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Bhalla A, Baudin F, Takeuchi M, Cruces P. Monitoring in Pediatric Acute Respiratory Distress Syndrome: From the Second Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2023; 24:S112-S123. [PMID: 36661440 PMCID: PMC9980912 DOI: 10.1097/pcc.0000000000003163] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES Monitoring is essential to assess changes in the lung condition, to identify heart-lung interactions, and to personalize and improve respiratory support and adjuvant therapies in pediatric acute respiratory distress syndrome (PARDS). The objective of this article is to report the rationale of the revised recommendations/statements on monitoring from the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2). DATA SOURCES MEDLINE (Ovid), Embase (Elsevier), and CINAHL Complete (EBSCOhost). STUDY SELECTION We included studies focused on respiratory or cardiovascular monitoring of children less than 18 years old with a diagnosis of PARDS. We excluded studies focused on neonates. DATA EXTRACTION Title/abstract review, full-text review, and data extraction using a standardized data collection form. DATA SYNTHESIS The Grading of Recommendations Assessment, Development and Evaluation approach was used to identify and summarize evidence and develop recommendations. We identified 342 studies for full-text review. Seventeen good practice statements were generated related to respiratory and cardiovascular monitoring. Four research statements were generated related to respiratory mechanics and imaging monitoring, hemodynamics monitoring, and extubation readiness monitoring. CONCLUSIONS PALICC-2 monitoring good practice and research statements were developed to improve the care of patients with PARDS and were based on new knowledge generated in recent years in patients with PARDS, specifically in topics of general monitoring, respiratory system mechanics, gas exchange, weaning considerations, lung imaging, and hemodynamic monitoring.
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Affiliation(s)
- Anoopindar Bhalla
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Florent Baudin
- Hospices civils de Lyon, Hôpital Femme Mère Enfant, Service de réanimation pédiatrique, Bron F-69500, France
| | - Muneyuki Takeuchi
- Department of Intensive Care Medicine, Osaka Women’s and Children’s Hospital, Osaka, Japan
| | - Pablo Cruces
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile; and Pediatric Intensive Care Unit, Hospital el Carmen de Maipú, Santiago, Chile
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Longhini F, Bruni A, Garofalo E, Tutino S, Vetrugno L, Navalesi P, De Robertis E, Cammarota G. Monitoring the patient-ventilator asynchrony during non-invasive ventilation. Front Med (Lausanne) 2023; 9:1119924. [PMID: 36743668 PMCID: PMC9893016 DOI: 10.3389/fmed.2022.1119924] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 12/27/2022] [Indexed: 01/20/2023] Open
Abstract
Patient-ventilator asynchrony is a major issue during non-invasive ventilation and may lead to discomfort and treatment failure. Therefore, the identification and prompt management of asynchronies are of paramount importance during non-invasive ventilation (NIV), in both pediatric and adult populations. In this review, we first define the different forms of asynchronies, their classification, and the method of quantification. We, therefore, describe the technique to properly detect patient-ventilator asynchronies during NIV in pediatric and adult patients with acute respiratory failure, separately. Then, we describe the actions that can be implemented in an attempt to reduce the occurrence of asynchronies, including the use of non-conventional modes of ventilation. In the end, we analyzed what the literature reports on the impact of asynchronies on the clinical outcomes of infants, children, and adults.
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Affiliation(s)
- Federico Longhini
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy,*Correspondence: Federico Longhini,
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Simona Tutino
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Græcia University, Catanzaro, Italy
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care Unit, SS Annunziata Hospital, Chieti, Italy,Department of Medical, Oral and Biotechnological Sciences, “Gabriele D’Annunzio” University of Chieti-Pescara, Chieti, Italy
| | - Paolo Navalesi
- Anaesthesia and Intensive Care, Padua Hospital, Department of Medicine, University of Padua, Padua, Italy
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Kiger J. Neonatal ventilation. Semin Pediatr Surg 2022; 31:151199. [PMID: 36038215 DOI: 10.1016/j.sempedsurg.2022.151199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Affiliation(s)
- James Kiger
- University of Pittsburgh Medical Center, Department of Pediatrics, Pittsburgh, PA USA.
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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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Abstract
Patient-ventilator asynchrony is very common in newborns. Achieving synchrony is quite challenging because of small tidal volumes, high respiratory rates, and the presence of leaks. Leaks also cause unreliable monitoring of respiratory metrics. In addition, ventilator adjustment must take into account that infants have strong vagal reflexes and demonstrate central apnea and periodic breathing, with a high variability in breathing pattern. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation whereby the timing and amount of ventilatory assist is controlled by the patient's own neural respiratory drive. As NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized assist, both invasively and noninvasively (NIV-NAVA), to follow the variability in breathing pattern, and to monitor patient respiratory drive, independent of leaks. This article provides an updated review of the physiology and the scientific literature pertaining to the use of NAVA in children (neonatal and pediatric age groups). Both the invasive NAVA and NIV-NAVA publications since 2016 are summarized, as well as the use of Edi monitoring. Overall, the use of NAVA and Edi monitoring is feasible and safe. Compared with conventional ventilation, NAVA improves patient-ventilator interaction, provides lower peak inspiratory pressure, and lowers oxygen requirements. Evidence from several studies suggests improved comfort, less sedation requirements, less apnea, and some trends toward reduced length of stay and more successful extubation.
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Affiliation(s)
- Jennifer Beck
- Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B1W8, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada.
| | - Christer Sinderby
- Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, Ontario M5B1W8, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St-Michael's Hospital, Toronto, Canada; Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
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Abstract
OBJECTIVES To explore the level and time course of patient-ventilator asynchrony in mechanically ventilated children and the effects on duration of mechanical ventilation, PICU stay, and Comfort Behavior Score as indicator for patient comfort. DESIGN Secondary analysis of physiology data from mechanically ventilated children. SETTING Mixed medical-surgical tertiary PICU in a university hospital. PATIENTS Mechanically ventilated children 0-18 years old were eligible for inclusion. Excluded were patients who were unable to initiate and maintain spontaneous breathing from any cause. MEASUREMENTS AND MAIN RESULTS Twenty-nine patients were studied with a total duration of 109 days. Twenty-two study days (20%) were excluded because patients were on neuromuscular blockade or high-frequency oscillatory ventilation, yielding 87 days (80%) for analysis. Patient-ventilator asynchrony was detected through analysis of daily recorded ventilator airway pressure, flow, and volume versus time scalars. Approximately one of every three breaths was asynchronous. The percentage of asynchronous breaths significantly increased over time, with the highest prevalence on the day of extubation. There was no correlation with the Comfort Behavior score. The percentage of asynchronous breaths during the first 24 hours was inversely correlated with the duration of mechanical ventilation. Patients with severe patient-ventilator asynchrony (asynchrony index > 10% or > 75th percentile of the calculated asynchrony index) did not have a prolonged duration of ventilation. CONCLUSIONS The level of patient-ventilator asynchrony increased over time was not related to patient discomfort and inversely related to the duration of mechanical ventilation.
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Lee J, Parikka V, Lehtonen L, Soukka H. Backup ventilation during neurally adjusted ventilatory assist in preterm infants. Pediatr Pulmonol 2021; 56:3342-3348. [PMID: 34310871 DOI: 10.1002/ppul.25583] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 06/30/2021] [Accepted: 07/14/2021] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To analyze the proportion of backup ventilation during neurally adjusted ventilatory assist (NAVA) in preterm infants at different postmenstrual ages (PMAs) and to analyze the trends in backup ventilation in relation to clinical deteriorations. METHODS A prospective observational study was conducted in 18 preterm infants born at a median (range) 27+4 (23+4 -34+4 ) weeks of gestation with a median (range) birth weight of 1,100 (460-2,820) g, who received respiratory support with either invasive or noninvasive NAVA. Data on ventilator settings and respiratory variables were collected daily; the mean values of each 24-h recording were computed for each respiratory variable. For clinical deterioration, ventilator data were reviewed at 6-h intervals for 30 h before the event. RESULTS A total of 354 patient days were included: 269 and 85 days during invasive and noninvasive NAVA, respectively. The time on backup ventilation (%/min) significantly decreased with increasing PMA during both invasive and noninvasive NAVA. The neural respiratory rate did not change over time. The median time on backup ventilation was less than 15%/min, and the median neural respiratory rate was more than 45 breaths/min for infants above 26+0 weeks PMA during invasive NAVA. The relative backup ventilation significantly increased before the episode of clinical deterioration. CONCLUSION The proportion of backup ventilation during NAVA showed how the control of breathing matured with increasing PMA. Even the most immature infants triggered most of their breaths by their own respiratory effort. An acute increase in the proportion of backup ventilation anticipated clinical deterioration.
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Affiliation(s)
- Juyoung Lee
- Department of Pediatrics, Inha University Hospital, Incheon, South Korea
- Department of Pediatrics, Inha University College of Medicine, Incheon, South Korea
| | - Vilhelmiina Parikka
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Department of Pediatrics, University of Turku, Turku, Finland
| | - Liisa Lehtonen
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Department of Pediatrics, University of Turku, Turku, Finland
| | - Hanna Soukka
- Department of Pediatrics, Turku University Hospital, Turku, Finland
- Department of Pediatrics, University of Turku, Turku, Finland
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Neurally-Adjusted Ventilatory Assist (NAVA) versus Pneumatically Synchronized Ventilation Modes in Children Admitted to PICU. J Clin Med 2021; 10:jcm10153393. [PMID: 34362173 PMCID: PMC8347771 DOI: 10.3390/jcm10153393] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/27/2021] [Accepted: 07/29/2021] [Indexed: 12/02/2022] Open
Abstract
Traditionally, invasively ventilated children in the paediatric intensive care unit (PICU) are weaned using pneumatically-triggered ventilation modes with a fixed level of assist. The best weaning mode is currently not known. Neurally adjusted ventilatory assist (NAVA), a newer weaning mode, uses the electrical activity of the diaphragm (Edi) to synchronise ventilator support proportionally to the patient’s respiratory drive. We aimed to perform a systematic literature review to assess the effect of NAVA on clinical outcomes in invasively ventilated children with non-neonatal lung disease. Three studies (n = 285) were included for analysis. One randomised controlled trial (RCT) of all comers showed a significant reduction in PICU length of stay and sedative use. A cohort study of acute respiratory distress syndrome (ARDS) patients (n = 30) showed a significantly shorter duration of ventilation and improved sedation with the use of NAVA. A cohort study of children recovering from cardiac surgery (n = 75) showed significantly higher extubation success, shorter duration of ventilation and PICU length of stay, and a reduction in sedative use. Our systematic review presents weak evidence that NAVA may shorten the duration of ventilation and PICU length of stay, and reduce the requirement of sedatives. However, further RCTs are required to more fully assess the effect of NAVA on clinical outcomes and treatment costs in ventilated children.
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Ventre KM. The inscrutable signatures of patient-ventilator asynchrony: all the light we cannot see. Minerva Anestesiol 2020; 87:278-282. [PMID: 33054023 DOI: 10.23736/s0375-9393.20.15087-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Kathleen M Ventre
- Department of Pediatrics, Critical Care Medicine, Albany Medical Center, Albany, NY, USA -
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DI Nardo M, Lonero M, Staffieri F, DI Mussi R, Murgolo F, Lorusso P, Pham T, Picardo SG, Perrotta D, Cecchetti C, RavÀ L, Grasso S. Can visual inspection of the electrical activity of the diaphragm improve the detection of patient-ventilator asynchronies by pediatric critical care physicians? Minerva Anestesiol 2020; 87:319-324. [PMID: 32755090 DOI: 10.23736/s0375-9393.20.14543-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Patient-ventilator asynchronies are challenging during pediatric mechanical ventilation. We hypothesized that monitoring the electrical activity of the diaphragm (EAdi) together with the "standard" airway opening pressure (Pao) and flow-time waveforms during pressure support ventilation would improve the ability of a cohort of critical care physicians to detect asynchronies in ventilated children. METHODS We recorded the flow, Pao and EAdi waveforms in ten consecutive patients. The recordings were split in periods of 15 s, each reproducing a ventilator screenshot. From this pool, a team of four experts selected the most representative screenshots including at least one of the three most common asynchronies (missed efforts, auto-triggering and double triggering) and split them into two versions, respectively showing or not the EAdi waveforms. The screenshots were shown in random order in a questionnaire to sixty experienced pediatric intensivists that were asked to identify any episode of patient-ventilator asynchrony. RESULTS Among the ten patients included in the study, only eight had EAdi tracings without artifacts and were analyzed. When the Eadi waveform was shown, the auto-triggering detection improved from 13% to 67% (P<0.0001) and the missed efforts detection improved from 43% to 95% (P<0.0001). The detection of double triggering, instead, did not improve (85% with the EAdi vs. 78% without the EAdi waveform; P=0.52). CONCLUSIONS This single center study suggests that the EAdi waveform may improve the ability of pediatric intensivists to detect missed efforts and auto-triggering asynchronies. Further studies are required to determine the clinical implications of these findings.
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Affiliation(s)
- Matteo DI Nardo
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Margherita Lonero
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy -
| | - Francesco Staffieri
- Section of Veterinary Clinics and Animal Production, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Rosa DI Mussi
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Francesco Murgolo
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | - Pantaleo Lorusso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
| | | | - Sergio G Picardo
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Daniela Perrotta
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Corrado Cecchetti
- Department of Pediatric Anesthesia and Critical Care Medicine, Bambino Gesù Children's Hospital, Rome, Italy
| | - Lucilla RavÀ
- Unit of Epidemiology and Biostatistics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Salvatore Grasso
- Section of Anesthesia and Intensive Care, Department of Emergency and Organ Transplantation, Aldo Moro University of Bari, Bari, Italy
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Martos-Benítez FD, Domínguez-Valdés Y, Burgos-Aragüez D, Larrondo-Muguercia H, Orama-Requejo V, Lara-Ponce KX, González-Martínez I. Outcomes of ventilatory asynchrony in patients with inspiratory effort. Rev Bras Ter Intensiva 2020; 32:284-294. [PMID: 32667451 PMCID: PMC7405741 DOI: 10.5935/0103-507x.20200045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 02/04/2020] [Indexed: 01/21/2023] Open
Abstract
Objective To identify the relationship of patient-ventilator asynchrony with the level of sedation and hemogasometric and clinical results. Methods This was a prospective study of 122 patients admitted to the intensive care unit who underwent > 24 hours of invasive mechanical ventilation with inspiratory effort. In the first 7 days of ventilation, patient-ventilator asynchrony was evaluated daily for 30 minutes. Severe patient-ventilator asynchrony was defined as an asynchrony index > 10%. Results A total of 339,652 respiratory cycles were evaluated in 504 observations. The mean asynchrony index was 37.8% (standard deviation 14.1 - 61.5%). The prevalence of severe patient-ventilator asynchrony was 46.6%. The most frequent patient-ventilator asynchronies were ineffective trigger (13.3%), autotrigger (15.3%), insufficient flow (13.5%), and delayed cycling (13.7%). Severe patient-ventilator asynchrony was related to the level of sedation (ineffective trigger: p = 0.020; insufficient flow: p = 0.016; premature cycling: p = 0.023) and the use of midazolam (p = 0.020). Severe patient-ventilator asynchrony was also associated with hemogasometric changes. The persistence of severe patient-ventilator asynchrony was an independent risk factor for failure of the spontaneous breathing test, ventilation time, ventilator-associated pneumonia, organ dysfunction, mortality in the intensive care unit, and length of stay in the intensive care unit. Conclusion Patient-ventilator asynchrony is a frequent disorder in critically ill patients with inspiratory effort. The patient’s interaction with the ventilator should be optimized to improve hemogasometric parameters and clinical results. Further studies are required to confirm these results.
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Affiliation(s)
- Frank Daniel Martos-Benítez
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Yairén Domínguez-Valdés
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Dailé Burgos-Aragüez
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Hilev Larrondo-Muguercia
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Versis Orama-Requejo
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Karla Ximena Lara-Ponce
- Unidad de Cuidados Intensivos - 8B, Hospital Clínico Quirúrgico "Hermanos Ameijeiras", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
| | - Iraida González-Martínez
- Unidad de Cuidados Intensivos, Hospital Universitario "Dr. Miguel Enríquez", Universidad de Ciencias Médicas de La Habana, La Habana, Cuba
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¿Cuáles son los factores predictores de fracaso de ventilación no invasiva más fiables en una unidad de cuidados intensivos pediátricos? An Pediatr (Barc) 2019; 91:307-316. [DOI: 10.1016/j.anpedi.2019.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 01/17/2019] [Accepted: 01/21/2019] [Indexed: 11/24/2022] Open
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Pons-Òdena M, Medina A, Modesto V, Martín-Mateos MA, Tan W, Escuredo L, Cambra FJ. What are the most reliable predictive factors of non-invasive ventilation failure in paediatric intensive care units? An Pediatr (Barc) 2019. [DOI: 10.1016/j.anpede.2019.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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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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Bonacina D, Bronco A, Nacoti M, Ferrari F, Fazzi F, Bonanomi E, Bellani G. Pressure support ventilation, sigh adjunct to pressure support ventilation, and neurally adjusted ventilatory assist in infants after cardiac surgery: A physiologic crossover randomized study. Pediatr Pulmonol 2019; 54:1078-1086. [PMID: 31004420 DOI: 10.1002/ppul.24335] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 03/25/2019] [Accepted: 03/25/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVES We sought to compare gas exchange, respiratory mechanics, and asynchronies during pressure support ventilation (PSV), sigh adjunct to PSV (PSV SIGH), and neurally adjusted ventilatory assist (NAVA) in hypoxemic infants after cardiac surgery. DESIGN Prospective, single-center, crossover, randomized physiologic study. SETTING Tertiary-care pediatric intensive care unit. PATIENTS Fourteen hypoxemic infants (median age 11.5 days [8.7-74]). INTERVENTIONS The protocol begins with a 1 hour step of PSV, followed by two consecutive steps in PSV SIGH and NAVA in random order, with a washout period of 30 minutes (PSV) between them. MAIN RESULTS Three infants presented an irregular Eadi signal because of diaphragmatic paralysis and were excluded from analysis. For the remaining 11 infants, PaO2 /FiO 2 and oxygenation index improved in PSV SIGH compared with PSV (P < 0.05) but not in NAVA compared with PSV. PSV SIGH showed increased tidal volumes and lower respiratory rate than PSV (P < 0.05), as well as a significant improvement in compliance with respiratory system indexed to body weight when compared with both PSV and NAVA (P < 0.01). No changes in mean airway pressure was registered among steps. Inspiratory time resulted prolonged for both PSV SIGH and NAVA than PSV (P < 0.05). NAVA showed the higher coefficient of variability in respiratory parameters and a significative decrease in asynchrony index when compared with both PSV and PSV SIGH (P < 0.01). CONCLUSIONS The adjunct of one SIGH per minute to PSV improved oxygenation and lung mechanics while NAVA provided the best patient-ventilator synchrony in infants after cardiac surgery.
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Affiliation(s)
- Daniele Bonacina
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Alfio Bronco
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Mirco Nacoti
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Floriana Ferrari
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Francesco Fazzi
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Ezio Bonanomi
- Pediatric Intensive Care Unit, A.S.S.T. Papa Giovanni XXIII, Bergamo, Italy
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy.,Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy
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16
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Garofalo E, Bruni A, Pelaia C, Liparota L, Lombardo N, Longhini F, Navalesi P. Recognizing, quantifying and managing patient-ventilator asynchrony in invasive and noninvasive ventilation. Expert Rev Respir Med 2018; 12:557-567. [DOI: 10.1080/17476348.2018.1480941] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Eugenio Garofalo
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Andrea Bruni
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Corrado Pelaia
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Luisa Liparota
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Nicola Lombardo
- Otolaryngology, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Federico Longhini
- Anesthesia and Intensive Care, Sant’Andrea Hospital, Vercelli, Italy
| | - Paolo Navalesi
- Anesthesia and Intensive Care, Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
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17
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Sood SB, Mushtaq N, Brown K, Littlefield V, Barton RP. Neurally Adjusted Ventilatory Assist Is Associated with Greater Initial Extubation Success in Postoperative Congenital Heart Disease Patients when Compared to Conventional Mechanical Ventilation. J Pediatr Intensive Care 2018; 7:147-158. [PMID: 31073487 DOI: 10.1055/s-0038-1627099] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/08/2017] [Indexed: 01/23/2023] Open
Abstract
Extubation failure is associated with considerable morbidity and mortality in postoperative patients with congenital heart disease (CHD). The study purpose was to investigate initial extubation success utilizing neurally adjusted ventilatory assist (NAVA) compared with pressure-regulated volume controlled, synchronized intermittent mandatory ventilation with pressure support (SIMV-PRVC + PS) for ventilatory weaning in patients who required prolonged mechanical ventilation (MV). Also, total days on MV, inotropes, sedation, analgesia, and pediatric intensive care unit (PICU) length of stay (LOS) between both groups were compared. This was a non-randomized pilot study utilizing historical controls (SIMV-PRVC + PS; n = 40) compared with a prospective study population (NAVA; n = 35) in a Level I PICU and was implemented to help future trial designs. All patients ( n = 75) required prolonged MV ≥96 hours due to their complex postoperative course. Ventilator weaning initiation and management was standardized between both groups. Ninety-seven percent of the NAVA group was successfully extubated on the initial attempt, while 80% were in the SIMV-PRVC + PS group ( p = 0.0317). Patients placed on NAVA were eight times more likely to have successful initial extubation (odds ratio [OR]: 8.50, 95% confidence interval [CI]: 1.01, 71.82). The NAVA group demonstrated a shorter median duration on MV (9.0 vs. 11.0 days, p = 0.032), PICU LOS (9.0 vs. 13.5 days, p < 0.0001), and shorter median duration of days on dopamine (8.0 vs. 11.0 days, p = 0.0022), milrinone (9.0 vs. 12.0 days, p = 0.0002), midazolam (8.0 vs. 12.0 days, p < 0.0001), and fentanyl (9.0 vs. 12.5 days, p < 0.0001) compared with the SIMV-PRVC + PS group. NAVA compared with SIMV-PRVC + PS was associated with a greater initial extubation success rate. NAVA should be considered as a mechanical ventilator weaning strategy in postoperative congenital heart disease (CHD) patients and warrants further investigation.
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Affiliation(s)
- Shawn Berry Sood
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, United States
| | - Nasir Mushtaq
- Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, United States
| | - Kellie Brown
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
| | - Vanette Littlefield
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
| | - Roger Phillip Barton
- Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
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18
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Mortamet G, Larouche A, Ducharme-Crevier L, Fléchelles O, Constantin G, Essouri S, Pellerin-Leblanc AA, Beck J, Sinderby C, Jouvet P, Emeriaud G. Patient-ventilator asynchrony during conventional mechanical ventilation in children. Ann Intensive Care 2017; 7:122. [PMID: 29264742 PMCID: PMC5738329 DOI: 10.1186/s13613-017-0344-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 12/13/2017] [Indexed: 11/22/2022] Open
Abstract
Background We aimed (1) to describe the characteristics of patient–ventilator asynchrony in a population of critically ill children, (2) to describe the risk factors associated with patient–ventilator asynchrony, and (3) to evaluate the association between patient–ventilator asynchrony and ventilator-free days at day 28. Methods In this single-center prospective study, consecutive children admitted to the PICU and mechanically ventilated for at least 24 h were included. Patient–ventilator asynchrony was analyzed by comparing the ventilator pressure curve and the electrical activity of the diaphragm (Edi) signal with (1) a manual analysis and (2) using a standardized fully automated method. Results Fifty-two patients (median age 6 months) were included in the analysis. Eighteen patients had a very low ventilatory drive (i.e., peak Edi < 2 µV on average), which prevented the calculation of patient–ventilator asynchrony. Children spent 27% (interquartile 22–39%) of the time in conflict with the ventilator. Cycling-off errors and trigger delays contributed to most of this asynchronous time. The automatic algorithm provided a NeuroSync index of 45%, confirming the high prevalence of asynchrony. No association between the severity of asynchrony and ventilator-free days at day 28 or any other clinical secondary outcomes was observed, but the proportion of children with good synchrony was very low. Conclusion Patient–ventilator interaction is poor in children supported by conventional ventilation, with a high frequency of depressed ventilatory drive and a large proportion of time spent in asynchrony. The clinical benefit of strategies to improve patient–ventilator interactions should be evaluated in pediatric critical care.
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Affiliation(s)
- Guillaume Mortamet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,INSERM U 955, Equipe 13, Créteil, France.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Alexandrine Larouche
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Laurence Ducharme-Crevier
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Olivier Fléchelles
- Pediatric Intensive Care Unit, CHU Fort-de-France, Fort-de-France, France
| | - Gabrielle Constantin
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Sandrine Essouri
- CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada.,Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada
| | | | - Jennifer Beck
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Department of Pediatrics, University of Toronto, Toronto, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada.,Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St-Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada.,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Montreal, QC, Canada. .,CHU Sainte-Justine Research Center, Université de Montréal, Montreal, Canada.
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19
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Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med 2017; 43:1764-1780. [PMID: 28936698 PMCID: PMC5717127 DOI: 10.1007/s00134-017-4920-z] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Accepted: 08/22/2017] [Indexed: 12/15/2022]
Abstract
Purpose Much of the common practice in paediatric mechanical ventilation is based on personal experiences and what paediatric critical care practitioners have adopted from adult and neonatal experience. This presents a barrier to planning and interpretation of clinical trials on the use of specific and targeted interventions. We aim to establish a European consensus guideline on mechanical ventilation of critically children. Methods The European Society for Paediatric and Neonatal Intensive Care initiated a consensus conference of international European experts in paediatric mechanical ventilation to provide recommendations using the Research and Development/University of California, Los Angeles, appropriateness method. An electronic literature search in PubMed and EMBASE was performed using a combination of medical subject heading terms and text words related to mechanical ventilation and disease-specific terms. Results The Paediatric Mechanical Ventilation Consensus Conference (PEMVECC) consisted of a panel of 15 experts who developed and voted on 152 recommendations related to the following topics: (1) general recommendations, (2) monitoring, (3) targets of oxygenation and ventilation, (4) supportive measures, (5) weaning and extubation readiness, (6) normal lungs, (7) obstructive diseases, (8) restrictive diseases, (9) mixed diseases, (10) chronically ventilated patients, (11) cardiac patients and (12) lung hypoplasia syndromes. There were 142 (93.4%) recommendations with “strong agreement”. The final iteration of the recommendations had none with equipoise or disagreement. Conclusions These recommendations should help to harmonise the approach to paediatric mechanical ventilation and can be proposed as a standard-of-care applicable in daily clinical practice and clinical research. Electronic supplementary material The online version of this article (doi:10.1007/s00134-017-4920-z) contains supplementary material, which is available to authorized users.
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20
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Rimensberger PC, Cheifetz IM, Kneyber MCJ. The top ten unknowns in paediatric mechanical ventilation. Intensive Care Med 2017; 44:366-370. [DOI: 10.1007/s00134-017-4847-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/17/2017] [Indexed: 12/27/2022]
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21
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Nardi N, Mortamet G, Ducharme-Crevier L, Emeriaud G, Jouvet P. Recent Advances in Pediatric Ventilatory Assistance. F1000Res 2017; 6:290. [PMID: 28413621 PMCID: PMC5365224 DOI: 10.12688/f1000research.10408.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2017] [Indexed: 01/17/2023] Open
Abstract
In this review on respiratory assistance, we aim to discuss the following recent advances: the optimization and customization of mechanical ventilation, the use of high-frequency oscillatory ventilation, and the role of noninvasive ventilation. The prevention of ventilator-induced lung injury and diaphragmatic dysfunction is now a key aspect in the management of mechanical ventilation, since these complications may lead to higher mortality and prolonged length of stay in intensive care units. Different physiological measurements, such as esophageal pressure, electrical activity of the diaphragm, and volumetric capnography, may be useful objective tools to help guide ventilator assistance. Companies that design medical devices including ventilators and respiratory monitoring platforms play a key role in knowledge application. The creation of a ventilation consortium that includes companies, clinicians, researchers, and stakeholders could be a solution to promote much-needed device development and knowledge implementation.
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Affiliation(s)
- Nicolas Nardi
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Guillaume Mortamet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | | | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Philippe Jouvet
- Pediatric Intensive Care Unit, CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
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22
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Firestone KS, Beck J, Stein H. Neurally Adjusted Ventilatory Assist for Noninvasive Support in Neonates. Clin Perinatol 2016; 43:707-724. [PMID: 27837754 DOI: 10.1016/j.clp.2016.07.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Noninvasive ventilation (NIV) is frequently used in the NICU to avoid intubation or as postextubation support for spontaneously breathing infants experiencing respiratory distress. Neurally adjusted ventilatory assist (NAVA) is used as a mode of noninvasive support in which both the timing and degree of ventilatory assist are controlled by the patient. NIV-NAVA has been successfully used clinically in neonates as a mode of ventilation to prevent intubation, allow early extubation, and as a novel way to deliver nasal continuous positive airway pressure.
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Affiliation(s)
- Kimberly S Firestone
- Neonatal Respiratory Outreach Clinical Liaison, Neonatal Intensive Care Unit, Neonatology Department, Akron Children's Hospital, One Perkins Square, Akron, OH 44308, USA
| | - Jennifer Beck
- Keenan Research Centre for Biomedical Science, St. Michael's Hospital, Department of Pediatrics, University of Toronto, 30 Bond Street, Toronto, ON M5B 1W8, Canada; Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St. Michael's Hospital, Department of Chemistry and Biology, 350 Victoria Street, Toronto, ON M5B 2K3, Canada
| | - Howard Stein
- Neonatal Intensive Care Unit, Promedica Toledo Children's Hospital, Department of Pediatrics, 2142 North Cove Boulevard, Toledo, OH 43606, USA; University of Toledo, Department of Pediatrics, University of Toledo Health Science Campus, 3000 Arlington Avenue, Toledo, OH 43614, USA.
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23
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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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24
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Liet JM, Barrière F, Gaillard-Le Roux B, Bourgoin P, Legrand A, Joram N. Physiological effects of invasive ventilation with neurally adjusted ventilatory assist (NAVA) in a crossover study. BMC Pediatr 2016; 16:180. [PMID: 27821162 PMCID: PMC5100099 DOI: 10.1186/s12887-016-0717-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 10/25/2016] [Indexed: 12/19/2022] Open
Abstract
Background Neurally Adjusted Ventilatory Assist (NAVA) is a mode of assisted mechanical ventilation that delivers inspiratory pressure proportionally to the electrical activity of the diaphragm. To date, no pediatric study has focused on the effects of NAVA on hemodynamic parameters. This physiologic study with a randomized cross-over design compared hemodynamic parameters when NAVA or conventional ventilation (CV) was applied. Methods After a baseline period, infants received NAVA and CV in a randomized order during two consecutive 30-min periods. During the last 10 min of each period, respiratory and hemodynamic parameters were collected. No changes in PEEP, FiO2, sedation or inotropic doses were allowed during these two periods. The challenge was to keep minute volumes constant, with no changes in blood CO2 levels and in pH that may affect the results. Results Six infants who had undergone cardiac surgery (mean age 7.8 ± 4.1 months) were studied after parental consent. Four of them had low central venous oxygen saturation (ScvO2 < 65 %). The ventilatory settings resulted in similar minute volumes (1.7 ± 0.4 vs. 1.6 ± 0.6 ml/kg, P = 0.67) and in similar tidal volumes respectively with NAVA and with CV. There were no statistically significant differences on blood pH levels between the two modes of ventilation (7.32 ± 0.02 vs. 7.32 ± 0.04, P = 0.34). Ventilation with NAVA delivered lower peak inspiratory pressures than with CV: -32.7 % (95 % CI: -48.2 to –17.1 %, P = 0.04). With regard to hemodynamics, systolic arterial pressures were higher using NAVA: +8.4 % (95 % CI: +3.3 to +13.6 %, P = 0.03). There were no statistically significant differences on cardiac index between the two modes of ventilation. However, all children with a low baseline ScvO2 (<65 %) tended to increase their cardiac index with NAVA compared to CV: 2.03 ± 0.30 vs. 1.91 ± 0.39 L/min.m2 (median ± interquartile, P = 0.07). Conclusions This pilot study raises the hypothesis that NAVA could have beneficial effects on hemodynamics in children when compared to a conventional ventilatory mode that delivered identical PEEP and similar minute volumes. Trial registration ClinicalTrials.gov Identifier: NCT01490710. Date of registration: December 7, 2011.
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Affiliation(s)
- Jean-Michel Liet
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France.
| | - François Barrière
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Bénédicte Gaillard-Le Roux
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
| | - Arnaud Legrand
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France.,CIC-INSERM 1413, University of Nantes, Nantes, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, Hôpital Femme-Enfant-Adolescent, the University Hospital Center of Nantes (CHU), 38 bd Jean-Monnet, 44093, Nantes, France
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25
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Neurally adjusted ventilatory assist (NAVA) in preterm newborn infants with respiratory distress syndrome-a randomized controlled trial. Eur J Pediatr 2016; 175:1175-1183. [PMID: 27502948 DOI: 10.1007/s00431-016-2758-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/11/2016] [Accepted: 07/29/2016] [Indexed: 12/17/2022]
Abstract
UNLABELLED Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator synchrony during invasive ventilation and leads to lower peak inspiratory pressures (PIP) and oxygen requirements. The aim of this trial was to compare NAVA with current standard ventilation in preterm infants in terms of the duration of invasive ventilation. Sixty infants born between 28 + 0 and 36 + 6 weeks of gestation and requiring invasive ventilation due to neonatal respiratory distress syndrome (RDS) were randomized to conventional ventilation or NAVA. The median durations of invasive ventilation were 34.7 h (quartiles 22.8-67.9 h) and 25.8 h (15.6-52.1 h) in the NAVA and control groups, respectively (P = 0.21). Lower PIPs were achieved with NAVA (P = 0.02), and the rapid reduction in PIP after changing the ventilation mode to NAVA made following the predetermined extubation criteria challenging. The other ventilatory and vital parameters did not differ between the groups. Frequent apneas and persistent pulmonary hypertension were conditions that limited the use of NAVA in 17 % of the patients randomized to the NAVA group. Similar cumulative doses of opiates were used in both groups (P = 0.71). CONCLUSIONS NAVA was a safe and feasible ventilation mode for the majority of preterm infants suffering from RDS, but the traditional extubation criteria were not clinically applicable during NAVA. WHAT IS KNOWN • NAVA improves patient-ventilator synchrony during invasive ventilation. • Lower airway pressures and oxygen requirements are achieved with NAVA during invasive ventilation in preterm infants by comparison with conventional ventilation. What is new: • Infants suffering from PPHN did not tolerate NAVA in the acute phase of their illness. • The traditional extubation criteria relying on inspiratory pressures and spontaneous breathing efforts were not clinically applicable during NAVA.
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26
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Stein H, Beck J, Dunn M. Non-invasive ventilation with neurally adjusted ventilatory assist in newborns. Semin Fetal Neonatal Med 2016; 21:154-61. [PMID: 26899957 DOI: 10.1016/j.siny.2016.01.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation in which both the timing and degree of ventilatory assist are controlled by the patient. Since NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized non-invasive NAVA (NIV-NAVA) regardless of leaks and to monitor continuously patient respiratory pattern and drive. Advantages of NIV-NAVA over conventional modes include improved patient-ventilator interaction, reliable respiratory monitoring and self-regulation of respiratory support. In theory, these characteristics make NIV-NAVA an ideal mode to provide effective, appropriate non-invasive support to newborns with respiratory insufficiency. NIV-NAVA has been successfully used clinically in neonates as a mode of ventilation to prevent intubation, to allow early extubation, and as a novel way to deliver nasal continuous positive airway pressure. The use of NAVA in neonates is described with an emphasis on studies and clinical experience with NIV-NAVA.
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Affiliation(s)
- Howard Stein
- Neonatal Intensive Care Unit, Promedica Toledo Children's Hospital, Toledo, OH, USA; University of Toledo, Toledo, OH, USA
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Institute for Biomedical Engineering and Science Technology (iBEST), Ryerson University and St Michael's Hospital, Toronto, Ontario, Canada; Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Ontario, Canada
| | - Michael Dunn
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Newborn and Developmental Paediatrics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
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27
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Abstract
OBJECTIVE To describe the frequency and type of patient-ventilator asynchrony in mechanically ventilated children by analyzing ventilator flow and pressure signals. DESIGN Prospective observational study. SETTING Tertiary PICU in a university hospital. PATIENTS Mechanically ventilated children between 0 and 18 years old and who were able to initiate and maintain spontaneous breathing were eligible for inclusion. Patients with congenital or acquired neuromuscular disorders, those with congenital or acquired central nervous system disorders, and those who were unable to initiate and maintain spontaneous breathing from any other cause were excluded. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All patients were ventilated in a time-cycled, pressure-limited mode with flow triggering set at 1.0 L/min by using the Evita XL (Dräger, Lubeck, Germany). Patient-ventilator asynchrony was identified by a random 30-minute continuous recording and an offline analysis of the flow and pressure signals. Patient-ventilator asynchrony was categorized and labeled into four different groups: 1) trigger asynchrony (i.e., insensitive trigger, double triggering, autotriggering, or trigger delay), 2) flow asynchrony, 3) termination asynchrony (i.e., delayed or premature termination), and 4) expiratory asynchrony. Flow and pressure signals were recorded in 45 patients for 30 minutes. A total number of 57,651 breaths were analyzed. Patient-ventilator asynchrony occurred in 19,175 breaths (33%), and it was seen in every patient. Ineffective triggering was the most predominant type of asynchrony (68%), followed by delayed termination (19%), double triggering (4%), and premature termination (3%). Patient-ventilator asynchrony significantly increased with lower levels of peak inspiratory pressure, positive end-expiratory pressure, and set frequency. CONCLUSIONS Patient-ventilator asynchrony is extremely common in mechanically ventilated children, and the predominant cause is ineffective triggering.
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Ventilatory support in children with pediatric acute respiratory distress syndrome: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16:S51-60. [PMID: 26035364 DOI: 10.1097/pcc.0000000000000433] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To describe the recommendations of the Pediatric Acute Lung Injury Consensus Conference for mechanical ventilation management of pediatric patients with acute respiratory distress syndrome. DESIGN Consensus Conference of experts in pediatric acute lung injury. METHODS The Pediatric Acute Lung Injury Consensus Conference experts developed and voted on a total of 27 recommendations focused on the optimal mechanical ventilation approach of the patient with pediatric acute respiratory distress syndrome. Topics included ventilator mode, tidal volume delivery, inspiratory plateau pressure, high-frequency ventilation, cuffed endotracheal tubes, and gas exchange goals. When experimental data were lacking, a modified Delphi approach emphasizing the strong professional agreement was used. RESULTS There were 17 recommendations with strong agreement and 10 recommendations with weak agreement. There were no recommendations with equipoise or disagreement. There was weak agreement on recommendations concerning approach to tidal volume and inspiratory pressure limitation (88% to 72% agreement, respectively), whereas strong agreement could be achieved for accepting permissive hypercapnia. Using positive end-expiratory pressure levels greater than 15 cm H2O in severe pediatric acute respiratory distress syndrome, under the condition that the markers of oxygen delivery, respiratory system compliance, and hemodynamics are closely monitored as positive end-expiratory pressure is increased, is strongly recommended. The concept of exploring the effects of careful recruitment maneuvers during conventional ventilation met an agreement level of 88%, whereas the use of recruitment maneuvers during rescue high-frequency oscillatory ventilation is highly recommended (strong agreement). CONCLUSIONS The Consensus Conference developed pediatric-specific recommendations regarding mechanical ventilation of the patient with pediatric acute respiratory distress syndrome as well as future research priorities. These recommendations are intended to initiate discussion regarding optimal mechanical ventilation management for children with pediatric acute respiratory distress syndrome and identify areas of controversy requiring further investigation.
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Patthum A, Peters M, Lockwood C. Effectiveness and safety of Neurally Adjusted Ventilatory Assist (NAVA) mechanical ventilation compared to standard conventional mechanical ventilation in optimizing patient-ventilator synchrony in critically ill patients: a systematic review protocol. ACTA ACUST UNITED AC 2015; 13:31-46. [PMID: 26447047 DOI: 10.11124/jbisrir-2015-1914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 09/12/2014] [Accepted: 09/18/2014] [Indexed: 10/31/2022]
Affiliation(s)
- Arisara Patthum
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia.,Lyell McEwin Hospital, Adelaide, South Australia
| | - Micah Peters
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia
| | - Craig Lockwood
- Faculty of Health Sciences, Joanna Briggs Institute, University of Adelaide, South Australia
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Neurally adjusted ventilatory assist (NAVA) allows patient-ventilator synchrony during pediatric noninvasive ventilation: a crossover physiological study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:44. [PMID: 25886793 PMCID: PMC4342194 DOI: 10.1186/s13054-015-0770-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 01/23/2015] [Indexed: 11/16/2022]
Abstract
Introduction The need for intubation after a noninvasive ventilation (NIV) failure is frequent in the pediatric intensive care unit (PICU). One reason is patient-ventilator asynchrony during NIV. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation controlled by the patient’s neural respiratory drive. The aim of this study was to assess the feasibility and tolerance of NIV-NAVA in children and to evaluate its impact on synchrony and respiratory effort. Methods This prospective, physiologic, crossover study included 13 patients requiring NIV in the PICU of Sainte-Justine’s Hospital from October 2011 to May 2013. Patients were successively ventilated in conventional NIV as prescribed by the physician in charge (30 minutes), in NIV-NAVA (60 minutes), and again in conventional NIV (30 minutes). Electrical activity of the diaphragm (EAdi) and airway pressure were simultaneously recorded to assess patient-ventilator synchrony. Results NIV-NAVA was feasible and well tolerated in all patients. One patient asked to stop the study because of anxiety related to the leak-free facial mask. Inspiratory trigger dys-synchrony and cycling-off dys-synchrony were significantly shorter in NIV-NAVA versus initial and final conventional NIV periods (both P <0.05). Wasted efforts were also decreased in NIV-NAVA (all values expressed as median and interquartile values) (0 (0 to 0) versus 12% (4 to 20) and 6% (2 to 22), respectively; P <0.01). As a whole, total time spent in asynchrony was reduced to 8% (6 to 10) in NIV-NAVA, versus 27% (19 to 56) and 32% (21 to 38) in conventional NIV before and after NIV-NAVA, respectively (P =0.05). Conclusion NIV-NAVA is feasible and well tolerated in PICU patients and allows improved patient-ventilator synchronization. Larger controlled studies are warranted to evaluate the clinical impact of these findings. Trial registration ClinicalTrials.gov NCT02163382. Registered 9 June 2014.
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Longhini F, Ferrero F, De Luca D, Cosi G, Alemani M, Colombo D, Cammarota G, Berni P, Conti G, Bona G, Della Corte F, Navalesi P. Neurally adjusted ventilatory assist in preterm neonates with acute respiratory failure. Neonatology 2015; 107:60-7. [PMID: 25401284 DOI: 10.1159/000367886] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Accepted: 08/26/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is a novel mode of ventilation that has been demonstrated to improve infant-ventilator interaction, compared to the conventional modes in retrospective and short-term studies. OBJECTIVES To prospectively evaluate the physiologic effects of NAVA in comparison with pressure-regulated volume control (PRVC) in two nonrandomized 12-hour periods. METHODS We studied 14 consecutive intubated preterm neonates receiving mechanical ventilation for acute respiratory failure. Peak airway pressure (Pawpeak), diaphragm electrical activity (EAdi), tidal volume (VT), mechanical (RRmec) and neural (RRneu) respiratory rates, neural apneas, and the capillary arterialized blood gases were measured. The RRmec-to-RRneu ratio (MNR) and the asynchrony index were also calculated. The amount of fentanyl administered was recorded. RESULTS Pawpeak and VT were greater in PRVC (p < 0.01). Blood gases and RRmec were not different between modes, while RRneu and the EAdi swings were greater in NAVA (p = 0.02 and p < 0.001, respectively). MNR and the asynchrony index were remarkably lower in NAVA than in PRVC (p = 0.03 and p < 0.001, respectively). 1,841 neural apneas were observed during PRVC, with none in NAVA. Less fentanyl was administered during NAVA, as opposed to PRVC (p < 0.01). CONCLUSIONS In acutely ill preterm neonates, NAVA can be safely and efficiently applied for 12 consecutive hours. Compared to PRVC, NAVA is well tolerated with fewer sedatives.
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Affiliation(s)
- Federico Longhini
- Department of Translational Medicine, Eastern Piedmont University 'A. Avogadro', Novara, Italy
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Emeriaud G, Larouche A, Ducharme-Crevier L, Massicotte E, Fléchelles O, Pellerin-Leblanc AA, Morneau S, Beck J, Jouvet P. Evolution of inspiratory diaphragm activity in children over the course of the PICU stay. Intensive Care Med 2014; 40:1718-26. [PMID: 25118865 DOI: 10.1007/s00134-014-3431-4] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 07/30/2014] [Indexed: 01/06/2023]
Abstract
PURPOSE Diaphragm function should be monitored in critically ill patients, as full ventilatory support rapidly induces diaphragm atrophy. Monitoring the electrical activity of the diaphragm (EAdi) may help assess the level of diaphragm activity, but such monitoring results are difficult to interpret because reference values are lacking. The aim of this study was to describe EAdi values in critically ill children during a stay in the pediatric intensive care unit (PICU), from the acute to recovery phases, and to assess the impact of ventilatory support on EAdi. METHODS This was a prospective longitudinal observational study of children requiring mechanical ventilation for ≥24 h. EAdi was recorded using a validated method in the acute phase, before extubation, after extubation, and before PICU discharge. RESULTS Fifty-five critically ill children were enrolled in the study. Median maximum inspiratory EAdi (EAdimax) during mechanical ventilation was 3.6 [interquartile range (IQR) 1.2-7.6] μV in the acute phase and 4.8 (IQR 2.0-10.7) μV in the pre-extubation phase. Periods of diaphragm inactivity (with no detectable inspiratory EAdi) were frequent during conventional ventilation, even with a low level of support. EAdimax in spontaneous ventilation was 15.4 (IQR 7.4-20.7) μV shortly after extubation and 12.6 (IQR 8.1-21.3) μV before PICU discharge. The difference in EAdimax between mechanical ventilation and post-extubation periods was significant (p < 0.001). Patients intubated mainly because of a lung pathology exhibited higher EAdi (p < 0.01), with a similar temporal increase. CONCLUSIONS This is the first systematic description of EAdi evolution in children during their stay in the PICU. In our patient cohort, diaphragm activity was frequently low in conventional ventilation, suggesting that overassistance or oversedation is common in clinical practice. EAdi monitoring appears to be a helpful tool to detect such situations.
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Affiliation(s)
- Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, Montreal, Quebec, Canada,
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La ventilation non invasive en mode NAVA (neurally adjusted ventilatory assist) en réanimation pédiatrique. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0848-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Session orale pédiatrique (1). MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0738-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Patient-ventilator asynchrony during noninvasive pressure support ventilation and neurally adjusted ventilatory assist in infants and children*. Pediatr Crit Care Med 2013; 14:728-9. [PMID: 24162963 DOI: 10.1097/pcc.0b013e318291810b] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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