Randomized Crossover Study of Neurally Adjusted Ventilatory Assist in Preterm Infants

doi:10.1016/j.jpeds.2012.04.040

The Journal of Pediatrics

Volume 161, Issue 5, November 2012, Pages 808-813.e2

https://doi.org/10.1016/j.jpeds.2012.04.040 Get rights and content

Objective

To determine whether neurally adjusted ventilatory assist (NAVA), a new method of mechanical ventilation that delivers pressure assistance that is proportional to the electrical activity of the diaphragm (EAdi), could lower the inspiratory pressure and respiratory muscle load in preterm infants supported with ventilators.

Study design

Twenty-six mechanically ventilated preterm infants were randomized to crossover ventilation with NAVA and synchronized intermittent mandatory ventilation (SIMV) with pressure support (PS) for 4 hours each in a randomized order. A 1-hour interval for washout was provided between the 2 modes of ventilation. The ventilator settings were adjusted to maintain similar levels of end-tidal partial pressure of CO₂. The ventilator parameters, vital signs, and gas exchange effects under the 2 ventilatory modes were compared.

Results

Nineteen infants completed the 9-hour crossover comparison protocol. Peak inspiratory pressure (PIP), work of breathing, and peak EAdi with NAVA were lower than those in SIMV with PS. Calculated tidal volume to peak EAdi ratio and PIP to peak EAdi ratio were higher with NAVA. There were no significant differences in mean airway pressure, inspiratory oxygen fraction, and blood gas values. The measurements of vital signs did not differ significantly between the 2 modes.

Conclusion

NAVA lowered PIP and reduced respiratory muscle load in preterm infants at equivalent inspiratory oxygen fraction and partial pressure of CO₂ of capillary blood in comparison with SIMV with PS.

Section snippets

Methods

A prospective, randomized, controlled, crossover comparison of NAVA and SIMV with PS was conducted from March-August of 2011 in the neonatal intensive care unit of Seoul National University Children's Hospital in Seoul, Korea. Approval for this study was obtained by the Seoul National University Hospital Institutional Review Board, and written informed consent was obtained from the parents of neonates prior to their enrollment in this study. This study was conducted in compliance with the

Results

Of the 26 preterm infants enrolled, 2 patients were excluded prior to the study, and 5 patients discontinued the protocol because they met a criterion for termination during the study. The remaining 19 patients completed the 9-hour crossover comparison study (Figure 2).

One of the 5 patients was terminated after initiation of the protocol because the parents withdrew their consent for the study. For the remaining 4, tachypnea (RR >80/min) developed. Tachypnea developed in 3 of the patients

Discussion

The present study showed that NAVA lowered the delivered PIP with a decrease in the EAdi and lowered the respiratory work while maintaining an equivalent supply of oxygen and gas exchange relative to SIMV with PS. Although the absolute reduction of inspiratory pressure was small, the difference is probably significant because our study was conducted over a relatively short 4-hour period. Recently, Stein at al¹⁹ reported a retrospective analysis, which demonstrated NAVA provided better blood gas

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Newborn infants, particularly preterm infants, frequently need respiratory support. A wide array of noninvasive and invasive support techniques are available. There are also multiple ways of assessing an infant who requires respiratory support. Most neonatal diseases are characterized by increased alveolar surface forces causing atelectasis. These forces can be offset by pressure applied to the upper airway, either through noninvasive or invasive support. The standard for noninvasive support is nasal continuous positive airway pressure (CPAP), although there may be roles for high-flow nasal cannula (HFNC) and synchronized noninvasive ventilation in some infants. Intubated infants can be supported by multiple modes of ventilation. The most efficient modes of conventional tidal ventilation appear to be those that support every spontaneous breath with a ventilator breath (assist/control or A/C). Volume targeting, where the size of the breath is continually adjusted to stay within a narrow target range appears to be the optimal way to set the ventilator-delivered tidal volume. High-frequency ventilation can also support many infants with severe lung disease, or at risk of developing BPD. There are multiple ways of assessing an infant’s respiratory status, including noninvasive monitoring and ventilator graphics.
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Citation Excerpt :
The Edi signal is considered a respiratory vital sign (Stein and Firestone, 2014), and it provides us with a unique opportunity to investigate breathing patterns and breathing effort (Beck et al., 2011; De Waal et al., 2017; Gibu et al., 2017; Lee et al., 2021a, 2021b, 2015, 2012; Oda et al., 2021; Parikka et al., 2015; Soukka et al., 2014). In neonatal studies, it has been successfully used to compare the effects of different respiratory support modes on breathing (Lee et al., 2015, 2012; Mally et al., 2018; Nasef et al., 2015; Stein et al., 2013). In addition, the Edi signal has been used to assess the favorable effects of prone position, skin-to-skin care and medications on respiratory effort and drive (Kato et al., 2021; Lee et al., 2021b; Parikka et al., 2015; Soukka et al., 2014).
To evaluate whether noninvasive-neurally adjusted ventilatory assist (NIV-NAVA) decrease respiratory efforts compared to nasal continuous positive airway pressure (NCPAP) during the first hours of life.
Twenty infants born between 28⁺⁰ and 31⁺⁶ weeks were randomized to NIV-NAVA or NCPAP. Positive end-expiratory pressure was constantly kept at 6 cmH₂O for both groups and the NAVA level was 1.0 cmH₂O/µV for NIV-NAVA group. The electrical activity of diaphragm (Edi) were recorded for the first two hours.
Peak and minimum Edi decreased similarly in both groups (P = 0.98 and P = 0.59, respectively). Leakages were higher in the NIV-NAVA group than in the NCPAP group (P < 0.001). The neural apnea defined as a flat Edi for ≥ 5 s were less frequent in NIV-NAVA group than in NCPAP group (P = 0.046).
Immediately applied NIV-NAVA in premature infants did not reduce breathing effort, measured as peak Edi. However, NIV-NAVA decreased neural apneic episodes compared to NCPAP.
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: Supported by the Research and Development Project of Korea Health Industry Development Institute, Ministry of Health and Welfare, Republic of Korea (A080588-1122-1260200). The authors declare no conflicts of interest.

: Registered with ClinicalTrials.gov: NCT01389882.

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Original ArticleRandomized Crossover Study of Neurally Adjusted Ventilatory Assist in Preterm Infants

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

Semin Neonatol

Clin Chest Med

Semin Fetal Neonatal Med

Chest

Chest

Lung protective ventilatory strategies in very low birth weight infants

J Perinatol

Statement on the care of the child with chronic lung disease of infancy and childhood

Am J Respir Crit Care Med

Update in mechanical ventilation 2010

Am J Respir Crit Care Med

Neural control of mechanical ventilation in respiratory failure

Nat Med

Evaluation of a transportable capnometer for monitoring end-tidal carbon dioxide

Anaesthesia

Patient–ventilator interaction during neurally adjusted ventilatory assist in low birth weight infants

Pediatr Res

Nava ventilation

Minerva Anestesiol

Comparison of pressure-, flow-, and NAVA-triggering in pediatric and neonatal ventilatory care

Pediatr Pulmonol

Original Article
Randomized Crossover Study of Neurally Adjusted Ventilatory Assist in Preterm Infants