Effects of Neurally Adjusted Ventilatory Assist (NAVA) levels in non-invasive ventilated patients: titrating NAVA levels with electric diaphragmatic activity and tidal volume matching
[en] BACKGROUND:
Neurally adjusted ventilatory assist (NAVA) delivers pressure in proportion to diaphragm electrical activity (Eadi). However, each patient responds differently to NAVA levels. This study aims to examine the matching between tidal volume (Vt) and patients' inspiratory demand (Eadi), and to investigate patient-specific response to various NAVA levels in non-invasively ventilated patients.
METHODS:
12 patients were ventilated non-invasively with NAVA using three different NAVA levels. NAVA100 was set according to the manufacturer's recommendation to have similar peak airway pressure as during pressure support. NAVA level was then adjusted ±50% (NAVA50, NAVA150). Airway pressure, flow and Eadi were recorded for 15 minutes at each NAVA level. The matching of Vt and integral of Eadi (ʃEadi) were assessed at the different NAVA levels. A metric, Range90, was defined as the 5-95% range of Vt/ʃEadi ratio to assess matching for each NAVA level. Smaller Range90 values indicated better matching of supply to demand.
RESULTS:
Patients ventilated at NAVA50 had the lowest Range90 with median 25.6 uVs/ml [Interquartile range (IQR): 15.4-70.4], suggesting that, globally, NAVA50 provided better matching between ʃEadi and Vt than NAVA100 and NAVA150. However, on a per-patient basis, 4 patients had the lowest Range90 values in NAVA100, 1 patient at NAVA150 and 7 patients at NAVA50. Robust coefficient of variation for ʃEadi and Vt were not different between NAVA levels.
CONCLUSIONS:
The patient-specific matching between ʃEadi and Vt was variable, indicating that to obtain the best possible matching, NAVA level setting should be patient specific. The Range90 concept presented to evaluate Vt/ʃEadi is a physiologic metric that could help in individual titration of NAVA level.
Disciplines :
General & internal medicine
Author, co-author :
Chiew, YS
Chase, JG
LAMBERMONT, Bernard ; Centre Hospitalier Universitaire de Liège - CHU > Frais communs médecine
Roeseler, J
Pretty, C
Bialais, E
Sottiaux, T
Desaive, Thomas ; Université de Liège - ULiège > Département d'astrophys., géophysique et océanographie (AGO) > Thermodynamique des phénomènes irréversibles
Language :
English
Title :
Effects of Neurally Adjusted Ventilatory Assist (NAVA) levels in non-invasive ventilated patients: titrating NAVA levels with electric diaphragmatic activity and tidal volume matching
Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguía C, González M, Epstein SK, Hill NS, Nava S, Soares M-A, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004, 350:2452-2460. 10.1056/NEJMoa032736, 15190137.
Ferrer M, Valencia M, Nicolas JM, Bernadich O, Badia JR, Torres A. Early noninvasive ventilation averts extubation failure in patients at risk. Am J Respir Crit Care Med 2006, 173:164-170. 10.1164/rccm.200505-718OC, 16224108.
Vignaux L, Vargas F, Roeseler J, Tassaux D, Thille A, Kossowsky M, Brochard L, Jolliet P. Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med 2009, 35:840-846. 10.1007/s00134-009-1416-5, 19183949.
Piquilloud L, Vignaux L, Bialais E, Roeseler J, Sottiaux T, Laterre P-F, Jolliet P, Tassaux D. Neurally adjusted ventilatory assist improves patient-ventilator interaction. Intensive Care Med 2011, 37:263-271. 10.1007/s00134-010-2052-9, 20871978.
Schmidt M, Dres M, Raux M, Deslandes-Boutmy E, Kindler F, Mayaux J, Similowski T, Demoule A. Neurally adjusted ventilatory assist improves patient-ventilator interaction during postextubation prophylactic noninvasive ventilation*. Crit Care Med 2012, 40:1738-1744. 1710.1097/CCM.1730b1013e3182451f3182477, 10.1097/CCM.0b013e3182451f77, 22610179.
Spahija J, de Marchie M, Albert M, Bellemare P, Delisle S, Beck J, Sinderby C. Patient-ventilator interaction during pressure support ventilation and neurally adjusted ventilatory assist *. Crit Care Med 2010, 38:518-526. 510.1097/CCM.1090b1013e3181cb1090d1097b, 10.1097/CCM.0b013e3181cb0d7b, 20083921.
Colombo D, Cammarota G, Bergamaschi V, De Lucia M, Corte F, Navalesi P. Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure. Intensive Care Med 2008, 34:2010-2018. 10.1007/s00134-008-1208-3, 18629471.
Schmidt M, Demoule A, Cracco C, Gharbi A, Fiamma M-N, Straus C, Duguet A, Gottfried SB, Similowski T. Neurally adjusted ventilatory assist increases respiratory variability and complexity in acute respiratory failure. Anesthesiology 2010, 112:670-681. 610.1097/ALN.1090b1013e3181cea1375, 10.1097/ALN.0b013e3181cea375, 20179505.
Sinderby C, Navalesi P, Beck J, Skrobik Y, Comtois N, Friberg S, Gottfried SB, Lindstrom L. Neural control of mechanical ventilation in respiratory failure. Nat Med 1999, 5:1433-1436. 10.1038/71012, 10581089.
Rozé H, Lafrikh A, Perrier V, Germain A, Dewitte A, Gomez F, Janvier G, Ouattara A. Daily titration of neurally adjusted ventilatory assist using the diaphragm electrical activity. Intensive Care Med 2011, 37:1087-1094. 10.1007/s00134-011-2209-1, 21424827.
Brander L, Leong-Poi H, Beck J, Brunet F, Hutchison SJ, Slutsky AS, Sinderby C. Titration and implementation of neurally adjusted ventilatory assist in critically Ill patients. Chest 2009, 135:695-703. 10.1378/chest.08-1747, 19017889.
Barwing J, Linden N, Ambold M, Quintel M, Moerer O. Neurally adjusted ventilatory assist vs. pressure support ventilation in critically ill patients: an observational study. Acta Anaesthesiologica Scandinavica 2011, 55:1261-1271. 10.1111/j.1399-6576.2011.02522.x, 22092132.
Lecomte F, Brander L, Jalde F, Beck J, Qui H, Elie C, Slutsky AS, Brunet F, Sinderby C. Physiological response to increasing levels of neurally adjusted ventilatory assist (NAVA). Respiratory Physiology & Neurobiology 2009, 166:117-124. 10.1016/j.resp.2009.02.015, 23835979.
Ververidis D, van Gils M, Passath C, Takala J, Brander L. Identification of Adequate Neurally Adjusted Ventilatory Assist (NAVA) during systematic increases in the NAVA level. Biomedical Engineering, IEEE Transactions on 2011, 58:2598-2606.
Passath C, Takala J, Tuchscherer D, Jakob SM, Sinderby C, Brander L. Physiologic response to changing positive end-expiratory pressure during neurally adjusted ventilatory assist in sedated, critically Ill adults. Chest 2010, 138:578-587. 10.1378/chest.10-0286, 20435654.
Moorhead K, Piquilloud L, Lambermont B, Roeseler J, Chiew Y, Chase JG, Revelly J-P, Bialais E, Tassaux D, Laterre P-F, et al. NAVA enhances tidal volume and diaphragmatic electro-myographic activity matching: a Range90 analysis of supply and demand. J Clin Monit Comput 2013, 27:61-70. 10.1007/s10877-012-9398-1, 23015365.
Patroniti N, Bellani G, Saccavino E, Zanella A, Grasselli G, Isgrò S, Milan M, Foti G, Pesenti A. Respiratory pattern during neurally adjusted ventilatory assist in acute respiratory failure patients. Intensive Care Med 2012, 38:230-239. 10.1007/s00134-011-2433-8, 22127483.
Sinderby C, Beck J, Spahija J, de Marchie M, Lacroix J, Navalesi P, Slutsky AS. Inspiratory Muscle Unloading by Neurally Adjusted Ventilatory Assist During Maximal Inspiratory Efforts in Healthy Subjects*. Chest 2007, 131:711-717. 10.1378/chest.06-1909, 17356084.
Bertrand P-M, Futier E, Coisel Y, Matecki S, Jaber S, Constantin J-M. Neurally adjusted ventilator assist versus pressure support ventilation for noninvasive ventilation during acute respiratory failure: a cross-over physiological study. Chest 2013, 143:30-36. 10.1378/chest.12-0424, 22661448.
Piquilloud L, Tassaux D, Bialais E, Lambermont B, Sottiaux T, Roeseler J, Laterre P-F, Jolliet P, Revelly J-P. Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator interaction during non-invasive ventilation delivered by face mask. Intensive Care Med 2012, 38:1624-1631. 10.1007/s00134-012-2626-9, 22885649.
