Elsevier

Journal of Critical Care

Volume 29, Issue 2, April 2014, Pages 312.e1-312.e5
Journal of Critical Care

Electronic Article
Neurally adjusted ventilatory assist vs pressure support ventilation in infants recovering from severe acute respiratory distress syndrome: Nested study,☆☆

https://doi.org/10.1016/j.jcrc.2013.08.006Get rights and content

Abstract

Objective

Neurally adjusted ventilatory assist (NAVA) is a new ventilator modality with an innovative synchronization technique. Our aim is to verify if NAVA is feasible and safe in terms of physiological and clinical variables in infants recovering from severe acute respiratory distress syndrome (ARDS).

Design

This is a pilot nested study to help future trial design.

Setting

The study was performed in third-level academic pediatric intensive care units.

Patients

Infants affected by severe ARDS requiring high-frequency ventilation and weaned with NAVA during 2010 were included. Controls (2:1 ratio) were ARDS infants weaned with pressure support ventilation (PSV) during 2008-2009 matched for age, gas exchange impairment, and weight.

Main outcome measures

The main outcome measures were the physiological and ventilator parameters and the duration of ventilator support in PSV or NAVA.

Results

Ten infants treated with NAVA and 20 with PSV were studied. Heart rate (P < .001) and mean arterial pressure (P < .001) increased less during NAVA than during PSV. Similarly, Pao2/Fio2 ratio decreased less in NAVA than in PSV (P < .001). Neurally adjusted ventilatory assist also resulted in lower Paco2 (P < .001) and peak pressure (P = .001), as well as higher minute ventilation (P = .013). COMFORT score (P = .004) and duration of support were lower in NAVA than in PSV (P = .011).

Conclusions

Neurally adjusted ventilatory assist is safe and suitable in infants recovering from severe ARDS. It could provide better results than PSV and is worth to be investigated in a multicenter randomized trial.

Section snippets

Background

Mechanical ventilation has significantly evolved in recent years; and a general trend towards a more gentle ventilatory approach is widely accepted to reduce negative consequences, such as ventilation-associated pneumonia and ventilator-induced lung injury [1]. Accordingly, new ventilatory techniques have been proposed, especially for patients with severe lung injury needing long ventilation [1], [2], [3].

One of the most recent novelties is the neurally adjusted ventilatory assist (NAVA), which

Study population

Eligible patients were all infants younger than 1 year affected by ARDS according to the American/European Consensus criteria [20] and needing to be ventilated by “rescue” high-frequency oscillatory ventilation (HFOV). The criteria to start HFOV are defined below. Since NAVA was introduced in our pediatric intensive care unit (PICU) in January 2010, from this date onwards, NAVA was used to wean patients after the critical phase under HFOV.

For each study patient, 2 control infants were chosen

Results

All eligible infants with severe ARDS hospitalized during 2010 and treated with HFOV were enrolled. Table 1 reports baseline details of patients and the nested control group: the 2 groups were well matched for basic confounding variables and had similar clinical severity in terms of PRISM-III24. All babies were successfully extubated, and no reintubation was performed in both groups. Two babies per each group died several months after the extubation (2 for sepsis, 1 for bronchopulmonary

Discussion

This is the first preliminary study with a parallel design about NAVA in infants affected by severe ARDS. Physiologic and ventilatory findings suggest that NAVA is safe and noninferior to PSV in the weaning phase of severe pediatric ARDS.

Our data are consistent with previous results coming from an animal model of pediatric acute lung injury: similar reduction of peak pressure and improved synchrony were described [10]. In NAVA, we also found a tendency toward a RR higher than in PSV; and

Conclusions

Neurally adjusted ventilatory assist seems well tolerated and feasible in infants recovering from severe ARDS previously requiring HFOV. It may be valuable in the weaning phase of severe pediatric ARDS, and the present data are useful to build adequately powered randomized clinical trials.

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    Authors’ contribution: MP ideated the study, analyzed data, and wrote the first draft of the paper. DLD analyzed data, gave important contribution to study design, and wrote the article draft. RC collected data, performed the neurally adjusted ventilatory assist tracing analysis, and gave important intellectual contribution to the paper. DB, FV, LM, AP, and RDS collected data and helped in their analysis and interpretation. They also gave important intellectual contribution to the paper. GC helped to design the study, supervised the whole research, and gave important intellectual contribution both to the data acquisition and interpretation and to the paper preparation. All coauthors approved the paper in the final version.

    ☆☆

    Competing interests: The authors have no conflict of interests, financial relationship, or funding to declare.

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