1
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Lin HZ, Lin YF, Zheng YR. Comparison of neurally adjusted ventilatory assist and synchronized intermittent mandatory ventilation in preterm infants after patent ductus arteriosus ligation: a retrospective study. BMC Pediatr 2024; 24:277. [PMID: 38678190 PMCID: PMC11055325 DOI: 10.1186/s12887-024-04727-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 03/27/2024] [Indexed: 04/29/2024] Open
Abstract
OBJECTIVE This study aimed to compare the efficacy of neurally adjusted ventilatory assist (NAVA) to synchronized intermittent mandatory ventilation (SIMV) in preterm infants requiring mechanical ventilation after patent ductus arteriosus (PDA) ligation. METHODS A retrospective analysis was conducted on intubated preterm infants who underwent PDA ligation at our hospital from July 2021 to January 2023. Infants were divided into NAVA or SIMV groups based on the ventilation mode after surgery. RESULTS Fifty preterm infants were included. During treatment, peak inspiratory pressure (PIP) and mean airway pressure (MAP) were lower with NAVA compared to SIMV (PIP: 19.1 ± 2.9 vs. 22.4 ± 3.6 cmH2O, P < 0.001; MAP: 9.1 ± 1.8 vs. 10.9 ± 2.7 cmH2O, P = 0.002). PaO2 and PaO2/FiO2 were higher with NAVA (PaO2: 94.0 ± 11.7 vs. 84.8 ± 15.8 mmHg, P = 0.031; PaO2/FiO2: 267 [220-322] vs. 232 [186-290] mmHg, P = 0.025). Less sedation was required with NAVA (midazolam: 1.5 ± 0.5 vs. 1.1 ± 0.3 μg/kg/min, P < 0.001). CONCLUSION Compared to SIMV, early use of NAVA post PDA ligation in preterm infants was associated with decreased PIP and MAP. Early NAVA was also associated with reduced sedation needs and improved oxygenation. However, further studies are warranted to quantify the benefits of NAVA ventilation.
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Affiliation(s)
- Hui-Zi Lin
- Department of Neonatology, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China
| | - Yun-Feng Lin
- Department of Neonatology, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China.
- Department of Neonatology, Fujian Maternity and Child Health Hospital, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China.
| | - Yi-Rong Zheng
- Department of Cardiac Surgery, College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), Fuzhou, China.
- Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Women and Children's Hospital, Fuzhou, China.
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2
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McKinney RL, Wallström L, Courtney SE, Sindelar R. Novel forms of ventilation in neonates: Neurally adjusted ventilatory assist and proportional assist ventilation. Semin Perinatol 2024; 48:151889. [PMID: 38565434 DOI: 10.1016/j.semperi.2024.151889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Patient-triggered modes of ventilation are currently the standard of practice in the care of term and preterm infants. Maintaining spontaneous breathing during mechanical ventilation promotes earlier weaning and possibly reduces ventilator-induced diaphragmatic dysfunction. A further development of assisted ventilation provides support in proportion to the respiratory effort and enables the patient to have full control of their ventilatory cycle. In this paper we will review the literature on two of these modes of ventilation: neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation (PAV), propose future studies and suggest clinical applications of these modes.
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Affiliation(s)
- R L McKinney
- Alpert Medical School of Brown University, 593 Eddy Street, Providence, RI 02906, United States.
| | - L Wallström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - S E Courtney
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - R Sindelar
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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3
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Ferzli GTE, Jebbia M, Miller AN, Nelin LD, Shepherd EG. Respiratory management of established severe bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151816. [PMID: 37758578 DOI: 10.1016/j.semperi.2023.151816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Respiratory management of infants with established severe BPD is difficult and there is little evidence upon which to base decisions. Nonetheless, the physiology of severe BPD is well described with a predominantly obstructive pattern. This pulmonary dysfunction results in prolonged exhalatory time constants and thus ventilator management must be focused on maintaining adequate oxygenation and ventilation through achieving full exhalation. This approach is often difficult to maintain in acute care settings and a culture of chronic care focused on slow change and steady progress is imperative. Once respiratory stability is achieved, the focus should shift to growth and development and avoidance of care practices and medications that impair neurodevelopment.
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Affiliation(s)
- George T El- Ferzli
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States
| | - Maria Jebbia
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States
| | - Audrey N Miller
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States
| | - Leif D Nelin
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States
| | - Edward G Shepherd
- Division of Neonatology, Department of Pediatrics, Ohio State University, Nationwide Children's Hospital, Columbus, OH, United States; Comprehensive Center for Bronchopulmonary Dysplasia, Nationwide Children's Hospital, Columbus, OH, United States.
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4
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Brandt JB, Mahlknecht A, Werther T, Ullrich R, Hermon M. Comparing ventilation modes by electrical impedance segmentography in ventilated children. J Clin Monit Comput 2022; 36:1795-1803. [PMID: 35165819 PMCID: PMC8853312 DOI: 10.1007/s10877-022-00828-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
Electrical impedance segmentography offers a new radiation-free possibility of continuous bedside ventilation monitoring. The aim of this study was to evaluate the efficacy and reproducibility of this bedside tool by comparing synchronized intermittent mandatory ventilation (SIMV) with neurally adjusted ventilatory assist (NAVA) in critically-ill children. In this prospective randomized case-control crossover trial in a pediatric intensive care unit of a tertiary center, including eight mechanically-ventilated children, four sequences of two different ventilation modes were consecutively applied. All children were randomized into two groups; starting on NAVA or SIMV. During ventilation, electric impedance segmentography measurements were recorded. The relative difference of vertical impedance between both ventilatory modes was measured (median 0.52, IQR 0-0.87). These differences in left apical lung segments were present during the first (median 0.58, IQR 0-0.89, p = 0.04) and second crossover (median 0.50, IQR 0-0.88, p = 0.05) as well as across total impedance (0.52 IQR 0-0.87; p = 0.002). During NAVA children showed a shift of impedance towards caudal lung segments, compared to SIMV. Electrical impedance segmentography enables dynamic monitoring of transthoracic impedance. The immediate benefit of personalized ventilatory strategies can be seen when using this simple-to-apply bedside tool for measuring lung impedance.
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Affiliation(s)
- Jennifer Bettina Brandt
- Division of Neonatology, Medical University of Vienna, Pediatric Intensive Care & Neuropediatrics, Vienna, Austria
| | - Alex Mahlknecht
- Hospital of the Brothers of St. John of God, Eisenstadt, Austria
| | - Tobias Werther
- Division of Neonatology, Medical University of Vienna, Pediatric Intensive Care & Neuropediatrics, Vienna, Austria
| | - Roman Ullrich
- Department for Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Hermon
- Division of Neonatology, Medical University of Vienna, Pediatric Intensive Care & Neuropediatrics, Vienna, Austria.
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5
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Abstract
Extremely preterm infants who must suddenly support their own gas exchange with lungs that are incompletely developed and lacking adequate amount of surfactant and antioxidant defenses are susceptible to lung injury. The decades-long quest to prevent bronchopulmonary dysplasia has had limited success, in part because of increasing survival of more immature infants. The process must begin in the delivery room with gentle assistance in establishing and maintaining adequate lung aeration, followed by noninvasive support and less invasive surfactant administration. Various modalities of invasive and noninvasive support have been used with varying degree of effect and are reviewed in this article.
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6
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Abstract
For infants with the most severe forms of chronic lung disease, regardless of etiology, chronic mechanical ventilation can provide stability, reduce acute respiratory events, and alleviate increased work of breathing. This approach prioritizes the baby's growth and development during early life. Once breathing comfortably, these infants can tolerate developmental therapies with the goal of achieving the best neurocognitive outcomes possible.
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Affiliation(s)
- Christopher D Baker
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, 13123 East 16th Avenue Box B-395, Aurora, CO 80045, USA.
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7
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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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8
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Oda A, Parikka V, Lehtonen L, Azimi S, Porres I, Soukka H. Neurally adjusted ventilatory assist in ventilated very preterm infants: A crossover study. Pediatr Pulmonol 2021; 56:3857-3862. [PMID: 34437773 DOI: 10.1002/ppul.25639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Revised: 08/03/2021] [Accepted: 08/19/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To assess the effects of neurally adjusted ventilatory assist (NAVA) ventilation on oxygenation and respiratory parameters in preterm infants. STUDY DESIGN An observational crossover study with a convenience sample of 19 infants born before 30 gestational weeks. Study parameters were recorded during 3-h periods of both NAVA and conventional ventilation. The proportion of time peripheral oxygen saturation (SpO2 ) and cerebral regional oxygen saturation (cRSO2 ) were within their target ranges, plus the number and severity of desaturation episodes were analyzed. In addition, electrical activity of the diaphragm (Edi), neural respiratory rates, and peak inspiratory pressures (PIPs) were recorded. RESULTS Infants were born at a median age of 264/7 gestational weeks (range: 230/7 -293/7 ); the study was performed at a median age of 20 days (range: 1-82). The proportion of time SpO2 was within the target range, the number of peripheral desaturations or cRSO2 did not differ between the modes. However, the desaturation severity index was lower (131 vs. 152; p = .03) and fewer manual supplemental oxygen adjustments (1.3 vs. 2.2/h; p = .006) were needed during the period of NAVA ventilation following conventional ventilation. The mean Edi (8.1 vs. 11.4 µV; p < .006) and PIP values (14.9 vs. 19.1; p < .001) were lower during the NAVA mode. CONCLUSIONS Although NAVA ventilation did not increase the proportion of time with optimal saturation, it was associated with decreased diaphragmatic activity, lower PIPs, less severe hypoxemic events, and fewer manual oxygen adjustments in very preterm infants.
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Affiliation(s)
- Arata Oda
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Vilhelmiina Parikka
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland.,Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Liisa Lehtonen
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland.,Department of Clinical Medicine, University of Turku, Turku, Finland
| | - Sepinoud Azimi
- Department of Information Technology, Faculty of Natural Sciences and Technology, Åbo Akademi University, Turku, Finland
| | - Ivan Porres
- Department of Information Technology, Faculty of Natural Sciences and Technology, Åbo Akademi University, Turku, Finland
| | - Hanna Soukka
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland.,Department of Clinical Medicine, University of Turku, Turku, Finland
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9
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McKinney RL, Keszler M, Truog WE, Norberg M, Sindelar R, Wallström L, Schulman B, Gien J, Abman SH. Multicenter Experience with Neurally Adjusted Ventilatory Assist in Infants with Severe Bronchopulmonary Dysplasia. Am J Perinatol 2021; 38:e162-e166. [PMID: 32208500 DOI: 10.1055/s-0040-1708559] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE The aim of this study is to determine patterns of neurally adjusted ventilatory assist (NAVA) use in ventilator-dependent preterm infants with evolving or established severe bronchopulmonary dysplasia (sBPD) among centers of the BPD Collaborative, including indications for its initiation, discontinuation, and outcomes. STUDY DESIGN Retrospective review of infants with developing or established sBPD who were placed on NAVA after ≥4 weeks of mechanical ventilation and were ≥ 30 weeks of postmenstrual age (PMA). RESULTS Among the 13 sites of the BPD collaborative, only four centers (31%) used NAVA in the management of infants with evolving or established BPD. A total of 112 patients met inclusion criteria from these four centers. PMA, weight at the start of NAVA and median number of days on NAVA, were different among the four centers. The impact of NAVA therapy was assessed as being successful in 67% of infants, as defined by the ability to achieve respiratory stability at a lower level of ventilator support, including extubation to noninvasive positive pressure ventilation or support with a home ventilator. In total 87% (range: 78-100%) of patients survived until discharge. CONCLUSION We conclude that NAVA can be used safely and effectively in selective infants with sBPD. Indications and current strategies for the application of NAVA in infants with evolving or established BPD, however, are highly variable between centers. Although this pilot study suggests that NAVA may be successfully used for the management of infants with BPD, sufficient experience and well-designed clinical studies are needed to establish standards of care for defining the role of NAVA in the care of infants with sBPD.
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Affiliation(s)
- Robin L McKinney
- Department of Pediatric Critical Care Medicine, Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, Rhode Island
| | - Martin Keszler
- Department of Pediatrics, Alpert Medical School of Brown University, Women and Infants Hospital, Providence, Rhode Island
| | - William E Truog
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Michael Norberg
- Department of Neonatology, Children's Mercy Hospital, Kansas City, Missouri
| | - Richard Sindelar
- Division of Neonatology, Department of Women's and Children's Health Uppsala University Children's Hospital, Uppsala, Sweden
| | - Linda Wallström
- Division of Neonatology, Department of Women's and Children's Health Uppsala University Children's Hospital, Uppsala, Sweden
| | - Bruce Schulman
- Department of Neonatology, Joe DiMaggio Children's Hospital, Hollywood, Florida
| | - Jason Gien
- Department of Pediatrics, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
| | - Steven H Abman
- Department of Pediatrics, University of Colorado Anschutz Medical Center and Children's Hospital Colorado, Aurora, Colorado
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10
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Kato Y, Takemoto A, Oumi C, Hisaichi T, Shimaji Y, Takaoka M, Moriyama H, Hirata K, Wada K. Effects of skin-to-skin care on electrical activity of the diaphragm in preterm infants during neurally adjusted ventilatory assist. Early Hum Dev 2021; 157:105379. [PMID: 33962362 DOI: 10.1016/j.earlhumdev.2021.105379] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/17/2021] [Accepted: 04/20/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Skin-to-skin care (SSC) reduces neonatal mortality and morbidity and is widely implemented in the neonatal intensive care unit. However, changes in respiratory effort during SSC in ventilated preterm infants remain unclear. AIMS To evaluate the effect of SSC on electrical activity of the diaphragm (Edi) and vital signs in premature infants who are intubated and under neurally adjusted ventilatory assist ventilation. STUDY DESIGN We performed an observational cross-over study. Data were measured in three periods: before (pre-SSC period), during (SSC period), and after (post-SSC period) SSC. Stable 30-min data in each period were extracted. SUBJECTS Thirty-four SSC procedures were performed in 14 preterm infants with a median gestational age of 25.3 weeks (interquartile range, 24, 26.4) and a birth weight of 659 g (566, 694). The median postnatal age was 41 days (31, 53) at the study with a median postmenstrual age of 31.3 weeks (30.4, 32.5). OUTCOME MEASURES Median values of Edi peak, Edi minimum, respiratory rate, SpO2, and heart rate were measured in each condition. The Kruskal-Wallis test with Bonferroni multiple comparisons was used to compare each parameter in each period. RESULTS Median Edi peak and Edi minimum values were significantly lower during SSC compared with pre- and post-SSC, without any change in respiratory rate, SpO2, or heart rate. CONCLUSIONS Respiratory efforts as evaluated by Edi are significantly reduced during SSC in ventilated preterm infants.
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Affiliation(s)
- Yuta Kato
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Ayumi Takemoto
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Chiyo Oumi
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Tomomi Hisaichi
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Yuki Shimaji
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Misa Takaoka
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan
| | - Hiroko Moriyama
- Department of Nursing, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Katsuya Hirata
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
| | - Kazuko Wada
- Department of Neonatal Medicine, Osaka Women's and Children's Hospital, 840 Murodo-cho, Izumi, Osaka 594-1101, Japan.
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11
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Neurally adjusted ventilatory assist in neonates with congenital diaphragmatic hernia. J Perinatol 2021; 41:1910-1915. [PMID: 34112964 PMCID: PMC8191439 DOI: 10.1038/s41372-021-01098-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 04/27/2021] [Accepted: 05/06/2021] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To measure short-term outcomes of neonates with congenital diaphragmatic hernia (CDH) while on Neurally Adjusted Ventilator Assist (NAVA), and to measure the impact of a congenitally abnormal diaphragm on NAVA ventilator indices. STUDY DESIGN First, we conducted a retrospective-cohort analysis of 16 neonates with CDH placed on NAVA over a treatment period of 72 h. Second, we performed a case-control study comparing NAVA level and Edi between neonates with CDH and those without CDH. RESULTS Compared to pre-NAVA, there were clinically meaningful improvements in PIP (p < 0.003), Respiratory Severity Score (p < 0.001), MAP (p < 0.001), morphine (p = 0.004), and midazolam use (p = 0.037). Compared to a 1:2 matched group without CDH, there was no meaningful difference in NAVA level (p = 0.286), Edi-Peak (p = 0.315), or Edi-Min (p = 0.266). CONCLUSIONS The potential benefits of NAVA extend to neonates with CDH. There is minimal compensatory change in Edis, and higher/lower ventilator settings compared to neonates without CDH.
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12
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Rong X, Liang F, Li YJ, Liang H, Zhao XP, Zou HM, Lu WN, Shi H, Zhang JH, Guan RL, Sun Y, Zhang H. Application of Neurally Adjusted Ventilatory Assist in Premature Neonates Less Than 1,500 Grams With Established or Evolving Bronchopulmonary Dysplasia. Front Pediatr 2020; 8:110. [PMID: 32266188 PMCID: PMC7105827 DOI: 10.3389/fped.2020.00110] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 03/03/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Very low birth weight premature (VLBW) infants with bronchopulmonary dysplasia (BPD) often need prolonged respiratory support, which is associated with worse outcomes. The application of neurally adjusted ventilatory assist ventilation (NAVA) in infants with BPD has rarely been reported. This study investigated whether NAVA is safe and can reduce the duration respiratory support in VLBW premature infants with established or evolving BPD. Methods: This retrospective matched-cohort study included patients admitted to our NICU between April 2017 to April 2019 who were born at <32 weeks' gestation with birthweight of <1,500 g. The study groups (NAVA group) were infants who received NAVA ventilation as a sequel mode of ventilation after at least 2 weeks of traditional respiratory support after birth. The control group were preterm infants who required traditional respiratory support beyond first 2 weeks of life and were closely matched to the NAVA patients by gestational age and birthweight. The primary outcome was to compare the total duration of respiratory support between the NAVA group and the control group. The secondary outcomes were comparisons of duration of invasive and non-invasive support, oxygen therapy, length of stay, severity of BPD, weight gain and sedation need between the groups. Results: There were no significant differences between NAVA group and control group in the primary and most of the secondary outcomes (all P > 0.05). However, NAVA was well tolerated and there was a decrease in the need of sedation (p = 0.012) after switching to NAVA. Conclusion: NAVA, when used as a sequel mode of ventilation, in premature neonates <1,500 g with evolving or established BPD showed a similar effect compared to conventional ventilation in respiratory outcomes. NAVA can be safely used in this patient population and potentially can decrease the need of sedation.
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Affiliation(s)
- Xiao Rong
- Division of Neonatology, Guangzhou Women and Children's Medical Center Affiliated With Jinan University, Guanghzou, China
| | - Feng Liang
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Yuan-Jing Li
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Hong Liang
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Xiao-Peng Zhao
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Hong-Mei Zou
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Wei-Neng Lu
- Division of Neonatology, Guangzhou Women and Children's Medical Center Affiliated With Jinan University, Guanghzou, China
| | - Hui Shi
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Jing-Hua Zhang
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Rui-Lian Guan
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Yi Sun
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China
| | - Huayan Zhang
- Division of Neonatology, Guangzhou Women and Children's Medical Center, Guanghzou, China.,Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States
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13
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Ventilation strategies in transition from neonatal respiratory distress to chronic lung disease. Semin Fetal Neonatal Med 2019; 24:101035. [PMID: 31759915 DOI: 10.1016/j.siny.2019.101035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Despite the advance in neonatal care over the past few decades, preventing preterm infants with respiratory distress syndrome progress to bronchopulmonary dysplasia remained challenging. In this review, we will discuss the respiratory support strategies in preterm infants with RDS evolving into BPD based on the changes in pulmonary mechanics and pathophysiology as well as currently available evidence.
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14
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Abstract
Introduction: Bronchopulmonary dysplasia (BPD) is a common long-term adverse complication of very premature delivery. Affected infants can suffer chronic respiratory morbidities including lung function abnormalities and reduced exercise capacity even as young adults. Many studies have investigated possible preventative strategies; however, it is equally important to identify optimum management strategies for infants with evolving or established BPD. Areas covered: Respiratory support modalities and established and novel pharmacological treatments. Expert opinion: Respiratory support modalities including proportional assist ventilation and neurally adjusted ventilatory assist are associated with short term improvements in oxygenation indices. Such modalities need to be investigated in appropriate RCTs. Many pharmacological treatments are routinely used with a limited evidence base, for example diuretics. Stem cell therapies in small case series are associated with promising results. More research is required before it is possible to determine if such therapies should be investigated in large RCTs with long-term outcomes.
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Affiliation(s)
- Emma Williams
- a Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , UK.,b The Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London , UK
| | - Anne Greenough
- a Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London , UK.,c NIHR Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London , London , UK
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15
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Baez Hernandez N, Milad A, Li Y, Van Bergen AH. Utilization of Neurally Adjusted Ventilatory Assist (NAVA) Mode in Infants and Children Undergoing Congenital Heart Surgery: A Retrospective Review. Pediatr Cardiol 2019; 40:563-569. [PMID: 30600371 DOI: 10.1007/s00246-018-2027-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 11/29/2018] [Indexed: 01/15/2023]
Abstract
We assessed the feasibility and the impact of NAVA compared to conventional modes of mechanical ventilation in ventilatory and gas exchange parameters in post-operative children with congenital heart disease. Infants and children (age < 18 years) that underwent congenital heart surgery were enrolled. Patients were ventilated with conventional synchronized intermittent mechanical ventilation (SIMV) and subsequently transitioned to NAVA during their cardiovascular intensive care unit (CVICU) stay. The ventilatory and gas exchange parameters for the 24 h pre- and post-transition to NAVA were compared. Additional parameters assessed included pain scores and sedation requirements. Eighty-one patients met inclusion criteria with a median age of 21 days (interquartile range 13 days-2 months). The majority of patients enrolled (75.3%) had complex congenital heart disease with high surgical severity scores. The transition to NAVA was tolerated by all patients without complications. The mean peak inspiratory pressure (PIP) was 1.8 cm H2O lower (p < 0.001) and mean airway pressure (Paw) was 0.5 cm H2O lower (p = 0.009) on NAVA compared to conventional modes of mechanical ventilation. There was no significant difference in patients' respiratory rate, tidal volume, arterial pH, pCO2, and lactate levels between the two modes of ventilation. There was a decreased sedation requirement during the time of NAVA ventilation. Comfort scores did not differ significantly with ventilator mode change. We concluded that NAVA is safe and well-tolerated mode of mechanical ventilation for our cohort of patients after congenital heart surgery. Compared to conventional ventilation there was a statistically significant decrease in PIP and Paw on NAVA.
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Affiliation(s)
- Nathanya Baez Hernandez
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Abdulhamid Milad
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Yi Li
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA
| | - Andrew H Van Bergen
- Advocate Children's Hospital, Advocate Children's Heart Institute, 4440 West 95th Street, Oak Lawn, IL, 60453, USA.
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16
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Oda A, Kamei Y, Hiroma T, Nakamura T. Neurally adjusted ventilatory assist in extremely low-birthweight infants. Pediatr Int 2018; 60:844-848. [PMID: 29944776 DOI: 10.1111/ped.13646] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 05/28/2018] [Accepted: 06/22/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is expected to improve respiratory outcomes in preterm infants, but it has not yet been evaluated. We investigated whether NAVA could improve respiratory outcomes and reduce sedation use in extremely low-birthweight infants (ELBWI). METHODS A retrospective cohort study was conducted based on patient charts at the Nagano Children's Hospital neonatal intensive care unit, Japan. Infants who were born at <27 weeks' gestation were included. We assessed the prevalence of bronchopulmonary dysplasia (BPD), home oxygen therapy (HOT), duration of intubation, and sedation use. RESULTS The NAVA group consisted of 14 ELBWI who were born at <27 weeks' gestation between September 2013 and September 2015. A total of 21 ELBWI born between September 2011 and September 2013, before NAVA implementation, served as the control group. There were no significant differences in the perinatal background characteristics between the two groups. For respiratory outcomes, no significant between-group differences were found in the prevalence of BPD and HOT or the duration of intubation. The total duration of sedation use was not significantly different between the two groups, but in the NAVA group, midazolam was discontinued in all cases after the infants were switched to NAVA. CONCLUSIONS NAVA was safe in preterm infants and had a similar effect to conventional mechanical ventilation with regard to respiratory outcomes and sedation use in the chronic phase; thus, NAVA could be used in the early phase, at least before BPD worsens to improve respiratory outcomes in ELBWI.
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Affiliation(s)
- Arata Oda
- Division of Neonatology, Nagano Children's Hospital, Shinshu University, Nagano, Japan.,Division of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
| | - Yoshiya Kamei
- Division of Neonatology, Nagano Children's Hospital, Shinshu University, Nagano, Japan
| | - Takehiko Hiroma
- Division of Neonatology, Nagano Children's Hospital, Shinshu University, Nagano, Japan.,Division of Neonatology, Shinshu University, Nagano, Japan
| | - Tomohiko Nakamura
- Division of Neonatology, Nagano Children's Hospital, Shinshu University, Nagano, Japan.,Division of Neonatology, Shinshu University, Nagano, Japan
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17
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Liu G, Wu H, Li Z. Current views of complications associated with neonatal ventilation. Minerva Pediatr 2018; 72:60-64. [PMID: 29479941 DOI: 10.23736/s0026-4946.18.04822-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Infants born prematurely require external respiratory support device like ventilation for the purpose of life saving. However, these ventilation machines have complications that sometimes unfortunately result in morbidity. New ventilation techniques have been developed to prevent morbidity, but have yet to be fully evaluated. The present review article would discuss current aspects of this life saving gear especially for pediatric patients in clinical setting. Besides basic ventilation apparatus, advancements in the filed like proportional assist ventilation, volume targeted ventilation would be discussed.
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Affiliation(s)
- Gang Liu
- Department of Neonatology, Xunzhou Children's Hospital, Xuzhou, China
| | - Hongwei Wu
- Department of Neonatology, Xunzhou Children's Hospital, Xuzhou, China
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18
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Rossor TE, Hunt KA, Shetty S, Greenough A. Neurally adjusted ventilatory assist compared to other forms of triggered ventilation for neonatal respiratory support. Cochrane Database Syst Rev 2017; 10:CD012251. [PMID: 29077984 PMCID: PMC6485908 DOI: 10.1002/14651858.cd012251.pub2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Effective synchronisation of infant respiratory effort with mechanical ventilation may allow adequate gas exchange to occur at lower peak airway pressures, potentially reducing barotrauma and volutrauma and development of air leaks and bronchopulmonary dysplasia. During neurally adjusted ventilatory assist ventilation (NAVA), respiratory support is initiated upon detection of an electrical signal from the diaphragm muscle, and pressure is provided in proportion to and synchronous with electrical activity of the diaphragm (EADi). Compared to other modes of triggered ventilation, this may provide advantages in improving synchrony. OBJECTIVES Primary• To determine whether NAVA, when used as a primary or rescue mode of ventilation, results in reduced rates of bronchopulmonary dysplasia (BPD) or death among term and preterm newborn infants compared to other forms of triggered ventilation• To assess the safety of NAVA by determining whether it leads to greater risk of intraventricular haemorrhage (IVH), periventricular leukomalacia, or air leaks when compared to other forms of triggered ventilation Secondary• To determine whether benefits of NAVA differ by gestational age (term or preterm)• To determine whether outcomes of cross-over trials performed during the first two weeks of life include peak pressure requirements, episodes of hypocarbia or hypercarbia, oxygenation index, and the work of breathing SEARCH METHODS: We performed searches of the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cohrane Library; MEDLINE via Ovid SP (January 1966 to March 2017); Embase via Ovid SP (January 1980 to March 2017); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCO host (1982 to March 2017); and the Web of Science (1985 to 2017). We searched abstracts from annual meetings of the Pediatric Academic Societies (PAS) (2000 to 2016); meetings of the European Society of Pediatric Research (published in Pediatric Research); and meetings of the Perinatal Society of Australia and New Zealand (PSANZ) (2005 to 2016). We also searched clinical trials databases to March 2017. SELECTION CRITERIA We included randomised and quasi-randomised clinical trials including cross-over trials comparing NAVA with other modes of triggered ventilation (assist control ventilation (ACV),synchronous intermittent mandatory ventilation plus pressure support (SIMV ± PS), pressure support ventilation (PSV), or proportional assist ventilation (PAV)) used in neonates. DATA COLLECTION AND ANALYSIS Primary outcomes of interest from randomised controlled trials were all-cause mortality, bronchopulmonary dysplasia (BPD; defined as oxygen requirement at 28 days), and a combined outcome of all-cause mortality or BPD. Secondary outcomes were duration of mechanical ventilation, incidence of air leak, incidence of IVH or periventricular leukomalacia, and survival with an oxygen requirement at 36 weeks' postmenstrual age.Outcomes of interest from cross-over trials were maximum fraction of inspired oxygen, mean peak inspiratory pressure, episodes of hypocarbia, and episodes of hypercarbia measured across the time period of each arm of the cross-over. We planned to assess work of breathing; oxygenation index, and thoraco-abdominal asynchrony at the end of the time period of each arm of the cross-over study. MAIN RESULTS We included one randomised controlled study comparing NAVA versus patient-triggered time-cycled pressure-limited ventilation. This study found no significant difference in duration of mechanical ventilation, nor in rates of BPD, pneumothorax, or IVH. AUTHORS' CONCLUSIONS Risks and benefits of NAVA compared to other forms of ventilation for neonates are uncertain. Well-designed trials are required to evaluate this new form of triggered ventilation.
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Affiliation(s)
- Thomas E Rossor
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
| | | | - Sandeep Shetty
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
| | - Anne Greenough
- King’s College LondonDivision of Asthma, Allergy and Lung Biology, MRC Centre for Allergic Mechanisms in AsthmaBessemer RoadLondonUK
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