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Poole G, Harris C, Shetty S, Dassios T, Jenkinson A, Greenough A. Study protocol for a randomised cross-over trial of Neurally adjusted ventilatory Assist for Neonates with Congenital diaphragmatic hernias: the NAN-C study. Trials 2024; 25:72. [PMID: 38245741 PMCID: PMC10800044 DOI: 10.1186/s13063-023-07874-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation that delivers oxygen pressures in proportion to electrical signals of the diaphragm. The proportional assistance can be adjusted by the clinician to reduce the patient's work of breathing. Several case series of infants with congenital diaphragmatic hernias (CDH) have shown that NAVA may reduce oxygenation index and mean airway pressures. To date, no clinical trial has compared NAVA to standard methods of mechanical ventilation for babies with CDH. METHODS The aim of this dual-centre randomised cross-over trial is to compare post-operative NAVA with assist control ventilation (ACV) for infants with CDH. If eligible, infants will be enrolled for a ventilatory support tolerance trial (VSTT) to assess their suitability for randomisation. If clinically stable during the VSTT, infants will be randomised to receive either NAVA or ACV first in a 1:1 ratio for a 4-h period. The oxygenation index, respiratory severity score and cumulative sedative medication use will be measured. DISCUSSION Retrospective studies comparing NAVA to ACV in neonates with congenital diaphragmatic hernia have shown the ventilatory mode may improve respiratory parameters and benefit neonates. To our knowledge, this is the first prospective cross-over trial comparing NAVA to ACV. TRIAL REGISTRATION NAN-C was prospectively registered on ClinicalTrials.gov NCT05839340 Registered on May 2023.
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Affiliation(s)
- Grace Poole
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK.
| | - Christopher Harris
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Sandeep Shetty
- Neonatal Intensive Care Unit, St. George's University NHS Foundation Trust, London, UK
| | - Theodore Dassios
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Allan Jenkinson
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
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2
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Betz LH, Dillman JR, Jones BV, Tkach JA. MRI safety screening of children with implants: updates and challenges. Pediatr Radiol 2023; 53:1454-1468. [PMID: 37079039 DOI: 10.1007/s00247-023-05651-4] [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] [Received: 10/06/2022] [Revised: 03/15/2023] [Accepted: 03/18/2023] [Indexed: 04/21/2023]
Abstract
MRI is the imaging modality of choice for assessing many pediatric medical conditions. Although there are several inherent potential safety risks associated with the electromagnetic fields exploited for MRI, they are effectively mitigated through strict adherence to established MRI safety practices, enabling the safe and effective use of MRI in clinical practice. The potential hazards of the MRI environment may be exacerbated by/in the presence of implanted medical devices. Awareness of the unique MRI safety and screening challenges associated with these implanted devices is critical to ensuring MRI safety for the affected patients. In this review article, we will discuss the basics of MRI physics as they relate to MRI safety in the presence of implanted medical devices, strategies for assessing children with known or suspected implanted medical devices, and the particular management of several well-established common, as well as recently developed, implanted devices encountered at our institution.
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Affiliation(s)
- Lisa H Betz
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH, 45229, USA.
| | - Jonathan R Dillman
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Blaise V Jones
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jean A Tkach
- Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Ave, Cincinnati, OH, 45229, USA
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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3
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Koopman AA, van Dijk J, Oppersma E, Blokpoel RGT, Kneyber MCJ. Surface electromyography to quantify neuro-respiratory drive and neuro-mechanical coupling in mechanically ventilated children. Respir Res 2023; 24:77. [PMID: 36915106 PMCID: PMC10010013 DOI: 10.1186/s12931-023-02374-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Accepted: 02/22/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND The patient's neuro-respiratory drive, measured as electrical activity of the diaphragm (EAdi), quantifies the mechanical load on the respiratory muscles. It correlates with respiratory effort but requires a dedicated esophageal catheter. Transcutaneous (surface) monitoring of respiratory muscle electromyographic (sEMG) signals may be considered a suitable alternative to EAdi because of its non-invasive character, with the additional benefit that it allows for simultaneously monitoring of other respiratory muscles. We therefore sought to study the neuro-respiratory drive and timing of inspiratory muscles using sEMG in a cohort of children enrolled in a pediatric ventilation liberation trial. The neuro-mechanical coupling, relating the pressure generated by the inspiratory muscles to the sEMG signals of these muscles, was also calculated. METHODS This is a secondary analysis of data from a randomized cross-over trial in ventilated patients aged < 5 years. sEMG recordings of the diaphragm and parasternal intercostal muscles (ICM), esophageal pressure tracings and ventilator scalars were simultaneously recorded during continuous spontaneous ventilation and pressure controlled-intermittent mandatory ventilation, and at three levels of pressure support. Neuro-respiratory drive, timing of diaphragm and ICM relative to the mechanical ventilator's inspiration and neuro-mechanical coupling were quantified. RESULTS Twenty-nine patients were included (median age: 5.9 months). In response to decreasing pressure support, both amplitude of sEMG (diaphragm: p = 0.001 and ICM: p = 0.002) and neuro-mechanical efficiency indices increased (diaphragm: p = 0.05 and ICM: p < 0.001). Poor correlations between neuro-respiratory drive and respiratory effort were found, with R2: 0.088 [0.021-0.152]. CONCLUSIONS sEMG allows for the quantification of the electrical activity of the diaphragm and ICM in mechanically ventilated children. Both neuro-respiratory drive and neuro-mechanical efficiency increased in response to lower inspiratory assistance. There was poor correlation between neuro-respiratory drive and respiratory effort. TRIAL REGISTRATION ClinicalTrials.gov ID NCT05254691. Registered 24 February 2022, registered retrospectively.
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Affiliation(s)
- Alette A Koopman
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.
| | - Jefta van Dijk
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Eline Oppersma
- Cardiovascular and Respiratory Physiology Group, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Robert G T Blokpoel
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands
| | - Martin C J Kneyber
- Division of Paediatric Critical Care Medicine, Department of Paediatrics, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GZ, Groningen, The Netherlands.,Critical Care, Anaesthesiology, Peri-Operative & Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
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4
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Abstract
Respiratory care of premature neonates has witnessed substantial advances in the last two decades and has played a crucial role in decreasing early mortality in this population. This review outlines advances in techniques of synchronization and modes of synchronized invasive mechanical ventilation in neonates. The use of synchronized ventilation in the neonatal population was delayed as compared to adults, mainly because of technical reasons. Coordinating the infant's respiratory effort and the onset of mechanical ventilation in the neonatal population has requested high sensitivity instruments.
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Affiliation(s)
- Ilia Bresesti
- Division of Neonatology, "V.Buzzi" Children's Hospital, ASST-FBF-Sacco, Via Castelvetro 32, Milan 20154, Italy; Division of Neonatology, "F. Del Ponte" Hospital, Woman and Child Department, University of Insubria, Varese, Italy
| | - Massimo Agosti
- Division of Neonatology, "F. Del Ponte" Hospital, Woman and Child Department, University of Insubria, Varese, Italy
| | | | - Gianluca Lista
- Division of Neonatology, "V.Buzzi" Children's Hospital, ASST-FBF-Sacco, Via Castelvetro 32, Milan 20154, Italy.
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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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Abstract
OBJECTIVES To explore the level and time course of patient-ventilator asynchrony in mechanically ventilated children and the effects on duration of mechanical ventilation, PICU stay, and Comfort Behavior Score as indicator for patient comfort. DESIGN Secondary analysis of physiology data from mechanically ventilated children. SETTING Mixed medical-surgical tertiary PICU in a university hospital. PATIENTS Mechanically ventilated children 0-18 years old were eligible for inclusion. Excluded were patients who were unable to initiate and maintain spontaneous breathing from any cause. MEASUREMENTS AND MAIN RESULTS Twenty-nine patients were studied with a total duration of 109 days. Twenty-two study days (20%) were excluded because patients were on neuromuscular blockade or high-frequency oscillatory ventilation, yielding 87 days (80%) for analysis. Patient-ventilator asynchrony was detected through analysis of daily recorded ventilator airway pressure, flow, and volume versus time scalars. Approximately one of every three breaths was asynchronous. The percentage of asynchronous breaths significantly increased over time, with the highest prevalence on the day of extubation. There was no correlation with the Comfort Behavior score. The percentage of asynchronous breaths during the first 24 hours was inversely correlated with the duration of mechanical ventilation. Patients with severe patient-ventilator asynchrony (asynchrony index > 10% or > 75th percentile of the calculated asynchrony index) did not have a prolonged duration of ventilation. CONCLUSIONS The level of patient-ventilator asynchrony increased over time was not related to patient discomfort and inversely related to the duration of mechanical ventilation.
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Miller AG, Bartle RM, Feldman A, Mallory P, Reyes E, Scott B, Rotta AT. A narrative review of advanced ventilator modes in the pediatric intensive care unit. Transl Pediatr 2021; 10:2700-2719. [PMID: 34765495 PMCID: PMC8578787 DOI: 10.21037/tp-20-332] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/26/2020] [Indexed: 01/29/2023] Open
Abstract
Respiratory failure is a common reason for pediatric intensive care unit admission. The vast majority of children requiring mechanical ventilation can be supported with conventional mechanical ventilation (CMV) but certain cases with refractory hypoxemia or hypercapnia may require more advanced modes of ventilation. This paper discusses what we have learned about the use of advanced ventilator modes [e.g., high-frequency oscillatory ventilation (HFOV), high-frequency percussive ventilation (HFPV), high-frequency jet ventilation (HFJV) airway pressure release ventilation (APRV), and neurally adjusted ventilatory assist (NAVA)] from clinical, animal, and bench studies. The evidence supporting advanced ventilator modes is weak and consists of largely of single center case series, although a few RCTs have been performed. Animal and bench models illustrate the complexities of different modes and the challenges of applying these clinically. Some modes are proprietary to certain ventilators, are expensive, or may only be available at well-resourced centers. Future efforts should include large, multicenter observational, interventional, or adaptive design trials of different rescue modes (e.g., PROSpect trial), evaluate their use during ECMO, and should incorporate assessments through volumetric capnography, electric impedance tomography, and transpulmonary pressure measurements, along with precise reporting of ventilator parameters and physiologic variables.
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Affiliation(s)
- Andrew G Miller
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Renee M Bartle
- Duke University Medical Center, Durham, NC, USA.,Respiratory Care Services, Duke University Medical Center, Durham, NC, USA
| | - Alexandra Feldman
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Palen Mallory
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Edith Reyes
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Briana Scott
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Alexandre T Rotta
- Duke University Medical Center, Durham, NC, USA.,Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
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8
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Harris J, Tibby SM, Endacott R, Latour JM. Neurally Adjusted Ventilator Assist in Infants With Acute Respiratory Failure: A Literature Scoping Review. Pediatr Crit Care Med 2021; 22:915-924. [PMID: 33852545 DOI: 10.1097/pcc.0000000000002727] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To map the evidence for neurally adjusted ventilatory assist strategies, outcome measures, and sedation practices in infants less than 12 months with acute respiratory failure using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidance. DATA SOURCES CINAHL, MEDLINE, COCHRANE, JBI, EMBASE, PsycINFO, Google scholar, BNI, AMED. Trial registers included the following: ClinicalTrials.gov, European Union clinical trials register, International Standardized Randomized Controlled Trial Number register. Also included were Ethos, Grey literature, Google, dissertation abstracts, EMBASE conference proceedings. STUDY SELECTION Abstracts were screened followed by review of full text. Articles incorporating a heterogeneous population of both infants and older children were assessed, and where possible, data for infants were extracted. Fifteen articles were included. Ten articles were primary research: randomized controlled trial (n = 3), cohort studies (n = 4), retrospective data analysis (n = 2), case series (n = 1). Other articles are expert opinion (n = 2), neurally adjusted ventilatory assist updates (n = 1), and a literature review (n = 2). Three studies included exclusively infants. We also included 12 studies reporting jointly on infants and children. DATA EXTRACTION A standardized data extraction tool was used. DATA SYNTHESIS Key findings were that evidence related to neurally adjusted ventilatory assist ventilation strategies in infants and related to specific primary conditions is limited. The setting of neurally adjusted ventilatory assist level is not consistent, and how to optimize this mode of ventilation was not documented. Outcome measures varied considerably, most studies focused on improvements in respiratory and physiological variables. Sedation use is variable with regard to medication type and dose. There is an indication that less sedation is required in patients receiving neurally adjusted ventilatory assist, but no conclusive evidence to support this. CONCLUSIONS This review highlights a lack of standardized strategies for neurally adjusted ventilatory assist ventilation and sedation practices among infants with acute respiratory failure. Studies were limited by small sample sizes and a lack of focus on specific patient groups. Robust studies are needed to provide evidence-based clinical recommendations for the use of neurally adjusted ventilatory assist in infants with acute respiratory failure.
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Affiliation(s)
- Julia Harris
- Department of Advanced and Integrated Practice, London South Bank University, London, United Kingdom
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
| | - Shane M Tibby
- Pediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Ruth Endacott
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
- School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University, Frankston, VIC, Australia
| | - Jos M Latour
- Department of Children's Nursing, School of Nursing and Midwifery, Faculty of Health: Medicine, Dentistry and Human Sciences, University of Plymouth, Plymouth, United Kingdom
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9
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Neurally-Adjusted Ventilatory Assist (NAVA) versus Pneumatically Synchronized Ventilation Modes in Children Admitted to PICU. J Clin Med 2021; 10:jcm10153393. [PMID: 34362173 PMCID: PMC8347771 DOI: 10.3390/jcm10153393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/02/2022] Open
Abstract
Traditionally, invasively ventilated children in the paediatric intensive care unit (PICU) are weaned using pneumatically-triggered ventilation modes with a fixed level of assist. The best weaning mode is currently not known. Neurally adjusted ventilatory assist (NAVA), a newer weaning mode, uses the electrical activity of the diaphragm (Edi) to synchronise ventilator support proportionally to the patient’s respiratory drive. We aimed to perform a systematic literature review to assess the effect of NAVA on clinical outcomes in invasively ventilated children with non-neonatal lung disease. Three studies (n = 285) were included for analysis. One randomised controlled trial (RCT) of all comers showed a significant reduction in PICU length of stay and sedative use. A cohort study of acute respiratory distress syndrome (ARDS) patients (n = 30) showed a significantly shorter duration of ventilation and improved sedation with the use of NAVA. A cohort study of children recovering from cardiac surgery (n = 75) showed significantly higher extubation success, shorter duration of ventilation and PICU length of stay, and a reduction in sedative use. Our systematic review presents weak evidence that NAVA may shorten the duration of ventilation and PICU length of stay, and reduce the requirement of sedatives. However, further RCTs are required to more fully assess the effect of NAVA on clinical outcomes and treatment costs in ventilated children.
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10
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Takahashi D, Liu L, Sinderby C, Beck J. Feasibility of neurally synchronized and proportional negative pressure ventilation in a small animal model. Physiol Rep 2021; 8:e14499. [PMID: 32633080 PMCID: PMC7379043 DOI: 10.14814/phy2.14499] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 05/15/2020] [Indexed: 11/24/2022] Open
Abstract
RATIONALE Synchronized positive pressure ventilation is possible using diaphragm electrical activity (EAdi) to control the ventilator. It is unknown whether EAdi can be used to control negative pressure ventilation. AIM To evaluate the feasibility of using EAdi to control negative pressure ventilation. METHODS Fourteen anesthetized rats were studied (380-590 g) during control, resistive breathing, acute lung injury or CO2 rebreathing. Positive pressure continuous neurally adjusted ventilatory assist (cNAVAP+ ) was applied via intubation. Negative pressure cNAVA (cNAVAP- ) was applied with the animal placed in a sealed box. In part 1, automatic stepwise increments in cNAVA level by 0.2 cmH2 O/µV every 30 s was applied for cNAVAP+ , cNAVAP- , and a 50/50 combination of the two (cNAVAP± ). In part 2: During 5-min ventilation with cNAVAP+ or cNAVAP- we measured circuit, box, and esophageal (Pes) pressure, EAdi, blood pressure, and arterial blood gases. RESULTS Part 1: During cNAVAP+ , pressure in the circuit increased with increasing cNAVA levels, reaching a plateau, and similarly for cNAVAP- , albeit reversed in sign. This was associated with downregulation of the EAdi. Pes swings became less negative with cNAVAP+ but, in contrast, Pes swings were more negative during increasing cNAVAP- levels. Increasing the cNAVA level during cNAVAP± resulted in an intermediate response. Part 2: no significant differences were observed for box/circuit pressures, EAdi, blood pressure, or arterial blood gases. Pes swings during cNAVAP- were significantly more negative than during cNAVAP+ . CONCLUSION Negative pressure ventilation synchronized and proportional to the diaphragm activity is feasible in small animals.
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Affiliation(s)
| | - Ling Liu
- Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, ON, Canada.,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, ON, Canada
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11
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DI Nardo M, Lonero M, Staffieri F, DI Mussi R, Murgolo F, Lorusso P, Pham T, Picardo SG, Perrotta D, Cecchetti C, RavÀ L, Grasso S. Can visual inspection of the electrical activity of the diaphragm improve the detection of patient-ventilator asynchronies by pediatric critical care physicians? Minerva Anestesiol 2020; 87:319-324. [PMID: 32755090 DOI: 10.23736/s0375-9393.20.14543-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patient-ventilator asynchronies are challenging during pediatric mechanical ventilation. We hypothesized that monitoring the electrical activity of the diaphragm (EAdi) together with the "standard" airway opening pressure (Pao) and flow-time waveforms during pressure support ventilation would improve the ability of a cohort of critical care physicians to detect asynchronies in ventilated children. METHODS We recorded the flow, Pao and EAdi waveforms in ten consecutive patients. The recordings were split in periods of 15 s, each reproducing a ventilator screenshot. From this pool, a team of four experts selected the most representative screenshots including at least one of the three most common asynchronies (missed efforts, auto-triggering and double triggering) and split them into two versions, respectively showing or not the EAdi waveforms. The screenshots were shown in random order in a questionnaire to sixty experienced pediatric intensivists that were asked to identify any episode of patient-ventilator asynchrony. RESULTS Among the ten patients included in the study, only eight had EAdi tracings without artifacts and were analyzed. When the Eadi waveform was shown, the auto-triggering detection improved from 13% to 67% (P<0.0001) and the missed efforts detection improved from 43% to 95% (P<0.0001). The detection of double triggering, instead, did not improve (85% with the EAdi vs. 78% without the EAdi waveform; P=0.52). CONCLUSIONS This single center study suggests that the EAdi waveform may improve the ability of pediatric intensivists to detect missed efforts and auto-triggering asynchronies. Further studies are required to determine the clinical implications of these findings.
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Affiliation(s)
- Matteo DI Nardo
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Margherita Lonero
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy -
| | - Francesco Staffieri
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Rosa DI Mussi
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Francesco Murgolo
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Pantaleo Lorusso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | | | - Sergio G Picardo
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Daniela Perrotta
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Corrado Cecchetti
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lucilla RavÀ
- Unit of Epidemiology and Biostatistics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Salvatore Grasso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
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12
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Spinazzola G, Costa R, De Luca D, Chidini G, Ferrone G, Piastra M, Conti G. Pressure Support Ventilation (PSV) versus Neurally Adjusted Ventilatory Assist (NAVA) in difficult to wean pediatric ARDS patients: a physiologic crossover study. BMC Pediatr 2020; 20:334. [PMID: 32631305 PMCID: PMC7338290 DOI: 10.1186/s12887-020-02227-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is an innovative mode for assisted ventilation that improves patient-ventilator interaction in children. The aim of this study was to assess the effects of patient-ventilator interaction comparing NAVA with pressure support ventilation (PSV) in patients difficult to wean from mechanical ventilation after moderate pediatric acute respiratory distress syndrome (PARDS). METHODS In this physiological crossover study, 12 patients admitted in the Pediatric Intensive Care Unit (PICU) with moderate PARDS failing up to 3 spontaneous breathing trials in less than 7 days, were enrolled. Patients underwent three study conditions lasting 1 h each: PSV1, NAVA and PSV2. RESULTS The Asynchrony Index (AI) was significantly reduced during the NAVA trial compared to both the PSV1 and PSV2 trials (p = 0.001). During the NAVA trial, the inspiratory and expiratory trigger delays were significantly shorter compared to those obtained during PSV1 and PSV2 trials (Delaytrinspp < 0.001, Delaytrexpp = 0.013). These results explain the significantly longer Timesync observed during the NAVA trial (p < 0.001). In terms of gas exchanges, PaO2 value significantly improved in the NAVA trial with respect to the PSV trials (p < 0.02). The PaO2/FiO2 ratio showed a significant improvement during the NAVA trial compared to both the PSV1 and PSV2 trials (p = 0.004). CONCLUSIONS In this specific PICU population, presenting difficulty in weaning after PARDS, NAVA was associated with a reduction of the AI and a significant improvement in oxygenation compared to PSV mode. TRIAL REGISTRATION ClinicalTrial.gov Identifier: NCT04360590 "Retrospectively registered".
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Affiliation(s)
- Giorgia Spinazzola
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy.
| | - Roberta Costa
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy
| | - Daniele De Luca
- Division of Pediatric and Neonatal Critical Care, South Paris University Hospital, Medical Centers "A. Beclere" Assistance Publique-Hopitaux de Paris (APHP), Paris, France
| | - Giovanna Chidini
- Pediatric Intensive Care Unit, Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuliano Ferrone
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy
| | - Marco Piastra
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy
| | - Giorgio Conti
- Department of Anesthesia and Intensive Care, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo F. Vito 1, 00168, Rome, Italy.,Division of Pediatric and Neonatal Critical Care, South Paris University Hospital, Medical Centers "A. Beclere" Assistance Publique-Hopitaux de Paris (APHP), Paris, France.,Pediatric Intensive Care Unit, Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Università Cattolica del Sacro Cuore, Roma, Italy
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13
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Abstract
OBJECTIVES This review discusses the different techniques used at the bedside to assess respiratory muscle function in critically ill children and their clinical applications. DATA SOURCES A scoping review of the medical literature on respiratory muscle function assessment in critically ill children was conducted using the PubMed search engine. STUDY SELECTION We included all scientific, peer-reviewed studies about respiratory muscle function assessment in critically ill children, as well as some key adult studies. DATA EXTRACTION Data extracted included findings or comments about techniques used to assess respiratory muscle function. DATA SYNTHESIS Various promising physiologic techniques are available to assess respiratory muscle function at the bedside of critically ill children throughout the disease process. During the acute phase, this assessment allows a better understanding of the pathophysiological mechanisms of the disease and an optimization of the ventilatory support to increase its effectiveness and limit its potential complications. During the weaning process, these physiologic techniques may help predict extubation success and therefore optimize ventilator weaning. CONCLUSIONS Physiologic techniques are useful to precisely assess respiratory muscle function and to individualize and optimize the management of mechanical ventilation in children. Among all the available techniques, the measurements of esophageal pressure and electrical activity of the diaphragm appear particularly helpful in the era of individualized ventilatory management.
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14
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Yagui ACZ, Gonçalves PA, Murakami SH, Santos AZ, Zacharias RSB, Rebello CM. Is noninvasive neurally adjusted ventilatory assistance (NIV-NAVA) an alternative to NCPAP in preventing extubation failure in preterm infants? J Matern Fetal Neonatal Med 2019; 34:3756-3760. [PMID: 31762348 DOI: 10.1080/14767058.2019.1697669] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Prolonged use of mechanical ventilation is associated with some complications as high mortality and high morbidities as bronchopulmonary dysplasia, ventilator-associated pneumonia, and pneumothorax. However, extubation failure in preterm infants is still high (40-60%) in very low birth weight infants (VLBW). Noninvasive neurally adjusted ventilatory assistance (NIV-NAVA) is triggered by the diaphragmatic electrical activity through a nasogastric tube that synchronizes patient/ventilator respiration, cycle by cycle effectively shortening the assisted cycle trigger and the degree of ventilatory assistance, optimizing the effects of intermittent inspiratory pressure on nasal continuous positive airway pressure (NCPAP). This study aims to compare reintubation rates until 72 h after extubation in preterm infants of high risk for reintubation using NIV-NAVA or NCPAP. Methods: A retrospective study of chart review data collection was performed in a private tertiary hospital. The study was approved by the local institutional Ethics Committee. We included infants considered at high risk of reintubation (BW < 1000 grams; use of invasive mechanical ventilation (IMV) for at least 7 days; or previous extubation failure episode) and compared the two groups according to the type of respiratory support after extubation: 1) NCPAP (n = 32); or 2) NIV-NAVA (n = 17). Demographics data were collected, the primary outcome was reintubation rate until 72 h after extubation. Secondary outcome was time to reintubation, BPD rate, IVH grade ≥ III, pneumothorax and death. Results: There was no difference between both groups in demographic data. The reintubation rate decreased significantly in the NIV-NAVA group compared to NCPAP (50.0-11.7, p < 0.02) despite the significantly higher length of invasive mechanical ventilation (IMV) before extubation attempt in NIV-NAVA group (12.4 versus 5.5 days, p < 0.04). There was no difference between both groups in secondary outcomes. Conclusions: In this small retrospective cohort study, the use of NIV-NAVA as postextubation strategy was effective in reducing extubation failure within 72 hours in preterm infants when compared to traditional NCPAP.
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Affiliation(s)
- Ana C Z Yagui
- Hospital Israelita Albert Einstein , São Paulo, Brazil
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15
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Karikari S, Rausa J, Flores S, Loomba RS. Neurally adjusted ventilatory assist versus conventional ventilation in the pediatric population: Are there benefits? Pediatr Pulmonol 2019; 54:1374-1381. [PMID: 31231985 DOI: 10.1002/ppul.24413] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 05/09/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Neurally-adjusted ventilator assist (NAVA) is a relatively new form of ventilation in which the electrical activity of the diaphragm is sensed by a catheter. The amplitude of this electrical signal is then used to deliver an appropriately proportioned pressure supported breath to the patient. Due to the synchronous nature of the breaths and the patient-adjusted nature of the support, NAVA has been shown to have benefits over conventional ventilation. Meta-analyses were conducted of published pediatric studies to compare ventilatory endpoints between NAVA and conventional ventilation. METHODS Studies comparing ventilatory parameters between NAVA and conventional ventilation in pediatric patients were identified. These studies were reviewed for appropriateness for inclusion and studies of only pediatric patients with data for similar endpoints between both arms were then pooled. RESULTS Statistically significant differences were noted in asynchrony, peak inspiratory pressure (PIP), and oxygen saturation by pulse oximetry. Asynchrony was 17% lower with NAVA, PIP was 1.74 cmH2 0 lower with NAVA, and oxygen saturation was 1.1% greater with NAVA. There was no statistically significant difference in peak expiratory pressure, mean airway pressure, electrical diaphragmatic activity, respiratory rate, hydrogen ion concentration, partial pressure of oxygen, or partial pressure of carbon dioxide. CONCLUSION Statistically significant differences were noted in percent asynchrony, PIP, and oxygen saturation when comparing NAVA to conventional ventilation. These all tended to favor NAVA. Other than percent asynchrony, however, the other statistically significant findings were not clinically significant.
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Affiliation(s)
- Serwaa Karikari
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Jacqueline Rausa
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
| | - Saul Flores
- Division of Critical Care, Texas Children's Hospital, Houston, Texas
| | - Rohit S Loomba
- Division of Cardiology, Advocate Children's Hospital, Chicago Medical School/ Rosalind Franklin University of Medicine and Science, Chicago, Illinois
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16
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When the Children Control the Ventilator, They Adopt an Appropriate Ventilation with a Strict Control of Blood pH. Ann Am Thorac Soc 2019; 16:1585-1587. [PMID: 31310725 DOI: 10.1513/annalsats.201902-169rl] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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17
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Relationship Between Diaphragmatic Electrical Activity and Esophageal Pressure Monitoring in Children. Pediatr Crit Care Med 2019; 20:e319-e325. [PMID: 31107378 DOI: 10.1097/pcc.0000000000001981] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES Mechanical ventilation is an essential life support technology, but it is associated with side effects in case of over or under-assistance. The monitoring of respiratory effort may facilitate titration of the support. The gold standard for respiratory effort measurement is based on esophageal pressure monitoring, a technology not commonly available at bedside. Diaphragmatic electrical activity can be routinely monitored in clinical practice and reflects the output of the respiratory centers. We hypothesized that diaphragmatic electrical activity changes accurately reflect changes in mechanical efforts. The objectives of this study were to characterize the relationship between diaphragmatic electrical activity and esophageal pressure. DESIGN Prospective crossover study. SETTING Esophageal pressure and diaphragmatic electrical activity were simultaneously recorded using a specific nasogastric tube in three conditions: in pressure support ventilation and in neurally adjusted ventilatory support in a random order, and then after extubation. PATIENTS Children in the weaning phase of mechanical ventilation. INTERVENTIONS The maximal swing in esophageal pressure and esophageal pressure-time product, maximum diaphragmatic electrical activity, and inspiratory diaphragmatic electrical activity integral were calculated from 100 consecutive breaths. Neuroventilatory efficiency was estimated using the ratio of tidal volume/maximum diaphragmatic electrical activity. MEASUREMENTS AND MAIN RESULTS Sixteen patients, with a median age of 4 months (interquartile range, 0.5-13 mo), and weight 5.8 kg (interquartile range, 4.1-8 kg) were included. A strong linear correlation between maximum diaphragmatic electrical activity and maximal swing in esophageal pressure (r > 0.95), and inspiratory diaphragmatic electrical activity integral and esophageal pressure-time product (r > 0.71) was observed in all ventilatory conditions. This correlation was not modified by the type of ventilatory support. CONCLUSIONS On a short-term basis, diaphragmatic electrical activity changes are strongly correlated with esophageal pressure changes. In clinical practice, diaphragmatic electrical activity monitoring may help to inform on changes in respiratory efforts.
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18
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Bonacina D, Bronco A, Nacoti M, Ferrari F, Fazzi F, Bonanomi E, Bellani G. Pressure support ventilation, sigh adjunct to pressure support ventilation, and neurally adjusted ventilatory assist in infants after cardiac surgery: A physiologic crossover randomized study. Pediatr Pulmonol 2019; 54:1078-1086. [PMID: 31004420 DOI: 10.1002/ppul.24335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVES We sought to compare gas exchange, respiratory mechanics, and asynchronies during pressure support ventilation (PSV), sigh adjunct to PSV (PSV SIGH), and neurally adjusted ventilatory assist (NAVA) in hypoxemic infants after cardiac surgery. DESIGN Prospective, single-center, crossover, randomized physiologic study. SETTING Tertiary-care pediatric intensive care unit. PATIENTS Fourteen hypoxemic infants (median age 11.5 days [8.7-74]). INTERVENTIONS The protocol begins with a 1 hour step of PSV, followed by two consecutive steps in PSV SIGH and NAVA in random order, with a washout period of 30 minutes (PSV) between them. MAIN RESULTS Three infants presented an irregular Eadi signal because of diaphragmatic paralysis and were excluded from analysis. For the remaining 11 infants, PaO2 /FiO 2 and oxygenation index improved in PSV SIGH compared with PSV (P < 0.05) but not in NAVA compared with PSV. PSV SIGH showed increased tidal volumes and lower respiratory rate than PSV (P < 0.05), as well as a significant improvement in compliance with respiratory system indexed to body weight when compared with both PSV and NAVA (P < 0.01). No changes in mean airway pressure was registered among steps. Inspiratory time resulted prolonged for both PSV SIGH and NAVA than PSV (P < 0.05). NAVA showed the higher coefficient of variability in respiratory parameters and a significative decrease in asynchrony index when compared with both PSV and PSV SIGH (P < 0.01). CONCLUSIONS The adjunct of one SIGH per minute to PSV improved oxygenation and lung mechanics while NAVA provided the best patient-ventilator synchrony in infants after cardiac surgery.
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Affiliation(s)
- Daniele Bonacina
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Alfio Bronco
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Mirco Nacoti
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Floriana Ferrari
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Francesco Fazzi
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Ezio Bonanomi
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
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19
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Baez Hernandez N, Milad A, Li Y, Van Bergen AH. Utilization of Neurally Adjusted Ventilatory Assist (NAVA) Mode in Infants and Children Undergoing Congenital Heart Surgery: A Retrospective Review. Pediatr Cardiol 2019; 40:563-569. [PMID: 30600371 DOI: 10.1007/s00246-018-2027-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/29/2018] [Indexed: 01/15/2023]
Abstract
We assessed the feasibility and the impact of NAVA compared to conventional modes of mechanical ventilation in ventilatory and gas exchange parameters in post-operative children with congenital heart disease. Infants and children (age < 18 years) that underwent congenital heart surgery were enrolled. Patients were ventilated with conventional synchronized intermittent mechanical ventilation (SIMV) and subsequently transitioned to NAVA during their cardiovascular intensive care unit (CVICU) stay. The ventilatory and gas exchange parameters for the 24 h pre- and post-transition to NAVA were compared. Additional parameters assessed included pain scores and sedation requirements. Eighty-one patients met inclusion criteria with a median age of 21 days (interquartile range 13 days-2 months). The majority of patients enrolled (75.3%) had complex congenital heart disease with high surgical severity scores. The transition to NAVA was tolerated by all patients without complications. The mean peak inspiratory pressure (PIP) was 1.8 cm H2O lower (p < 0.001) and mean airway pressure (Paw) was 0.5 cm H2O lower (p = 0.009) on NAVA compared to conventional modes of mechanical ventilation. There was no significant difference in patients' respiratory rate, tidal volume, arterial pH, pCO2, and lactate levels between the two modes of ventilation. There was a decreased sedation requirement during the time of NAVA ventilation. Comfort scores did not differ significantly with ventilator mode change. We concluded that NAVA is safe and well-tolerated mode of mechanical ventilation for our cohort of patients after congenital heart surgery. Compared to conventional ventilation there was a statistically significant decrease in PIP and Paw on NAVA.
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Affiliation(s)
- Nathanya Baez Hernandez
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Abdulhamid Milad
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Yi Li
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Andrew H Van Bergen
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA.
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20
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Conti G, Spinazzola G, Gregoretti C, Ferrone G, Cortegiani A, Festa O, Piastra M, Tortorolo L, Costa R. Comparative bench study evaluation of different infant interfaces for non-invasive ventilation. BMC Pulm Med 2018; 18:57. [PMID: 29625596 PMCID: PMC5889592 DOI: 10.1186/s12890-018-0620-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 03/29/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To compare, in terms of patient-ventilator interaction and performance, a new nasal mask (Respireo, AirLiquide, FR) with the Endotracheal tube (ET) and a commonly used nasal mask (FPM, Fisher and Paykel, NZ) for delivering Pressure Support Ventilation (PSV) in an infant model of Acute Respiratory Failure (ARF). METHODS An active test lung (ASL 5000) connected to an infant mannequin through 3 different interfaces (Respireo, ET and FPM), was ventilated with a standard ICU ventilator set in PSV. The test lung was set to simulate a 5.5 kg infant with ARF, breathing at 50 and 60 breaths/min). Non-invasive ventilation (NIV) mode was not used and the leaks were nearly zero. RESULTS The ET showed the shortest inspiratory trigger delay and pressurization time compared to FPM and Respireo (p < 0.01). At each respiratory rate tested, the FPM showed the shortest Expiratory trigger delay compared to ET and Respireo (p < 0.01). The Respireo presented a lower value of Inspiratory pressure-time product and trigger pressure drop than ET (p < 0.01), while no significant difference was found in terms of pressure-time product at 300 and 500 ms. During all tests, compared with the FPM, ET showed a significantly higher tidal volume (VT) delivered (p < 0.01), while Respireo showed a trend toward an increase of tidal volume delivered compared with FPM. CONCLUSIONS The ET showed a better patient-ventilator interaction and performance compared to both the nasal masks. Despite the higher internal volume, Respireo showed a trend toward an increase of the delivered tidal volume; globally, its efficiency in terms of patient-ventilator interaction was comparable to the FPM, which is the infant NIV mask characterized by the smaller internal volume among the (few) models on the market.
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Affiliation(s)
- Giorgio Conti
- Intensive Care and Anaesthesia Department and Ventilab, Catholic University of Rome, Policlinico A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Giorgia Spinazzola
- Intensive Care and Anaesthesia Department and Ventilab, Catholic University of Rome, Policlinico A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Cesare Gregoretti
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy
| | - Giuliano Ferrone
- Intensive Care and Anaesthesia Department and Ventilab, Catholic University of Rome, Policlinico A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Andrea Cortegiani
- Department of Biopathology and Medical Biotechnologies (DIBIMED), Section of Anesthesia, Analgesia, Intensive Care and Emergency. Policlinico Paolo Giaccone, University of Palermo, Via del vespro 129, 90127, Palermo, Italy.
| | - Olimpia Festa
- Intensive Care and Anaesthesia Department and Ventilab, Catholic University of Rome, Policlinico A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Marco Piastra
- Intensive Care and Anaesthesia Department and Ventilab, Catholic University of Rome, Policlinico A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Luca Tortorolo
- Intensive Care and Anaesthesia Department and Ventilab, Catholic University of Rome, Policlinico A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Roberta Costa
- Intensive Care and Anaesthesia Department and Ventilab, Catholic University of Rome, Policlinico A. Gemelli, Largo Agostino Gemelli 8, 00168, Rome, Italy
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21
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Neural Breathing Pattern and Patient-Ventilator Interaction During Neurally Adjusted Ventilatory Assist and Conventional Ventilation in Newborns. Pediatr Crit Care Med 2018; 19:48-55. [PMID: 29189671 DOI: 10.1097/pcc.0000000000001385] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To compare neurally adjusted ventilatory assist and conventional ventilation on patient-ventilator interaction and neural breathing patterns, with a focus on central apnea in preterm infants. DESIGN Prospective, observational cross-over study of intubated and ventilated newborns. Data were collected while infants were successively ventilated with three different ventilator conditions (30 min each period): 1) synchronized intermittent mandatory ventilation (SIMV) combined with pressure support at the clinically prescribed, SIMV with baseline settings (SIMVBL), 2) neurally adjusted ventilatory assist, 3) same as SIMVBL, but with an adjustment of the inspiratory time of the mandatory breaths (SIMV with adjusted settings [SIMVADJ]) using feedback from the electrical activity of the diaphragm). SETTING Regional perinatal center neonatal ICU. PATIENTS Neonates admitted in the neonatal ICU requiring invasive mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Twenty-three infants were studied, with median (range) gestational age at birth 27 weeks (24-41 wk), birth weight 780 g (490-3,610 g), and 7 days old (1-87 d old). Patient ventilator asynchrony, as quantified by the NeuroSync index, was lower during neurally adjusted ventilatory assist (18.3% ± 6.3%) compared with SIMVBL (46.5% ±11.7%; p < 0.05) and SIMVADJ (45.8% ± 9.4%; p < 0.05). There were no significant differences in neural breathing parameters, or vital signs, except for the end-expiratory electrical activity of the diaphragm, which was lower during neurally adjusted ventilatory assist. Central apnea, defined as a flat electrical activity of the diaphragm more than 5 seconds, was significantly reduced during neurally adjusted ventilatory assist compared with both SIMV periods. These results were comparable for term and preterm infants. CONCLUSIONS Patient-ventilator interaction appears to be improved with neurally adjusted ventilatory assist. Analysis of the neural breathing pattern revealed a reduction in central apnea during neurally adjusted ventilatory assist use.
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22
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Mortamet G, Larouche A, Ducharme-Crevier L, Fléchelles O, Constantin G, Essouri S, Pellerin-Leblanc AA, Beck J, Sinderby C, Jouvet P, Emeriaud G. Patient-ventilator asynchrony during conventional mechanical ventilation in children. Ann Intensive Care 2017; 7:122. [PMID: 29264742 PMCID: PMC5738329 DOI: 10.1186/s13613-017-0344-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 12/13/2017] [Indexed: 11/22/2022] Open
Abstract
Background We aimed (1) to describe the characteristics of patient–ventilator asynchrony in a population of critically ill children, (2) to describe the risk factors associated with patient–ventilator asynchrony, and (3) to evaluate the association between patient–ventilator asynchrony and ventilator-free days at day 28. Methods In this single-center prospective study, consecutive children admitted to the PICU and mechanically ventilated for at least 24 h were included. Patient–ventilator asynchrony was analyzed by comparing the ventilator pressure curve and the electrical activity of the diaphragm (Edi) signal with (1) a manual analysis and (2) using a standardized fully automated method. Results Fifty-two patients (median age 6 months) were included in the analysis. Eighteen patients had a very low ventilatory drive (i.e., peak Edi < 2 µV on average), which prevented the calculation of patient–ventilator asynchrony. Children spent 27% (interquartile 22–39%) of the time in conflict with the ventilator. Cycling-off errors and trigger delays contributed to most of this asynchronous time. The automatic algorithm provided a NeuroSync index of 45%, confirming the high prevalence of asynchrony. No association between the severity of asynchrony and ventilator-free days at day 28 or any other clinical secondary outcomes was observed, but the proportion of children with good synchrony was very low. Conclusion Patient–ventilator interaction is poor in children supported by conventional ventilation, with a high frequency of depressed ventilatory drive and a large proportion of time spent in asynchrony. The clinical benefit of strategies to improve patient–ventilator interactions should be evaluated in pediatric critical care.
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Affiliation(s)
- Guillaume Mortamet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,INSERM U 955, Equipe 13, Créteil, France.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Alexandrine Larouche
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Laurence Ducharme-Crevier
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Olivier Fléchelles
- Pediatric Intensive Care Unit, CHU Fort-de-France, Fort-de-France, France
| | - Gabrielle Constantin
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Sandrine Essouri
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada.,Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Jennifer Beck
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada. .,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada.
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23
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Rossor TE, Hunt KA, Shetty S, Greenough A. Neurally adjusted ventilatory assist compared to other forms of triggered ventilation for neonatal respiratory support. Cochrane Database Syst Rev 2017; 10:CD012251. [PMID: 29077984 PMCID: PMC6485908 DOI: 10.1002/14651858.cd012251.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Effective synchronisation of infant respiratory effort with mechanical ventilation may allow adequate gas exchange to occur at lower peak airway pressures, potentially reducing barotrauma and volutrauma and development of air leaks and bronchopulmonary dysplasia. During neurally adjusted ventilatory assist ventilation (NAVA), respiratory support is initiated upon detection of an electrical signal from the diaphragm muscle, and pressure is provided in proportion to and synchronous with electrical activity of the diaphragm (EADi). Compared to other modes of triggered ventilation, this may provide advantages in improving synchrony. OBJECTIVES Primary• To determine whether NAVA, when used as a primary or rescue mode of ventilation, results in reduced rates of bronchopulmonary dysplasia (BPD) or death among term and preterm newborn infants compared to other forms of triggered ventilation• To assess the safety of NAVA by determining whether it leads to greater risk of intraventricular haemorrhage (IVH), periventricular leukomalacia, or air leaks when compared to other forms of triggered ventilation Secondary• To determine whether benefits of NAVA differ by gestational age (term or preterm)• To determine whether outcomes of cross-over trials performed during the first two weeks of life include peak pressure requirements, episodes of hypocarbia or hypercarbia, oxygenation index, and the work of breathing SEARCH METHODS: We performed searches of the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cohrane Library; MEDLINE via Ovid SP (January 1966 to March 2017); Embase via Ovid SP (January 1980 to March 2017); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to March 2017); and the Web of Science (1985 to 2017). We searched abstracts from annual meetings of the Pediatric Academic Societies (PAS) (2000 to 2016); meetings of the European Society of Pediatric Research (published in Pediatric Research); and meetings of the Perinatal Society of Australia and New Zealand (PSANZ) (2005 to 2016). We also searched clinical trials databases to March 2017. SELECTION CRITERIA We included randomised and quasi-randomised clinical trials including cross-over trials comparing NAVA with other modes of triggered ventilation (assist control ventilation (ACV),synchronous intermittent mandatory ventilation plus pressure support (SIMV ± PS), pressure support ventilation (PSV), or proportional assist ventilation (PAV)) used in neonates. DATA COLLECTION AND ANALYSIS Primary outcomes of interest from randomised controlled trials were all-cause mortality, bronchopulmonary dysplasia (BPD; defined as oxygen requirement at 28 days), and a combined outcome of all-cause mortality or BPD. Secondary outcomes were duration of mechanical ventilation, incidence of air leak, incidence of IVH or periventricular leukomalacia, and survival with an oxygen requirement at 36 weeks' postmenstrual age.Outcomes of interest from cross-over trials were maximum fraction of inspired oxygen, mean peak inspiratory pressure, episodes of hypocarbia, and episodes of hypercarbia measured across the time period of each arm of the cross-over. We planned to assess work of breathing; oxygenation index, and thoraco-abdominal asynchrony at the end of the time period of each arm of the cross-over study. MAIN RESULTS We included one randomised controlled study comparing NAVA versus patient-triggered time-cycled pressure-limited ventilation. This study found no significant difference in duration of mechanical ventilation, nor in rates of BPD, pneumothorax, or IVH. AUTHORS' CONCLUSIONS Risks and benefits of NAVA compared to other forms of ventilation for neonates are uncertain. Well-designed trials are required to evaluate this new form of triggered ventilation.
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Affiliation(s)
- Thomas E Rossor
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
| | | | - Sandeep Shetty
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
| | - Anne Greenough
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
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Gibu CK, Cheng PY, Ward RJ, Castro B, Heldt GP. Feasibility and physiological effects of noninvasive neurally adjusted ventilatory assist in preterm infants. Pediatr Res 2017; 82:650-657. [PMID: 28399118 PMCID: PMC5605676 DOI: 10.1038/pr.2017.100] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 03/24/2017] [Accepted: 03/28/2017] [Indexed: 11/09/2022]
Abstract
BackgroundNoninvasive neurally adjusted ventilator assist (NIV-NAVA) was introduced to our clinical practice via a pilot and a randomized observational study to assess its safety, feasibility, and short-term physiological effects.MethodsThe pilot protocol applied NIV-NAVA to 11 infants on nasal CPAP, high-flow nasal cannula, or nasal intermittent mandatory ventilation (NIMV), in multiple 2- to 4-h periods of NIV-NAVA for comparison. This provided the necessary data to design a randomized, controlled observational crossover study in eight additional infants to compare the physiological effects of NIV-NAVA with NIMV during 2-h steady-state conditions. We recorded the peak inspiratory pressure (PIP), FiO2, Edi, oxygen saturations (histogram analysis), transcutaneous PCO2, and movement with an Acoustic Respiratory Movement Sensor.ResultsThe NAVA catheter was used for 81 patient days without complications. NIV-NAVA produced significant reductions (as a percentage of measurements on NIMV) in the following: PIP, 13%; FiO2, 13%; frequency of desaturations, 42%; length of desaturations, 32%; and phasic Edi, 19%. Infant movement and caretaker movement were reduced by 42% and 27%, respectively. Neural inspiratory time was increased by 39 ms on NIV-NAVA, possibly due to Head's paradoxical reflex.ConclusionNIV-NAVA was a safe, alternative mode of noninvasive support that produced beneficial short-term physiological effects, especially compared with NIMV.
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Affiliation(s)
- Christopher K Gibu
- Department of Pediatrics, Division of Neonatology, University of California, San Diego, California
| | - Phillip Y Cheng
- Department of Pediatrics, Division of Neonatology, University of California, San Diego, California
| | | | - Benjamin Castro
- Department of Pediatrics, Division of Neonatology, University of California, San Diego, California
| | - Gregory P Heldt
- Department of Pediatrics, Division of Neonatology, University of California, San Diego, California
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Gupta M, Bergel M, Betancourt N, Mahan VL. Neurally Adjusted Ventilatory Assist Mode in Pediatric Intensive Care Unit and Pediatric Cardiac Care Unit. EXPLORATORY RESEARCH AND HYPOTHESIS IN MEDICINE 2017; 2:33-37. [DOI: 10.14218/erhm.2016.00027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Shetty S, Hunt K, Peacock J, Ali K, Greenough A. Crossover study of assist control ventilation and neurally adjusted ventilatory assist. Eur J Pediatr 2017; 176:509-513. [PMID: 28180985 DOI: 10.1007/s00431-017-2866-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 01/22/2017] [Accepted: 01/25/2017] [Indexed: 10/20/2022]
Abstract
UNLABELLED Some studies of infants with acute respiratory distress have demonstrated that neurally adjusted ventilator assist (NAVA) had better short-term results compared to non-triggered or other triggered models. We determined if very prematurely born infants with evolving or established bronchopulmonary dysplasia (BPD) had a lower oxygenation index (OI) on NAVA compared to assist control ventilation (ACV). Infants were studied for 1 h each on each mode. At the end of each hour, blood gas analysis was performed and the OI calculated. The inspired oxygen concentration (FiO2), the peak inflation (PIP) and mean airway pressures (MAP) and compliance were averaged from the last 5 min on each mode. Nine infants, median gestational age of 25 (range 22-27) weeks, were studied at a median postnatal age of 20 (range 8-84) days. The mean OI after 1 h on NAVA was 7.9 compared to 11.1 on ACV (p = 0.0007). The FiO2 (0.36 versus 0.45, p = 0.007), PIP (16.7 versus 20.1 cm H2O, p = 0.017) and MAP (9.2 versus 10.5 cm H2O, p = 0.004) were lower on NAVA. Compliance was higher on NAVA (0.62 versus 0.50 ml/cmH2O/kg, p = 0.005). CONCLUSION NAVA compared to ACV improved oxygenation in prematurely born infants with evolving or established BPD. What is Known: • Neurally assist ventilator adjust (NAVA) uses the electrical activity of the diaphragm to servo control the applied pressure. • In infants with acute RDS, use of NAVA was associated with lower peak inflation pressures and higher tidal volumes. What is New: • This study uniquely reports infants with evolving or established BPD, and their results were compared on 1 h each of NAVA and assist controlled ventilation. • On NAVA, infants had superior (lower) oxygen indices, lower inspired oxygen concentrations and peak and mean airway pressures and higher compliance.
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Affiliation(s)
- Sandeep Shetty
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Katie Hunt
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK
| | - Janet Peacock
- Division of Health and Social Care Research, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Kamal Ali
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC & Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, UK. .,NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK. .,Neonatal Intensive Care Unit, 4th Floor Golden Jubilee Wing, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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Nardi N, Mortamet G, Ducharme-Crevier L, Emeriaud G, Jouvet P. Recent Advances in Pediatric Ventilatory Assistance. F1000Res 2017; 6:290. [PMID: 28413621 PMCID: PMC5365224 DOI: 10.12688/f1000research.10408.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 01/17/2023] Open
Abstract
In this review on respiratory assistance, we aim to discuss the following recent advances: the optimization and customization of mechanical ventilation, the use of high-frequency oscillatory ventilation, and the role of noninvasive ventilation. The prevention of ventilator-induced lung injury and diaphragmatic dysfunction is now a key aspect in the management of mechanical ventilation, since these complications may lead to higher mortality and prolonged length of stay in intensive care units. Different physiological measurements, such as esophageal pressure, electrical activity of the diaphragm, and volumetric capnography, may be useful objective tools to help guide ventilator assistance. Companies that design medical devices including ventilators and respiratory monitoring platforms play a key role in knowledge application. The creation of a ventilation consortium that includes companies, clinicians, researchers, and stakeholders could be a solution to promote much-needed device development and knowledge implementation.
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Affiliation(s)
- Nicolas Nardi
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | | | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
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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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Neurally Adjusted Ventilatory Assist in Preterm Infants With Established or Evolving Bronchopulmonary Dysplasia on High-Intensity Mechanical Ventilatory Support: A Single-Center Experience. Pediatr Crit Care Med 2016; 17:1142-1146. [PMID: 27918385 DOI: 10.1097/pcc.0000000000000981] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVES The aim of the present study was to report possible improvements in ventilator variables associated with a transition from synchronized intermittent mandatory ventilation to neurally adjusted ventilatory assist in preterm infants with bronchopulmonary dysplasia who required a high level of mechanical ventilatory support in a single center. DESIGN Retrospective study. SETTING Neonatal ICU. PATIENTS Twenty-nine preterm infants with a median gestational age of 25.4 weeks (range, 23.4-30.3 wk) and a median birth weight of 680 g (range, 370-1,230 g) and who were supported with a mechanical ventilator for more than 4 weeks and had a respiratory severity score greater than four during conventional mechanical ventilation prior to conversion to neurally adjusted ventilatory assist. INTERVENTIONS Comparison of ventilatory variables, work of breathing, and blood gas values during conventional ventilation and at various time intervals after the change to neurally adjusted ventilatory assist. MEASUREMENTS AND MAIN RESULTS The values of various ventilatory variables and other measurements were obtained 1 hour before neurally adjusted ventilatory assist and 1, 4, 12, and 24 hours after conversion to neurally adjusted ventilatory assist. During neurally adjusted ventilatory assist, the peak inspiratory pressure (20.12 ± 2.93 vs 14.15 ± 3.55 cm H2O; p < 0.05), mean airway pressure (11.15 ± 1.29 vs 9.57 ± 1.27 cm H2O; p < 0.05), and work of breathing (0.86 ± 0.22 vs 0.46 ± 0.12 J/L; p < 0.05) were significantly decreased, and the blood gas values were significantly improved. Significantly lower FIO2 and improved oxygen saturation were observed during neurally adjusted ventilatory assist compared with conventional ventilation support. The RSS values decreased and sustained during neurally adjusted ventilatory assist (4.85 ± 1.63 vs 3.21 ± 1.01; p < 0.001). CONCLUSIONS The transition from synchronized intermittent mandatory ventilation to neurally adjusted ventilatory assist ventilation was associated with improvements in ventilator variables, oxygen saturation, and blood gas values in infants with bronchopulmonary dysplasia in a single center. This study suggests the possible clinical utility of neurally adjusted ventilatory assist as a weaning modality for bronchopulmonary dysplasia patients in the neonatal ICU.
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Liet JM, Barrière F, Gaillard-Le Roux B, Bourgoin P, Legrand A, Joram N. Physiological effects of invasive ventilation with neurally adjusted ventilatory assist (NAVA) in a crossover study. BMC Pediatr 2016; 16:180. [PMID: 27821162 PMCID: PMC5100099 DOI: 10.1186/s12887-016-0717-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 10/25/2016] [Indexed: 12/19/2022] Open
Abstract
Background Neurally Adjusted Ventilatory Assist (NAVA) is a mode of assisted mechanical ventilation that delivers inspiratory pressure proportionally to the electrical activity of the diaphragm. To date, no pediatric study has focused on the effects of NAVA on hemodynamic parameters. This physiologic study with a randomized cross-over design compared hemodynamic parameters when NAVA or conventional ventilation (CV) was applied. Methods After a baseline period, infants received NAVA and CV in a randomized order during two consecutive 30-min periods. During the last 10 min of each period, respiratory and hemodynamic parameters were collected. No changes in PEEP, FiO2, sedation or inotropic doses were allowed during these two periods. The challenge was to keep minute volumes constant, with no changes in blood CO2 levels and in pH that may affect the results. Results Six infants who had undergone cardiac surgery (mean age 7.8 ± 4.1 months) were studied after parental consent. Four of them had low central venous oxygen saturation (ScvO2 < 65 %). The ventilatory settings resulted in similar minute volumes (1.7 ± 0.4 vs. 1.6 ± 0.6 ml/kg, P = 0.67) and in similar tidal volumes respectively with NAVA and with CV. There were no statistically significant differences on blood pH levels between the two modes of ventilation (7.32 ± 0.02 vs. 7.32 ± 0.04, P = 0.34). Ventilation with NAVA delivered lower peak inspiratory pressures than with CV: -32.7 % (95 % CI: -48.2 to –17.1 %, P = 0.04). With regard to hemodynamics, systolic arterial pressures were higher using NAVA: +8.4 % (95 % CI: +3.3 to +13.6 %, P = 0.03). There were no statistically significant differences on cardiac index between the two modes of ventilation. However, all children with a low baseline ScvO2 (<65 %) tended to increase their cardiac index with NAVA compared to CV: 2.03 ± 0.30 vs. 1.91 ± 0.39 L/min.m2 (median ± interquartile, P = 0.07). Conclusions This pilot study raises the hypothesis that NAVA could have beneficial effects on hemodynamics in children when compared to a conventional ventilatory mode that delivered identical PEEP and similar minute volumes. Trial registration ClinicalTrials.gov Identifier: NCT01490710. Date of registration: December 7, 2011.
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Affiliation(s)
- Jean-Michel Liet
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France.
| | - François Barrière
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Bénédicte Gaillard-Le Roux
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Arnaud Legrand
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France.,CIC-INSERM 1413, University of Nantes, Nantes, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
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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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Abstract
OBJECTIVE To describe the frequency and type of patient-ventilator asynchrony in mechanically ventilated children by analyzing ventilator flow and pressure signals. DESIGN Prospective observational study. SETTING Tertiary PICU in a university hospital. PATIENTS Mechanically ventilated children between 0 and 18 years old and who were able to initiate and maintain spontaneous breathing were eligible for inclusion. Patients with congenital or acquired neuromuscular disorders, those with congenital or acquired central nervous system disorders, and those who were unable to initiate and maintain spontaneous breathing from any other cause were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients were ventilated in a time-cycled, pressure-limited mode with flow triggering set at 1.0 L/min by using the Evita XL (Dräger, Lubeck, Germany). Patient-ventilator asynchrony was identified by a random 30-minute continuous recording and an offline analysis of the flow and pressure signals. Patient-ventilator asynchrony was categorized and labeled into four different groups: 1) trigger asynchrony (i.e., insensitive trigger, double triggering, autotriggering, or trigger delay), 2) flow asynchrony, 3) termination asynchrony (i.e., delayed or premature termination), and 4) expiratory asynchrony. Flow and pressure signals were recorded in 45 patients for 30 minutes. A total number of 57,651 breaths were analyzed. Patient-ventilator asynchrony occurred in 19,175 breaths (33%), and it was seen in every patient. Ineffective triggering was the most predominant type of asynchrony (68%), followed by delayed termination (19%), double triggering (4%), and premature termination (3%). Patient-ventilator asynchrony significantly increased with lower levels of peak inspiratory pressure, positive end-expiratory pressure, and set frequency. CONCLUSIONS Patient-ventilator asynchrony is extremely common in mechanically ventilated children, and the predominant cause is ineffective triggering.
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Larouche A, Massicotte E, Constantin G, Ducharme-Crevier L, Essouri S, Sinderby C, Beck J, Emeriaud G. Tonic diaphragmatic activity in critically ill children with and without ventilatory support. Pediatr Pulmonol 2015; 50:1304-12. [PMID: 25940232 DOI: 10.1002/ppul.23182] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Revised: 01/27/2015] [Accepted: 03/15/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Infants have to actively maintain their end expiratory lung volume (EELV). In mechanically ventilated infants, the diaphragm stays activated until the end of expiration (tonic activity), contributing to EELV maintenance. It is unclear whether tonic activity compensates for the lack of laryngeal braking due to intubation or if it is normally present. OBJECTIVE To determine if tonic diaphragm activity remains after extubation in infants, and if it can be observed in older children. METHODS Prospective observational study of pediatric patients ventilated for >24 hr. Diaphragm electrical activity (EAdi) was recorded using a specific nasogastric catheter during four periods: (i) the acute phase, (ii) pre-extubation, (iii) post-extubation, and (iv) at PICU discharge. Tonic EAdi was defined as the EAdi in the last quartile of expiration. RESULTS Fifty-five patients, median age 10 months (Interquartile range: 1-48) were studied. In infants (<1 year, n = 28), tonic EAdi was always present, and represented 33% (22-43) of inspiratory EAdi at PICU discharge. No significant change was observed between pre- and post-extubation periods. In older patients (n = 27), tonic activity was negligible as a whole, but 10 patients exhibited significant tonic EAdi at one time-point during PICU stay. Bronchiolitis was the only independent factor associated with tonic EAdi. CONCLUSIONS In infants, tonic EAdi remains involved in ventilatory control after extubation and restoration of laryngeal braking. Tonic EAdi may play a pathophysiological role in bronchiolitis and it can be reactivated in older patients. The interest of tonic EAdi as a tool to titrate mechanical ventilation warrants further evaluation.
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Affiliation(s)
- Alexandrine Larouche
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Erika Massicotte
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | - Gabrielle Constantin
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
| | | | - Sandrine Essouri
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada.,Pediatric Intensive Care Unit, CHU Kremlin Bicêtre, Université Paris Sud, Le Kremlin Bicêtre, France
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada.,Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada
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Narchi H, Chedid F. Neurally adjusted ventilator assist in very low birth weight infants: Current status. World J Methodol 2015; 5:62-67. [PMID: 26140273 PMCID: PMC4482823 DOI: 10.5662/wjm.v5.i2.62] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 03/07/2015] [Accepted: 04/14/2015] [Indexed: 02/07/2023] Open
Abstract
Continuous improvements in perinatal care have resulted in increased survival of premature infants. Their immature lungs are prone to injury with mechanical ventilation and this may develop into chronic lung disease (CLD) or bronchopulmonary dysplasia. Strategies to minimize the risk of lung injury have been developed and include improved antenatal management (education, regionalization, steroids, and antibiotics), exogenous surfactant administration and reduction of barotrauma by using exclusive or early noninvasive ventilatory support. The most frequently used mode of assisted ventilation is pressure support ventilation that may lead to patient-ventilator asynchrony that is associated with poor outcome. Ventilator-induced diaphragmatic dysfunction or disuse atrophy of diaphragm fibers may also occur. This has led to the development of new ventilation modes including neurally adjusted ventilatory assist (NAVA). This ventilation mode is controlled by electrodes embedded within a nasogastric catheter which detect the electrical diaphragmatic activity (Edi) and transmit it to trigger the ventilator in synchrony with the patient’s own respiratory efforts. This permits the patient to control peak inspiratory pressure, mean airway pressure and tidal volume. Back up pressure control (PC) is provided when there is no Edi signal and no pneumatic trigger. Compared with standard conventional ventilation, NAVA improves blood gas regulation with lower peak inspiratory pressure and oxygen requirements in preterm infants. NAVA is safe mode of ventilation. The majority of studies have shown no significant adverse events in neonates ventilated with NAVA nor a difference in the rate of intraventricular hemorrhage, pneumothorax, or necrotizing enterocolitis when compared to conventional ventilation. Future large size randomized controlled trials should be established to compare NAVA with volume targeted and pressure controlled ventilation in newborns with mature respiratory drive. Most previous studies and trials were not sufficiently large and did not include long-term patient oriented outcomes. Multicenter, randomized, outcome trials are needed to determine whether NAVA is effective in avoiding intubation, facilitating extubation, decreasing time of ventilation, reducing the incidence of CLD, decreasing length of stay, and improving long-term outcomes such as the duration of ventilation, length of hospital stay, rate of pneumothorax, CLD and other major complications of prematurity. In order to prevent barotrauma, next generations of NAVA equipment for neonatal use should enable automatic setting of ventilator parameters in the backup PC mode based on the values generated by NAVA. They should also include an upper limit to the inspiratory time as in conventional ventilation. The manufacturers of Edi catheters should produce smaller sizes available for extreme low birth weight infants. Newly developed ventilators should also include leak compensation and high frequency ventilation. A peripheral flow sensor is also essential to the proper delivery of all modes of conventional ventilation as well as NAVA.
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Ventilatory support in children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S51-60. [PMID: 26035364 DOI: 10.1097/pcc.0000000000000433] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To describe the recommendations of the Pediatric Acute Lung Injury Consensus Conference for mechanical ventilation management of pediatric patients with acute respiratory distress syndrome. DESIGN Consensus Conference of experts in pediatric acute lung injury. METHODS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 27 recommendations focused on the optimal mechanical ventilation approach of the patient with pediatric acute respiratory distress syndrome. Topics included ventilator mode, tidal volume delivery, inspiratory plateau pressure, high-frequency ventilation, cuffed endotracheal tubes, and gas exchange goals. When experimental data were lacking, a modified Delphi approach emphasizing the strong professional agreement was used. RESULTS There were 17 recommendations with strong agreement and 10 recommendations with weak agreement. There were no recommendations with equipoise or disagreement. There was weak agreement on recommendations concerning approach to tidal volume and inspiratory pressure limitation (88% to 72% agreement, respectively), whereas strong agreement could be achieved for accepting permissive hypercapnia. Using positive end-expiratory pressure levels greater than 15 cm H2O in severe pediatric acute respiratory distress syndrome, under the condition that the markers of oxygen delivery, respiratory system compliance, and hemodynamics are closely monitored as positive end-expiratory pressure is increased, is strongly recommended. The concept of exploring the effects of careful recruitment maneuvers during conventional ventilation met an agreement level of 88%, whereas the use of recruitment maneuvers during rescue high-frequency oscillatory ventilation is highly recommended (strong agreement). CONCLUSIONS The Consensus Conference developed pediatric-specific recommendations regarding mechanical ventilation of the patient with pediatric acute respiratory distress syndrome as well as future research priorities. These recommendations are intended to initiate discussion regarding optimal mechanical ventilation management for children with pediatric acute respiratory distress syndrome and identify areas of controversy requiring further investigation.
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Patthum A, Peters M, Lockwood C. Effectiveness and safety of Neurally Adjusted Ventilatory Assist (NAVA) mechanical ventilation compared to standard conventional mechanical ventilation in optimizing patient-ventilator synchrony in critically ill patients: a systematic review protocol. ACTA ACUST UNITED AC 2015; 13:31-46. [PMID: 26447047 DOI: 10.11124/jbisrir-2015-1914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 09/12/2014] [Accepted: 09/18/2014] [Indexed: 10/31/2022]
Affiliation(s)
- Arisara Patthum
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia.,Lyell McEwin Hospital, Adelaide, South Australia
| | - Micah Peters
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia
| | - Craig Lockwood
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia
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Neurally adjusted ventilatory assist (NAVA) allows patient-ventilator synchrony during pediatric noninvasive ventilation: a crossover physiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:44. [PMID: 25886793 PMCID: PMC4342194 DOI: 10.1186/s13054-015-0770-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 01/23/2015] [Indexed: 11/16/2022]
Abstract
Introduction The need for intubation after a noninvasive ventilation (NIV) failure is frequent in the pediatric intensive care unit (PICU). One reason is patient-ventilator asynchrony during NIV. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation controlled by the patient’s neural respiratory drive. The aim of this study was to assess the feasibility and tolerance of NIV-NAVA in children and to evaluate its impact on synchrony and respiratory effort. Methods This prospective, physiologic, crossover study included 13 patients requiring NIV in the PICU of Sainte-Justine’s Hospital from October 2011 to May 2013. Patients were successively ventilated in conventional NIV as prescribed by the physician in charge (30 minutes), in NIV-NAVA (60 minutes), and again in conventional NIV (30 minutes). Electrical activity of the diaphragm (EAdi) and airway pressure were simultaneously recorded to assess patient-ventilator synchrony. Results NIV-NAVA was feasible and well tolerated in all patients. One patient asked to stop the study because of anxiety related to the leak-free facial mask. Inspiratory trigger dys-synchrony and cycling-off dys-synchrony were significantly shorter in NIV-NAVA versus initial and final conventional NIV periods (both P <0.05). Wasted efforts were also decreased in NIV-NAVA (all values expressed as median and interquartile values) (0 (0 to 0) versus 12% (4 to 20) and 6% (2 to 22), respectively; P <0.01). As a whole, total time spent in asynchrony was reduced to 8% (6 to 10) in NIV-NAVA, versus 27% (19 to 56) and 32% (21 to 38) in conventional NIV before and after NIV-NAVA, respectively (P =0.05). Conclusion NIV-NAVA is feasible and well tolerated in PICU patients and allows improved patient-ventilator synchronization. Larger controlled studies are warranted to evaluate the clinical impact of these findings. Trial registration ClinicalTrials.gov NCT02163382. Registered 9 June 2014.
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Kallio M, Peltoniemi O, Anttila E, Pokka T, Kontiokari T. Neurally adjusted ventilatory assist (NAVA) in pediatric intensive care--a randomized controlled trial. Pediatr Pulmonol 2015; 50:55-62. [PMID: 24482284 DOI: 10.1002/ppul.22995] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 01/05/2014] [Indexed: 11/09/2022]
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) has been shown to improve patient-ventilator synchrony during invasive ventilation. The aim of this trial was to study NAVA as a primary ventilation mode in pediatric intensive care and to compare it with current standard ventilation modes. METHODS One hundred seventy pediatric intensive care patients were randomized to conventional ventilation or NAVA. The primary endpoints were time on the ventilator and the amount of sedation needed. To enable comparison between sedative agents, a "sedative unit" was defined for each drug. RESULTS The median time on the ventilator was 3.3 hr in the NAVA group and 6.6 hr in the control group (P = 0.17), and the length of stay in the PICU 49.5 hr in the NAVA group and 72.8 hr in the control group (P = 0.10, per protocol P = 0.03). The amount of sedation needed in the total patient population did not differ between the groups (P = 0.20), but when postoperative patients were excluded (19 vs. 20 patients), the amount was significantly lower in the NAVA group (0.80 vs. 2.23 units/hr, P = 0.03). Lower peak inspiratory pressure and a lower inspired oxygen fraction were found in the NAVA group (P = 0.001 for both). Arterial blood CO2 tensions were slightly higher in the NAVA group up to 32 hr of treatment (P = 0.008). There were no significant differences in the other ventilatory or vital parameters, arterial blood gas values or complications. CONCLUSIONS We found NAVA to be a safe and feasible primary ventilation mode for use with children. It outscored standard ventilation in some aspects, as it was able to enhance oxygenation even at lower airway pressures and led to reduced use of sedatives during longer periods of treatment.
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Affiliation(s)
- Merja Kallio
- Department of Pediatrics, Oulu University Hospital, Oulu, Finland
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Wu HT, Baudin F, Frasch MG, Emeriaud G. Respiratory Variability during NAVA Ventilation in Children: Authors' Reply. Front Pediatr 2015; 3:13. [PMID: 25745627 PMCID: PMC4333872 DOI: 10.3389/fped.2015.00013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/06/2015] [Indexed: 11/22/2022] Open
Affiliation(s)
- Hau-Tieng Wu
- Department of Mathematics, University of Toronto , Toronto, ON , Canada
| | - Florent Baudin
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal , Montreal, QC , Canada
| | - Martin G Frasch
- Department of Obstetrics and Gynecology, CHU Sainte-Justine Research Center, Université de Montréal , Montreal, QC , Canada ; Department of Neurosciences, CHU Sainte-Justine Research Center, Université de Montréal , Montreal, QC , Canada ; Centre de Recherche en Reproduction Animale, Université de Montréal , St-Hyacinthe, QC , Canada
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal , Montreal, QC , Canada
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Longhini F, Ferrero F, De Luca D, Cosi G, Alemani M, Colombo D, Cammarota G, Berni P, Conti G, Bona G, Della Corte F, Navalesi P. Neurally adjusted ventilatory assist in preterm neonates with acute respiratory failure. Neonatology 2015; 107:60-7. [PMID: 25401284 DOI: 10.1159/000367886] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 08/26/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is a novel mode of ventilation that has been demonstrated to improve infant-ventilator interaction, compared to the conventional modes in retrospective and short-term studies. OBJECTIVES To prospectively evaluate the physiologic effects of NAVA in comparison with pressure-regulated volume control (PRVC) in two nonrandomized 12-hour periods. METHODS We studied 14 consecutive intubated preterm neonates receiving mechanical ventilation for acute respiratory failure. Peak airway pressure (Pawpeak), diaphragm electrical activity (EAdi), tidal volume (VT), mechanical (RRmec) and neural (RRneu) respiratory rates, neural apneas, and the capillary arterialized blood gases were measured. The RRmec-to-RRneu ratio (MNR) and the asynchrony index were also calculated. The amount of fentanyl administered was recorded. RESULTS Pawpeak and VT were greater in PRVC (p < 0.01). Blood gases and RRmec were not different between modes, while RRneu and the EAdi swings were greater in NAVA (p = 0.02 and p < 0.001, respectively). MNR and the asynchrony index were remarkably lower in NAVA than in PRVC (p = 0.03 and p < 0.001, respectively). 1,841 neural apneas were observed during PRVC, with none in NAVA. Less fentanyl was administered during NAVA, as opposed to PRVC (p < 0.01). CONCLUSIONS In acutely ill preterm neonates, NAVA can be safely and efficiently applied for 12 consecutive hours. Compared to PRVC, NAVA is well tolerated with fewer sedatives.
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Affiliation(s)
- Federico Longhini
- Department of Translational Medicine, Eastern Piedmont University 'A. Avogadro', Novara, Italy
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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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Piastra M, De Luca D, Costa R, Pizza A, De Sanctis R, Marzano L, Biasucci D, Visconti F, Conti G. Neurally adjusted ventilatory assist vs pressure support ventilation in infants recovering from severe acute respiratory distress syndrome: Nested study. J Crit Care 2014; 29:312.e1-5. [DOI: 10.1016/j.jcrc.2013.08.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2013] [Revised: 08/06/2013] [Accepted: 08/06/2013] [Indexed: 11/15/2022]
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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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La ventilation non invasive en mode NAVA (neurally adjusted ventilatory assist) en réanimation pédiatrique. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0848-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Baudin F, Wu HT, Bordessoule A, Beck J, Jouvet P, Frasch MG, Emeriaud G. Impact of ventilatory modes on the breathing variability in mechanically ventilated infants. Front Pediatr 2014; 2:132. [PMID: 25505779 PMCID: PMC4242927 DOI: 10.3389/fped.2014.00132] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 11/10/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Reduction of breathing variability is associated with adverse outcome. During mechanical ventilation, the variability of ventilatory pressure is dependent on the ventilatory mode. During neurally adjusted ventilatory assist (NAVA), the support is proportional to electrical activity of the diaphragm (EAdi), which reflects the respiratory center output. The variability of EAdi is, therefore, translated into a similar variability in pressures. Contrastingly, conventional ventilatory modes deliver less variable pressures. The impact of the mode on the patient's own respiratory drive is less clear. This study aims to compare the impact of NAVA, pressure-controlled ventilation (PCV), and pressure support ventilation (PSV) on the respiratory drive patterns in infants. We hypothesized that on NAVA, EAdi variability resembles most of the endogenous respiratory drive pattern seen in a control group. METHODS Electrical activity of the diaphragm was continuously recorded in 10 infants ventilated successively on NAVA (5 h), PCV (30 min), and PSV (30 min). During the last 10 min of each period, the EAdi variability pattern was assessed using non-rhythmic to rhythmic (NRR) index. These variability profiles were compared to the pattern of a control group of 11 spontaneously breathing and non-intubated infants. RESULTS In control infants, NRR was higher as compared to mechanically ventilated infants (p < 0.001), and NRR pattern was relatively stable over time. While the temporal stability of NRR was similar in NAVA and controls, the NRR profile was less stable during PCV. PSV exhibited an intermediary pattern. PERSPECTIVES Mechanical ventilation impacts the breathing variability in infants. NAVA produces EAdi pattern resembling most that of control infants. NRR can be used to characterize respiratory variability in infants. Larger prospective studies are necessary to understand the differential impact of the ventilatory modes on the cardio-respiratory variability and to study their impact on clinical outcomes.
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Affiliation(s)
- Florent Baudin
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal , Montreal, QC , Canada
| | - Hau-Tieng Wu
- Department of Mathematics, University of Toronto , Toronto, ON , Canada
| | - Alice Bordessoule
- Pediatric Critical Care Unit, Geneva University Hospital , Geneva , Switzerland
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto, ON , Canada ; Department of Pediatrics, University of Toronto , Toronto, ON , Canada
| | - Philippe Jouvet
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal , Montreal, QC , Canada
| | - Martin G Frasch
- Department of Obstetrics and Gynecology, CHU Ste-Justine Research Center, Université de Montréal , Montreal, QC , Canada ; Department of Neurosciences, CHU Ste-Justine Research Center, Université de Montréal , Montreal, QC , Canada ; Centre de recherche en reproduction animale, Université de Montréal , St-Hyacinthe, QC , Canada
| | - Guillaume Emeriaud
- Department of Pediatrics, CHU Sainte-Justine, Université de Montréal , Montreal, QC , Canada
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Sinderby C, Liu S, Colombo D, Camarotta G, Slutsky AS, Navalesi P, Beck J. An automated and standardized neural index to quantify patient-ventilator interaction. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R239. [PMID: 24131701 PMCID: PMC4056567 DOI: 10.1186/cc13063] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 09/16/2013] [Indexed: 11/10/2022]
Abstract
INTRODUCTION The aim of this study was to validate an automated, objective and standardized algorithm for quantifying and displaying patient-ventilator interaction. METHODS Using a new method to detect patient-ventilator synchrony, the present study re-analyzed previously acquired and published data from 24 mechanically ventilated adult patients (Colombo et al., Crit Care Med. 2011 Nov;39(11):2452-7). Patient-ventilator interactions were evaluated by comparing ventilator pressure and diaphragm electrical activity (EAdi) waveforms, recorded during pressure support ventilation. The EAdi and ventilator pressure waveforms were analyzed for their timings (manually and automatically determined), and the error between the two waveforms was quantified. A new index of patient-ventilator interaction (NeuroSync index), which is standardized and automated, was validated and compared to manual analysis and previously published indices of asynchrony. RESULTS The comparison of manual and automated detection methods produced high test-retest and inter-rater reliability (Intraclass correlation coefficient = 0.95). The NeuroSync index increased the sensitivity of detecting dyssynchronies, compared to previously published indices, which were found to only detect asynchronies. CONCLUSION The present study introduces an automated method and the NeuroSync index to determine patient-ventilator interaction with a more sensitive analysis method than those previously described. A dashboard-style of graphical display allows a rapid overview of patient-ventilator interaction and breathing pattern at the bedside.
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Patient-ventilator asynchrony during noninvasive pressure support ventilation and neurally adjusted ventilatory assist in infants and children. Pediatr Crit Care Med 2013; 14:e357-64. [PMID: 23863816 DOI: 10.1097/pcc.0b013e3182917922] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To document the prevalence of asynchrony events during noninvasive ventilation in pressure support in infants and in children and to compare the results with neurally adjusted ventilatory assist. DESIGN Prospective randomized cross-over study in children undergoing noninvasive ventilation. SETTING The study was performed in a PICU. PATIENTS From 4 weeks to 5 years. INTERVENTIONS Two consecutive ventilation periods (pressure support and neurally adjusted ventilatory assist) were applied in random order. During pressure support (PS), three levels of expiratory trigger (ETS) setting were compared: initial ETS (PSinit), and ETS value decreased and increased by 15%. Of the three sessions, the period allowing for the lowest number of asynchrony events was defined as PSbest. Neurally adjusted ventilator assist level was adjusted to match the maximum airway pressure during PSinit. Positive end-expiratory pressure was the same during pressure support and neurally adjusted ventilator assist. Asynchrony events, trigger delay, and cycling-off delay were quantified for each period. RESULTS Six infants and children were studied. Trigger delay was lower with neurally adjusted ventilator assist versus PSinit and PSbest (61 ms [56-79] vs 149 ms [134-180] and 146 ms [101-162]; p = 0.001 and 0.02, respectively). Inspiratory time in excess showed a trend to be shorter during pressure support versus neurally adjusted ventilator assist. Main asynchrony events during PSinit were autotriggering (4.8/min [1.7-12]), ineffective efforts (9.9/min [1.7-18]), and premature cycling (6.3/min [3.2-18.7]). Premature cycling (3.4/min [1.1-7.7]) was less frequent during PSbest versus PSinit (p = 0.059). The asynchrony index was significantly lower during PSbest versus PSinit (40% [28-65] vs 65.5% [42-76], p < 0.001). With neurally adjusted ventilator assist, all types of asynchronies except double triggering were reduced. The asynchrony index was lower with neurally adjusted ventilator assist (2.3% [0.7-5] vs PSinit and PSbest, p < 0.05 for both comparisons). CONCLUSION Asynchrony events are frequent during noninvasive ventilation with pressure support in infants and in children despite adjusting the cycling-off criterion. Compared with pressure support, neurally adjusted ventilator assist allows improving patient-ventilator synchrony by reducing trigger delay and the number of asynchrony events. Further studies should determine the clinical impact of these findings.
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Optimizing patient-ventilator synchrony during invasive ventilator assist in children and infants remains a difficult task*. Pediatr Crit Care Med 2013; 14:e316-25. [PMID: 23842584 DOI: 10.1097/pcc.0b013e31828a8606] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To document and compare the prevalence of asynchrony events during invasive-assisted mechanical ventilation in pressure support mode and in neurally adjusted ventilatory assist in children. DESIGN Prospective, randomized, and crossover study. SETTING Pediatric and Neonatal Intensive Care Unit, University Hospital of Geneva, Switzerland. PATIENTS Intubated and mechanically ventilated children, between 4 weeks and 5 years old. INTERVENTIONS Two consecutive ventilation periods (pressure support and neurally adjusted ventilatory assist) were applied in random order. During pressure support, three levels of expiratory trigger setting were compared: expiratory trigger setting as set by the clinician in charge (PSinit), followed by a 10% (in absolute values) increase and decrease of the clinician's expiratory trigger setting. The pressure support session with the least number of asynchrony events was defined as PSbest. Therefore, three periods were compared: PSinit, PSbest, and neurally adjusted ventilatory assist. Asynchrony events, trigger delay, and inspiratory time in excess were quantified for each of them. MEASUREMENTS AND MAIN RESULTS Data from 19 children were analyzed. Main asynchrony events during PSinit were autotriggering (3.6 events/min [0.7-8.2]), ineffective efforts (1.2/min [0.6-5]), and premature cycling (3.5/min [1.3-4.9]). Their number was significantly reduced with PSbest: autotriggering 1.6/min (0.2-4.9), ineffective efforts 0.7/min (0-2.6), and premature cycling 2/min (0.1-3.1), p < 0.005 for each comparison. The median asynchrony index (total number of asynchronies/triggered and not triggered breaths ×100) was significantly different between PSinit and PSbest: 37.3% [19-47%] and 29% [24-43%], respectively, p < 0.005). With neurally adjusted ventilatory assist, all types of asynchrony events except double-triggering and inspiratory time in excess were significantly reduced resulting in an asynchrony index of 3.8% (2.4-15%) (p < 0.005 compared to PSbest). CONCLUSIONS Asynchrony events are frequent during pressure support in children despite adjusting the cycling off criteria. Neurally adjusted ventilatory assist allowed for an almost ten-fold reduction in asynchrony events. Further studies should determine the clinical impact of these findings.
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Patient-ventilator asynchrony during noninvasive pressure support ventilation and neurally adjusted ventilatory assist in infants and children*. Pediatr Crit Care Med 2013; 14:728-9. [PMID: 24162963 DOI: 10.1097/pcc.0b013e318291810b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Interest of monitoring diaphragmatic electrical activity in the pediatric intensive care unit. Crit Care Res Pract 2013; 2013:384210. [PMID: 23509617 PMCID: PMC3594948 DOI: 10.1155/2013/384210] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 01/15/2013] [Accepted: 01/21/2013] [Indexed: 01/03/2023] Open
Abstract
The monitoring of electrical activity of the diaphragm (EAdi) is a new minimally invasive bedside technology that was developed for the neurally adjusted ventilatory assist (NAVA) mode of ventilation. In addition to its role in NAVA ventilation, this technology provides the clinician with previously unavailable and essential information on diaphragm activity. In this paper, we review the clinical interests of EAdi in the pediatric intensive care setting. Firstly, the monitoring of EAdi allows the clinician to tailor the ventilatory settings on an individual basis, avoiding frequent overassistance leading potentially to diaphragmatic atrophy. Increased inspiratory EAdi levels can also suggest insufficient support, while a strong tonic activity may reflect the patient efforts to increase its lung volume. EAdi monitoring also allows detection of patient-ventilator asynchrony. It can play a role in evaluation of extubation readiness. Finally, EAdi monitoring provides the clinician with better understanding of the ventilatory capacity of patients with acute neuromuscular disease. Further studies are warranted to evaluate the clinical impact of these potential benefits.
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