - Michael Dunn
- Women and Babies Program; Sunnybrook Health Sciences Centre; Toronto ON Canada
- Division of Neonatology; Department of Paediatrics; University of Toronto; Toronto ON Canada
| | - Eugene Ng
- Women and Babies Program; Sunnybrook Health Sciences Centre; Toronto ON Canada
- Division of Neonatology; Department of Paediatrics; University of Toronto; Toronto ON Canada
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Emeriaud G, Larouche A, Ducharme-Crevier L, Massicotte E, Fléchelles O, Pellerin-Leblanc AA, Morneau S, Beck J, Jouvet P. Evolution of inspiratory diaphragm activity in children over the course of the PICU stay. Intensive Care Med 2014; 40:1718-26. [PMID: 25118865 DOI: 10.1007/s00134-014-3431-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/30/2014] [Indexed: 01/06/2023]
Abstract
PURPOSE Diaphragm function should be monitored in critically ill patients, as full ventilatory support rapidly induces diaphragm atrophy. Monitoring the electrical activity of the diaphragm (EAdi) may help assess the level of diaphragm activity, but such monitoring results are difficult to interpret because reference values are lacking. The aim of this study was to describe EAdi values in critically ill children during a stay in the pediatric intensive care unit (PICU), from the acute to recovery phases, and to assess the impact of ventilatory support on EAdi. METHODS This was a prospective longitudinal observational study of children requiring mechanical ventilation for ≥24 h. EAdi was recorded using a validated method in the acute phase, before extubation, after extubation, and before PICU discharge. RESULTS Fifty-five critically ill children were enrolled in the study. Median maximum inspiratory EAdi (EAdimax) during mechanical ventilation was 3.6 [interquartile range (IQR) 1.2-7.6] μV in the acute phase and 4.8 (IQR 2.0-10.7) μV in the pre-extubation phase. Periods of diaphragm inactivity (with no detectable inspiratory EAdi) were frequent during conventional ventilation, even with a low level of support. EAdimax in spontaneous ventilation was 15.4 (IQR 7.4-20.7) μV shortly after extubation and 12.6 (IQR 8.1-21.3) μV before PICU discharge. The difference in EAdimax between mechanical ventilation and post-extubation periods was significant (p < 0.001). Patients intubated mainly because of a lung pathology exhibited higher EAdi (p < 0.01), with a similar temporal increase. CONCLUSIONS This is the first systematic description of EAdi evolution in children during their stay in the PICU. In our patient cohort, diaphragm activity was frequently low in conventional ventilation, suggesting that overassistance or oversedation is common in clinical practice. EAdi monitoring appears to be a helpful tool to detect such situations.
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Affiliation(s)
- Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada,
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Abstract
Neurally adjusted ventilatory assist (NAVA) uses the electrical activity of the diaphragm (Edi) as a neural trigger to synchronize mechanical ventilatory breaths with the patient's neural respiratory drive. Using this signal enables the ventilator to proportionally support the patient's instantaneous drive on a breath-by-breath basis. Synchrony can be achieved even in the presence of significant air leaks, which make this an attractive choice for invasive and non-invasive ventilation of the neonate. This paper describes the Edi signal, neuroventilatory coupling, and patient-ventilator synchrony including the functional concept of NAVA. Safety features, NAVA terminology, and clinical application of NAVA to unload respiratory musculature are presented. The use of the Edi signal as a respiratory vital sign for conventional ventilation is discussed. The results of animal and adult studies are briefly summarized and detailed descriptions of all NAVA-related research in pediatric and neonatal patients are provided. Further studies are needed to determine whether NAVA will have significant impact on the overall outcomes of neonates.
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