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Mehra K, Kresch M. Trends in the Incidence of Bronchopulmonary Dysplasia after the Introduction of Neurally Adjusted Ventilatory Assist (NAVA). CHILDREN (BASEL, SWITZERLAND) 2024; 11:113. [PMID: 38255426 PMCID: PMC10814022 DOI: 10.3390/children11010113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/04/2023] [Accepted: 01/09/2024] [Indexed: 01/24/2024]
Abstract
OBJECTIVE This study investigates the difference in the rates of bronchopulmonary dysplasia in very low birth weight infants before and after the introduction of neurally adjusted ventilatory assist (NAVA). STUDY DESIGN A retrospective cohort study comparing rates of Bronchopulmonary dysplasia (BPD) before and after implementation of NAVA. Eligibility criteria included all very low birth weight VLBW neonates needing ventilation. For analysis, each cohort was divided into three subgroups based on gestational age. Changes in the rate of BPD, length of stay, tracheostomy rates, invasive ventilator days, and home oxygen therapy were compared. RESULTS There were no differences in the incidence of BPD in neonates at 23-25 6/7 weeks' and 29-32 weeks' gestation between the two cohorts. A higher incidence of BPD was seen in the 26-28 5/7 weeks' gestation NAVA subgroup compared to controls (86% vs. 68%, p = 0.05). No significant difference was found for ventilator days, but infants in the 26-28 6/7 subgroup in the NAVA cohort had a longer length of stay (98 ± 34 days vs. 82 ± 24 days, p = 0.02), a higher percentage discharged on home oxygen therapy (45% vs. 18%, respectively, p = 0.006), and higher tracheostomy rates (3/36 vs. 0/60, p = 0.02), compared to the control group. CONCLUSIONS The NAVA mode was not associated with a reduction in BPD when compared to other modes of ventilation. Unexpected increases were seen in BPD rates, home oxygen therapy rates, tracheostomy rates, and the length of stay in the NAVA subgroup born at 26-28 6/7 weeks' gestation.
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Affiliation(s)
- Kashish Mehra
- Division of Neonatal-Perinatal Medicine, Penn State Health Children’s Hospital, Hershey, PA 17033, USA;
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Umbrello M, Antonucci E, Muttini S. Neurally Adjusted Ventilatory Assist in Acute Respiratory Failure-A Narrative Review. J Clin Med 2022; 11:jcm11071863. [PMID: 35407471 PMCID: PMC9000024 DOI: 10.3390/jcm11071863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 03/25/2022] [Indexed: 02/08/2023] Open
Abstract
Maintaining spontaneous breathing has both potentially beneficial and deleterious consequences in patients with acute respiratory failure, depending on the balance that can be obtained between the protecting and damaging effects on the lungs and the diaphragm. Neurally adjusted ventilatory assist (NAVA) is an assist mode, which supplies the respiratory system with a pressure proportional to the integral of the electrical activity of the diaphragm. This proportional mode of ventilation has the theoretical potential to deliver lung- and respiratory-muscle-protective ventilation by preserving the physiologic defense mechanisms against both lung overdistention and ventilator overassistance, as well as reducing the incidence of diaphragm disuse atrophy while maintaining patient–ventilator synchrony. This narrative review presents an overview of NAVA technology, its basic principles, the different methods to set the assist level and the findings of experimental and clinical studies which focused on lung and diaphragm protection, machine–patient interaction and preservation of breathing pattern variability. A summary of the findings of the available clinical trials which investigate the use of NAVA in acute respiratory failure will also be presented and discussed.
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Wu M, Yuan X, Liu L, Yang Y. Neurally Adjusted Ventilatory Assist vs. Conventional Mechanical Ventilation in Adults and Children With Acute Respiratory Failure: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2022; 9:814245. [PMID: 35273975 PMCID: PMC8901502 DOI: 10.3389/fmed.2022.814245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 01/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background Patient-ventilator asynchrony is a common problem in mechanical ventilation (MV), resulting in increased complications of MV. Despite there being some pieces of evidence for the efficacy of improving the synchronization of neurally adjusted ventilatory assist (NAVA), controversy over its physiological and clinical outcomes remain. Herein, we conducted a systematic review and meta-analysis to determine the relative impact of NAVA or conventional mechanical ventilation (CMV) modes on the important outcomes of adults and children with acute respiratory failure (ARF). Methods Qualified studies were searched in PubMed, EMBASE, Medline, Web of Science, Cochrane Library, and additional quality evaluations up to October 5, 2021. The primary outcome was asynchrony index (AI); secondary outcomes contained the duration of MV, intensive care unit (ICU) mortality, the incidence rate of ventilator-associated pneumonia, pH, and Partial Pressure of Carbon Dioxide in Arterial Blood (PaCO2). A statistical heterogeneity for the outcomes was assessed using the I 2 test. A data analysis of outcomes using odds ratio (OR) for ICU mortality and ventilator-associated pneumonia incidence and mean difference (MD) for AI, duration of MV, pH, and PaCO2, with 95% confidence interval (CI), was expressed. Results Eighteen eligible studies (n = 926 patients) were eventually enrolled. For the primary outcome, NAVA may reduce the AI (MD = -18.31; 95% CI, -24.38 to -12.25; p < 0.001). For the secondary outcomes, the duration of MV in the NAVA mode was 2.64 days lower than other CMVs (MD = -2.64; 95% CI, -4.88 to -0.41; P = 0.02), and NAVA may decrease the ICU mortality (OR =0.60; 95% CI, 0.42 to 0.86; P = 0.006). There was no statistically significant difference in the incidence of ventilator-associated pneumonia, pH, and PaCO2 between NAVA and other MV modes. Conclusions Our study suggests that NAVA ameliorates the synchronization of patient-ventilator and improves the important clinical outcomes of patients with ARF compared with CMV modes.
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Affiliation(s)
- Mengfan Wu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
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COVID-19 ARDS: Points to Be Considered in Mechanical Ventilation and Weaning. J Pers Med 2021; 11:jpm11111109. [PMID: 34834461 PMCID: PMC8618434 DOI: 10.3390/jpm11111109] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 12/21/2022] Open
Abstract
The COVID-19 disease can cause hypoxemic respiratory failure due to ARDS, requiring invasive mechanical ventilation. Although early studies reported that COVID-19-associated ARDS has distinctive features from ARDS of other causes, recent observational studies have demonstrated that ARDS related to COVID-19 shares common clinical characteristics and respiratory system mechanics with ARDS of other origins. Therefore, mechanical ventilation in these patients should be based on strategies aiming to mitigate ventilator-induced lung injury. Assisted mechanical ventilation should be applied early in the course of mechanical ventilation by considering evaluation and minimizing factors associated with patient-inflicted lung injury. Extracorporeal membrane oxygenation should be considered in selected patients with refractory hypoxia not responding to conventional ventilation strategies. This review highlights the current and evolving practice in managing mechanically ventilated patients with ARDS related to COVID-19.
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Haudebourg AF, Maraffi T, Tuffet S, Perier F, de Prost N, Razazi K, Mekontso Dessap A, Carteaux G. Refractory ineffective triggering during pressure support ventilation: effect of proportional assist ventilation with load-adjustable gain factors. Ann Intensive Care 2021; 11:147. [PMID: 34669080 PMCID: PMC8527439 DOI: 10.1186/s13613-021-00935-0] [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: 06/07/2021] [Accepted: 10/07/2021] [Indexed: 12/21/2022] Open
Abstract
Background Ineffective triggering is frequent during pressure support ventilation (PSV) and may persist despite ventilator adjustment, leading to refractory asynchrony. We aimed to assess the effect of proportional assist ventilation with load-adjustable gain factors (PAV+) on the occurrence of refractory ineffective triggering. Design Observational assessment followed by prospective cross-over physiological study. Setting Academic medical ICU. Patients Ineffective triggering was detected during PSV by a twice-daily inspection of the ventilator’s screen. The impact of pressure support level (PSL) adjustments on the occurrence of asynchrony was recorded. Patients experiencing refractory ineffective triggering, defined as persisting asynchrony at the lowest tolerated PSL, were included in the physiological study. Interventions Physiological study: Flow, airway, and esophageal pressures were continuously recorded during 10 min under PSV with the lowest tolerated PSL, and then under PAV+ with the gain adjusted to target a muscle pressure between 5 and 10 cmH2O. Measurements Primary endpoint was the comparison of asynchrony index between PSV and PAV+ after PSL and gain adjustments. Results Among 36 patients identified having ineffective triggering under PSV, 21 (58%) exhibited refractory ineffective triggering. The lowest tolerated PSL was higher in patients with refractory asynchrony as compared to patients with non-refractory ineffective triggering. Twelve out of the 21 patients with refractory ineffective triggering were included in the physiological study. The median lowest tolerated PSL was 17 cmH2O [12–18] with a PEEP of 7 cmH2O [5–8] and FiO2 of 40% [39–42]. The median gain during PAV+ was 73% [65–80]. The asynchrony index was significantly lower during PAV+ than PSV (2.7% [1.0–5.4] vs. 22.7% [10.3–40.1], p < 0.001) and consistently decreased in every patient with PAV+. Esophageal pressure–time product (PTPes) did not significantly differ between the two modes (107 cmH2O/s/min [79–131] under PSV vs. 149 cmH2O/s/min [129–170] under PAV+, p = 0.092), but the proportion of PTPes lost in ineffective triggering was significantly lower with PAV+ (2 cmH2O/s/min [1–6] vs. 8 cmH2O/s/min [3–30], p = 0.012). Conclusions Among patients with ineffective triggering under PSV, PSL adjustment failed to eliminate asynchrony in 58% of them (21 of 36 patients). In these patients with refractory ineffective triggering, switching from PSV to PAV+ significantly reduced or even suppressed the incidence of asynchrony. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00935-0.
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Affiliation(s)
- Anne-Fleur Haudebourg
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France. .,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.
| | - Tommaso Maraffi
- Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Service de Réanimation et Surveillance Continue Adulte, Centre hospitalier intercommunal de Créteil, 94000, Créteil, France
| | - Samuel Tuffet
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
| | - François Perier
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Nicolas de Prost
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Keyvan Razazi
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France
| | - Guillaume Carteaux
- Service de Médecine Intensive Réanimation, DHU A-TVB, Hôpitaux Universitaires Henri Mondor - Albert Chenevier, Assistance Publique - Hôpitaux de Paris (AP-HP), Créteil, France.,Groupe de Recherche Clinique CARMAS, IMRB, Faculté de Médecine de Créteil, Université Paris Est-Créteil, Créteil, France.,Institut Mondor de Recherche Biomédicale INSERM 955, Créteil, France
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Yuan X, Lu X, Chao Y, Beck J, Sinderby C, Xie J, Yang Y, Qiu H, Liu L. Neurally adjusted ventilatory assist as a weaning mode for adults with invasive mechanical ventilation: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:222. [PMID: 34187528 PMCID: PMC8240429 DOI: 10.1186/s13054-021-03644-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 06/16/2021] [Indexed: 11/29/2022]
Abstract
Background Prolonged ventilatory support is associated with poor clinical outcomes. Partial support modes, especially pressure support ventilation, are frequently used in clinical practice but are associated with patient–ventilation asynchrony and deliver fixed levels of assist. Neurally adjusted ventilatory assist (NAVA), a mode of partial ventilatory assist that reduces patient–ventilator asynchrony, may be an alternative for weaning. However, the effects of NAVA on weaning outcomes in clinical practice are unclear. Methods We searched PubMed, Embase, Medline, and Cochrane Library from 2007 to December 2020. Randomized controlled trials and crossover trials that compared NAVA and other modes were identified in this study. The primary outcome was weaning success which was defined as the absence of ventilatory support for more than 48 h. Summary estimates of effect using odds ratio (OR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with accompanying 95% confidence interval (CI) were expressed. Results Seven studies (n = 693 patients) were included. Regarding the primary outcome, patients weaned with NAVA had a higher success rate compared with other partial support modes (OR = 1.93; 95% CI 1.12 to 3.32; P = 0.02). For the secondary outcomes, NAVA may reduce duration of mechanical ventilation (MD = − 2.63; 95% CI − 4.22 to − 1.03; P = 0.001) and hospital mortality (OR = 0.58; 95% CI 0.40 to 0.84; P = 0.004) and prolongs ventilator-free days (MD = 3.48; 95% CI 0.97 to 6.00; P = 0.007) when compared with other modes. Conclusions Our study suggests that the NAVA mode may improve the rate of weaning success compared with other partial support modes for difficult to wean patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03644-z.
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Affiliation(s)
- Xueyan Yuan
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Xinxing Lu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yali Chao
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Canada.,Department of Critical Care, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care, Keenan Research Centre for Biomedical Science of St. Michael's Hospital, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China.
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Pulmonary volume-feedback and ventilatory pattern after bilateral lung transplantation using neurally adjusted ventilatory assist ventilation. Br J Anaesth 2021; 127:143-152. [PMID: 33892948 DOI: 10.1016/j.bja.2021.03.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 02/23/2021] [Accepted: 03/01/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Bilateral lung transplantation results in pulmonary vagal denervation, which potentially alters respiratory drive, volume-feedback, and ventilatory pattern. We hypothesised that Neurally Adjusted Ventilatory Assist (NAVA) ventilation, which is driven by diaphragm electrical activity (EAdi), would reveal whether vagally mediated pulmonary-volume feedback is preserved in the early phases after bilateral lung transplantation. METHODS We prospectively studied bilateral lung transplant recipients within 48 h of surgery. Subjects were ventilated with NAVA and randomised to receive 3 ventilatory modes (baseline NAVA, 50%, and 150% of baseline NAVA values) and 2 PEEP levels (6 and 12 cm H2O). We recorded airway pressure, flow, and EAdi. RESULTS We studied 30 subjects (37% female; age: 37 (27-56) yr), of whom 19 (63%) had stable EAdi. The baseline NAVA level was 0.6 (0.2-1.0) cm H2O μV-1. Tripling NAVA level increased the ventilatory peak pressure over PEEP by 6.3 (1.8), 7.6 (2.4), and 8.7 (3.2) cm H2O, at 50%, 100%, and 150% of baseline NAVA level, respectively (P<0.001). EAdi peak decreased by 10.1 (9.0), 9.5 (9.4) and 8.8 μV (8.7) (P<0.001), accompanied by small increases in tidal volume, 8.3 (3.0), 8.7 (3.6), and 8.9 (3.3) ml kg-1 donor's predicted body weight at 50%, 100%, and 150% of baseline NAVA levels, respectively (P<0.001). Doubling PEEP did not affect tidal volume. CONCLUSIONS NAVA ventilation was feasible in the majority of patients during the early postoperative period after bilateral lung transplantation. Despite surgical vagotomy distal to the bronchial anastomoses, bilateral lung transplant recipients maintained an unmodified respiratory pattern in response to variations in ventilatory assistance and PEEP. CLINICAL TRIAL REGISTRATION NCT03367221.
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Neural control of pressure support ventilation improved patient-ventilator synchrony in patients with different respiratory system mechanical properties: a prospective, crossover trial. Chin Med J (Engl) 2021; 134:281-291. [PMID: 33470654 PMCID: PMC7846453 DOI: 10.1097/cm9.0000000000001357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Conventional pressure support ventilation (PSP) is triggered and cycled off by pneumatic signals such as flow. Patient-ventilator asynchrony is common during pressure support ventilation, thereby contributing to an increased inspiratory effort. Using diaphragm electrical activity, neurally controlled pressure support (PSN) could hypothetically eliminate the asynchrony and reduce inspiratory effort. The purpose of this study was to compare the differences between PSN and PSP in terms of patient-ventilator synchrony, inspiratory effort, and breathing pattern. Methods Eight post-operative patients without respiratory system comorbidity, eight patients with acute respiratory distress syndrome (ARDS) and obvious restrictive acute respiratory failure (ARF), and eight patients with chronic obstructive pulmonary disease (COPD) and mixed restrictive and obstructive ARF were enrolled. Patient-ventilator interactions were analyzed with macro asynchronies (ineffective, double, and auto triggering), micro asynchronies (inspiratory trigger delay, premature, and late cycling), and the total asynchrony index (AI). Inspiratory efforts for triggering and total inspiration were analyzed. Results Total AI of PSN was consistently lower than that of PSP in COPD (3% vs. 93%, P = 0.012 for 100% support level; 8% vs. 104%, P = 0.012 for 150% support level), ARDS (8% vs. 29%, P = 0.012 for 100% support level; 16% vs. 41%, P = 0.017 for 150% support level), and post-operative patients (21% vs. 35%, P = 0.012 for 100% support level; 15% vs. 50%, P = 0.017 for 150% support level). Improved support levels from 100% to 150% statistically increased total AI during PSP but not during PSN in patients with COPD or ARDS. Patients’ inspiratory efforts for triggering and total inspiration were significantly lower during PSN than during PSP in patients with COPD or ARDS under both support levels (P < 0.05). There was no difference in breathing patterns between PSN and PSP. Conclusions PSN improves patient-ventilator synchrony and generates a respiratory pattern similar to PSP independently of any level of support in patients with different respiratory system mechanical properties. PSN, which reduces the trigger and total patient's inspiratory effort in patients with COPD or ARDS, might be an alternative mode for PSP. Trial Registration ClinicalTrials.gov, NCT01979627; https://clinicaltrials.gov/ct2/show/record/NCT01979627.
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Abstract
PURPOSE OF REVIEW Complications of mechanical ventilation, such as ventilator-induced lung injury (VILI) and ventilator-induced diaphragmatic dysfunction (VIDD), adversely affect the outcome of critically ill patients. Although mostly studied during control ventilation, it is increasingly appreciated that VILI and VIDD also occur during assisted ventilation. Hence, current research focuses on identifying ways to monitor and deliver protective ventilation in assisted modes. This review describes the operating principles of proportional modes of assist, their implications for lung and diaphragm protective ventilation, and the supporting clinical data. RECENT FINDINGS Proportional modes of assist, proportional assist ventilation, PAV, and neurally adjusted ventilatory assist, NAVA, deliver a pressure assist that is proportional to the patient's effort, enabling ventilation to be better controlled by the patient's brain. This control underlies the potential of proportional modes to avoid over-assist and under-assist, improve patient--ventilator interaction, and provide protective ventilation. Indeed, in clinical studies, proportional modes have been associated with reduced asynchronies, enhanced diaphragmatic recovery, and limitation of excessive tidal volume. Additionally, proportional modes facilitate better monitoring of the delivery of protective assisted ventilation. SUMMARY Physiological rationale and clinical data suggest a potential role for proportional modes of assist in providing and monitoring lung and diaphragm protective ventilation.
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Neurally adjusted ventilatory assist in acute respiratory failure: a randomized controlled trial. Intensive Care Med 2020; 46:2327-2337. [PMID: 32893313 PMCID: PMC7474954 DOI: 10.1007/s00134-020-06181-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/11/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE We hypothesized that neurally adjusted ventilatory assist (NAVA) compared to conventional lung-protective mechanical ventilation (MV) decreases duration of MV and mortality in patients with acute respiratory failure (ARF). METHODS We carried out a multicenter, randomized, controlled trial in patients with ARF from several etiologies. Intubated patients ventilated for ≤ 5 days expected to require MV for ≥ 72 h and able to breathe spontaneously were eligible for enrollment. Eligible patients were randomly assigned based on balanced treatment assignments with a computerized randomization allocation sequence to two ventilatory strategies: (1) lung-protective MV (control group), and (2) lung-protective MV with NAVA (NAVA group). Allocation concealment was maintained at all sites during the trial. Primary outcome was the number of ventilator-free days (VFDs) at 28 days. Secondary outcome was all-cause hospital mortality. All analyses were done according to the intention-to-treat principle. RESULTS Between March 2014 and October 2019, we enrolled 306 patients and randomly assigned 153 patients to the NAVA group and 153 to the control group. Median VFDs were higher in the NAVA than in the control group (22 vs. 18 days; between-group difference 4 days; 95% confidence interval [CI] 0 to 8 days; p = 0.016). At hospital discharge, 39 (25.5%) patients in the NAVA group and 47 (30.7%) patients in the control group had died (between-group difference - 5.2%, 95% CI - 15.2 to 4.8, p = 0.31). Other clinical, physiological or safety outcomes did not differ significantly between the trial groups. CONCLUSION NAVA decreased duration of MV although it did not improve survival in ventilated patients with ARF.
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Effect of Neurally Adjusted Ventilatory Assist on Patient-Ventilator Interaction in Mechanically Ventilated Adults: A Systematic Review and Meta-Analysis. Crit Care Med 2020; 47:e602-e609. [PMID: 30882481 DOI: 10.1097/ccm.0000000000003719] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Patient-ventilator asynchrony is common among critically ill patients undergoing mechanical ventilation and has been associated with adverse outcomes. Neurally adjusted ventilatory assist is a ventilatory mode that may lead to improved patient-ventilator synchrony. We conducted a systematic review to determine the impact of neurally adjusted ventilatory assist on patient-ventilator asynchrony, other physiologic variables, and clinical outcomes in adult patients undergoing invasive mechanical ventilation in comparison with conventional pneumatically triggered ventilatory modes. DATA SOURCES We searched Medline, EMBASE, Cochrane Database of Systematic Reviews, Cochrane Central, CINAHL, Scopus, Web of Science, conference abstracts, and ClinicalTrials.gov until July 2018. STUDY SELECTION Two authors independently screened titles and abstracts for randomized and nonrandomized controlled trials (including crossover design) comparing the occurrence of patient-ventilator asynchrony between neurally adjusted ventilatory assist and pressure support ventilation during mechanical ventilation in critically ill adults. The asynchrony index and severe asynchrony (i.e., asynchrony index > 10%) were the primary outcomes. DATA EXTRACTION Two authors independently extracted study characteristics and outcomes and assessed risk of bias of included studies. DATA SYNTHESIS Of 11,139 unique citations, 26 studies (522 patients) met the inclusion criteria. Sixteen trials were included in the meta-analysis using random effects models through the generic inverse variance method. In several different clinical scenarios, the use of neurally adjusted ventilatory assist was associated with significantly reduced asynchrony index (mean difference, -8.12; 95% CI, -11.61 to -4.63; very low quality of evidence) and severe asynchrony (odds ratio, 0.42; 95% CI, 0.23-0.76; moderate quality of evidence) as compared with pressure support ventilation. Furthermore, other measurements of asynchrony were consistently improved during neurally adjusted ventilatory assist. CONCLUSIONS Neurally adjusted ventilatory assist improves patient-ventilator synchrony; however, its effects on clinical outcomes remain uncertain. Randomized controlled trials are needed to determine whether the physiologic efficiency of neurally adjusted ventilatory assist affects patient-important outcomes in critically ill adults.
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Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR, Ferreira JC. Neurally adjusted ventilatory assist vs. pressure support to deliver protective mechanical ventilation in patients with acute respiratory distress syndrome: a randomized crossover trial. Ann Intensive Care 2020; 10:18. [PMID: 32040785 PMCID: PMC7010869 DOI: 10.1186/s13613-020-0638-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Accepted: 02/02/2020] [Indexed: 01/06/2023] Open
Abstract
Background Protective mechanical ventilation is recommended for patients with acute respiratory distress syndrome (ARDS), but it usually requires controlled ventilation and sedation. Using neurally adjusted ventilatory assist (NAVA) or pressure support ventilation (PSV) could have additional benefits, including the use of lower sedative doses, improved patient–ventilator interaction and shortened duration of mechanical ventilation. We designed a pilot study to assess the feasibility of keeping tidal volume (VT) at protective levels with NAVA and PSV in patients with ARDS. Methods We conducted a prospective randomized crossover trial in five ICUs from a university hospital in Brazil and included patients with ARDS transitioning from controlled ventilation to partial ventilatory support. NAVA and PSV were applied in random order, for 15 min each, followed by 3 h in NAVA. Flow, peak airway pressure (Paw) and electrical activity of the diaphragm (EAdi) were captured from the ventilator, and a software (Matlab, Mathworks, USA), automatically detected inspiratory efforts and calculated respiratory rate (RR) and VT. Asynchrony events detection was based on waveform analysis. Results We randomized 20 patients, but the protocol was interrupted for five (25%) patients for whom we were unable to maintain VT below 6.5 mL/kg in PSV due to strong inspiratory efforts and for one patient for whom we could not detect EAdi signal. For the 14 patients who completed the protocol, VT was 5.8 ± 1.1 mL/kg for NAVA and 5.6 ± 1.0 mL/kg for PSV (p = 0.455) and there were no differences in RR (24 ± 7 for NAVA and 23 ± 7 for PSV, p = 0.661). Paw was greater in NAVA (21 ± 3 cmH2O) than in PSV (19 ± 3 cmH2O, p = 0.001). Most patients were under continuous sedation during the study. NAVA reduced triggering delay compared to PSV (p = 0.020) and the median asynchrony Index was 0.7% (0–2.7) in PSV and 0% (0–2.2) in NAVA (p = 0.6835). Conclusions It was feasible to keep VT in protective levels with NAVA and PSV for 75% of the patients. NAVA resulted in similar VT, RR and Paw compared to PSV. Our findings suggest that partial ventilatory assistance with NAVA and PSV is feasible as a protective ventilation strategy in selected ARDS patients under continuous sedation. Trial registration ClinicalTrials.gov (NCT01519258). Registered 26 January 2012, https://clinicaltrials.gov/ct2/show/NCT01519258
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Affiliation(s)
- Fabia Diniz-Silva
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Escola Politécnica da USP, Av. Prof. Luciano Gualberto, trav. 3, 158, Cidade Universitária, São Paulo, SP, CEP 05586-0600, Brazil
| | - Adriano M Alencar
- Instituto de Física, Universidade de São Paulo, Caixa Postal 66318, São Paulo, SP, CEP 05314-970, Brazil
| | - Marcelo B P Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil
| | - Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, SP, BR, Av. Dr. Enéas de Carvalho Aguiar, 44, 5 andar, bloco 2, sala 1, São Paulo, SP, CEP 05403900, Brazil.
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Akoumianaki E, Vaporidi K, Georgopoulos D. The Injurious Effects of Elevated or Nonelevated Respiratory Rate during Mechanical Ventilation. Am J Respir Crit Care Med 2019; 199:149-157. [PMID: 30199652 DOI: 10.1164/rccm.201804-0726ci] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Respiratory rate is one of the key variables that is set and monitored during mechanical ventilation. As part of increasing efforts to optimize mechanical ventilation, it is prudent to expand understanding of the potential harmful effects of not only volume and pressures but also respiratory rate. The mechanisms by which respiratory rate may become injurious during mechanical ventilation can be distinguished in two broad categories. In the first, well-recognized category, concerning both controlled and assisted ventilation, the respiratory rate per se may promote ventilator-induced lung injury, dynamic hyperinflation, ineffective efforts, and respiratory alkalosis. It may also be misinterpreted as distress delaying the weaning process. In the second category, which concerns only assisted ventilation, the respiratory rate may induce injury in a less apparent way by remaining relatively quiescent while being challenged by chemical feedback. By responding minimally to chemical feedback, respiratory rate leaves the control of V. e almost exclusively to inspiratory effort. In such cases, when assist is high, weak inspiratory efforts promote ineffective triggering, periodic breathing, and diaphragmatic atrophy. Conversely, when assist is low, diaphragmatic efforts are intense and increase the risk for respiratory distress, asynchronies, ventilator-induced lung injury, diaphragmatic injury, and cardiovascular complications. This review thoroughly presents the multiple mechanisms by which respiratory rate may induce injury during mechanical ventilation, drawing the attention of critical care physicians to the potential injurious effects of respiratory rate insensitivity to chemical feedback during assisted ventilation.
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Affiliation(s)
- Evangelia Akoumianaki
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Katerina Vaporidi
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
| | - Dimitris Georgopoulos
- 1 Intensive Care Medicine Department, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Crete, Greece
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Chen C, Wen T, Liao W. Neurally adjusted ventilatory assist versus pressure support ventilation in patient-ventilator interaction and clinical outcomes: a meta-analysis of clinical trials. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:382. [PMID: 31555696 DOI: 10.21037/atm.2019.07.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background The objective of this study was to conduct a meta-analysis comparing neurally adjusted ventilatory assist (NAVA) with pressure support ventilation (PSV) in adult ventilated patients with patient-ventilator interaction and clinical outcomes. Methods The PubMed, the Web of Science, Scopus, and Medline were searched for appropriate clinical trials (CTs) comparing NAVA with PSV for the adult ventilated patients. RevMan 5.3 was performed for comparing NAVA with PSV in asynchrony index (AI), ineffective efforts, auto-triggering, double asynchrony, premature asynchrony, breathing pattern (Peak airway pressure (Pawpeek), mean airway pressure (Pawmean), tidal volume (VT, mL/kg), minute volume (MV), respiratory muscle unloading (peak electricity of diaphragm (EAdipeak), P 0.1, VT/EAdi), clinical outcomes (ICU mortality, duration of ventilation days, ICU stay time, hospital stay time). Results Our meta-analysis included 12 studies involving a total of 331 adult ventilated patients, AI was significantly lower in NAVA group [mean difference (MD) -12.82, 95% confidence interval (CI): -21.20 to -4.44, I2=88%], and using subgroup analysis, grouped by mechanical ventilation, the results showed that NAVA also had lower AI than PSV (Mechanical ventilation, MD -9.52, 95% CI: -17.85 to -1.20, I2=87%), (Non-invasive ventilation (NIV), MD -24.55, 95% CI: -35.40 to -13.70, I2=0%). NAVA was significantly lower than the PSV in auto-triggering (MD -0.28, 95% CI: -0.51 to -0.05, I2=10%), and premature triggering (MD -2.49, 95% CI: -3.77 to -1.21, I2=29%). There were no significant differences in double triggering, ineffective efforts, breathing pattern (Pawmean, Pawpeak, VT, MV), and respiratory muscle unloading (EAdipeak, P 0.1, VT/EAdi). For clinical outcomes, NAVA was significantly lower than the PSV (MD -2.82, 95% CI: -5.55 to -0.08, I2=0%) in the duration of ventilation, but two groups did not show significant differences in ICU mortality, ICU stay time, and hospital stay time. Conclusions NAVA is more beneficial in patient-ventilator interaction than PSV, and could decrease the duration of ventilation.
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Affiliation(s)
- Chongxiang Chen
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China.,Guangzhou Institute of Respiratory Diseases, the First Affiliated Hospital of Guangzhou Medical University, State Key Laboratory of Respiratory Disease, Guangzhou 510120, China
| | - Tianmeng Wen
- School of Public Health, Sun Yat-sen University, Guangzhou 510000, China
| | - Wei Liao
- Department of Intensive Care Unit, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Guangzhou 510060, China
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15
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Nam SK, Lee J, Jun YH. Neural feedback is insufficient in preterm infants during neurally adjusted ventilatory assist. Pediatr Pulmonol 2019; 54:1277-1283. [PMID: 31077579 DOI: 10.1002/ppul.24352] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 04/02/2019] [Accepted: 04/17/2019] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To investigate the effects of changing assistance levels on respiratory patterns, including peak inspiratory pressure (PIP), overassistance, work of breathing, and discomfort in preterm infants during neurally adjusted ventilatory assist (NAVA). WORKING HYPOTHESIS Once the lungs reach optimal inflation, negative feedback suppresses neural respiratory drive and therefore, the electrical activity of the diaphragm (Edi) such that the lungs are protected from overinflation and breathing work is reduced. STUDY DESIGN A prospective study was conducted in 14 preterm infants (median postconceptional age of 32.1 weeks) who received at least 24 hours of ventilatory support for respiratory distress. METHODOLOGY Increasing and decreasing NAVA levels (from 0.5 to 4.0 cmH2 O/µV with an interval of 0.5 cmH 2 O/µV) were applied for 10 minutes each. Data recorded for the last 5 minutes of each NAVA level were analyzed. Heart rate and oxygen saturation were recorded and premature infant pain profiles were calculated. RESULTS An inflection point for PIP was not evident during increasing and decreasing assistance. Increasing NAVA levels caused greater variability in PIP and a higher proportion of the excessive tidal volume of more than 10 mL/kg. Peak Edi and discomfort scale decreased shortly after a small change in NAVA levels during increasing assistance. However, during decreasing assistance, peak Edi and discomfort scale remained low until a large reduction in NAVA levels. CONCLUSION Although NAVA can effectively alleviate the respiratory muscle work and discomfort, the neural feedback for protection from lung overinflation seems to be insufficient in preterm infants.
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Affiliation(s)
- Soo Kyung Nam
- Department of Pediatrics, Inha University Hospital, Incheon, Korea
| | - Juyoung Lee
- Department of Pediatrics, Inha University Hospital, Incheon, Korea.,Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
| | - Yong Hoon Jun
- Department of Pediatrics, Inha University Hospital, Incheon, Korea.,Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
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Peñuelas O, Keough E, López-Rodríguez L, Carriedo D, Gonçalves G, Barreiro E, Lorente JÁ. Ventilator-induced diaphragm dysfunction: translational mechanisms lead to therapeutical alternatives in the critically ill. Intensive Care Med Exp 2019; 7:48. [PMID: 31346802 PMCID: PMC6658639 DOI: 10.1186/s40635-019-0259-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023] Open
Abstract
Mechanical ventilation [MV] is a life-saving technique delivered to critically ill patients incapable of adequately ventilating and/or oxygenating due to respiratory or other disease processes. This necessarily invasive support however could potentially result in important iatrogenic complications. Even brief periods of MV may result in diaphragm weakness [i.e., ventilator-induced diaphragm dysfunction [VIDD]], which may be associated with difficulty weaning from the ventilator as well as mortality. This suggests that VIDD could potentially have a major impact on clinical practice through worse clinical outcomes and healthcare resource use. Recent translational investigations have identified that VIDD is mainly characterized by alterations resulting in a major decline of diaphragmatic contractile force together with atrophy of diaphragm muscle fibers. However, the signaling mechanisms responsible for VIDD have not been fully established. In this paper, we summarize the current understanding of the pathophysiological pathways underlying VIDD and highlight the diagnostic approach, as well as novel and experimental therapeutic options.
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Affiliation(s)
- Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain. .,Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.
| | - Elena Keough
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Lucía López-Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Demetrio Carriedo
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Gesly Gonçalves
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.,Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department [CEXS], Barcelona, Spain.,Universitat Pompeu Fabra [UPF], Barcelona Biomedical Research Park [PRBB], Barcelona, Spain
| | - José Ángel Lorente
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.,Universidad Europea, Madrid, Spain
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17
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Bruni A, Garofalo E, Pelaia C, Messina A, Cammarota G, Murabito P, Corrado S, Vetrugno L, Longhini F, Navalesi P. Patient-ventilator asynchrony in adult critically ill patients. Minerva Anestesiol 2019; 85:676-688. [PMID: 30762325 DOI: 10.23736/s0375-9393.19.13436-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Patient-ventilator asynchrony is considered a major clinical problem for mechanically ventilated patients. It occurs during partial ventilatory support, when the respiratory muscles and the ventilator interact to contribute generating the volume output. In this review article, we consider all studies published on patient-ventilator asynchrony in the last 25 years. EVIDENCE ACQUISITION We selected 62 studies. The different forms of asynchrony are first defined and classified. We also describe the methods used for detecting and quantifying asynchronies. We then outline the outcome variables considered for evaluating the clinical consequences of asynchronies. The methodology for detection and quantification of patient-ventilator asynchrony are quite heterogeneous. In particular, the Asynchrony Index is calculated differently among studies. EVIDENCE SYNTHESIS Sixteen studies established some relationship between asynchronies and one or more clinical outcomes, such as duration of mechanical ventilation (seven studies), mortality (five studies), length of intensive care and hospital stay (four studies), patient comfort (four studies), quality of sleep (three studies), and rate of tracheotomy (three studies). In patients with severe patient-ventilator asynchrony, four of seven studies (57%) report prolonged duration of mechanical ventilation, one of five (20%) increased mortality, one of four (25%) longer intensive care and hospital lengths of stay, four of four (100%) worsened comfort, three of four (75%) deteriorated quality of sleep, and one of three (33%) increased rate of tracheotomy. CONCLUSIONS Given the varying outcomes considered and the erratic results, it remains unclear whether asynchronies really affects patient outcome, and the relationship between asynchronies and outcome is causative or associative.
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Affiliation(s)
- Andrea Bruni
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | | | - Gianmaria Cammarota
- Unit of Anesthesia and Intensive Care, "Maggiore della Carità" Hospital, Novara, Italy
| | - Paolo Murabito
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", "G. Rodolico" University Policlinic, University of Catania, Catania, Italy
| | - Silvia Corrado
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, University of Udine, Udine, Italy
| | - Federico Longhini
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy -
| | - Paolo Navalesi
- Intensive Care Unit, Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
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Lamouret O, Crognier L, Vardon Bounes F, Conil JM, Dilasser C, Raimondi T, Ruiz S, Rouget A, Delmas C, Seguin T, Minville V, Georges B. Neurally adjusted ventilatory assist (NAVA) versus pressure support ventilation: patient-ventilator interaction during invasive ventilation delivered by tracheostomy. Crit Care 2019; 23:2. [PMID: 30616669 PMCID: PMC6323755 DOI: 10.1186/s13054-018-2288-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/04/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prolonged weaning is a major issue in intensive care patients and tracheostomy is one of the last resort options. Optimized patient-ventilator interaction is essential to weaning. The purpose of this study was to compare patient-ventilator synchrony between pressure support ventilation (PSV) and neurally adjusted ventilatory assist (NAVA) in a selected population of tracheostomised patients. METHODS We performed a prospective, sequential, non-randomized and single-centre study. Two recording periods of 60 min of airway pressure, flow, and electrical activity of the diaphragm during PSV and NAVA were recorded in a random assignment and eight periods of 1 min were analysed for each mode. We searched for macro-asynchronies (ineffective, double, and auto-triggering) and micro-asynchronies (inspiratory trigger delay, premature, and late cycling). The number and type of asynchrony events per minute and asynchrony index (AI) were determined. The two respiratory phases were compared using the non-parametric Wilcoxon test after testing the equality of the two variances (F-Test). RESULTS Among the 61 patients analysed, the total AI was lower in NAVA than in PSV mode: 2.1% vs 14% (p < 0.0001). This was mainly due to a decrease in the micro-asynchronies index: 0.35% vs 9.8% (p < 0.0001). The occurrence of macro-asynchronies was similar in both ventilator modes except for double triggering, which increased in NAVA. The tidal volume (ml/kg) was lower in NAVA than in PSV (5.8 vs 6.2, p < 0.001), and the respiratory rate was higher in NAVA than in PSV (28 vs 26, p < 0.05). CONCLUSION NAVA appears to be a promising ventilator mode in tracheotomised patients, especially for those requiring prolonged weaning due to the decrease in asynchronies.
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Affiliation(s)
- Olivier Lamouret
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France. .,Department of Anaesthesiology and Critical Care Unit, University Hospital of Toulouse, 31059, Toulouse Cedex 9, France.
| | - Laure Crognier
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Fanny Vardon Bounes
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Jean-Marie Conil
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Caroline Dilasser
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thibaut Raimondi
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Stephanie Ruiz
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Antoine Rouget
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Clément Delmas
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Thierry Seguin
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Vincent Minville
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
| | - Bernard Georges
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse Cedex 9, France
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Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5423639. [PMID: 30402484 PMCID: PMC6198583 DOI: 10.1155/2018/5423639] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/22/2018] [Accepted: 08/26/2018] [Indexed: 12/14/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is characterized by severe inflammatory response and hypoxemia. The use of mechanical ventilation (MV) for correction of gas exchange can cause worsening of this inflammatory response, called “ventilator-induced lung injury” (VILI). The process of withdrawing mechanical ventilation, referred to as weaning from MV, may cause worsening of lung injury by spontaneous ventilation. Currently, there are few specific studies in patients with ARDS. Herein, we reviewed the main aspects of spontaneous ventilation and also discussed potential methods to predict the failure of weaning in this patient category. We also reviewed new treatments (modes of mechanical ventilation, neuromuscular blocker use, and extracorporeal membrane oxygenation) that could be considered in weaning ARDS patients from MV.
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Holanda MA, Vasconcelos RDS, Ferreira JC, Pinheiro BV. Patient-ventilator asynchrony. ACTA ACUST UNITED AC 2018; 44:321-333. [PMID: 30020347 DOI: 10.1590/s1806-37562017000000185] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/03/2017] [Indexed: 11/22/2022]
Abstract
Patient-v entilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.
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Affiliation(s)
- Marcelo Alcantara Holanda
- . Departamento de Medicina Clínica, Universidade Federal do Ceará, Fortaleza (CE) Brasil.,. Programa de Pós-Graduação de Mestrado em Ciências Médicas, Universidade Federal do Ceará, Fortaleza (CE) Brasil
| | | | - Juliana Carvalho Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Bruno Valle Pinheiro
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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Pham T, Telias I, Piraino T, Yoshida T, Brochard LJ. Asynchrony Consequences and Management. Crit Care Clin 2018; 34:325-341. [DOI: 10.1016/j.ccc.2018.03.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
Patient-v entilator asynchrony (PVA) is a mismatch between the patient, regarding time, flow, volume, or pressure demands of the patient respiratory system, and the ventilator, which supplies such demands, during mechanical ventilation (MV). It is a common phenomenon, with incidence rates ranging from 10% to 85%. PVA might be due to factors related to the patient, to the ventilator, or both. The most common PVA types are those related to triggering, such as ineffective effort, auto-triggering, and double triggering; those related to premature or delayed cycling; and those related to insufficient or excessive flow. Each of these types can be detected by visual inspection of volume, flow, and pressure waveforms on the mechanical ventilator display. Specific ventilatory strategies can be used in combination with clinical management, such as controlling patient pain, anxiety, fever, etc. Deep sedation should be avoided whenever possible. PVA has been associated with unwanted outcomes, such as discomfort, dyspnea, worsening of pulmonary gas exchange, increased work of breathing, diaphragmatic injury, sleep impairment, and increased use of sedation or neuromuscular blockade, as well as increases in the duration of MV, weaning time, and mortality. Proportional assist ventilation and neurally adjusted ventilatory assist are modalities of partial ventilatory support that reduce PVA and have shown promise. This article reviews the literature on the types and causes of PVA, as well as the methods used in its evaluation, its potential implications in the recovery process of critically ill patients, and strategies for its resolution.
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Affiliation(s)
- Marcelo Alcantara Holanda
- . Departamento de Medicina Clínica, Universidade Federal do Ceará, Fortaleza (CE) Brasil.,. Programa de Pós-Graduação de Mestrado em Ciências Médicas, Universidade Federal do Ceará, Fortaleza (CE) Brasil
| | | | - Juliana Carvalho Ferreira
- . Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Bruno Valle Pinheiro
- . Faculdade de Medicina, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo (SP) Brasil
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Antonogiannaki EM, Georgopoulos D, Akoumianaki E. Patient-Ventilator Dyssynchrony. Korean J Crit Care Med 2017; 32:307-322. [PMID: 31723652 PMCID: PMC6786679 DOI: 10.4266/kjccm.2017.00535] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/23/2017] [Indexed: 11/30/2022] Open
Abstract
In mechanically ventilated patients, assisted mechanical ventilation (MV) is employed early, following the acute phase of critical illness, in order to eliminate the detrimental effects of controlled MV, most notably the development of ventilator-induced diaphragmatic dysfunction. Nevertheless, the benefits of assisted MV are often counteracted by the development of patient-ventilator dyssynchrony. Patient-ventilator dyssynchrony occurs when either the initiation and/or termination of mechanical breath is not in time agreement with the initiation and termination of neural inspiration, respectively, or if the magnitude of mechanical assist does not respond to the patient's respiratory demand. As patient-ventilator dyssynchrony has been associated with several adverse effects and can adversely influence patient outcome, every effort should be made to recognize and correct this occurrence at bedside. To detect patient-ventilator dyssynchronies, the physician should assess patient comfort and carefully inspect the pressure- and flow-time waveforms, available on the ventilator screen of all modern ventilators. Modern ventilators offer several modifiable settings to improve patient-ventilator interaction. New proportional modes of ventilation are also very helpful in improving patient-ventilator interaction.
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Affiliation(s)
| | - Dimitris Georgopoulos
- Intensive Care Unit, University Hospital of Heraklion, Heraklion, Greece.,Medical School, University of Crete, Heraklion, Greece
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24
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Ferreira JC, Diniz-Silva F, Moriya HT, Alencar AM, Amato MBP, Carvalho CRR. Neurally Adjusted Ventilatory Assist (NAVA) or Pressure Support Ventilation (PSV) during spontaneous breathing trials in critically ill patients: a crossover trial. BMC Pulm Med 2017; 17:139. [PMID: 29115949 PMCID: PMC5678780 DOI: 10.1186/s12890-017-0484-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 10/31/2017] [Indexed: 12/12/2022] Open
Abstract
Background Neurally Adjusted Ventilatory Assist (NAVA) is a proportional ventilatory mode that uses the electrical activity of the diaphragm (EAdi) to offer ventilatory assistance in proportion to patient effort. NAVA has been increasingly used for critically ill patients, but it has not been evaluated during spontaneous breathing trials (SBT). We designed a pilot trial to assess the feasibility of using NAVA during SBTs, and to compare the breathing pattern and patient-ventilator asynchrony of NAVA with Pressure Support (PSV) during SBTs. Methods We conducted a crossover trial in the ICU of a university hospital in Brazil and included mechanically ventilated patients considered ready to undergo an SBT on the day of the study. Patients underwent two SBTs in randomized order: 30 min in PSV of 5 cmH2O or NAVA titrated to generate equivalent peak airway pressure (Paw), with a positive end-expiratory pressure of 5 cmH2O. The ICU team, blinded to ventilatory mode, evaluated whether patients passed each SBT. We captured flow, Paw and electrical activity of the diaphragm (EAdi) from the ventilator and used it to calculate respiratory rate (RR), tidal volume (VT), and EAdi. Detection of asynchrony events used waveform analysis and we calculated the asynchrony index as the number of asynchrony events divided by the number of neural cycles. Results We included 20 patients in the study. All patients passed the SBT in PSV, and three failed the SBT in NAVA. Five patients were reintubated and the extubation failure rate was 25% (95% CI 9–49%). Respiratory parameters were similar in the two modes: VT = 6.1 (5.5–6.5) mL/Kg in NAVA vs. 5.5 (4.8–6.1) mL/Kg in PSV (p = 0.076) and RR = 27 (17–30) rpm in NAVA vs. 26 (20–30) rpm in PSV, p = 0.55. NAVA reduced AI, with a median of 11.5% (4.2–19.7) compared to 24.3% (6.3–34.3) in PSV (p = 0.033). Conclusions NAVA reduces patient-ventilator asynchrony index and generates a respiratory pattern similar to PSV during SBTs. Patients considered ready for mechanical ventilation liberation may be submitted to an SBT in NAVA using the same objective criteria used for SBTs in PSV. Trial registration ClinicalTrials.gov (NCT01337271), registered April 12, 2011. Electronic supplementary material The online version of this article (10.1186/s12890-017-0484-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juliana C Ferreira
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil.
| | - Fabia Diniz-Silva
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Henrique T Moriya
- Biomedical Engineering Laboratory, Escola Politécnica da Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Adriano M Alencar
- Instituto de Física, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Marcelo B P Amato
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | - Carlos R R Carvalho
- Divisao de Pneumologia, Instituto do Coracao, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
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Akoumianaki E, Dousse N, Lyazidi A, Lefebvre JC, Graf S, Cordioli RL, Rey N, Richard JCM, Brochard L. Can proportional ventilation modes facilitate exercise in critically ill patients? A physiological cross-over study : Pressure support versus proportional ventilation during lower limb exercise in ventilated critically ill patients. Ann Intensive Care 2017; 7:64. [PMID: 28608135 PMCID: PMC5468357 DOI: 10.1186/s13613-017-0289-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 06/03/2017] [Indexed: 12/30/2022] Open
Abstract
Background Early exercise of critically ill patients may have beneficial effects on muscle strength, mass and systemic inflammation. During pressure support ventilation (PSV), a mismatch between demand and assist could increase work of breathing and limit exercise. A better exercise tolerance is possible with a proportional mode of ventilation (Proportional Assist Ventilation, PAV+ and Neurally Adjusted Ventilatory Assist, NAVA). We examined whether, in critically ill patients, PSV and proportional ventilation have different effects on respiratory muscles unloading and work efficiency during exercise. Methods Prospective pilot randomized cross-over study performed in a medico-surgical ICU. Patients requiring mechanical ventilation >48 h were enrolled. At initiation, the patients underwent an incremental workload test on a cycloergometer to determine the maximum level capacity. The next day, 2 15-min exercise, at 60% of the maximum capacity, were performed while patients were randomly ventilated with PSV and PAV+ or NAVA. The change in oxygen consumption (ΔVO2, indirect calorimetry) and the work efficiency (ratio of ΔVO2 per mean power) were computed. Results Ten patients were examined, 6 ventilated with PSV/PAV+ and 4 with PSV/NAVA. Despite the same mean inspiratory pressure at baseline between the modes, baseline VO2 (median, IQR) was higher during proportional ventilation (301 ml/min, 270–342) compared to PSV (249 ml/min, 206–353). Exercise with PSV was associated with a significant increase in VO2 (ΔVO2, median, IQR) (77.6 ml/min, 59.9–96.5), while VO2 did not significantly change during exercise with proportional modes (46.3 ml/min, 5.7–63.7, p < 0.05). As a result, exercise with proportional modes was associated with a better work efficiency than with PSV. The ventilator modes did not affect patient’s dyspnea, limb fatigue, distance, hemodynamics and breathing pattern. Conclusions Proportional ventilation during exercise results in higher work efficiency and less increase in VO2 compared to ventilation with PSV. These preliminary findings suggest that proportional ventilation could enhance the training effect and facilitate rehabilitation. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0289-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Nicolas Dousse
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Aissam Lyazidi
- Institut Supérieur des Sciences de la Santé, Laboratory Rayonnement-Matiére et Instrumentation, Université Hassan 1er, Settat, Morocco
| | - Jean-Claude Lefebvre
- Department of Anesthesiology and Critical Care, Université Laval, Quebec, QC, Canada
| | - Severine Graf
- Division of Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Ricardo Luiz Cordioli
- Department of Adult Intensive Care Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nathalie Rey
- Department of Anesthesia and Intensive Care Unit, Rouen University Hospital, Rouen, France
| | | | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
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26
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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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27
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Lee J, Kim HS, Jung YH, Choi CW, Jun YH. Neurally adjusted ventilatory assist for infants under prolonged ventilation. Pediatr Int 2017; 59:540-544. [PMID: 28063223 DOI: 10.1111/ped.13233] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 11/11/2016] [Accepted: 01/05/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severe bronchopulmonary dysplasia often leads to prolonged mechanical ventilation lasting several months. Cyanotic episodes frequently occur in these patients, necessitating long-term sedation and/or intermittent muscle paralysis. Neurally adjusted ventilatory assist (NAVA) might provide precisely the amount of support that these patients need without sedation. METHODS We reviewed the medical records of preterm infants who underwent tracheostomy and required mechanical ventilation for >6 months during a period of 6 years. We compared two groups of patients: those supported with NAVA for ≥2 months versus those supported by pneumatically triggered assist methods. We also evaluated any change after NAVA use in the NAVA group. RESULTS Among 14 prematurely born patients who received prolonged ventilation, nine were supported with NAVA and five were supported using other ventilator modes. Duration of continuous sedation was significantly shorter and the bolus use of sedatives was also significantly lower in the NAVA group than in the pneumatically triggered assist group. In addition, the NAVA group received a lower dose of dexamethasone than the pneumatically triggered assist group. Compared with before NAVA, the frequency of cyanotic episodes and of the bolus sedatives was significantly decreased after implementation of NAVA. CONCLUSIONS For infants on prolonged mechanical ventilation, NAVA could reduce cyanotic episodes and the need for sedatives and dexamethasone. NAVA may be superior to pneumatically triggered modes in terms of the minimization of patient-ventilator dyssynchrony while delivering appropriate respiratory support in premature infants with tracheostomy.
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Affiliation(s)
- Juyoung Lee
- Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
| | - Han-Suk Kim
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Hwa Jung
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Won Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Yong Hoon Jun
- Department of Pediatrics, Inha University College of Medicine, Incheon, Korea
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Brander L, Moerer O, Hedenstierna G, Beck J, Takala J, Slutsky AS, Sinderby C. Neural control of ventilation prevents both over-distension and de-recruitment of experimentally injured lungs. Respir Physiol Neurobiol 2016; 237:57-67. [PMID: 28013057 DOI: 10.1016/j.resp.2016.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/25/2016] [Accepted: 12/20/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Endogenous pulmonary reflexes may protect the lungs during mechanical ventilation. We aimed to assess integration of continuous neurally adjusted ventilatory assist (cNAVA), delivering assist in proportion to diaphragm's electrical activity during inspiration and expiration, and Hering-Breuer inflation and deflation reflexes on lung recruitment, distension, and aeration before and after acute lung injury (ALI). METHODS In 7 anesthetised rabbits with bilateral pneumothoraces, we identified adequate cNAVA level (cNAVAAL) at the plateau in peak ventilator pressure during titration procedures before (healthy lungs with endotracheal tube, [HLETT]) and after ALI (endotracheal tube [ALIETT] and during non-invasive ventilation [ALINIV]). Following titration, cNAVAAL was maintained for 5min. In 2 rabbits, procedures were repeated after vagotomy (ALIETT+VAG). In 3 rabbits delivery of assist was temporarily modulated to provide assist on inspiration only. Computed tomography was performed before intubation, before ALI, during cNAVA titration, and after maintenance at cNAVAAL. RESULTS During ALIETT and ALINIV, normally aerated lung-regions doubled and poorly aerated lung-regions decreased to less than a third (p<0.05) compared to HLETT; no over-distension was observed. Tidal volumes were<5ml/kg throughout. Removing assist during expiration resulted in lung de-recruitment during ALIETT, but not during ALINIV. During ALIETT+VAG the expiratory portion of EAdi disappeared, resulting in cyclic lung collapse and recruitment. CONCLUSIONS When using cNAVA in ALI, vagally mediated reflexes regulated lung recruitment preventing both lung over-distension and atelectasis. During non-invasive cNAVA the upper airway muscles play a role in preventing atelectasis. Future studies should be performed to compare these findings with conventional lung-protective approaches.
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Affiliation(s)
- Lukas Brander
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Department of Intensive Care Medicine, Cantonal Hospital of Lucerne, Switzerland.
| | - Onnen Moerer
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Department of Anaesthesiology, Emergency and Critical Care Medicine, University of Göttingen, Germany
| | - Göran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, University of Uppsala, Uppsala, Sweden
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St. Michael's Hospital, Toronto, Canada
| | - Jukka Takala
- Department of Intensive Care Medicine, Bern University Hospital - Inselspital, and University of Bern, Switzerland
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St. Michael's Hospital, Toronto, Canada
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Abstract
Controlled Mechanical Ventilation may be essential in the setting of severe respiratory failure but consequences to the patient including increased use of sedation and neuromuscular blockade may contribute to delirium, atelectasis, and diaphragm dysfunction. Assisted ventilation allows spontaneous breathing activity to restore physiological displacement of the diaphragm and recruit better perfused lung regions. Pressure Support Ventilation is the most frequently used mode of assisted mechanical ventilation. However, this mode continues to provide a monotonous pattern of support for respiration which is normally a dynamic process. Noisy Pressure Support Ventilation where tidal volume is varied randomly by the ventilator may improve ventilation and perfusion matching but the degree of support is still determined by the ventilator. Two more recent modes of ventilation, Proportional Assist Ventilation and Neurally Adjusted Ventilatory Assist (NAVA), allow patient determination of the pattern and depth of ventilation. Proposed advantages of Proportional Assist Ventilation and NAVA include decrease in patient ventilator asynchrony and improved adaptation of ventilator support to changing patient demand. Work of breathing can be normalized with these modes as well. To date, however, a clear pattern of clinical benefit has not been demonstrated. Existing challenges for both of the newer assist modes include monitoring patients with dynamic hyperinflation (auto-positive end expiratory pressure), obstructive lung disease, and air leaks in the ventilator system. NAVA is dependent on consistent transduction of diaphragm activity by an electrode system placed in the esophagus. Longevity of effective support with this technique is unclear.
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30
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Management of Mechanical Ventilation in Decompensated Heart Failure. J Cardiovasc Dev Dis 2016; 3:jcdd3040033. [PMID: 29367576 PMCID: PMC5715720 DOI: 10.3390/jcdd3040033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Revised: 11/22/2016] [Accepted: 11/29/2016] [Indexed: 02/04/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving intervention for respiratory failure, including decompensated congestive heart failure. MV can reduce ventricular preload and afterload, decrease extra-vascular lung water, and decrease the work of breathing in heart failure. The advantages of positive pressure ventilation must be balanced with potential harm from MV: volutrauma, hyperoxia-induced injury, and difficulty assessing readiness for liberation. In this review, we will focus on cardiac, pulmonary, and broader effects of MV on patients with decompensated HF, focusing on practical considerations for management and supporting evidence.
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31
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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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32
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Abstract
Ventilatory muscle fatigue is a reversible loss of the ability to generate force or velocity of contraction in response to increased elastic and resistive loads. Mechanical ventilation should provide support without imposing additional loads from the ventilator (dys-synchrony). Interactive breaths optimize this relationship but require that patient effort and the ventilator response be synchronous during breath initiation, flow delivery, and termination. Proper delivery considers all 3 phases and uses clinical data, ventilator graphics, and sometimes a trial-and-error approach to optimize patient-ventilator interactions. Newer modes optimize interactions but await good clinical outcome data before routine use.
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Affiliation(s)
- Daniel Gilstrap
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University Medical Center, Box 102355, Hanes House Room 101, Durham, NC 27710, USA.
| | - John Davies
- Respiratory Care Services, Duke University Hospital, Box 3911 Duke North, Erwin Road, Durham, NC 27710, USA
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33
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Villar J, Belda J, Blanco J, Suarez-Sipmann F, Añón JM, Pérez-Méndez L, Ferrando C, Parrilla D, Montiel R, Corpas R, González-Higueras E, Pestaña D, Martínez D, Fernández L, Soro M, García-Bello MA, Fernández RL, Kacmarek RM. Neurally adjusted ventilatory assist in patients with acute respiratory failure: study protocol for a randomized controlled trial. Trials 2016; 17:500. [PMID: 27737690 PMCID: PMC5064782 DOI: 10.1186/s13063-016-1625-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 09/25/2016] [Indexed: 12/25/2022] Open
Abstract
Background Patient-ventilator asynchrony is a common problem in mechanically ventilated patients with acute respiratory failure. It is assumed that asynchronies worsen lung function and prolong the duration of mechanical ventilation (MV). Neurally Adjusted Ventilatory Assist (NAVA) is a novel approach to MV based on neural respiratory center output that is able to trigger, cycle, and regulate the ventilatory cycle. We hypothesized that the use of NAVA compared to conventional lung-protective MV will result in a reduction of the duration of MV. It is further hypothesized that NAVA compared to conventional lung-protective MV will result in a decrease in the length of ICU and hospital stay, and mortality. Methods/design This is a prospective, multicenter, randomized controlled trial in 306 mechanically ventilated patients with acute respiratory failure from several etiologies. Only patients ventilated for less than 5 days, and who are expected to require prolonged MV for an additional 72 h or more and are able to breathe spontaneously, will be considered for enrollment. Eligible patients will be randomly allocated to two ventilatory arms: (1) conventional lung-protective MV (n = 153) and conventional lung-protective MV with NAVA (n = 153). Primary outcome is the number of ventilator-free days, defined as days alive and free from MV at day 28 after endotracheal intubation. Secondary outcomes are total length of MV, and ICU and hospital mortality. Discussion This is the first randomized clinical trial examining, on a multicenter scale, the beneficial effects of NAVA in reducing the dependency on MV of patients with acute respiratory failure. Trial registration ClinicalTrials.gov website (NCT01730794). Registered on 15 November 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1625-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain. .,Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 4th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain. .,Keenan Research Center for Biomedical Science at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond St, Toronto, ON, M5B 1W8, Canada.
| | - Javier Belda
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Jesús Blanco
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Intensive Care Unit, Hospital Universitario Río Hortega, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Fernando Suarez-Sipmann
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Hedenstierna Laboratory, Department of Surgical Sciences, Uppsala University Hospital, Akademiska Sjukhuset, Ing 40, Tr 3, SE-75185, Uppsala, Sweden
| | - José Manuel Añón
- Intensive Care Unit, Hospital Virgen de La Luz, Hermandad de Donantes de Sangre s/n, 16002, Cuenca, Spain
| | - Lina Pérez-Méndez
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Division of Clinical Epidemiology and Biostatistics, Research Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Carlos Ferrando
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Dácil Parrilla
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Raquel Montiel
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Carretera General del Rosario 145, 38010, Santa Cruz de Tenerife, Spain
| | - Ruth Corpas
- Intensive Care Unit, Hospital General NS del Prado, Carretera de Madrid, Km. 114, 45600, Talavera de la Reina, Toledo, Spain
| | - Elena González-Higueras
- Intensive Care Unit, Hospital Virgen de La Luz, Hermandad de Donantes de Sangre s/n, 16002, Cuenca, Spain
| | - David Pestaña
- Department of Anesthesiology, Hospital Universitario Ramón y Cajal, Carretera de Colmenar Viejo, Km. 9,100, 28034, Madrid, Spain
| | - Domingo Martínez
- Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Carretera Madrid-Cartagena s/n, 30120, El Palmar, Murcia, Spain
| | - Lorena Fernández
- Intensive Care Unit, Hospital Universitario Río Hortega, Calle Dulzaina, 2, 47012, Valladolid, Spain
| | - Marina Soro
- Department of Anesthesiology, Hospital Clínico Universitario de Valencia, Avda. Blasco Ibañez 17, 46010, Valencia, Spain
| | - Miguel Angel García-Bello
- Division of Biostatistics, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 35019, Las Palmas de Gran Canaria, Spain
| | - Rosa Lidia Fernández
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Monforte de Lemos 3-5, Pabellon 11, 28029, Madrid, Spain.,Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrín, Barranco de la Ballena s/n, 4th Floor-South Wing, 35019, Las Palmas de Gran Canaria, Spain
| | - Robert M Kacmarek
- Department of Respiratory Care, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA.,Department of Anesthesiology, Harvard University, 55 Fruit Street Gray-Bigelow 444, Boston, MA, 02144, USA
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Berger D, Bloechlinger S, von Haehling S, Doehner W, Takala J, Z'Graggen WJ, Schefold JC. Dysfunction of respiratory muscles in critically ill patients on the intensive care unit. J Cachexia Sarcopenia Muscle 2016; 7:403-12. [PMID: 27030815 PMCID: PMC4788634 DOI: 10.1002/jcsm.12108] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 12/18/2015] [Accepted: 01/27/2016] [Indexed: 12/13/2022] Open
Abstract
Muscular weakness and muscle wasting may often be observed in critically ill patients on intensive care units (ICUs) and may present as failure to wean from mechanical ventilation. Importantly, mounting data demonstrate that mechanical ventilation itself may induce progressive dysfunction of the main respiratory muscle, i.e. the diaphragm. The respective condition was termed 'ventilator-induced diaphragmatic dysfunction' (VIDD) and should be distinguished from peripheral muscular weakness as observed in 'ICU-acquired weakness (ICU-AW)'. Interestingly, VIDD and ICU-AW may often be observed in critically ill patients with, e.g. severe sepsis or septic shock, and recent data demonstrate that the pathophysiology of these conditions may overlap. VIDD may mainly be characterized on a histopathological level as disuse muscular atrophy, and data demonstrate increased proteolysis and decreased protein synthesis as important underlying pathomechanisms. However, atrophy alone does not explain the observed loss of muscular force. When, e.g. isolated muscle strips are examined and force is normalized for cross-sectional fibre area, the loss is disproportionally larger than would be expected by atrophy alone. Nevertheless, although the exact molecular pathways for the induction of proteolytic systems remain incompletely understood, data now suggest that VIDD may also be triggered by mechanisms including decreased diaphragmatic blood flow or increased oxidative stress. Here we provide a concise review on the available literature on respiratory muscle weakness and VIDD in the critically ill. Potential underlying pathomechanisms will be discussed before the background of current diagnostic options. Furthermore, we will elucidate and speculate on potential novel future therapeutic avenues.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
| | - Stefan Bloechlinger
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland; Department of Clinical Cardiology, Inselspital University Hospital of Bern Bern Switzerland
| | - Stephan von Haehling
- Department of Cardiology and Center for Innovative Clinical Trials University of Göttingen Göttingen Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin Charite Universitätsmedizin Berlin Berlin Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery and Dept. of Neurology, Inselspital University Hospital of Bern Bern Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
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Zhu L, Xu Z, Gong X, Zheng J, Sun Y, Liu L, Han L, Zhang H, Xu Z, Liu J, Rimensberger PC. Mechanical Ventilation After Bidirectional Superior Cavopulmonary Anastomosis for Single-Ventricle Physiology: A Comparison of Pressure Support Ventilation and Neurally Adjusted Ventilatory Assist. Pediatr Cardiol 2016; 37:1064-71. [PMID: 27090649 DOI: 10.1007/s00246-016-1392-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 04/05/2016] [Indexed: 11/29/2022]
Abstract
We evaluated the effects of different respiratory assist modes on cerebral blood flow (CBF) and arterial oxygenation in single-ventricle patients after bidirectional superior cavopulmonary anastomosis (BCPA). We hypothesized that preserved auto-regulation of respiration during neurally adjusted ventilatory assist (NAVA) may have potential advantages for CBF and pulmonary blood flow regulation after the BCPA procedure. We enrolled 23 patients scheduled for BCPA, who underwent pressure-controlled ventilation (PCV), pressure support ventilation (PSV), and NAVA at two assist levels for all modes in a randomized order. PCV targeting large V T (15 mL × kg(-1)) resulted in lower CBF and oxygenation compared to targeting low V T (10 mL × kg(-1)). During PSV and NAVA, ventilation assist levels were titrated to reduce EAdi from baseline by 75 % (high assist) and 50 % (low assist). High assist levels during PSV (PSVhigh) were associated with lower PaCO2, PaO2, and O2SAT, lower CBF, and higher pulsatility index compared with those during NAVAhigh. There were no differences in parameters when using low assist levels, except for slightly greater oxygenation in the NAVAlow group. Modifying assist levels during NAVA did not influence hemodynamics, cerebral perfusion, or gas exchange. Targeting the larger V T during PCV resulted in hyperventilation, did not improve oxygenation, and was accompanied by reduced CBF. Similarly, high assist levels during PSV led to mild hyperventilation, resulting in reduced CBF. NAVA's results were independent of the assist level chosen, causing normalized PaCO2, improved oxygenation, and better CBF than did any other mode, with the exception of PSV at low assist levels.
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Affiliation(s)
- Limin Zhu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China.
| | - Zhuoming Xu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Xiaolei Gong
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Jinghao Zheng
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Yanjun Sun
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Liping Liu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Lu Han
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Haibo Zhang
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Zhiwei Xu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Jinfen Liu
- Cardiac Intensive Care Unit, Department of Cardiovascular and Thoracic Surgery, Shanghai Children's Medical Center, Medical School of Shanghai Jiaotong University, Shanghai, 200127, China
| | - Peter C Rimensberger
- Pediatric and Neonatal Intensive Care Unit, Department of Pediatrics, University Hospital of Geneva, Geneva, Switzerland
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Comparison Between Neurally Adjusted Ventilatory Assist and Pressure Support Ventilation Levels in Terms of Respiratory Effort. Crit Care Med 2016; 44:503-11. [PMID: 26540399 DOI: 10.1097/ccm.0000000000001418] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To understand the potential equivalence between neurally adjusted ventilatory assist and pressure support ventilation levels in terms of respiratory muscle unloading. To compare the respiratory pattern, variability, synchronization, and neuromuscular coupling within comparable ranges of assistance. DESIGN Prospective single-center physiologic study. SETTING A 13-bed university medical ICU. PATIENTS Eleven patients recovering from respiratory failure. INTERVENTIONS The following levels of assistance were consecutively applied in a random order: neurally adjusted ventilatory assist levels: 0.5, 1, 1.5, 2, 2.5, 3, 4, 5, and 7 cm H2O/μvolt; pressure support levels: 7, 10, 15, 20, and 25 cm H2O. MEASUREMENTS AND MAIN RESULTS Flow, airway pressure, esophageal pressures, and peak electrical activity of the diaphragm were continuously recorded. Breathing effort was calculated. To express the percentage of assist assumed by the ventilator, the total pressure including muscular and ventilator pressure was calculated. The median percentage of assist ranged from 33% (24-47%) to 82% (72-90%) between pressure support 7 and 25 cm H2O. Similar levels of unloading were observed for neurally adjusted ventilatory assist levels from 0.5 cm H2O/μvolt (46% [40-51%]) to 2.5 cm H2O/μvolt (80% [74-84%]). Tidal variability was higher during neurally adjusted ventilatory assist and ineffective efforts appeared only in pressure support. In neurally adjusted ventilatory assist, double triggering occurred sometimes when electrical activity of the diaphragm signal depicted a biphasic aspect, and an abnormal oscillatory pattern was frequently observed from 4 cm H2O/μvolt. For both modes, the relationship between peak electrical activity of the diaphragm and muscle pressure depicted a curvilinear profile. CONCLUSIONS In patients recovering from acute respiratory failure, levels of neurally adjusted ventilatory assist between 0.5 and 2.5 cm H2O/μvolt are comparable to pressure support levels ranging from 7 to 25 cm H2O in terms of respiratory muscle unloading. Neurally adjusted ventilatory assist provides better patient-ventilator interactions but can be sometimes excessively sensitive to electrical activity of the diaphragm in terms of triggering.
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Hjelmgren J, Bruce Wirta S, Huetson P, Myrén KJ, Göthberg S. Health economic modeling of the potential cost saving effects of Neurally Adjusted Ventilator Assist. Ther Adv Respir Dis 2016; 10:3-17. [PMID: 26424363 PMCID: PMC5933658 DOI: 10.1177/1753465815603659] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Asynchrony between patient and ventilator breaths is associated with increased duration of mechanical ventilation (MV). Neurally Adjusted Ventilatory Assist (NAVA) controls MV through an esophageal reading of diaphragm electrical activity via a nasogastric tube mounted with electrode rings. NAVA has been shown to decrease asynchrony in comparison to pressure support ventilation (PSV). The objective of this study was to conduct a health economic evaluation of NAVA compared with PSV. METHODS We developed a model based on an indirect link between improved synchrony with NAVA versus PSV and fewer days spent on MV in synchronous patients. Unit costs for MV were obtained from the Swedish intensive care unit register, and used in the model along with NAVA-specific costs. The importance of each parameter (proportion of asynchronous patients, costs, and average MV duration) for the overall results was evaluated through sensitivity analyses. RESULTS Base case results showed that 21% of patients ventilated with NAVA were asynchronous versus 52% of patients receiving PSV. This equals an absolute difference of 31% and an average of 1.7 days less on MV and a total cost saving of US$7886 (including NAVA catheter costs). A breakeven analysis suggested that NAVA was cost effective compared with PSV given an absolute difference in the proportion of asynchronous patients greater than 2.5% (49.5% versus 52% asynchronous patients with NAVA and PSV, respectively). The base case results were stable to changes in parameters, such as difference in asynchrony, duration of ventilation and daily intensive care unit costs. CONCLUSION This study showed economically favorable results for NAVA versus PSV. Our results show that only a minor decrease in the proportion of asynchronous patients with NAVA is needed for investments to pay off and generate savings. Future studies need to confirm this result by directly relating improved synchrony to the number of days on MV.
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Affiliation(s)
- Jonas Hjelmgren
- IMS Health HEOR, Sveavägen 155, Stockholm, Sweden Amgen (Europe) GmbH, Dammstrasse 23, Zug, Switzerland
| | | | | | - Karl-Johan Myrén
- IMS Health HEOR, Sveavägen 155, Stockholm, Sweden SOBI, Tomtebodavägen 23A, Solna, Sweden
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Abstract
Purpose of review Compared with the conventional forms of partial support, neurally adjusted ventilatory assist was repeatedly shown to improve patient–ventilator synchrony and reduce the risk of overassistance, while guaranteeing adequate inspiratory effort and gas exchange. A few animal studies also suggested the potential of neurally adjusted ventilatory assist in averting the risk of ventilator-induced lung injury. Recent work adds new information on the physiological effects of neurally adjusted ventilatory assist. Recent findings Compared with pressure support, neurally adjusted ventilatory assist has been shown to improve patient–ventilator interaction and synchrony in patients with the most challenging respiratory system mechanics, such as very low compliance consequent to severe acute respiratory distress syndrome and high resistance and air trapping due to chronic airflow obstruction; enhance redistribution of the ventilation in the dependent lung regions; avert the risk of patient–ventilator asynchrony due to sedation; avoid central apneas; limit the risk of high (injurious) tidal volumes in patients with acute respiratory distress syndrome of varied severity; and improve patient–ventilator interaction and synchrony during noninvasive ventilation, irrespective of the interface utilized. Summary Several studies nowadays prove the physiological benefits of neurally adjusted ventilatory assist, as opposed to the conventional modes of partial support. Whether these advantages translate into improvement of clinical outcomes remains to be determined.
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Yonis H, Crognier L, Conil JM, Serres I, Rouget A, Virtos M, Cougot P, Minville V, Fourcade O, Georges B. Patient-ventilator synchrony in Neurally Adjusted Ventilatory Assist (NAVA) and Pressure Support Ventilation (PSV): a prospective observational study. BMC Anesthesiol 2015; 15:117. [PMID: 26253784 PMCID: PMC4528778 DOI: 10.1186/s12871-015-0091-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 07/14/2015] [Indexed: 11/10/2022] Open
Abstract
Background Weaning from mechanical ventilation is associated with the presence of asynchronies between the patient and the ventilator. The main objective of the present study was to demonstrate a decrease in the total number of patient-ventilator asynchronies in invasively ventilated patients for whom difficulty in weaning is expected by comparing neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV) ventilatory modes. Methods We performed a prospective, non-randomized, non-interventional, single-center study. Thirty patients were included in the study. Each patient included in the study benefited in an unpredictable way from both modes of ventilation, NAVA or PSV. Patients were successively ventilated for 23 h in NAVA or in PSV, and then they were ventilated for another 23 h in the other mode. Demographic, biological and ventilatory data were collected during this period. The two modes of ventilatory support were compared using the non-parametric Wilcoxon test after checking for normal distribution by the Kolmogorov–Smirnov test. The groups were compared using the chi-square test. Results The median level of support was 12.5 cmH2O (4–20 cmH2O) in PSV and 0.8 cmH2O/μvolts (0.2–3 cmH2O/μvolts) in NAVA. The total number of asynchronies per minute in NAVA was lower than that in PSV (0.46 vs 1, p < 0.001). The asynchrony index was also reduced in NAVA compared with PSV (1.73 vs 3.36, p < 0.001). In NAVA, the percentage of ineffective efforts (0.77 vs 0.94, p = 0.036) and the percentage of auto-triggering were lower compared with PSV (0.19 vs 0.71, p = 0.038). However, there was a higher percentage of double triggering in NAVA compared with PSV (0.76 vs 0.71, p = 0.046). Conclusion The total number of asynchronies in NAVA is lower than that in PSV. This finding reflects improved patient-ventilator interaction in NAVA compared with the PSV mode, which is consistent with previous studies. Our study is the first to analyze patient-ventilator asynchronies in NAVA and PSV on such an important duration. The decrease in the number of asynchronies in NAVA is due to reduced ineffective efforts and auto-triggering.
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Affiliation(s)
- Hodane Yonis
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Laure Crognier
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Jean-Marie Conil
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Isabelle Serres
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Antoine Rouget
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Marie Virtos
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Pierre Cougot
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Vincent Minville
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Olivier Fourcade
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
| | - Bernard Georges
- Service de Réanimation Polyvalente, CHU Rangueil, 1 Avenue Jean Poulhès, Pôle d'Anesthésie et Réanimation, TSA 50032, 31059, Toulouse, Cedex 9, France.
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Abstract
Abstract
Background:
In patients with acute respiratory distress syndrome (ARDS), the use of assisted mechanical ventilation is a subject of debate. Assisted ventilation has benefits over controlled ventilation, such as preserved diaphragm function and improved oxygenation. Therefore, higher level of “patient control” of ventilator assist may be preferable in ARDS. However, assisted modes may also increase the risk of high tidal volumes and lung-distending pressures. The current study aims to quantify how differences in freedom to control the ventilator affect lung-protective ventilation, breathing pattern variability, and patient–ventilator interaction.
Methods:
Twelve patients with ARDS were ventilated in a randomized order with assist pressure control ventilation (PCV), pressure support ventilation (PSV), and neurally adjusted ventilatory assist (NAVA). Transpulmonary pressure, tidal volume, diaphragm electrical activity, and patient–ventilator interaction were measured. Respiratory variability was assessed using the coefficient of variation of tidal volume.
Results:
During inspiration, transpulmonary pressure was slightly lower with NAVA (10.3 ± 0.7, 11.2 ± 0.7, and 9.4 ± 0.7 cm H2O for PCV, PSV, and NAVA, respectively; P < 0.01). Tidal volume was similar between modes (6.6 [5.7 to 7.0], 6.4 [5.8 to 7.0], and 6.0 [5.6 to 7.3] ml/kg for PCV, PSV, and NAVA, respectively), but respiratory variability was higher with NAVA (8.0 [6.4 to 10.0], 7.1 [5.9 to 9.0], and 17.0 [12.0 to 36.1] % for PCV, PSV, and NAVA, respectively; P < 0.001). Patient–ventilator interaction improved with NAVA (6 [5 to 8] % error) compared with PCV (29 [14 to 52] % error) and PSV (12 [9 to 27] % error); P < 0.0001.
Conclusion:
In patients with mild-to-moderate ARDS, increasing freedom to control the ventilator maintains lung-protective ventilation in terms of tidal volume and lung-distending pressure, but it improves patient–ventilator interaction and preserves respiratory variability.
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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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Guillon B, Van-Hecke G, Iddir J, Pellegrini N, Beghoul N, Vaugier I, Figère M, Pradon D, Lofaso F. Evaluation of 3 Pushrim-Activated Power-Assisted Wheelchairs in Patients With Spinal Cord Injury. Arch Phys Med Rehabil 2015; 96:894-904. [DOI: 10.1016/j.apmr.2015.01.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Revised: 12/23/2014] [Accepted: 01/06/2015] [Indexed: 10/24/2022]
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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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Schmidt M, Kindler F, Cecchini J, Poitou T, Morawiec E, Persichini R, Similowski T, Demoule A. Neurally adjusted ventilatory assist and proportional assist ventilation both improve patient-ventilator interaction. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:56. [PMID: 25879592 PMCID: PMC4355459 DOI: 10.1186/s13054-015-0763-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 01/22/2015] [Indexed: 12/02/2022]
Abstract
Introduction The objective was to compare the impact of three assistance levels of different modes of mechanical ventilation; neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), and pressure support ventilation (PSV) on major features of patient-ventilator interaction. Methods PSV, NAVA, and PAV were set to obtain a tidal volume (VT) of 6 to 8 ml/kg (PSV100, NAVA100, and PAV100) in 16 intubated patients. Assistance was further decreased by 50% (PSV50, NAVA50, and PAV50) and then increased by 50% (PSV150, NAVA150, and PAV150) with all modes. The three modes were randomly applied. Airway flow and pressure, electrical activity of the diaphragm (EAdi), and blood gases were measured. VT, peak EAdi, coefficient of variation of VT and EAdi, and the prevalence of the main patient-ventilator asynchronies were calculated. Results PAV and NAVA prevented the increase of VT with high levels of assistance (median 7.4 (interquartile range (IQR) 5.7 to 10.1) ml/kg and 7.4 (IQR, 5.9 to 10.5) ml/kg with PAV150 and NAVA150 versus 10.9 (IQR, 8.9 to 12.0) ml/kg with PSV150, P <0.05). EAdi was higher with PAV than with PSV at level100 and level150. The coefficient of variation of VT was higher with NAVA and PAV (19 (IQR, 14 to 31)% and 21 (IQR 16 to 29)% with NAVA100 and PAV100 versus 13 (IQR 11 to 18)% with PSV100, P <0.05). The prevalence of ineffective triggering was lower with PAV and NAVA than with PSV (P <0.05), but the prevalence of double triggering was higher with NAVA than with PAV and PSV (P <0.05). Conclusions PAV and NAVA both prevent overdistention, improve neuromechanical coupling, restore the variability of the breathing pattern, and decrease patient-ventilator asynchrony in fairly similar ways compared with PSV. Further studies are needed to evaluate the possible clinical benefits of NAVA and PAV on clinical outcomes. Trial registration Clinicaltrials.gov NCT02056093. Registered 18 December 2013. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0763-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matthieu Schmidt
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,INSERM, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département R3S), F-75013, Paris, France. .,Service de Pneumologie et Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, 47-83 boulevard de l'Hôpital, 75651, Paris, Cedex 13, France.
| | - Felix Kindler
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département R3S), F-75013, Paris, France.
| | - Jérôme Cecchini
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,INSERM, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France.
| | - Tymothée Poitou
- Université Pierre et Marie Curie-CNRS-INSERM, ICM, Equipe Neurologie et Thérapeutique Expérimentale, Hôpital de la Salpêtrière, Paris, France.
| | - Elise Morawiec
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,INSERM, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département R3S), F-75013, Paris, France.
| | - Romain Persichini
- AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département R3S), F-75013, Paris, France.
| | - Thomas Similowski
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,INSERM, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département R3S), F-75013, Paris, France.
| | - Alexandre Demoule
- Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,INSERM, UMR_S 1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005, Paris, France. .,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département R3S), F-75013, Paris, France. .,U974, Institut National de la Santé et de la Recherche médicale, Paris, France.
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Liu L, Liu S, Xie J, Yang Y, Slutsky AS, Beck J, Sinderby C, Qiu H. Assessment of patient-ventilator breath contribution during neurally adjusted ventilatory assist in patients with acute respiratory failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:43. [PMID: 25882607 PMCID: PMC4339109 DOI: 10.1186/s13054-015-0775-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 01/07/2015] [Indexed: 12/18/2022]
Abstract
INTRODUCTION We previously showed in animals that the ratio of inspired tidal volume (Vtinsp) to inspiratory peak electrical activity of the diaphragm (EAdipk) can be used to quantify the respective patient and ventilator breath contributions (PVBCs) during neurally adjusted ventilatory assist (NAVA). The PVBC index has not been tested clinically. METHODS We studied 12 intubated and mechanically ventilated patients with acute respiratory failure and measured EAdipk, airway (Paw) and inspiratory esophageal pressure (Pes) and Vtinsp. We applied 11 different NAVA levels, increasing them every 3 minutes in steps of 0.3 cm H₂O/μV from 0 to 3.0 cmH₂O/μV. At each NAVA level, one breath was non-assisted (NAVA level 0). PVBC indices were calculated by relating Vtinsp/EAdipk of the non-assisted breath to Vtinsp/EAdipk of the assisted breath(s) using one ((N1)PVBC) or the mean value of five preceding assisted breaths ((X5)PVBC). During assisted breaths, inspiratory changes in Pes (∆Pes) and transpulmonary (ΔPtp) pressures were used to calculate the relative contribution of patient to total inspiratory lung-distending pressures (ΔPes/ΔPtp). Matching of respiratory drive indices and squaring of the PVBC was evaluated for their effect on the correlation between PVBC and ΔPes/ΔPtp. Linear regression analysis and Bland-Altman analysis were applied to compare indices. RESULTS Using an average of five assisted breaths prior to the non-assisted breath and squaring the PVBC ((X5)PVBC(2)) improved determination coefficients (P <0.05), adjusted the regression slope and intercept between PVBC and ΔPes/ΔPtp toward identity (P <0.05) and reduced bias (P <0.05). Matching EAdipk between non-assisted and assisted breaths within the range of 0.77 to 1.30 improved the relationship between (X5)PVBC(2) and ΔPes/ΔPtp (P <0.05) and abolished the need for EAdi normalization in the PVBC calculation (R(2) = 0.96; bias = 0.16 ± 0.06; precision = 0.33 ± 0.08 (mean and 95% confidence interval)). CONCLUSIONS This clinical study confirms previous experimental results showing that the PVBC(2) predicts the contribution of the inspiratory muscles versus that of the ventilator during NAVA, when differences in effort (EAdi) between non-assisted and assisted breaths are limited. PVBC could help to quantify and standardize the adjustment of the level of assist, and hence reduce the risks of excessive ventilatory assist in patients. TRIAL REGISTRATION ClinicalTrials.gov NCT01663480. Registered 9 August 2012.
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Affiliation(s)
- Ling Liu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Songqiao Liu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Jianfeng Xie
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Yi Yang
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. .,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Suit RFE3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. .,Department of Pediatrics, University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science and Department of Critical Care, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B1W8, Canada. .,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Suit RFE3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.
| | - Haibo Qiu
- Department of Critical Care Medicine, Zhongda Hospital, Southeast University, School of Medicine, 87 Dingjiaqiao Street, Nanjing, 210009, China.
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Increased diaphragmatic contribution to inspiratory effort during neurally adjusted ventilatory assistance versus pressure support: an electromyographic study. Anesthesiology 2014; 121:1028-36. [PMID: 25208082 DOI: 10.1097/aln.0000000000000432] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA), regulated exclusively by the electromyographic activity (EA) of the diaphragm (EAdi), could affect the distribution of neural drive to the various inspiratory muscles. The objective of this study was to compare EAdi, EA of the scalene (EAscal), and EA of the alae nasi (EAan), according to the ventilatory mode and assist level in 12 mechanically ventilated patients. METHODS Seven assist levels of pressure support ventilation (PSV) and NAVA were sequentially applied. EAdi, EAscal, and EAan were quantified and expressed as a percentage of their maximum values. The relative contributions of extradiaphragmatic muscles to inspiratory efforts were assessed by calculating EAscal/EAdi and EAan/EAdi ratios. Three assist levels for each of the two ventilatory modes that resulted in EAdi values of 80 to 100%, 60 to 80%, and 40 to 60% were assigned to three groups (N1, N2, and N3). Results are expressed as median and interquartile range. RESULTS EA of inspiratory muscles decreased during PSV and NAVA (P < 0.0001). Although EAdi remained constant within groups (P = 0.9), EAscal was reduced during NAVA compared with PSV in N1 and N3 (65% [62 to 64] and 27% [18 to 34] in NAVA vs. 90% [81 to 100] and 49% [40 to 55] in PSV, P = 0.007). Altogether, EAscal/EAdi and EAan/EAdi ratios were lower in NAVA than PSV (0.7 [0.6 to 0.7] and 0.7 [0.6 to 0.8] in NAVA vs. 0.9 [0.8 to 1.1] and 0.9 [0.7 to 1.1] in PSV, P < 0.05). CONCLUSIONS NAVA and PSV both reduced extradiaphragmatic inspiratory muscle activity, in proportion to the level of assistance. Compared with PSV, NAVA resulted in a predominant contribution of the diaphragm to inspiratory effort.
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Inspiratory Muscle Activity in Neurally Adjusted Ventilatory Assist. Anesthesiology 2014; 121:916-8. [DOI: 10.1097/aln.0000000000000433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Spontaneous breathing in mild and moderate versus severe acute respiratory distress syndrome. Curr Opin Crit Care 2014; 20:69-76. [PMID: 24335656 DOI: 10.1097/mcc.0000000000000055] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
PURPOSE OF REVIEW This review summarizes the most recent clinical and experimental data on the impact of spontaneous breathing in acute respiratory distress syndrome (ARDS). RECENT FINDINGS Spontaneous breathing during assisted as well as nonassisted modes of mechanical ventilation improves lung function and reduces lung damage in mild and moderate ARDS. New modes of assisted mechanical ventilation with improved patient ventilator interaction and enhanced variability of the respiratory pattern offer additional benefit on lung function and damage. However, data supporting an outcome benefit of spontaneous breathing in ARDS, even in its mild and moderate forms, are missing. In contrast, controlled mechanical ventilation with muscle paralysis in the first 48 h of severe ARDS has been shown to improve survival, as compared with placebo. Currently, it is unclear whether ventilator settings, rather than the severity of lung injury, determine the potential of spontaneous breathing for benefit or harm. SUMMARY Clinical and experimental studies show that controlled mechanical ventilation with muscle paralysis in the early phase of severe ARDS reduces lung injury and even mortality. At present, spontaneous breathing should be avoided in the early phase of severe ARDS, but considered in mild-to-moderate ARDS.
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Physiological comparison of breathing patterns with neurally adjusted ventilatory assist (NAVA) and pressure-support ventilation to improve NAVA settings. Respir Physiol Neurobiol 2014; 195:11-8. [DOI: 10.1016/j.resp.2014.01.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Revised: 01/30/2014] [Accepted: 01/30/2014] [Indexed: 11/18/2022]
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