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01.12.2010 | Original

Autoregulation of ventilation with neurally adjusted ventilatory assist on extracorporeal lung support

verfasst von: Christian Karagiannidis, Matthias Lubnow, Alois Philipp, Guenter A. J. Riegger, Christof Schmid, Michael Pfeifer, Thomas Mueller

Erschienen in: Intensive Care Medicine | Ausgabe 12/2010

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Abstract

Purpose

Extracorporeal membrane oxygenation (ECMO) can support oxygenation and carbon dioxide elimination in severe lung failure. Usually it is accompanied by controlled mechanical ventilation. Neurally adjusted ventilatory assist (NAVA) is a new mode of ventilation triggered by the diaphragmatic electrical activity and controlled by the patient’s respiratory centre, which may allow a close interaction between ventilation and extracorporeal perfusion. This pilot study intended to measure the physiologic ventilatory response in patients with severe lung failure treated with ECMO and NAVA. We hypothesized that the combination of both methods could automatically provide a protective ventilation with optimized blood gases.

Methods

We report a case series of six patients treated with ECMO for severe lung failure. In the recovery phase of the disease, patients were ventilated with NAVA and ventilatory response and gas exchange parameters were measured under different sweep gas flows and temporarily inactivated ECMO.

Results

Tidal volumes on ECMO ranged between 2 and 5 ml/kg predicted body weight and increased up to 8 ml/kg with inactivated ECMO. Peak inspiratory pressure reached 19–29 cmH₂O with active, and 21–45 cmH₂O with inactivated ECMO. Ventilatory response to decreased sweep gas flow was rapid, and patients immediately regulated PaCO₂ tightly towards a physiological pH value. Increase in minute ventilation was a result of increased breathing frequency and tidal volumes, and protective ventilation was only abandoned if pH control was not achieved.

Conclusions

With NAVA ventilatory response to decreased ECMO sweep gas flow was rapid, and patients immediately regulated PaCO₂ tightly towards a physiological pH value. Therefore, combination of NAVA and ECMO may permit a closed-loop ventilation with automated protective ventilation.

Nur mit Berechtigung zugänglich

The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 342:1301–1308

Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, Raymondos K, Nin N, Hurtado J, Tomicic V, Gonzalez M, Elizalde J, Nightingale P, Abroug F, Pelosi P, Arabi Y, Moreno R, Jibaja M, D’Empaire G, Sandi F, Matamis D, Montanez AM, Anzueto A (2008) Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med 177:170–177CrossRefPubMed

Brochard L, Rouby JJ (2009) Changing mortality in acute respiratory distress syndrome? Yes, we can! Am J Respir Crit Care Med 179:177–178CrossRefPubMed

Ranieri VM, Giunta F, Suter PM, Slutsky AS (2000) Mechanical ventilation as a mediator of multisystem organ failure in acute respiratory distress syndrome. JAMA 284:43–44CrossRefPubMed

Brun-Buisson C, Minelli C, Bertolini G, Brazzi L, Pimentel J, Lewandowski K, Bion J, Romand JA, Villar J, Thorsteinsson A, Damas P, Armaganidis A, Lemaire F (2004) Epidemiology and outcome of acute lung injury in European intensive care units. Results from the ALIVE study. Intensive Care Med 30:51–61CrossRefPubMed

Rubenfeld GD, Caldwell E, Peabody E, Weaver J, Martin DP, Neff M, Stern EJ, Hudson LD (2005) Incidence and outcomes of acute lung injury. N Engl J Med 353:1685–1693CrossRefPubMed

Lewandowski K, Rossaint R, Pappert D, Gerlach H, Slama KJ, Weidemann H, Frey DJ, Hoffmann O, Keske U, Falke KJ (1997) High survival rate in 122 ARDS patients managed according to a clinical algorithm including extracorporeal membrane oxygenation. Intensive Care Med 23:819–835CrossRefPubMed

Hemmila MR, Rowe SA, Boules TN, Miskulin J, McGillicuddy JW, Schuerer DJ, Haft JW, Swaniker F, Arbabi S, Hirschl RB, Bartlett RH (2004) Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg 240:595–605; discussion 605–597PubMed

Schuerer DJ, Kolovos NS, Boyd KV, Coopersmith CM (2008) Extracorporeal membrane oxygenation: current clinical practice, coding, and reimbursement. Chest 134:179–184CrossRefPubMed

10.

Pesenti A, Zanella A, Patroniti N (2009) Extracorporeal gas exchange. Curr Opin Crit Care 15:52–58CrossRefPubMed

11.

Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D (2009) Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 374:1351–1363CrossRefPubMed

12.

Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL (2009) Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 35:2105–2114CrossRefPubMed

13.

Kumar A, Zarychanski R, Pinto R, Cook DJ, Marshall J, Lacroix J, Stelfox T, Bagshaw S, Choong K, Lamontagne F, Turgeon AF, Lapinsky S, Ahern SP, Smith O, Siddiqui F, Jouvet P, Khwaja K, McIntyre L, Menon K, Hutchison J, Hornstein D, Joffe A, Lauzier F, Singh J, Karachi T, Wiebe K, Olafson K, Ramsey C, Sharma S, Dodek P, Meade M, Hall R, Fowler R (2009) Critically ill patients with 2009 influenza A (H1N1) infection in Canada. JAMA 302:1872–1879CrossRefPubMed

14.

Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, Zhu J, Sachdeva R, Sonnad S, Kaiser LR, Rubinstein NA, Powers SK, Shrager JB (2008) Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 358:1327–1335CrossRefPubMed

15.

Vassilakopoulos T, Zakynthinos S, Roussos C (2006) Bench-to-bedside review: weaning failure—should we rest the respiratory muscles with controlled mechanical ventilation? Crit Care 10:204CrossRefPubMed

16.

Schweickert WD, Pohlman MC, Pohlman AS, Nigos C, Pawlik AJ, Esbrook CL, Spears L, Miller M, Franczyk M, Deprizio D, Schmidt GA, Bowman A, Barr R, McCallister KE, Hall JB, Kress JP (2009) Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet 373:1874–1882CrossRefPubMed

17.

Sinderby C, Navalesi P, Beck J, Skrobik Y, Comtois N, Friberg S, Gottfried SB, Lindstrom L (1999) Neural control of mechanical ventilation in respiratory failure. Nat Med 5:1433–1436CrossRefPubMed

18.

Sinderby C (2003) Ventilatory assist driven by patient demand. Am J Respir Crit Care Med 168:729–730CrossRefPubMed

19.

Lellouche F, Brochard L (2009) Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare). Best Pract Res Clin Anaesthesiol 23:81–93CrossRefPubMed

20.

Beck J, Reilly M, Grasselli G, Mirabella L, Slutsky AS, Dunn MS, Sinderby C (2009) Patient-ventilator interaction during neurally adjusted ventilatory assist in very low birth weight infants. Pediatr Res 65:663–668CrossRefPubMed

21.

Barwing J, Ambold M, Linden N, Quintel M, Moerer O (2009) Evaluation of the catheter positioning for neurally adjusted ventilatory assist. Intensive Care Med 35:1809–1814CrossRefPubMed

22.

Colombo D, Cammarota G, Bergamaschi V, De Lucia M, Corte FD, Navalesi P (2008) Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure. Intensive Care Med 34:2010–2018CrossRefPubMed

23.

Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, Lamy M, Legall JR, Morris A, Spragg R (1994) The American–European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824PubMed

24.

Sinderby C, Beck J, Spahija J, de Marchie M, Lacroix J, Navalesi P, Slutsky AS (2007) Inspiratory muscle unloading by neurally adjusted ventilatory assist during maximal inspiratory efforts in healthy subjects. Chest 131:711–717CrossRefPubMed

25.

Sessler CN, Gosnell MS, Grap MJ, Brophy GM, O’Neal PV, Keane KA, Tesoro EP, Elswick RK (2002) The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 166:1338–1344CrossRefPubMed

26.

Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK (1997) Extracorporeal membrane oxygenation for adult respiratory failure. Chest 112:759–764CrossRefPubMed

27.

Gattinoni L, Pesenti A, Mascheroni D, Marcolin R, Fumagalli R, Rossi F, Iapichino G, Romagnoli G, Uziel L, Agostoni A et al (1986) Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA 256:881–886CrossRefPubMed

28.

Mols G, Loop T, Geiger K, Farthmann E, Benzing A (2000) Extracorporeal membrane oxygenation: a ten-year experience. Am J Surg 180:144–154CrossRefPubMed

29.

Putensen C, Hering R, Muders T, Wrigge H (2005) Assisted breathing is better in acute respiratory failure. Curr Opin Crit Care 11:63–68CrossRefPubMed

30.

Putensen C, Zech S, Wrigge H, Zinserling J, Stuber F, Von Spiegel T, Mutz N (2001) Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 164:43–49PubMed

31.

Esteban A, Frutos F, Tobin MJ, Alia I, Solsona JF, Valverdu I, Fernandez R, de la Cal MA, Benito S, Tomas R et al (1995) A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med 332:345–350CrossRefPubMed

32.

Kolobow T, Gattinoni L, Tomlinson TA, Pierce JE (1977) Control of breathing using an extracorporeal membrane lung. Anesthesiology 46:138–141CrossRefPubMed

33.

Brander L, Sinderby C, Lecomte F, Leong-Poi H, Bell D, Beck J, Tsoporis JN, Vaschetto R, Schultz MJ, Parker TG, Villar J, Zhang H, Slutsky AS (2009) Neurally adjusted ventilatory assist decreases ventilator-induced lung injury and non-pulmonary organ dysfunction in rabbits with acute lung injury. Intensive Care Med 35:1979–1989CrossRefPubMed

Titel: Autoregulation of ventilation with neurally adjusted ventilatory assist on extracorporeal lung support
verfasst von: Christian Karagiannidis
Matthias Lubnow
Alois Philipp
Guenter A. J. Riegger
Christof Schmid
Michael Pfeifer
Thomas Mueller
Publikationsdatum: 01.12.2010
Verlag: Springer-Verlag
Erschienen in: Intensive Care Medicine / Ausgabe 12/2010
Print ISSN: 0342-4642
Elektronische ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-010-1982-6

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Autoregulation of ventilation with neurally adjusted ventilatory assist on extracorporeal lung support