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Sammour I, Karnati S. Non-invasive Respiratory Support of the Premature Neonate: From Physics to Bench to Practice. Front Pediatr 2020; 8:214. [PMID: 32457860 PMCID: PMC7227410 DOI: 10.3389/fped.2020.00214] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 04/09/2020] [Indexed: 12/04/2022] Open
Abstract
Premature births continue to rise globally with a corresponding increase in various morbidities among this population. Rates of respiratory distress syndrome and the consequent development of Bronchopulmonary Dysplasia (BPD) are highest among the extremely preterm infants. The majority of extremely low birth weight premature neonates need some form of respiratory support during their early days of life. Invasive modes of respiratory assistance have been popular amongst care providers for many years. However, the practice of prolonged invasive mechanical ventilation is associated with an increased likelihood of developing BPD along with other comorbidities. Due to the improved understanding of the pathophysiology of BPD, and technological advances, non-invasive respiratory support is gaining popularity; whether as an initial mode of support, or for post-extubation of extremely preterm infants with respiratory insufficiency. Due to availability of a wide range of modalities, wide variations in practice exist among care providers. This review article aims to address the physical and biological basis for providing non-invasive respiratory support, the current clinical evidence, and the most recent developments in this field of Neonatology.
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Affiliation(s)
- Ibrahim Sammour
- Department of Neonatology, Lerner College of Medicine, Pediatric Institute, Cleveland Clinic, Cleveland Clinic Foundation, Cleveland, OH, United States
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Goel D, Oei JL, Smyth J, Schindler T. Diaphragm-triggered non-invasive respiratory support in preterm infants. Cochrane Database Syst Rev 2020; 3:CD012935. [PMID: 32176939 PMCID: PMC7075711 DOI: 10.1002/14651858.cd012935.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Diaphragm-triggered non-invasive respiratory support, commonly referred to as NIV-NAVA (non-invasive neurally adjusted ventilatory assist), uses the electrical activity of the crural diaphragm to trigger the start and end of a breath. It provides variable inspiratory pressure that is proportional to an infant's changing inspiratory effort. NIV-NAVA has the potential to provide effective, non-invasive, synchronised, multilevel support and may reduce the need for invasive ventilation; however, its effects on short- and long-term outcomes, especially in the preterm infant, are unclear. OBJECTIVES To assess the effectiveness and safety of diaphragm-triggered non-invasive respiratory support in preterm infants (< 37 weeks' gestation) when compared to other non-invasive modes of respiratory support (nasal intermittent positive pressure ventilation (NIPPV); nasal continuous positive airway pressure (nCPAP); high-flow nasal cannulae (HFNC)), and to assess preterm infants with birth weight less than 1000 grams or less than 28 weeks' corrected gestation at the time of intervention as a sub-group. SEARCH METHODS We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL 2019, Issue 5), MEDLINE via PubMed (1946 to 10 May 2019), Embase (1947 to 10 May 2019), and CINAHL (1982 to 10 May 2019). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-randomised trials. SELECTION CRITERIA Randomised and quasi-randomised controlled trials that compared diaphragm-triggered non-invasive versus other non-invasive respiratory support in preterm infants. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed trial quality and extracted data from included studies. We performed fixed-effect analyses and expressed treatment effects as mean difference (MD), risk ratio (RR), and risk difference (RD) with 95% confidence intervals (CIs). We used the generic inverse variance method to analyse specific outcomes for cross-over trials. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS There were two small randomised controlled trials including a total of 23 infants eligible for inclusion in the review. Only one trial involving 16 infants included in the analysis reported on either of the primary outcomes of the review. This found no difference in failure of modality between NIV-NAVA and NIPPV (RR 0.33, 95% CI 0.02 to 7.14; RD -0.13, 95% CI -0.41 to 0.16; 1 study, 16 infants; heterogeneity not applicable). Both trials reported on secondary outcomes of the review, specific for cross-over trials (total 22 infants; 1 excluded due to failure of initial modality). One study involving seven infants reported a significant reduction in maximum FiO₂ with NIV-NAVA compared to NIPPV (MD -4.29, 95% CI -5.47 to -3.11; heterogeneity not applicable). There was no difference in maximum electric activity of the diaphragm (Edi) signal between modalities (MD -1.75, 95% CI -3.75 to 0.26; I² = 0%) and a significant increase in respiratory rate with NIV-NAVA compared to NIPPV (MD 7.22, 95% CI 0.21 to 14.22; I² = 72%) on a meta-analysis of two studies involving a total of 22 infants. The included studies did not report on other outcomes of interest. AUTHORS' CONCLUSIONS Due to limited data and very low certainty evidence, we were unable to determine if diaphragm-triggered non-invasive respiratory support is effective or safe in preventing respiratory failure in preterm infants. Large, adequately powered randomised controlled trials are needed to determine if diaphragm-triggered non-invasive respiratory support in preterm infants is effective or safe.
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Affiliation(s)
- Dimple Goel
- Westmead HospitalNeonatal Intensive CareHawkesbury Rd & Darcy RoadWestmeadNSWAustralia2145
| | - Ju Lee Oei
- Royal Hospital for WomenNewborn CareBarker StreetRandwickNSWAustralia2031
| | - John Smyth
- Royal Hospital for WomenNewborn CareBarker StreetRandwickNSWAustralia2031
| | - Tim Schindler
- Royal Hospital for WomenNewborn CareBarker StreetRandwickNSWAustralia2031
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Walesa M, Bayat S, Albu G, Baudat A, Petak F, Habre W. Comparison between neurally-assisted, controlled, and physiologically variable ventilation in healthy rabbits. Br J Anaesth 2018; 121:918-927. [DOI: 10.1016/j.bja.2018.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 01/08/2018] [Accepted: 01/25/2018] [Indexed: 10/17/2022] Open
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Goel D, Oei JL, Smyth J, Schindler T. Diaphragm-triggered non-invasive respiratory support for preventing respiratory failure in preterm infants. Hippokratia 2018. [DOI: 10.1002/14651858.cd012935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Dimple Goel
- Westmead Hospital; Neonatal Intensive care; Hawkesbury Rd & Darcy Road Westmead NSW Australia 2145
| | - Ju Lee Oei
- Royal Hospital for Women; Newborn Care; Barker Street Randwick NSW Australia 2031
| | - John Smyth
- Royal Hospital for Women; Newborn Care; Barker Street Randwick NSW Australia 2031
| | - Tim Schindler
- Royal Hospital for Women; Newborn Care; Barker Street Randwick NSW Australia 2031
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Nativ-Zeltzer N, Kuhn MA, Imai DM, Traslavina RP, Domer AS, Litts JK, Adams B, Belafsky PC. The effects of aspirated thickened water on survival and pulmonary injury in a rabbit model. Laryngoscope 2017; 128:327-331. [DOI: 10.1002/lary.26698] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/09/2017] [Accepted: 04/26/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Nogah Nativ-Zeltzer
- Center for Voice and Swallowing; Department of Otolaryngology-Head and Neck Surgery, University of California, Davis School of Medicine; Sacramento California
| | - Maggie A. Kuhn
- Center for Voice and Swallowing; Department of Otolaryngology-Head and Neck Surgery, University of California, Davis School of Medicine; Sacramento California
| | - Denise M. Imai
- Comparative Pathology Laboratory; University of California, Davis School of Veterinary Medicine; Sacramento California
| | - Ryan P. Traslavina
- Comparative Pathology Laboratory; University of California, Davis School of Veterinary Medicine; Sacramento California
- United States Army Institute of Chemical Defense; Aberdeen Proving Grounds; Maryland U.S.A
| | | | - Juliana K. Litts
- Department of Otolaryngology-Head and Neck Surgery; University of Colorado; Denver Colorado
| | | | - Peter C. Belafsky
- Center for Voice and Swallowing; Department of Otolaryngology-Head and Neck Surgery, University of California, Davis School of Medicine; Sacramento California
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Brander L, Moerer O, Hedenstierna G, Beck J, Takala J, Slutsky AS, Sinderby C. Neural control of ventilation prevents both over-distension and de-recruitment of experimentally injured lungs. Respir Physiol Neurobiol 2016; 237:57-67. [PMID: 28013057 DOI: 10.1016/j.resp.2016.12.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 10/25/2016] [Accepted: 12/20/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Endogenous pulmonary reflexes may protect the lungs during mechanical ventilation. We aimed to assess integration of continuous neurally adjusted ventilatory assist (cNAVA), delivering assist in proportion to diaphragm's electrical activity during inspiration and expiration, and Hering-Breuer inflation and deflation reflexes on lung recruitment, distension, and aeration before and after acute lung injury (ALI). METHODS In 7 anesthetised rabbits with bilateral pneumothoraces, we identified adequate cNAVA level (cNAVAAL) at the plateau in peak ventilator pressure during titration procedures before (healthy lungs with endotracheal tube, [HLETT]) and after ALI (endotracheal tube [ALIETT] and during non-invasive ventilation [ALINIV]). Following titration, cNAVAAL was maintained for 5min. In 2 rabbits, procedures were repeated after vagotomy (ALIETT+VAG). In 3 rabbits delivery of assist was temporarily modulated to provide assist on inspiration only. Computed tomography was performed before intubation, before ALI, during cNAVA titration, and after maintenance at cNAVAAL. RESULTS During ALIETT and ALINIV, normally aerated lung-regions doubled and poorly aerated lung-regions decreased to less than a third (p<0.05) compared to HLETT; no over-distension was observed. Tidal volumes were<5ml/kg throughout. Removing assist during expiration resulted in lung de-recruitment during ALIETT, but not during ALINIV. During ALIETT+VAG the expiratory portion of EAdi disappeared, resulting in cyclic lung collapse and recruitment. CONCLUSIONS When using cNAVA in ALI, vagally mediated reflexes regulated lung recruitment preventing both lung over-distension and atelectasis. During non-invasive cNAVA the upper airway muscles play a role in preventing atelectasis. Future studies should be performed to compare these findings with conventional lung-protective approaches.
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Affiliation(s)
- Lukas Brander
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Department of Intensive Care Medicine, Cantonal Hospital of Lucerne, Switzerland.
| | - Onnen Moerer
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Department of Anaesthesiology, Emergency and Critical Care Medicine, University of Göttingen, Germany
| | - Göran Hedenstierna
- Department of Medical Sciences, Clinical Physiology, University of Uppsala, Uppsala, Sweden
| | - Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St. Michael's Hospital, Toronto, Canada
| | - Jukka Takala
- Department of Intensive Care Medicine, Bern University Hospital - Inselspital, and University of Bern, Switzerland
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada
| | - Christer Sinderby
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Department of Critical Care Medicine, St. Michael's Hospital, Toronto, Canada; Keenan Research Centre for Biomedical Science and Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Canada; Institute for Biomedical Engineering and Science Technology (iBEST) at Ryerson University and St. Michael's Hospital, Toronto, Canada
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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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Georgopoulos D, Xirouchaki N, Tzanakis N, Younes M. Driving pressure during assisted mechanical ventilation. Respir Physiol Neurobiol 2016; 228:69-75. [DOI: 10.1016/j.resp.2016.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2016] [Revised: 03/03/2016] [Accepted: 03/15/2016] [Indexed: 10/22/2022]
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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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Ibuprofen protects ventilator-induced lung injury by downregulating Rho-kinase activity in rats. BIOMED RESEARCH INTERNATIONAL 2014; 2014:749097. [PMID: 25019086 PMCID: PMC4075182 DOI: 10.1155/2014/749097] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 05/15/2014] [Accepted: 05/19/2014] [Indexed: 12/20/2022]
Abstract
Background. Ventilator-induced lung injury-(VILI-) induced endothelial permeability is regulated through the Rho-dependent signaling pathway. Ibuprofen inhibits Rho activation in animal models of spinal-cord injury and Alzheimer's disease. The study aims to investigate ibuprofen effects on high tidal volume associated VILI. Methods. Twenty-eight adult male Sprague-Dawley rats were randomized to receive a ventilation strategy with three different interventions for 2 h: (1) a high-volume zero-positive end-expiratory pressure (PEEP) (HVZP) group; (2) an HVZP + ibuprofen 15 mg/kg group; and (3) an HVZP + ibuprofen 30 mg/kg group. A fourth group without ventilation served as the control group. Rho-kinase activity was determined by ratio of phosphorylated ezrin, radixin, and moesin (p-ERM), substrates of Rho-kinase, to total ERM. VILI was characterized by increased pulmonary protein leak, wet-to-dry weight ratio, cytokines level, and Rho guanine nucleotide exchange factor (GEF-H1), RhoA activity, p-ERM/total ERM, and p-myosin light chain (MLC) protein expression. Results. Ibuprofen pretreatment significantly reduced the HVZP ventilation-induced increase in pulmonary protein leak, wet-to-dry weight ratio, bronchoalveolar lavage fluid interleukin-6 and RANTES levels, and lung GEF-H1, RhoA activity, p-ERM/total ERM, and p-MLC protein expression. Conclusion. Ibuprofen attenuated high tidal volume induced pulmonary endothelial hyperpermeability. This protective effect was associated with a reduced Rho-kinase activity.
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Abstract
Ventilator-induced lung injury and ventilator-induced diaphragmatic dysfunction are major complications in mechanically ventilated patients with acute respiratory failure. Invasive ventilation adds a further burden by increasing the risk of infections. An approach that protects both lung and diaphragm is pivotal. Mirabella and colleagues compared conventional controlled ventilation with a mode that combines several potentially lung-protective properties - non-invasively applied neurally adjusted ventilatory assist - in an animal experiment. This approach seemed to be as effective but potentially more lung-protective. Although the experimental setup and results cannot be translated directly to the clinical setting, they should motivate us to further study this innovative approach.
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