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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Matlock DN, Ratcliffe SJ, Courtney SE, Kirpalani H, Firestone K, Stein H, Dysart K, Warren K, Goldstein MR, Lund KC, Natarajan A, Demissie E, Foglia EE. The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial: study protocol for a randomized controlled trial comparing rates of extubation failure in extremely premature infants undergoing extubation to non-invasive neurally adjusted ventilatory assist versus non-synchronized nasal intermittent positive pressure ventilation. Trials 2024; 25:201. [PMID: 38509583 PMCID: PMC10953115 DOI: 10.1186/s13063-024-08038-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 03/06/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Invasive mechanical ventilation contributes to bronchopulmonary dysplasia (BPD), the most common complication of prematurity and the leading respiratory cause of childhood morbidity. Non-invasive ventilation (NIV) may limit invasive ventilation exposure and can be either synchronized or non-synchronized (NS). Pooled data suggest synchronized forms may be superior. Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) delivers NIV synchronized to the neural signal for breathing, which is detected with a specialized catheter. The DIVA (Diaphragmatic Initiated Ventilatory Assist) trial aims to determine in infants born 240/7-276/7 weeks' gestation undergoing extubation whether NIV-NAVA compared to non-synchronized nasal intermittent positive pressure ventilation (NS-NIPPV) reduces the incidence of extubation failure within 5 days of extubation. METHODS This is a prospective, unblinded, pragmatic, multicenter phase III randomized clinical trial. Inclusion criteria are preterm infants 24-276/7 weeks gestational age who were intubated within the first 7 days of life for at least 12 h and are undergoing extubation in the first 28 postnatal days. All sites will enter an initial run-in phase, where all infants are allocated to NIV-NAVA, and an independent technical committee assesses site performance. Subsequently, all enrolled infants are randomized to NIV-NAVA or NS-NIPPV at extubation. The primary outcome is extubation failure within 5 days of extubation, defined as any of the following: (1) rise in FiO2 at least 20% from pre-extubation for > 2 h, (2) pH ≤ 7.20 or pCO2 ≥ 70 mmHg; (3) > 1 apnea requiring positive pressure ventilation (PPV) or ≥ 6 apneas requiring stimulation within 6 h; (4) emergent intubation for cardiovascular instability or surgery. Our sample size of 478 provides 90% power to detect a 15% absolute reduction in the primary outcome. Enrolled infants will be followed for safety and secondary outcomes through 36 weeks' postmenstrual age, discharge, death, or transfer. DISCUSSION The DIVA trial is the first large multicenter trial designed to assess the impact of NIV-NAVA on relevant clinical outcomes for preterm infants. The DIVA trial design incorporates input from clinical NAVA experts and includes innovative features, such as a run-in phase, to ensure consistent technical performance across sites. TRIAL REGISTRATION www. CLINICALTRIALS gov , trial identifier NCT05446272 , registered July 6, 2022.
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Affiliation(s)
- David N Matlock
- University of Arkansas for Medical Sciences, 4301 W. Markham St., Slot 512-5B, Little Rock, AR, 72205, USA.
- University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | | | | | - Haresh Kirpalani
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- McMaster University, Hamilton, ON, Canada
| | | | | | - Kevin Dysart
- Nemours Children's Health Wilmington, Philadelphia, PA, USA
| | - Karen Warren
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | | - Aruna Natarajan
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Ejigayehu Demissie
- National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elizabeth E Foglia
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Poole G, Harris C, Shetty S, Dassios T, Jenkinson A, Greenough A. Study protocol for a randomised cross-over trial of Neurally adjusted ventilatory Assist for Neonates with Congenital diaphragmatic hernias: the NAN-C study. Trials 2024; 25:72. [PMID: 38245741 PMCID: PMC10800044 DOI: 10.1186/s13063-023-07874-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 12/14/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation that delivers oxygen pressures in proportion to electrical signals of the diaphragm. The proportional assistance can be adjusted by the clinician to reduce the patient's work of breathing. Several case series of infants with congenital diaphragmatic hernias (CDH) have shown that NAVA may reduce oxygenation index and mean airway pressures. To date, no clinical trial has compared NAVA to standard methods of mechanical ventilation for babies with CDH. METHODS The aim of this dual-centre randomised cross-over trial is to compare post-operative NAVA with assist control ventilation (ACV) for infants with CDH. If eligible, infants will be enrolled for a ventilatory support tolerance trial (VSTT) to assess their suitability for randomisation. If clinically stable during the VSTT, infants will be randomised to receive either NAVA or ACV first in a 1:1 ratio for a 4-h period. The oxygenation index, respiratory severity score and cumulative sedative medication use will be measured. DISCUSSION Retrospective studies comparing NAVA to ACV in neonates with congenital diaphragmatic hernia have shown the ventilatory mode may improve respiratory parameters and benefit neonates. To our knowledge, this is the first prospective cross-over trial comparing NAVA to ACV. TRIAL REGISTRATION NAN-C was prospectively registered on ClinicalTrials.gov NCT05839340 Registered on May 2023.
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Affiliation(s)
- Grace Poole
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK.
| | - Christopher Harris
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Sandeep Shetty
- Neonatal Intensive Care Unit, St. George's University NHS Foundation Trust, London, UK
| | - Theodore Dassios
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Allan Jenkinson
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Neonatal Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
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Fang SJ, Chen CC, Liao DL, Chung MY. Neurally adjusted ventilatory assist in infants: A review article. Pediatr Neonatol 2023; 64:5-11. [PMID: 36272922 DOI: 10.1016/j.pedneo.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/30/2022] [Accepted: 09/15/2022] [Indexed: 01/18/2023] Open
Abstract
Neurally adjusted ventilatory assist (NAVA) and non-invasive (NIV)-NAVA are innovative modes of synchronized and proportional respiratory support. They can synchronize with the patients' breathing and promote patient comfort. Both techniques are increasingly being used these years, however experience with their use in newborns and premature infants in Taiwan is relatively few. Because increasing evidence supports the use of NAVA and NIV-NAVA in newborns and premature infants requiring respiratory assist to achieve better synchrony, the aim of this article is to discuss whether NAVA can provide better synchronization and comfort for ventilated newborns and premature babies. In a review of recent literature, we found that NAVA and NIV-NAVA appear to be superior to conventional invasive and non-invasive ventilation. Nevertheless, some of the benefits are controversial. For example, treatment failure in premature infants is common due to insufficient triggering of electrical activity of the diaphragm (EAdi) and frequent apnea, highlighting the differences between premature infants and adults in settings and titration. Further, we suggest how to adjust the settings of NAVA and NIV-NAVA in premature infants to reduce clinical adverse events and extubation failure. In addition to assist in the use of NAVA, EAdi can also serve as a continuous and real-time monitor of vital signs, assisting physicians in the administration of sedatives, evaluation of successful extubation, and as a reference for the patient's respiratory condition during special procedures.
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Affiliation(s)
- Shih-Jou Fang
- Section of Neonatology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Chih-Cheng Chen
- Section of Neonatology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan; Department of Respiratory Care, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Da-Ling Liao
- Department of Respiratory Care, Kaohsiung Chang Gung Memorial Hospital, Taiwan
| | - Mei-Yung Chung
- Section of Neonatology, Department of Pediatrics, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan; Department of Respiratory Care, Kaohsiung Chang Gung Memorial Hospital, Taiwan; Chang Gung University of Science and Technology, Chiayi Campus, Taiwan.
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5
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Piątek K, Lehtonen L, Parikka V, Setänen S, Soukka H. Implementation of neurally adjusted ventilatory assist and high flow nasal cannula in very preterm infants in a tertiary level NICU. Pediatr Pulmonol 2022; 57:1293-1302. [PMID: 35243818 PMCID: PMC9314087 DOI: 10.1002/ppul.25879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 01/26/2022] [Accepted: 02/27/2022] [Indexed: 11/11/2022]
Abstract
Preterm infants treated with invasive ventilation are often affected by bronchopulmonary dysplasia, brain structure alterations, and later neurodevelopmental impairment. We studied the implementation of neurally adjusted ventilatory assist (NAVA) and high flow nasal cannula (HFNC) in a level III neonatal unit, and its effects on pulmonary and central nervous system outcomes. This retrospective cohort study included 193 surviving infants born below 32 weeks of gestation in preimplementation (2007-2008) and postimplementation (2016-2017) periods in a single study center in Finland. The proportion of infants requiring invasive ventilation decreased from 67% in the pre- to 48% in the postimplementation period (p = 0.009). Among infants treated with invasive ventilation, 68% were treated with NAVA after its implementation. At the same time, the duration of invasive ventilation of infants born at or below 28 weeks increased threefold compared with the preimplementation period (p = 0.042). The postimplementation period was characterized by a gradual replacement of nasal continuous positive airway pressure (nCPAP) with HFNC, earlier discontinuation of nCPAP, but a longer duration of positive pressure support. The proportion of normal magnetic resonance imaging (MRI) findings at term corrected age increased from 62% to 84% (p = 0.018). Cognitive outcome improved by one standard score between the study periods (p = 0.019). NAVA was used as the primary mode of ventilation in the postimplementation period. During this period, invasive ventilation time was significantly prolonged. HFNC led to a decrease in the use of nCPAP. The change in the respiratory support might have contributed to the improvement in brain MRI findings and cognitive outcomes.
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Affiliation(s)
- Katarzyna Piątek
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Liisa Lehtonen
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Vilhelmiina Parikka
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
| | - Sirkku Setänen
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
- Department of Pediatric NeurologyTurku University HospitalTurkuFinland
| | - Hanna Soukka
- Department of Pediatrics and Adolescent MedicineTurku University HospitalTurkuFinland
- Faculty of MedicineUniversity of TurkuTurkuFinland
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De Bisschop B, Peeters L, Sonnaert M. Successful conservative managements of extensive pneumatoceles in a preterm girl: A case report. J Neonatal Perinatal Med 2021; 14:139-142. [PMID: 31903998 DOI: 10.3233/npm-190382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We describe a preterm girl with severe respiratory distress syndrome, which was managed with mechanical ventilation. She developed severe ventilator induced lung injury, causing extensive unilateral emphysema. CT-scan of the lungs corresponded with extensive pneumatoceles. She was managed conservatively, using neurally adjusted ventilatory assist, with success and was extubated on day of life 38. She was discharged home without any respiratory support at 39 weeks of postmenstrual age. Our case illustrates the ongoing risk of severe ventilator induced lung injury and highlights a unique injury pattern in a preterm newborn that was managed conservatively using neurally adjusted ventilatory assist with an excellent outcome.
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Affiliation(s)
- B De Bisschop
- Department of Neonatology, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - L Peeters
- Department of Pediatrics, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - M Sonnaert
- Department of Neonatology, University Hospital Brussels (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Heinrich EC, Djokic MA, Gilbertson D, DeYoung PN, Bosompra NO, Wu L, Anza-Ramirez C, Orr JE, Powell FL, Malhotra A, Simonson TS. Cognitive function and mood at high altitude following acclimatization and use of supplemental oxygen and adaptive servoventilation sleep treatments. PLoS One 2019; 14:e0217089. [PMID: 31188839 PMCID: PMC6561544 DOI: 10.1371/journal.pone.0217089] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 05/03/2019] [Indexed: 11/19/2022] Open
Abstract
Impairments in cognitive function, mood, and sleep quality occur following ascent to high altitude. Low oxygen (hypoxia) and poor sleep quality are both linked to impaired cognitive performance, but their independent contributions at high altitude remain unknown. Adaptive servoventilation (ASV) improves sleep quality by stabilizing breathing and preventing central apneas without supplemental oxygen. We compared the efficacy of ASV and supplemental oxygen sleep treatments for improving daytime cognitive function and mood in high-altitude visitors (N = 18) during acclimatization to 3,800 m. Each night, subjects were randomly provided with ASV, supplemental oxygen (SpO2 > 95%), or no treatment. Each morning subjects completed a series of cognitive function tests and questionnaires to assess mood and multiple aspects of cognitive performance. We found that both ASV and supplemental oxygen (O2) improved daytime feelings of confusion (ASV: p < 0.01; O2: p < 0.05) and fatigue (ASV: p < 0.01; O2: p < 0.01) but did not improve other measures of cognitive performance at high altitude. However, performance improved on the trail making tests (TMT) A and B (p < 0.001), the balloon analog risk test (p < 0.0001), and the psychomotor vigilance test (p < 0.01) over the course of three days at altitude after controlling for effects of sleep treatments. Compared to sea level, subjects reported higher levels of confusion (p < 0.01) and performed worse on the TMT A (p < 0.05) and the emotion recognition test (p < 0.05) on nights when they received no treatment at high altitude. These results suggest that stabilizing breathing (ASV) or increasing oxygenation (supplemental oxygen) during sleep can reduce feelings of fatigue and confusion, but that daytime hypoxia may play a larger role in other cognitive impairments reported at high altitude. Furthermore, this study provides evidence that some aspects of cognition (executive control, risk inhibition, sustained attention) improve with acclimatization.
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Affiliation(s)
- Erica C. Heinrich
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Matea A. Djokic
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Dillon Gilbertson
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Pamela N. DeYoung
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Naa-Oye Bosompra
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Lu Wu
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Cecilia Anza-Ramirez
- Departamento de Ciencias Biológicas y Fisiológicas, Facultad de Ciencias y Filosofía, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Jeremy E. Orr
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Frank L. Powell
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
| | - Tatum S. Simonson
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California, United States of America
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Amin R, Arca MJ. Feasibility of Non-invasive Neurally Adjusted Ventilator Assist After Congenital Diaphragmatic Hernia Repair. J Pediatr Surg 2019; 54:434-438. [PMID: 29884552 DOI: 10.1016/j.jpedsurg.2018.05.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 03/28/2018] [Accepted: 05/15/2018] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of neurally adjusted ventilator assist (NAVA) in congenital diaphragmatic hernia (CDH) patients has been historically deemed unwise, since the trigger for breaths is the electromyographic activity of the diaphragmatic muscle. We report on our NAVA experience in CDH patients. METHODS We performed an IRB-approved retrospective review of newborns from 1/1/2012-1/1/2017 at a Level I Children's Surgery Center undergoing CDH repair. Data obtained included demographics, defect type and repair, respiratory support, and outcomes. RESULTS Seven infants with CDH were placed on noninvasive-NAVA (NIV-NAVA) after extubation. All seven patients underwent open transabdominal repair, with five requiring patch repair. All survived to discharge, and one year after birth. When we compared this group to a contemporary cohort of patients who also underwent CDH repair, we found no significant differences in birth weight, postmenstrual age, or gender. However, there was a significantly higher need for inhaled nitric oxide (p = 0.002), high frequency oscillatory ventilation (p = 0.016), and extracorporeal membranous oxygenation support (p = 0.045) in the NIV-NAVA cohort. CONCLUSION This is the first report of NIV-NAVA being successfully utilized as an adjunct to wean infants from conventional ventilation after CDH repair, even in those who require patch repair or with more significant disease severity. LEVELS OF EVIDENCE III- Retrospective Comparative Study.
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Affiliation(s)
- Ruchi Amin
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA; Children's Hospital of Wisconsin, 999 N. 92nd Street Suite 320, Milwaukee, WI, USA
| | - Marjorie J Arca
- Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI, USA; Children's Hospital of Wisconsin, 999 N. 92nd Street Suite 320, Milwaukee, WI, USA.
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Orr JE, Heinrich EC, Djokic M, Gilbertson D, Deyoung PN, Anza-Ramirez C, Villafuerte FC, Powell FL, Malhotra A, Simonson T. Adaptive Servoventilation as Treatment for Central Sleep Apnea Due to High-Altitude Periodic Breathing in Nonacclimatized Healthy Individuals. High Alt Med Biol 2018; 19:178-184. [PMID: 29641294 PMCID: PMC6014053 DOI: 10.1089/ham.2017.0147] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/20/2018] [Indexed: 12/17/2022] Open
Abstract
Orr, Jeremy E., Erica C. Heinrich, Matea Djokic, Dillon Gilbertson, Pamela N. Deyoung, Cecilia Anza-Ramirez, Francisco C. Villafuerte, Frank L. Powell, Atul Malhotra, and Tatum Simonson. Adaptive servoventilation as treatment for central sleep apnea due to high-altitude periodic breathing in nonacclimatized healthy individuals. High Alt Med Biol. 19:178-184, 2018. AIMS Central sleep apnea (CSA) is common at high altitude, leading to desaturation and sleep disruption. We hypothesized that noninvasive ventilation using adaptive servoventilation (ASV) would be effective at stabilizing CSA at altitude. Supplemental oxygen was evaluated for comparison. METHODS Healthy subjects were brought from sea level to 3800 m and underwent polysomnography on three consecutive nights. Subjects underwent each condition-No treatment, ASV, and supplemental oxygen-in random order. The primary outcome was the effect of ASV on oxygen desaturation index (ODI). Secondary outcomes included oxygen saturation, arousals, symptoms, and comparison to supplemental oxygen. RESULTS Eighteen subjects underwent at least two treatment conditions. There was a significant difference in ODI across the three treatments. There was no statistical difference in ODI between no treatment and ASV (17.1 ± 4.2 vs. 10.7 ± 2.9 events/hour; p > 0.17) and no difference in saturation or arousal index. Compared with no treatment, oxygen improved the ODI (16.5 ± 4.5 events/hour vs. 0.5 ± 0.2 events/hour; p < 0.003), in addition to saturation and arousal index. CONCLUSIONS We found that ASV was not clearly efficacious at controlling CSA in persons traveling to 3800 m, whereas supplemental oxygen resolved CSA. Adjustment in the ASV algorithm may improve efficacy. ASV may have utility in acclimatized persons or at more modest altitudes.
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Affiliation(s)
- Jeremy E. Orr
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Erica C. Heinrich
- Department of Medicine, Division of Physiology, University of California San Diego, La Jolla, California
| | - Matea Djokic
- Department of Medicine, Division of Physiology, University of California San Diego, La Jolla, California
| | - Dillon Gilbertson
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Pamela N. Deyoung
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Cecilia Anza-Ramirez
- Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Francisco C. Villafuerte
- Departamento de Ciencias Biológicas y Fisiológicas, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Frank L. Powell
- Department of Medicine, Division of Physiology, University of California San Diego, La Jolla, California
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of California San Diego, La Jolla, California
| | - Tatum Simonson
- Department of Medicine, Division of Physiology, University of California San Diego, La Jolla, California
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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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11
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Gibu CK, Cheng PY, Ward RJ, Castro B, Heldt GP. Feasibility and physiological effects of noninvasive neurally adjusted ventilatory assist in preterm infants. Pediatr Res 2017; 82:650-657. [PMID: 28399118 PMCID: PMC5605676 DOI: 10.1038/pr.2017.100] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2016] [Revised: 03/24/2017] [Accepted: 03/28/2017] [Indexed: 11/09/2022]
Abstract
BackgroundNoninvasive neurally adjusted ventilator assist (NIV-NAVA) was introduced to our clinical practice via a pilot and a randomized observational study to assess its safety, feasibility, and short-term physiological effects.MethodsThe pilot protocol applied NIV-NAVA to 11 infants on nasal CPAP, high-flow nasal cannula, or nasal intermittent mandatory ventilation (NIMV), in multiple 2- to 4-h periods of NIV-NAVA for comparison. This provided the necessary data to design a randomized, controlled observational crossover study in eight additional infants to compare the physiological effects of NIV-NAVA with NIMV during 2-h steady-state conditions. We recorded the peak inspiratory pressure (PIP), FiO2, Edi, oxygen saturations (histogram analysis), transcutaneous PCO2, and movement with an Acoustic Respiratory Movement Sensor.ResultsThe NAVA catheter was used for 81 patient days without complications. NIV-NAVA produced significant reductions (as a percentage of measurements on NIMV) in the following: PIP, 13%; FiO2, 13%; frequency of desaturations, 42%; length of desaturations, 32%; and phasic Edi, 19%. Infant movement and caretaker movement were reduced by 42% and 27%, respectively. Neural inspiratory time was increased by 39 ms on NIV-NAVA, possibly due to Head's paradoxical reflex.ConclusionNIV-NAVA was a safe, alternative mode of noninvasive support that produced beneficial short-term physiological effects, especially compared with NIMV.
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Affiliation(s)
- Christopher K Gibu
- Department of Pediatrics, Division of Neonatology, University of California, San Diego, California
| | - Phillip Y Cheng
- Department of Pediatrics, Division of Neonatology, University of California, San Diego, California
| | | | - Benjamin Castro
- Department of Pediatrics, Division of Neonatology, University of California, San Diego, California
| | - Gregory P Heldt
- Department of Pediatrics, Division of Neonatology, University of California, San Diego, California
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Nilius G, Katamadze N, Domanski U, Schroeder M, Franke KJ. Non-invasive ventilation with intelligent volume-assured pressure support versus pressure-controlled ventilation: effects on the respiratory event rate and sleep quality in COPD with chronic hypercapnia. Int J Chron Obstruct Pulmon Dis 2017; 12:1039-1045. [PMID: 28408814 PMCID: PMC5383083 DOI: 10.2147/copd.s126970] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND COPD patients who develop chronic hypercapnic respiratory failure have a poor prognosis. Treatment of choice, especially the best form of ventilation, is not well known. OBJECTIVES This study compared the effects of pressure-controlled (spontaneous timed [ST]) non-invasive ventilation (NIV) and NIV with intelligent volume-assured pressure support (IVAPS) in chronic hypercapnic COPD patients regarding the effects on alveolar ventilation, adverse patient/ventilator interactions and sleep quality. METHODS This prospective, single-center, crossover study randomized patients to one night of NIV using ST then one night with the IVAPS function activated, or vice versa. Patients were monitored using polysomnography (PSG) and transcutaneous carbon dioxide pressure (PtcCO2) measurement. Patients rated their subjective experience (total score, 0-45; lower scores indicate better acceptability). RESULTS Fourteen patients were included (4 females, age 59.4±8.9 years). The total number of respiratory events was low, and similar under pressure-controlled (5.4±6.7) and IVAPS (8.3±10.2) conditions (P=0.064). There were also no clinically relevant differences in PtcCO2 between pressure-controlled and IVAPS NIV (52.9±6.2 versus 49.1±6.4 mmHg). Respiratory rate was lower under IVAPS overall; between-group differences reached statistical significance during wakefulness and non-rapid eye movement sleep. Ventilation pressures were 2.6 cmH2O higher under IVAPS versus pressure-controlled ventilation, resulting in a 20.1 mL increase in breathing volume. Sleep efficiency was slightly higher under pressure-controlled ventilation versus IVAPS. Respiratory arousals were uncommon (24.4/h [pressure-controlled] versus 25.4/h [IVAPS]). Overall patient assessment scores were similar, although there was a trend toward less discomfort during IVAPS. CONCLUSION Our results show that IVAPS NIV allows application of higher nocturnal ventilation pressures versus ST without affecting sleep quality or inducing ventilation- associated events.
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Affiliation(s)
- Georg Nilius
- HELIOS Klinik Hagen-Ambrock
- Internal Medicine I, Witten/Herdecke University, Witten, Germany
| | - Nato Katamadze
- HELIOS Klinik Hagen-Ambrock
- Internal Medicine I, Witten/Herdecke University, Witten, Germany
| | | | | | - Karl-Josef Franke
- HELIOS Klinik Hagen-Ambrock
- Internal Medicine I, Witten/Herdecke University, Witten, Germany
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Andrade LB, Ghedini RG, Dias AS, Piva JP. Neurally adjusted ventilatory assist in pediatrics: why, when, and how? Rev Bras Ter Intensiva 2017; 29:408-413. [PMID: 29211188 PMCID: PMC5764551 DOI: 10.5935/0103-507x.20170064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Accepted: 07/20/2017] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lívia Barboza Andrade
- Instituto de Medicina Integral Prof. Fernando Figueira) - Recife
(PE), Brazil
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto
Alegre), Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),
Brazil
- Corresponding author: Lívia Barboza Andrade,
Instituto de Medicina Integral Prof. Fernando Figueira, Rua dos Coelhos, 300 -
Boa Vista, Zip code: 50070-550 - Recife (PE), Brazil. E-mail:
| | - Rodrigo Guellner Ghedini
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto
Alegre), Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),
Brazil
| | - Alexandre Simões Dias
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto
Alegre), Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),
Brazil
| | - Jefferson Pedro Piva
- Pediatric Intensive Care Unit, Hospital de Clínicas de Porto
Alegre), Universidade Federal do Rio Grande do Sul - Porto Alegre (RS),
Brazil
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14
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Demoule A, Clavel M, Rolland-Debord C, Perbet S, Terzi N, Kouatchet A, Wallet F, Roze H, Vargas F, Guerin C, Dellamonica J, Jaber S, Brochard L, Similowski T. Neurally adjusted ventilatory assist as an alternative to pressure support ventilation in adults: a French multicentre randomized trial. Intensive Care Med 2016; 42:1723-1732. [PMID: 27686347 DOI: 10.1007/s00134-016-4447-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 07/05/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE Neurally adjusted ventilatory assist (NAVA) is a ventilatory mode that tailors the level of assistance delivered by the ventilator to the electromyographic activity of the diaphragm. The objective of this study was to compare NAVA and pressure support ventilation (PSV) in the early phase of weaning from mechanical ventilation. METHODS A multicentre randomized controlled trial of 128 intubated adults recovering from acute respiratory failure was conducted in 11 intensive care units. Patients were randomly assigned to NAVA or PSV. The primary outcome was the probability of remaining in a partial ventilatory mode (either NAVA or PSV) throughout the first 48 h without any return to assist-control ventilation. Secondary outcomes included asynchrony index, ventilator-free days and mortality. RESULTS In the NAVA and PSV groups respectively, the proportion of patients remaining in partial ventilatory mode throughout the first 48 h was 67.2 vs. 63.3 % (P = 0.66), the asynchrony index was 14.7 vs. 26.7 % (P < 0.001), the ventilator-free days at day 7 were 1.0 day [1.0-4.0] vs. 0.0 days [0.0-1.0] (P < 0.01), the ventilator-free days at day 28 were 21 days [4-25] vs. 17 days [0-23] (P = 0.12), the day-28 mortality rate was 15.0 vs. 22.7 % (P = 0.21) and the rate of use of post-extubation noninvasive mechanical ventilation was 43.5 vs. 66.6 % (P < 0.01). CONCLUSIONS NAVA is safe and feasible over a prolonged period of time but does not increase the probability of remaining in a partial ventilatory mode. However, NAVA decreases patient-ventilator asynchrony and is associated with less frequent application of post-extubation noninvasive mechanical ventilation. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02018666.
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Affiliation(s)
- A Demoule
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013, Paris, France.
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.
| | - M Clavel
- Réanimation Polyvalente, Hôpital Dupuytren, Limoges, France
| | - C Rolland-Debord
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - S Perbet
- Réanimation Médico-Chirurgicale, CHU de Clermont-Ferrand, Clermont-Ferrand, France
- R2D2 EA-7281, Université d'Auvergne, Clermont-Ferrand, France
| | - N Terzi
- INSERM U1042, Université Grenoble-Alpes, HP2, 38000, Grenoble, France
- Service de Réanimation Médicale, CHU Grenoble Alpes, 38000, Grenoble, France
| | - A Kouatchet
- Service de Réanimation Médicale et Médecine Hyperbare, CHU d'Angers, Angers, Angers, France
| | - F Wallet
- Réanimation Médicale et Chirurgicale, Centre Hospitalier Lyon-Sud, Lyon, France
- Laboratoire des Pathogènes Emergents, Centre International de Recherche en Infectiologie, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon, France
| | - H Roze
- Anesthésie et Réanimation, CHU de Bordeaux, Pessac, France
| | - F Vargas
- Réanimation Médicale, Hôpital Pellegrin-Tripode, Bordeaux, France
| | - C Guerin
- Réanimation Médicale, Hôpital de la Croix Rousse, Lyon, France
| | - J Dellamonica
- Réanimation Médicale, Hôpital de l'Archet, Centre Hospitalier Universitaire de Nice, Nice, France
- INSERM 1065 Team 3 C3 M, Nice, France
| | - S Jaber
- Anesthésie et Réanimation, Hôpital Saint-Eloi, Montpellier, France
- Montpellier School of Medicine, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - L Brochard
- Keenan Research Centre and Li Ka Shing Institute, Saint-Michael's Hospital, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - T Similowski
- Service de Pneumologie et Réanimation Médicale (Département "R3S"), Groupe Hospitalier Pitié-Salpêtrière Charles Foix, AP-HP, 75013, Paris, France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
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15
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Hu JY, Zheng ZG, Lu HN, Liu N, Wu WL, Li YX, Xiong Y, Wang XN, Chen RC. [The influence of condensate in the piezometric tube on patient ventilator interaction during noninvasive positive pressure ventilation]. Zhonghua Jie He He Hu Xi Za Zhi 2016; 39:704-708. [PMID: 27600420 DOI: 10.3760/cma.j.issn.1001-0939.2016.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To study the effects of condensate in the piezometric tube on patient ventilator interaction during noninvasive positive pressure ventilation. METHODS Eleven healthy adults volunteered to receive noninvasive positive pressure ventilation. Different capacity of physiological saline was injected gradually into the piezometric tube until the volunteers could not trigger the ventilator or the total volume of the water reached 1.5 ml. The dynamic changes of the pressure of mask(Pmask), piezometric tube near mask (Ppro), piezometric tube near breathing machine(Pdis), and the flow were observed. RESULTS With increasing volume of saline injected, the trigger time TItri(Pmask) increased from 0.09(0.07-0.11) to 0.31(0.22-0.39)s, the trigger pressure TPtri(Pmask) increased from 0.26(0.15-0.33) to 2.29(1.76-3.09)cmH2O, and the pressure-time product PTP (Pmask) increased from 0.02(0.01-0.03) to 0.55(0.41-0.68) cmH2O·s. Ineffective triggering rate increased from 0 up to 9 times/min, and spurious triggering rate increased from 0 up to 33 times/min. The plateau pressure of Pmask and Ppro exceeded the preset parameters, increased significantly as compared with 0 ml, from (9.74±0.34)to (15.79±3.10) cmH2O and from(9.80±0.31) to(15.44±3.47) cmH2O. The change of plateau pressure of Pdis was not significant [from (9.85±0.29)to (12.58±2.64)cmH2O]. The baseline pressure of Pmask, Ppro and Pdis changed from (3.67±0.36) to (8.40±3.22) cmH2O, from (3.71±0.32) to (8.13±3.55) cmH2O and from( 3.77±0.32) to (5.36±1.25) cmH2O, respectively. The pressure fluctuation of platform of Pmask increased significantly compare with 0 ml, from 0.60(0.48-0.71) to 7.94(7.11-8.63)cmH2O. The frequency of fluctuation of platform increased as many as 7 times during a single respiratory period. The time when the pressure of the Pdis began to change was delayed to Pmask and Ppro, 0.11(0.08-0.12)s compared with 0 ml. CONCLUSION Condensate in the piezometric tube during noninvasive positive pressure ventilation could influence patient-ventilator synchrony. To improve patient ventilator interaction in noninvasive positive pressure ventilation, condensate in the piezometric tube should be avoided.
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Affiliation(s)
- J Y Hu
- The First Affiliated Hospital of Guangzhou Medical University(State Key Laboratory of Respiratory Diseases), Guangzhou Institute of Respiratory Diseases, Guangzhou 510120, China
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16
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Wu R, Tian ZF, Zheng GF, Din SF, Gao ZB, Feng ZC. Treatment of neonates with meconium aspiration syndrome by proportional assist ventilation and synchronized intermittent mandatory ventilation: a comparison study. Minerva Pediatr 2016; 68:262-268. [PMID: 26633188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND This study aimed to compare the relevant clinical parameters of neonates with MAS who are supported by proportion assisted ventilation (PAV) and synchronized intermittent mandatory ventilation (SIMV). METHODS Forty neonates diagnosed as MAS who required mechanical ventilation were divided randomly into PAV group and SIMV group (N.=20). The respiratory rate (RR), heart rate (HR), peak inspiratory pressure (PIP), mean arterial blood pressure (MABP), arterial-to-alveolar oxygen tension ratio (a/APO2), fraction of inspiration oxygen (FiO2), mean airway pressure (MAP) and tidal volume (VT) were measured before the ventilation, 1,12, 24, 48 hours after the ventilation and before weaning. RESULTS We observed no significant differences in the mechanical ventilation time, oxygen supply time, hospital stay between PAV and SIMV groups. In addition, we found no significant differences in HR, MABP, a/APO2 and FiO2 at every time point between two groups (P>0.05). However, we observed significant differences in RR, MAP, PIP and VT at every time point between two groups (P<0.05). CONCLUSIONS PAV and SIMV might be a useful ventilator mode to support the neonates with MAS who require ventilation. To achieve the same effect, PAV adopts rapid shallow breathing pattern, with smaller tidal volume and lower MAP and PIP.
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Affiliation(s)
- Rong Wu
- Neonatal Medical Center, Huaian Maternity and Child Healthcare Hospital, Yangzhou University Medical School, Huaian, China -
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17
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Beck J, Emeriaud G, Liu Y, Sinderby C. Neurally-adjusted ventilatory assist (NAVA) in children: a systematic review. Minerva Anestesiol 2016; 82:874-883. [PMID: 26375790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Application of mechanical ventilation in spontaneously breathing children remains a challenge for several reasons: mainly, small tidal volumes and high respiratory rates, especially in the presence of leaks, interfere with patient-ventilator synchrony. Leaks also cause unreliable monitoring of respiratory drive and respiratory rate. Furthermore, ventilator adjustment must take into account that infants have strong vagal reflexes, 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 neural respiratory drive. Since NAVA uses the diaphragm electrical activity (Edi) as the controller signal, it is possible to deliver synchronized assist, both invasively and non-invasively (NIV-NAVA), to follow the variability in breathing pattern, and to monitor patient respiratory drive, independent of leaks. EVIDENCE ACQUISITION This article provides a review of the scientific literature pertaining to the use of NAVA in children (neonatal and pediatric age groups). Both the invasive and non-invasive NAVA publications are summarized, as well as the use of Edi monitoring. EVIDENCE SYNTHESIS Overall, the use of NAVA and Edi monitoring is feasible and safe. Compared to conventional ventilation, NAVA improves patient-ventilator interaction, and provides lower peak inspiratory pressure. CONCLUSIONS Evidence from a few trials suggests improved comfort, less sedation, and reduced length of stay.
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Affiliation(s)
- Jennifer Beck
- Department of Pediatrics, University of Toronto, Toronto, Canada -
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Chowdhury O, Bhat P, Rafferty GF, Hannam S, Milner AD, Greenough A. In vitro assessment of the effect of proportional assist ventilation on the work of breathing. Eur J Pediatr 2016; 175:639-43. [PMID: 26746416 DOI: 10.1007/s00431-015-2673-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 11/16/2015] [Accepted: 11/19/2015] [Indexed: 11/25/2022]
Abstract
UNLABELLED During proportional assist ventilation, elastic and resistive unloading can be delivered to reduce the work of breathing (WOB). Our aim was to determine the effects of different levels of elastic and resistive unloading on the WOB in lung models designed to mimic certain neonatal respiratory disorders. Two dynamic lung models were used, one with a compliance of 0.4 ml/cm H2O to mimic an infant with respiratory distress syndrome and one with a resistance of 300 cm H2O/l/s to mimic an infant with bronchopulmonary dypslasia. Pressure volume curves were constructed at each unloading level. Elastic unloading in the low compliance model was highly effective in reducing the WOB measured in the lung model; the effective compliance increased from 0.4 ml/cm H2O at baseline to 4.1 ml/cm H2O at maximum possible elastic unloading (2.0 cm H2O/ml). Maximum possible resistive unloading (200 cm H2O/l/s) in the high-resistance model only reduced the effective resistance from 300 to 204 cm H2O/l/s. At maximum resistive unloading, oscillations appeared in the airway pressure waveform. CONCLUSION Our results suggest that elastic unloading will be helpful in respiratory conditions characterised by a low compliance, but resistive unloading as currently delivered is unlikely to be of major clinical benefit. WHAT IS KNOWN • During PAV, the ventilator can provide elastic and resistive unloading. What is New: • Elastic unloading was highly effective in reducing the work of breathing. • Maximum resistive unloading only partially reduced the effective resistance.
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Affiliation(s)
- Olie Chowdhury
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, SE5 9RS, UK
| | - Prashanth Bhat
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, SE5 9RS, UK
| | - Gerrard F Rafferty
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, SE5 9RS, UK
| | - Simon Hannam
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, SE5 9RS, UK
| | - Anthony D Milner
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, SE5 9RS, UK
| | - Anne Greenough
- Division of Asthma, Allergy and Lung Biology, MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, King's College London, London, SE5 9RS, UK.
- NIHR Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.
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Hjelmgren J, Bruce Wirta S, Huetson P, Myrén KJ, Göthberg S. Health economic modeling of the potential cost saving effects of Neurally Adjusted Ventilator Assist. Ther Adv Respir Dis 2016; 10:3-17. [PMID: 26424363 PMCID: PMC5933658 DOI: 10.1177/1753465815603659] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Asynchrony between patient and ventilator breaths is associated with increased duration of mechanical ventilation (MV). Neurally Adjusted Ventilatory Assist (NAVA) controls MV through an esophageal reading of diaphragm electrical activity via a nasogastric tube mounted with electrode rings. NAVA has been shown to decrease asynchrony in comparison to pressure support ventilation (PSV). The objective of this study was to conduct a health economic evaluation of NAVA compared with PSV. METHODS We developed a model based on an indirect link between improved synchrony with NAVA versus PSV and fewer days spent on MV in synchronous patients. Unit costs for MV were obtained from the Swedish intensive care unit register, and used in the model along with NAVA-specific costs. The importance of each parameter (proportion of asynchronous patients, costs, and average MV duration) for the overall results was evaluated through sensitivity analyses. RESULTS Base case results showed that 21% of patients ventilated with NAVA were asynchronous versus 52% of patients receiving PSV. This equals an absolute difference of 31% and an average of 1.7 days less on MV and a total cost saving of US$7886 (including NAVA catheter costs). A breakeven analysis suggested that NAVA was cost effective compared with PSV given an absolute difference in the proportion of asynchronous patients greater than 2.5% (49.5% versus 52% asynchronous patients with NAVA and PSV, respectively). The base case results were stable to changes in parameters, such as difference in asynchrony, duration of ventilation and daily intensive care unit costs. CONCLUSION This study showed economically favorable results for NAVA versus PSV. Our results show that only a minor decrease in the proportion of asynchronous patients with NAVA is needed for investments to pay off and generate savings. Future studies need to confirm this result by directly relating improved synchrony to the number of days on MV.
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Affiliation(s)
- Jonas Hjelmgren
- IMS Health HEOR, Sveavägen 155, Stockholm, Sweden Amgen (Europe) GmbH, Dammstrasse 23, Zug, Switzerland
| | | | | | - Karl-Johan Myrén
- IMS Health HEOR, Sveavägen 155, Stockholm, Sweden SOBI, Tomtebodavägen 23A, Solna, Sweden
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Einecke D. [Adaptive servo-ventilation increases mortality]. MMW Fortschr Med 2015; 157:10. [PMID: 26783597 DOI: 10.1007/s15006-015-3506-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Abstract
Assisted ventilation is a highly complex process that requires an intimate interaction between the ventilator and the patient. The complexity of this form of ventilation is frequently underappreciated by the bedside clinician. In assisted mechanical ventilation, regardless of the specific mode, the ventilator's gas delivery pattern and the patient's breathing pattern must match near perfectly or asynchrony between the patient and the ventilator occurs. Asynchrony can be categorized into four general types: flow asynchrony; trigger asynchrony; cycle asynchrony; and mode asynchrony. In an article recently published in BMC Anesthesiology, Hodane et al. have demonstrated reduced asynchrony during assisted ventilation with Neurally Adjusted Ventilatory Assist (NAVA) as compared to pressure support ventilation (PSV). These findings add to the growing volume of data indicating that modes of ventilation that provide proportional assistance to ventilation - e.g., NAVA and Proportional Assist Ventilation (PAV) - markedly reduce asynchrony. As it becomes more accepted that the respiratory center of the patient in most circumstances is the most appropriate determinant of ventilatory pattern and as the negative outcome effects of patient-ventilator asynchrony become ever more recognized, we can expect NAVA and PAV to become the preferred modes of assisted ventilation!
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Affiliation(s)
- Robert M Kacmarek
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| | - Massimiliano Pirrone
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| | - Lorenzo Berra
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Fish E, Novack V, Banner-Goodspeed VM, Sarge T, Loring S, Talmor D. The Esophageal Pressure-Guided Ventilation 2 (EPVent2) trial protocol: a multicentre, randomised clinical trial of mechanical ventilation guided by transpulmonary pressure. BMJ Open 2014; 4:e006356. [PMID: 25287106 PMCID: PMC4187996 DOI: 10.1136/bmjopen-2014-006356] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Optimal ventilator management for patients with acute respiratory distress syndrome (ARDS) remains uncertain. Lower tidal volume ventilation appears to be beneficial, but optimal management of positive end-expiratory pressure (PEEP) remains unclear. The Esophageal Pressure-Guided Ventilation 2 Trial (EPVent2) aims to examine the impact of mechanical ventilation directed at maintaining a positive transpulmonary pressure (PTP) in patients with moderate-to-severe ARDS. METHODS AND ANALYSIS EPVent2 is a multicentre, prospective, randomised, phase II clinical trial testing the hypothesis that the use of a PTP-guided ventilation strategy will lead to improvement in composite outcomes of mortality and time off the ventilator at 28 days as compared with a high-PEEP control. This study will enrol 200 study participants from 11 hospitals across North America. The trial will utilise a primary composite end point that incorporates death and days off the ventilator at 28 days to test the primary hypothesis that adjusting ventilator pressure to achieve positive PTP values will result in improved mortality and ventilator-free days. ETHICS AND DISSEMINATION Safety oversight will be under the direction of an independent Data and Safety Monitoring Board (DSMB). Approval of the protocol was obtained from the DSMB prior to enrolling the first study participant. Approvals of the protocol as well as informed consent documents were also obtained from the Institutional Review Board of each participating institution prior to enrolling study participants at each respective site. The findings of this investigation, as well as associated ancillary studies, will be disseminated in the form of oral and abstract presentations at major national and international medical specialty meetings. The primary objective and other significant findings will also be presented in manuscript form. All final, published manuscripts resulting from this protocol will be submitted to PubMed Central in accordance with the National Institute of Health Public Access Policy. TRIAL REGISTRATION NUMBER ClinicalTrials.gov under number NCT01681225.
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Affiliation(s)
- Emily Fish
- Department of Anesthesia, Critical Care, & Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Victor Novack
- Soroka University Medical Center, Rager Boulevard, Beer-Sheva, Israel
| | - Valerie M Banner-Goodspeed
- Department of Anesthesia, Critical Care, & Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
- Department of Anesthesia, Critical Care, & Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Todd Sarge
- Department of Anesthesia, Critical Care, & Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephen Loring
- Department of Anesthesia, Critical Care, & Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel Talmor
- Department of Anesthesia, Critical Care, & Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
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Wu R, Li N, Hu J, Zha L, Zhu H, Zheng G, Zhao Y, Feng Z. [Application of lung recruitment maneuver in preterm infants with respiratory distress syndrome ventilated by proportional assist ventilation]. Zhonghua Er Ke Za Zhi 2014; 52:741-744. [PMID: 25537538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To understand the effect of lung recruitment maneuver (LRM) with positive end-expiratory pressure (PEEP) on oxygenation and outcomes in preterm infants with respiratory distress syndrome (RDS) ventilated by proportional assist ventilation (PAV). METHOD From January 2012 to June 2013, thirty neonates with a diagnosis of RDS who required mechanical ventilation were divided randomly into LRM group (n=15, received an LRM and surport by PAV) and control group (n=15, only surport by PAV). There were no statistically significant differences in female (7 vs. 6); gestational age [(29.3±1.2) vs. (29.5±1.1) weeks]; body weight[(1,319±97) vs. (1,295±85) g]; Silverman Anderson(SA) score for babies at start of ventilation (7.3±1.2 vs. 6.9±1.4); initial FiO2 (0.54±0.12 vs. 0.50±0.10) between the two groups (all P>0.05). LRM entailed increments of 0.2 cmH2O (1 cmH2O=0.098 kPa) PEEP every 5 minutes, until fraction of inspired oxygen (FiO2)=0.25. Then PEEP was reduced and the lung volume was set on the deflation limb of the pressure/volume curve.When saturation of peripheral oxygen fell and FiO2 rose, we reincremented PEEP until SpO2 became stable. The related clinical indicators of the two group were observed. RESULT The doses of surfactant administered (1.1±0.3 vs. 1.5±0.5, P=0.027), Lowest FiO2 (0.29±0.05 vs. 0.39±0.06, P=0.000), time to lowest FiO2[ (103±18) vs. (368±138) min, P=0.000] and O2 dependency [(7.6±1.0) vs.( 8.8±1.3) days, P=0.021] in LRM group were lower than that in control group (all P<0.05). The maximum PEEP during the first 12 hours of life [(8.4±0.8) vs. (6.8±0.8) cmH2O, P=0.000] in LRM group were higher than that in control group (P<0.05). FiO2 levels progressively decreased (F=35.681, P=0.000) and a/AO2 Gradually increased (F=37.654, P=0.000). No adverse events and no significant differences in the outcomes were observed. CONCLUSION LRM can reduce the doses of pulmonary surfactant administered, time of the respiratory support and the oxygen therapy in preterm children with RDS.
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Affiliation(s)
- Rong Wu
- Neonatal Medical Center, Huaian Maternity and Child Healthcare Hospital Affiliated to Yangzhou University Medical Academy, Huaian 223002, China
| | | | | | | | | | | | | | - Zhichun Feng
- Department of Neonatology, Bayi Children's Hospital Affiliated to General Hospital of Beijing Military Command, Beijing 100700, China.
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Clemente López FJ. [NEURALLY ADJUSTED VENTILATORY ASSIST (NAVA)]. Rev Enferm 2014; 37:42-46. [PMID: 26118013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Neurally Adjusted Ventilatory Assist (NAVA) is a new mode of mechanic ventilation and it's based on the electrical signal of the dia- phragm activity (Edi) for the ventilation control. This signal directly represents the central ventilatory drive reflecting the duration, frequency and intensity that the patient wants to ventilate. To capture the diaphragmatic electrical impulse, is required some specific electrodes inserted in a probe nasogastric tube. For this mode, depending upon proper placement positioning and care (probe Edi), the nurse is essential for their proper functioning.
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Abstract
RATIONALE Opioids have become part of contemporary treatment in the management of chronic pain. Although severe daytime ventilatory depression is uncommon, chronic use of opioids could be associated with severe central and obstructive sleep apnea. OBJECTIVES To determine the acute efficacy, and prolonged use of adaptive servoventilation (ASV) to treat central sleep apnea in patients on chronic opioids. METHODS Twenty patients on opioid therapy referred for evaluation of obstructive sleep apnea (OSA) were found to have central sleep apnea (CSA). The first 16 patients underwent continuous positive airway pressure (CPAP) titration, which showed persistent CSA. With the notion that CSA will be eliminated with continued use of CPAP, 4 weeks later, 9 of the 16 patients underwent a second CPAP titration which proved equally ineffective. Therefore, therapy with CPAP was abandoned. All patients underwent ASV titration. MAIN RESULTS Diagnostic polysomnography showed an average apnea-hypopnea index (AHI) of 61/h and a central-apnea index (CAI) of 32/h. On CPAP 1, AHI was 34/h and CAI was 20/h. Respective indices on CPAP 2 were AHI 33/h and CAI 19/h. During titration with ASV, CAI was 0/h and the average HI was 11/h on final pressures. With a reduction in AHI, oxyhemoglobin saturation nadir increased from 83% to 90%, and arousal index decreased from 29/h of sleep to 12/h on final ASV pressures. Seventeen patients were followed for a minimum of 9 months and up to 6 years. The mean long-term adherence was 5.1 ± 2.5 hours. CONCLUSIONS Chronic use of opioids could be associated with severe CSA which remains resistant to CPAP therapy. ASV device is effective in the treatment of CSA and over the long run, most patients remain compliant with the device. Randomized long-term studies are necessary to determine if treatment of sleep apnea with ASV improves quality of life and the known mortality associated with opioids.
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Affiliation(s)
| | | | | | - Eugene Chung
- Heart and Vascular Center, Christ Hospital, Cincinnati, OH
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Tehrani FT. A control system for mechanical ventilation of passive and active subjects. Comput Methods Programs Biomed 2013; 110:511-518. [PMID: 23422078 DOI: 10.1016/j.cmpb.2013.01.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 10/30/2012] [Accepted: 01/24/2013] [Indexed: 06/01/2023]
Abstract
Synchronization of spontaneous breathing with breaths supplied by the ventilator is essential for providing optimal ventilation to patients on mechanical ventilation. Some ventilation techniques such as Adaptive Support Ventilation (ASV), Proportional Assist Ventilation (PAV), and Neurally Adjusted Ventilatory Assist (NAVA) are designed to address this problem. In PAV, the pressure support is proportional to the patient's ongoing effort during inspiration. However, there is no guarantee that the patient receives adequate ventilation. The system described in this article is designed to automatically control the support level in PAV to guarantee delivery of patient's required ventilation. This system can also be used to control the PAV support level based on the patient's work of breathing. This technique further incorporates some of the features of ASV to deliver mandatory breaths for passive subjects. The system has been tested by using computer simulations and the controller has been implemented by using a prototype.
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Affiliation(s)
- Fleur T Tehrani
- Department of Electrical Engineering, California State University, Fullerton, USA.
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Abstract
Neurally adjusted ventilator assist (NAVA) is a ventilator mode based on providing assistance to the patient in proportion to the electrical activity of the diaphragm. NAVA may improve patient-ventilator interactions. We describe a very complex case of a child with a permanent ventricular assist device where we attempted to use NAVA during the weaning process and then realised that it was impossible to use.
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Affiliation(s)
- Francesca Iodice
- Department of Anesthesia and Intensive Care, Children's Hospital Bambino Gesu, Rome, Italy.
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Rozé H, Richard JCM, Mercat A, Brochard L. Recording of possible diaphragm fatigue under neurally adjusted ventilatory assist. Am J Respir Crit Care Med 2012; 184:1213-4. [PMID: 22086994 DOI: 10.1164/ajrccm.184.10.1213a] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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