NAVA Neurally Adjusted Ventilatory Assist In Neonates

Size: px

Start display at page:

Download "NAVA Neurally Adjusted Ventilatory Assist In Neonates"

Ira Page
6 years ago
Views:

1 NAVA Neurally Adjusted Ventilatory Assist In Neonates Howard Stein, M.D. Director Neonatology Toledo Children s Hospital Toledo, Ohio

2 Disclaimers Dr Stein: Is on the speaker s bureau for Maquet Is discussing products made by Maquet Has received no financial support or incentives from Maquet to use NAVA or collect this data

3 Neuro-ventilatory Coupling Central nervous system P hrenic nerve Diaphragm excitation Neural Trigger Ventilator Unit Diaphragm contraction C hest wall and lung expansion Airway pressure, flow and volume Flow Trigger Assisted Breath Adapted from S inderby, Nature Med 1999

4 Neural Trigger How do we measure EAdi? A feeding B EAdi C Courtesy of Sinderby and Beck

5 Edi Peak Edi Trough

6 Conventional Ventilation NAVA Ventilation Patient Controls using Flow Trigger: Initiation of Breath Rate (in some modes) Patient Controls using Neural Trigger: Initiation of Breath Inspiratory Time Rate Peak Pressure Termination of Breath Ventilator Controls: Peak Pressure or Tidal Volume Inspiratory Time Termination of Breath PEEP Minimum Rate FiO2 Synchrony: Only for Initiation of Breath Ventilator Controls: FiO2 PEEP NAVA Level Apnea time (minimum rate) Peak Inspiratory pressure alarm Synchrony: Initiation of Breath Size of Breath Termination of Breath

7 Conventional Ventilation NAVA Ventilation Flow Trigger: Based on patient s effort Leak dependent When breathing: Ventilator synchronous for: Breath initiation only When apneic: Ventilates in pressure (or volume) control Neural Trigger: Based on patient's drive Leak independent When breathing: Ventilator synchronous for: Breath initiation, size, and termination When apneic: Ventilates in pressure control

Using NAVA in Neoantes NAVA allows neonates

Set Peak Pressure limit high Is this safe?

8 Using NAVA in Neoantes NAVA allows neonates to choose their own Peak Pressures/Tidal Volumes breath to breath To do this we: Proportional assist using the NAVA level Set Peak Pressure limit high Is this safe? Changes in NAVA level What PIP and TV do they choose?

9 How to set the NAVA level NAVA level is the proportionality factor that converts the Edi signal into a pressure The higher the NAVA level the more work of breathing the ventilator does The lower the NAVA level the more work of breathing the patient does Goal to unload the work of breathing from the patient to the ventilator without over assisting the patient The ventilator continues to respond to the patient s respiratory drive but supports the patient s respiratory effort

10 Edi Titration Study to determine the optimal NAVA level NAVA Level Time (minutes) Firestone and Stein, J Perinatol 2015 Aug;35(8):612-6

11 Edi Titration Study to determine the optimal NAVA level 20 Breakpoint 15 Peak Inspiratory Pressure (cmh20) 10 5 Edi Peak (mcv) NAVA Level

NAVA Titration - Intubated 30 25 20 15 10 5 PIP-i Edi

12 NAVA Titration - Intubated PIP-i Edi P-M-i 0 BrP-1.5 BrP-1 BrP-0.5 BrP BrP+0.5 BrP+1 BrP+1.5 BrP+2

13 NAVA Titration - Extubated PIP-e Edi P-M-e 0 BrP-1.5 BrP-1 BrP-0.5 BrP BrP+0.5 BrP+1 BrP+1.5

14 Change in Breakpoint from NAVA to NIV NAVA 30 NAVA NIV NAVA Peak Pressure (cm H 2 O) BrP-1 BrP-0.5 BrP NAVA BrP+0.5 BrP+1 BrP+1.5 BrP+2 BrP-1.5 BrP-1 BrP-0.5 BrP NIV NAVA BrP+0.5 BrP+1 BrP+1.5

15 Pressure and Volume Distribution in Premature Neonates Variable (+ SD) NAVA NIV NAVA # Neonates Birth weight grams 857 (362) 835 (179) Study weight grams 862 (361) 844 (165) Gestational age weeks 26.5 (2.3) 26.8 (1.5) Study age - days 8 (9) 13 (12)

16 Number of Breaths Collected at Each NAVA Level NAVA Level PIP NAVA PIP NIV NAVA TV NAVA 0.5 1, , ,986 63,334 12, , , , ,068 95,160 44, , ,186 52, ,548 2,026 7,794 All 711, , ,661 Ave # Breaths /neonate 29,646 45,030 31,753

17 Number of Breaths Collected at Each NAVA Level NAVA Level PIP NAVA PIP NIV NAVA TV NAVA 0.5 1, , ,986 63,334 12, , , , ,068 95,160 44, , ,186 52, ,548 2,026 7,794 All 711, , ,661 Ave # Breaths /neonate 29,646 45,030 31,753

Conclusion Nava is synchronous for breath initiation, size and termination Neural trigger works independent of air leaks Synchronous non-invasive ventilation Neonates appear to have intact

21 Conclusion Nava is synchronous for breath initiation, size and termination Neural trigger works independent of air leaks Synchronous non-invasive ventilation Neonates appear to have intact neuro-respiratory feedback mechanisms titration studies Herring Breuer Self regulate ventilatory needs Appears safe PIP and TV are mostly below typical range for CV To date no adverse outcomes reported (235 peer reviewed publications, 54 are in pediatric patients)

22 NAVA WORKS IN NEONATES! But does it make a difference? Large multi-center trials are needed to answer questions if: NAVA prevents intubation or decreases time on ventilators? NIV NAVA NAVA decreases the incidence of chronic lung disease? NAVA improves outcomes?

Managing Patient-Ventilator Interaction in Pediatrics

Managing Patient-Ventilator Interaction in Pediatrics Robert L. Chatburn, MHHS, RRT-NPS, FAARC Clinical Research Manager - Section of Respiratory Therapy Professor of Medicine Case Western Reserve University