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Kuitunen I, Rannankari M, Räsänen K. Neurally adjusted ventilatory assist (NAVA) in neonatal and pediatric critical care-A scoping review of randomized controlled trials. Pediatr Pulmonol 2024. [PMID: 39330622 DOI: 10.1002/ppul.27293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 09/05/2024] [Accepted: 09/18/2024] [Indexed: 09/28/2024]
Abstract
We Aimed to analyze for which indications neurally adjusted ventilatory assist (NAVA) has been studied in pediatric patients by conducting a scoping review. PubMed, Scopus, and Web of Science databases were searched in September 2023. We included all randomized trials (including crossover, parallel, and cluster) comparing NAVA to other invasive ventilation modalities in children aged <18 years. We had three key outcomes. What have been the patient and disease groups where NAVA has been studied? What kind of trials and what has been the risk of bias in these randomized trials? What have been the most used outcomes and main findings? The risk of bias was assessed according to the risk of bias 2.0 tool. This review has been reported as preferred in PRISMA-ScR guidelines. After screening 367 abstracts, 27 full reports were assessed and finally 13 studies were included. Six studies were conducted in neonates and seven in older pediatric patients. Ten of the studies were crossover and three were parallel randomized. Overall risk of bias was low in two studies, had some concerns in six studies, and was high in five studies. Most issues came from the randomization process and bias in the selection of reported results. Most used outcomes were changes in clinical parameters or measurements (such as ventilation peak and mean airway pressures, oxygenation index), and ventilator synchrony. Three parallel group trials focused on ventilation duration. The majority of the studies found NAVA as a possible alternative ventilation strategy. Although NAVA is a widely used strategy in neonatal and pediatric intensive care the current literature has notable limitations due to the risk of bias in the original studies and lack of parallel studies focusing on clinical or cost-effectiveness outcomes.
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Affiliation(s)
- Ilari Kuitunen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics and Neonatology, Kuopio University Hospital, Kuopio, Finland
| | - Markus Rannankari
- Department of Pediatrics and Neonatology, Kuopio University Hospital, Kuopio, Finland
| | - Kati Räsänen
- Institute of Clinical Medicine and Department of Pediatrics, University of Eastern Finland, Kuopio, Finland
- Department of Pediatrics and Neonatology, Kuopio University Hospital, Kuopio, Finland
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2
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Lefevere J, van Delft B, Decaluwe W, Derriks F, Cools F. Neurally adjusted ventilatory assist in preterm infants: A systematic review and meta-analysis. Pediatr Pulmonol 2024; 59:1862-1870. [PMID: 38568097 DOI: 10.1002/ppul.27001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/22/2024] [Accepted: 03/23/2024] [Indexed: 07/22/2024]
Abstract
To compare the effects of neurally adjusted ventilatory assist (NAVA) with other forms of synchronized artificial ventilation in preterm infants. A systematic review of randomized and quasi-randomized controlled trials with individual group allocation, both parallel-group trials as well as crossover trials, that included preterm infants born at less than 37 weeks gestational age and compared NAVA with any other form of synchronized mechanical ventilation with or without volume guarantee. Primary outcomes were death or bronchopulmonary dysplasia (BPD) at 36 weeks, total duration of respiratory support and neurodevelopmental outcome at 2 years. Secondary outcomes consisted of important procedural and clinical outcomes. Seven studies with a total of 191 infants were included, five randomized crossover trials and two parallel group randomized trials. No significant difference in the primary outcome of death or BPD (RR: 1.08, 95% CI: 0.33-3.55) was found. Peak inspiratory pressures were significantly lower with NAVA than with other forms of ventilation (MD -1.83 cmH2O [95% CI: -2.95 to -0.71]). No difference in any other clinical or ventilatory outcome was detected. Although associated with lower peak inspiratory pressures, the use of NAVA does not result in a reduced risk of death or BPD as compared to other forms of synchronized ventilation in preterm infants. However, the certainty of evidence is low due to imprecision of the effect estimate. Larger studies are needed to detect possible short- and long-term differences between ventilation modes.
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Affiliation(s)
| | | | - Wim Decaluwe
- Department of Neonatology, AZ Sint-Jan, Brugge, Belgium
| | - Frank Derriks
- Department of Neonatology, UZ Brussel, Jette, Belgium
- Department of Neonatology, Clinique universitaires de Bruxelles, Hôpital Erasme, Bruxelles, Belgium
| | - Filip Cools
- Department of Neonatology, UZ Brussel, Jette, Belgium
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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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Lyle ANJ, Shaikh H, Oslin E, Gray MM, Weiss EM. Race and Ethnicity of Infants Enrolled in Neonatal Clinical Trials: A Systematic Review. JAMA Netw Open 2023; 6:e2348882. [PMID: 38127349 PMCID: PMC10739112 DOI: 10.1001/jamanetworkopen.2023.48882] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 11/08/2023] [Indexed: 12/23/2023] Open
Abstract
Importance Representativeness of populations within neonatal clinical trials is crucial to moving the field forward. Although racial and ethnic disparities in research inclusion are well documented in other fields, they are poorly described within neonatology. Objective To describe the race and ethnicity of infants included in a sample of recent US neonatal clinical trials and the variability in this reporting. Evidence Review A systematic search of US neonatal clinical trials entered into Cochrane CENTRAL 2017 to 2021 was conducted. Two individuals performed inclusion determination, data extraction, and quality assessment independently with discrepancies adjudicated by consensus. Findings Of 120 studies with 14 479 participants that met the inclusion criteria, 75 (62.5%) included any participant race or ethnicity data. In the studies that reported race and ethnicity, the median (IQR) percentage of participants of each background were 0% (0%-1%) Asian, 26% (9%-42%) Black, 3% (0%-12%) Hispanic, 0% (0%-0%) Indigenous (eg, Alaska Native, American Indian, and Native Hawaiian), 0% (0%-0%) multiple races, 57% (30%-68%) White, and 7% (1%-21%) other race or ethnicity. Asian, Black, Hispanic, and Indigenous participants were underrepresented, while White participants were overrepresented compared with a reference sample of the US clinical neonatal intensive care unit (NICU) population from the Vermont Oxford Network. Many participants were labeled as other race or ethnicity without adequate description. There was substantial variability in terms and methods of reporting race and ethnicity data. Geographic representation was heavily skewed toward the Northeast, with nearly one-quarter of states unrepresented. Conclusions and Relevance These findings suggest that neonatal research may perpetuate inequities by underrepresenting Asian, Black, Hispanic, and Indigenous neonates in clinical trials. Studies varied in documentation of race and ethnicity, and there was regional variation in the sites included. Based on these findings, funders and clinical trialists are advised to consider a 3-point targeted approach to address these issues: prioritize identifying ways to increase diversity in neonatal clinical trial participation, agree on a standardized method to report race and ethnicity among neonatal clinical trial participants, and prioritize the inclusion of participants from all regions of the US in neonatal clinical trials.
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Affiliation(s)
- Allison N J Lyle
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Henna Shaikh
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Ellie Oslin
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, Washington
| | - Megan M Gray
- Department of Pediatrics, University of Washington School of Medicine, Seattle
| | - Elliott Mark Weiss
- Department of Pediatrics, University of Washington School of Medicine, Seattle
- Treuman Katz Center for Pediatric Bioethics and Palliative Care, Seattle Children's Research Institute, Seattle, Washington
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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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Pavlek LR, Rivera BK, Smith CV, Randle J, Hanlon C, Small K, Bell EF, Rysavy MA, Conroy S, Backes CH. Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review. J Pediatr 2021; 235:63-74.e12. [PMID: 33894262 PMCID: PMC9348995 DOI: 10.1016/j.jpeds.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation). STUDY DESIGN PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale. RESULTS Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation. CONCLUSIONS The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.
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Affiliation(s)
- Leeann R. Pavlek
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Brian K. Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital
| | - Charles V. Smith
- Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
| | - Joanie Randle
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Cory Hanlon
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Kristi Small
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Edward F. Bell
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Matthew A. Rysavy
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Sara Conroy
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University,Biostatistics Resource at Nationwide Children’s Hospital
| | - Carl H. Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH,Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH,Obstetrics and Gynecology, The Ohio State University Wexner Medical Center,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
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8
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McKinney RL, Keszler M, Truog WE, Norberg M, Sindelar R, Wallström L, Schulman B, Gien J, Abman SH. Multicenter Experience with Neurally Adjusted Ventilatory Assist in Infants with Severe Bronchopulmonary Dysplasia. Am J Perinatol 2021; 38:e162-e166. [PMID: 32208500 DOI: 10.1055/s-0040-1708559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study is to determine patterns of neurally adjusted ventilatory assist (NAVA) use in ventilator-dependent preterm infants with evolving or established severe bronchopulmonary dysplasia (sBPD) among centers of the BPD Collaborative, including indications for its initiation, discontinuation, and outcomes. STUDY DESIGN Retrospective review of infants with developing or established sBPD who were placed on NAVA after ≥4 weeks of mechanical ventilation and were ≥ 30 weeks of postmenstrual age (PMA). RESULTS Among the 13 sites of the BPD collaborative, only four centers (31%) used NAVA in the management of infants with evolving or established BPD. A total of 112 patients met inclusion criteria from these four centers. PMA, weight at the start of NAVA and median number of days on NAVA, were different among the four centers. The impact of NAVA therapy was assessed as being successful in 67% of infants, as defined by the ability to achieve respiratory stability at a lower level of ventilator support, including extubation to noninvasive positive pressure ventilation or support with a home ventilator. In total 87% (range: 78-100%) of patients survived until discharge. CONCLUSION We conclude that NAVA can be used safely and effectively in selective infants with sBPD. Indications and current strategies for the application of NAVA in infants with evolving or established BPD, however, are highly variable between centers. Although this pilot study suggests that NAVA may be successfully used for the management of infants with BPD, sufficient experience and well-designed clinical studies are needed to establish standards of care for defining the role of NAVA in the care of infants with sBPD.
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Affiliation(s)
- Robin L McKinney
- Department of Pediatric Critical Care Medicine, Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, Rhode Island
| | - Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island
| | - William E Truog
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Michael Norberg
- Department of Neonatology, Children's Mercy Hospital, Kansas City, Missouri
| | - Richard Sindelar
- Division of Neonatology, Department of Women's and Children's Health Uppsala University Children's Hospital, Uppsala, Sweden
| | - Linda Wallström
- Division of Neonatology, Department of Women's and Children's Health Uppsala University Children's Hospital, Uppsala, Sweden
| | - Bruce Schulman
- Department of Neonatology, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Jason Gien
- Department of Pediatrics, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
| | - Steven H Abman
- Department of Pediatrics, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
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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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Araki R, Tomotaki S, Akita M, Motokura K, Tomobe Y, Yamauchi T, Hanaoka S, Tomotaki H, Iwanaga K, Niwa F, Takita J, Kawai M. Effect of electrical activity of the diaphragm waveform patterns on SpO 2 for extremely preterm infants ventilated with neurally adjusted ventilatory assist. Pediatr Pulmonol 2021; 56:2094-2101. [PMID: 33823078 DOI: 10.1002/ppul.25396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/27/2021] [Accepted: 03/27/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aimed to evaluate the association between electrical activity of the diaphragm (Edi) waveform patterns and peripheral oxygen saturation (SpO2 ) in extremely preterm infants who are ventilated with neurally adjusted ventilatory assist (NAVA). STUDY DESIGN We conducted a retrospective cohort study at a level III neonatal intensive care unit. Extremely preterm infants born at our hospital between November 2019 and November 2020 and ventilated with NAVA were included. We collected Edi waveform data and classified them into four Edi waveform patterns, including the phasic pattern, central apnea pattern, irregular low-voltage pattern, and tonic burst pattern. We analyzed the Edi waveform pattern for the first 15 h of collectable data in each patient. To investigate the association between Edi waveform patterns and SpO2 , we analyzed the dataset every 5 min as one data unit. We compared the proportion of each waveform pattern between the desaturation (Desat [+]) and non-desaturation (Desat [-]) groups. RESULTS We analyzed collected data for 105 h (1260 data units). The proportion of the phasic pattern in the Desat (+) group was significantly lower than that in the Desat (-) group (p < .001). However, the proportions of the central apnea, irregular low-voltage, and tonic burst patterns in the Desat (+) group were significantly higher than those in the Desat (-) group (all p < .05). CONCLUSION Our results indicate that proportions of Edi waveform patterns have an effect on desaturation of SpO2 in extremely preterm infants who are ventilated with NAVA.
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Affiliation(s)
- Ryosuke Araki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Seiichi Tomotaki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Mitsuyo Akita
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kouji Motokura
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yutaro Tomobe
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Takeru Yamauchi
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shintaro Hanaoka
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hiroko Tomotaki
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kogoro Iwanaga
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Fusako Niwa
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Junko Takita
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiko Kawai
- Department of Pediatrics, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Villosis MFB, Barseghyan K, Ambat MT, Rezaie KK, Braun D. Rates of Bronchopulmonary Dysplasia Following Implementation of a Novel Prevention Bundle. JAMA Netw Open 2021; 4:e2114140. [PMID: 34181013 PMCID: PMC8239950 DOI: 10.1001/jamanetworkopen.2021.14140] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) rates in the United States remain high and have changed little in the last decade. OBJECTIVE To develop a consistent BPD prevention bundle in a systematic approach to decrease BPD. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study included 484 infants with birth weights from 501 to 1500 g admitted to a level 3 neonatal intensive care unit in the Kaiser Permanente Southern California system from 2009 through 2019. The study period was divided into 3 periods: 1, baseline (2009); 2, initial changes based on ongoing cycles of Plan-Do-Study-Act (2010-2014); and 3, full implementation of successive Plan-Do-Study-Act results (2015-2019). INTERVENTIONS A BPD prevention system of care bundle evolved with a shared mental model that BPD is avoidable. MAIN OUTCOMES AND MEASURES The primary outcome was BPD in infants with less than 33 weeks' gestational age (hereafter referred to as BPD <33). Other measures included adjusted BPD <33, BPD severity grade, and adjusted median postmenstrual age (PMA) at hospital discharge. Balancing measures were adjusted mortality and adjusted mortality or specified morbidities. RESULTS The study population included 484 infants with a mean (SD) birth weight of 1070 (277) g; a mean (SD) gestational age of 28.6 (2.9) weeks; 252 female infants (52.1%); and 61 Black infants (12.6%). During the 3 study periods, BPD <33 decreased from 9 of 29 patients (31.0%) to 3 of 184 patients (1.6%) (P < .001 for trend); special cause variation was observed. The standardized morbidity ratio for the adjusted BPD <33 decreased from 1.2 (95% CI, 0.7-1.9) in 2009 to 0.4 (95% CI, 0.2-0.8) in 2019. The rates of combined grades 1, 2, and 3 BPD decreased from 7 of 29 patients (24.1%) to 17 of 183 patients (9.3%) (P < .008 for trend). Grade 2 BPD rates decreased from 3 of 29 patients (10.3%) to 5 of 183 patients (2.7%) (P = .02 for trend). Adjusted median PMA at home discharge decreased by 2 weeks, from 38.2 (95% CI, 37.3-39.1) weeks in 2009 to 36.8 (95% CI, 36.6-37.1) weeks during the last 3 years (2017-2019) of the full implementation period. Adjusted mortality was unchanged, whereas adjusted mortality or specified morbidities decreased significantly. CONCLUSIONS AND RELEVANCE A sustained low rate of BPD was observed in infants after the implementation of a detailed BPD system of care.
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Affiliation(s)
- Maria Fe B. Villosis
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Karine Barseghyan
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Ma. Teresa Ambat
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - Kambiz K. Rezaie
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
| | - David Braun
- Department of Pediatrics (Neonatology), Kaiser Permanente Panorama City, Panorama City, California
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena
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A multidisciplinary chronic lung disease team in a neonatal intensive care unit is associated with increased survival to discharge of infants with tracheostomy. J Perinatol 2021; 41:1963-1971. [PMID: 33795789 PMCID: PMC8013205 DOI: 10.1038/s41372-021-00974-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 11/20/2020] [Accepted: 01/27/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine if multidisciplinary team-based care of severe BPD/CLD infants improve survival to discharge. DESIGN/METHODS Retrospective review of severe BPD/CLD infants cared for by dedicated multidisciplinary CLD team using consensus-driven protocols and guidelines. RESULTS Total of 267 patients. Median gestational age was 26 weeks (IQR 24, 32); median birth-weight was 0.85 (IQR 0.64, 1.5). Twenty-four percent were preterm with severe BPD, 46% had other primary respiratory diseases (none BPD diseases). Total number of patients, proportion of patients with tracheostomy, prematurity, and genetic diagnoses increased over time. 88.8% survived to discharge. Unadjusted logistic regression showed that tracheostomy was not associated with odds of death; secondary pulmonary hypertension was associated with odds of tracheostomy (OR = 1.795 p value = 0.0264), or death (OR = 8.587 p value = <0.0001), or tracheostomy + death (OR = 13.58 p value = 0.0007). CONCLUSIONS Over time, mortality improved for infants with tracheostomy cared for by a multidisciplinary severe BPD/CLD team. Secondary pulmonary hypertension was associated with tracheostomy, or death, or tracheostomy + death.
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Vervenioti A, Fouzas S, Tzifas S, Karatza AA, Dimitriou G. Work of Breathing in Mechanically Ventilated Preterm Neonates. Pediatr Crit Care Med 2020; 21:430-436. [PMID: 32365285 DOI: 10.1097/pcc.0000000000002277] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To compare the imposed work of breathing by means of pressure-time product of the diaphragm in newborn infants receiving different modes of mechanical ventilation. DESIGN Prospective observational crossover study. SETTING Tertiary care neonatal unit. PATIENTS Forty preterm newborns (gestational age ≤ 37 wk) in the phase of weaning from mechanical ventilation. INTERVENTIONS Participants were ventilated in assist control, synchronized intermittent mandatory ventilation, and intermittent mandatory ventilation mode, in a crossover manner. The combination synchronized intermittent mandatory ventilation-pressure support (SIMV-PS) at 50% (SIMV-PS50) and 75% (SIMV-PS75) of the difference between peak inflating and positive end-expiratory pressure, was also applied in a subset of infants (n = 11). Each mode was maintained for 30 minutes. Transdiaphragmatic pressure was obtained by digital subtraction of esophageal from gastric pressure (both measured using a dual pressure-tipped catheter), and pressure-time product of the diaphragm was computed by integration of transdiaphragmatic pressure over inspiratory time. MEASUREMENTS AND MAIN RESULTS The pressure-time product of the diaphragm was 224.2 ± 112.8 in the intermittent mandatory ventilation mode, 165.8 ± 58.8 in the synchronized intermittent mandatory ventilation mode, and 125.5 ± 61.8 cm H2O × s × min in the assist control mode; all values were significantly different to each other (p < 0.0001). The pressure-time product of the diaphragm difference between assist control and intermittent mandatory ventilation, and assist control and synchronized intermittent mandatory ventilation was negatively related to postmenstrual age (regression coefficient, -0.365; p = 0.020 and -0.341; p = 0.031, respectively). In the SIMV-PS subcohort, the pressure-time product of the diaphragm was significantly higher in the intermittent mandatory ventilation mode as compared with assist control (p < 0.0001) or SIMV-PS75 (p = 0.0027), and in the synchronized intermittent mandatory ventilation mode as compared with assist control (p = 0.0301). CONCLUSIONS In preterm infants, patient-triggered ventilation modalities result in lower work of breathing than intermittent mandatory ventilation, while the assist control mode is also associated with lower pressure-time product of the diaphragm compared with synchronized intermittent mandatory ventilation. The difference in the imposed diaphragmatic workload between these ventilation modalities was inversely related to postmenstrual age, implying that less mature infants benefit more from assist control-based ventilation strategies.
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Affiliation(s)
- Aggeliki Vervenioti
- All authors: Neonatal Intensive Care Unit, Department of Pediatrics, University of Patras Medical School, Patras, Greece
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Hussain WA, Marks JD. Approaches to Noninvasive Respiratory Support in Preterm Infants: From CPAP to NAVA. Neoreviews 2019; 20:e213-e221. [PMID: 31261062 DOI: 10.1542/neo.20-4-e213] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Endotracheal intubation and invasive mechanical ventilation have been mainstays in respiratory care of neonates with respiratory distress syndrome. Together with antenatal steroids and surfactant, this approach has accounted for significant reductions in neonatal mortality. However, with the increased survival of very low birthweight infants, the incidence of bronchopulmonary dysplasia (BPD), the primary respiratory morbidity of prematurity, has also increased. Arrest of alveolar growth and development and the abnormal development of the pulmonary vasculature after birth are the primary causes of BPD. However, invasive ventilation-associated lung inflammation and airway injury have long been believed to be important contributors. In fact, discontinuing invasive ventilation in favor of noninvasive respiratory support has been considered the single best approach that neonatologists can implement to reduce BPD. In this review, we present and discuss the mechanisms, efficacy, and long-term outcomes of the four main approaches to noninvasive respiratory support of the preterm infant currently in use: nasal continuous positive airway pressure, high-flow nasal cannula, nasal intermittent mandatory ventilation, and neurally adjusted ventilatory assist. We show that noninvasive ventilation can decrease rates of intubation and the need for invasive ventilation in preterm infants with respiratory distress syndrome. However, none of these noninvasive approaches decrease rates of BPD. Accordingly, noninvasive respiratory support should be considered for clinical goals other than the reduction of BPD.
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Affiliation(s)
- Walid A Hussain
- Section of Neonatology, Department of Pediatrics, University of Chicago, Chicago, IL
| | - Jeremy D Marks
- Section of Neonatology, Department of Pediatrics, University of Chicago, Chicago, IL.,Committee on Neurobiology, Department of Neurology, University of Chicago, Chicago, IL
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