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

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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 discussing products made by Maquet Has no commercial interest in NAVA or Maquet Has received no financial support or incentives from Maquet to use NAVA or collect this data

3 Toledo Children s Hospital 151 bed hospital Level 3 NICU 60 beds Inborn 70% Outborn 30% 2012: > 800 admissions/year Average daily census patients

4 Neuro-ventilatory ventilatorycoupling Central nervous system P hrenic nerve D iaphragm excitation Neural Trigger Ventilator Unit Diaphragm contraction Chest wall and lung expansion Airway pressure, flow and volume Flow Trigger Assisted Breath Adapted from S inderby, Nature Med 1999

5 Central nervous system How NAVA works Phrenic nerve Diaphragm excitation Nasogastric tube Ventilator Unit Diaphragm contraction Chest wall and lung expansion Assisted Breath Airway pressure, flow and volume Adapted from Sinderby, Nature Med 1999

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 Is SIMV (pressure control) in premature infants really synchronized?

8 SIMV (pressure control) in a 3 week old ex 26 week infant with CLD shows evidence of flow triggering (purple lines).

9 SIMV (pressure control) with EDI superimposed shows the lack of synchrony on the flow triggered breaths

10 SIMV (Pressure Control) in an Apneic neonate

11 Apnea - Failure to trigger

12 Synchrony between chest movement and ventilator breaths

13 Data from Toledo Children s Hospital s NICU Normative Edi data Term neonates Premature neonates Prospective controlled study in VLBW neonates between NAVA and PC

14 Term Neonates with no active respiratory problems and feeding normally 20 * P < * * Overall Awake 10 Asleep Pre parandial Feeding 5 Post parandial 0 Edi Peak Edi Min Stein,Wilmoth and Burton J Resp Care 2012, 57(9):

15 Normative Edi Peak and Min at various gestational ages in non-ventilated premature neonates 20 Edi peak Edi (mcv) Edi min Gestational age (weeks) Stein, Davis and Hall J Perinatol 2013, 33:

16 NAVA Versus Pressure Control Gestational age: weeks Birth weight: grams Age at study: days NAVA ventilation for 4 hours Pressure Control ventilation for 4 hours Cycle repeated for 24 hours 4 hours NAVA 4 hours PC 4 hours NAVA 4 hours PC 4 hours NAVA 4 hours PC Stein. Alosh, Ethington and White 2032 J Perinatol 33 (6)

17 62 60,6 Tc pco2 (mmhg) 17 PIP (cm H2O) ,9 16, ,8 16,7 16, ,3 55,7 54,4 interval 1 interval 2 interval 3 15, , ,6 14,6 14,6 interval 1 interval 2 interval TV (ml/kg) Compliance (ml/cmh2o) 0,5 3,2 0,4 3 0,39 2,7 0,4 0,33 0,3 0,33 2,4 2,5 2,2 0,2 0,26 0,21 0,1 interval 1 interval 2 interval 3 interval 1 interval 2 interval 3 NAVA Pressure Control p < 0.05 Stein. Alosh, Ethington and White 2032 J Perinatol 33 (6)

18 Non-Invasive NAVA Ventilation Available since July 2010 About 90 patients treated with NIV NAVA Uses: Prevent intubation Facilitate earlier extubation

19 Case Presentation 26 weeks, 655 grams Extubated on day 1 to NIV NAVA NIV NAVA for 6 days and then HFNC 5 lpm 23 weeks, 650 grams NAVA invasively by 2 hours Extubated at 36 hours to NIV NAVA NIV NAVA for 8 days, CPAP for 1 day and then HFNC 5 lpm

20 NIV NAVA 3 day old, 655 grams vs. 3 day old, 650 grams 26 weeks gestation 23 weeks gestation

21 Clinical Guidelines Ventilator settings in NAVA: Apnea time Peak Inspiratory pressure alarm How to set the NAVA level

22 Apnea Time Time the neonate is apneic before getting a backup breath Apnea time can now be lowered to minimum of 2 seconds After 2 seconds the neonate gets a pressure control breath This allows the user to deliver a minimum guaranteed back-up rate of 30 breaths/min

23 Apnea Time Apnea alarm Minimum rate 15 sec 4 breaths/min 10 sec 6 breaths/min 5 sec 12 breaths/min 4 sec 15 breaths/min 3 sec 20 breaths/min 2 sec 30 breaths/min This is different from the backup rate: RR when the neonate is apneic and getting pressure control

24 Peak Inspiratory pressure alarm Case presentation: 32 weeks gestation Primary C-section for maternal PIH 1.8 kg Apgars 7/8 8 minutes developed grunting and retractions placed on CPAP 5 CXR showed mild to moderate RDS

25 ph 7.05 pco2 98 BE ph 7.14 pco2 80 BE -5 ph 7.25 pco2 56 BE -4 ph 7.30 pco2 50 BE Respiratory Rate 40 Edi Peak 20 Peak Pressure 0 3:18 4:18 5:18 6:18 7:18 8:18 9:18 10:18 11: CPAP NIV PC 14/5, rate NIV NAVA 2 PEEP 5 PIP Limit NIV NAVA 2 PEEP 5 PIP Limit 40

26 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

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28 Edi Titration Study to determine the optimal NAVA level 0,5 1 1,5 NAVA Level 2 2,5 3 3, Time (minutes)

29 Edi Titration Study to determine the optimal NAVA level Peak Inspiratory Pressure (cmh20) 10 5 Edi Peak (mcv) NAVA Level

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

31 Determining the Breakpoint (BP) 25 Edi (mcv) Peak Pressure (cmh2o) BP-2 BP-1.5 BP-1 BP-0.5 BP BP+0.5 BP+1 BP+1.5 BP+2 NAVA Level

32 NAVA WORKS IN NEONATES! But does it make a difference? TCH VON data - neonates < 1500 grams Comparison group Level 3 B NICUs Time line events: Feb 2008 moved into the new NICU May 2008 NAVA 2009 OPQC collaborative line infection July 2010 NIV NAVA

33 Changes in practice in TCH NICU From VON Database for Neonates < 1500 grams % NAVA OPQC NIV NAVA Ventilation

34 Changes in practice in TCH NICU From VON Database for Neonates < 1500 grams % NAVA OPQC NIV NAVA Ventilation NIV

35 Changes in practice in TCH NICU From VON Database for Neonates < 1500 grams % NAVA OPQC NIV NAVA Ventilation NIV CPAP before Intubation

36 % Late infection in neonates < 1500 grams - VON Data NAVA OPQC NIV NAVA % 75%

37 % Late infection in neonates < 1500 grams - VON Data NAVA OPQC NIV NAVA Late infection 50% 75%

38 % CLD in neonates < 1500 grams VON Data NAVA OPQC NIV NAVA % 75%

39 % CLD in neonates < 1500 grams VON Data NAVA OPQC NIV NAVA CLD < 33 weeks 50% 75%

40 Median LOS (days) in neonates < 1500 grams - VON Data NAVA OPQC NIV NAVA VON 50% VON 75%

41 Median LOS (days) in neonates < 1500 grams - VON Data NAVA OPQC NIV NAVA LOS VON 50% VON 75%

42 % Death or Morbidity in neonates < 1500 grams NAVA OPQC NIV NAVA % 75%

43 % Death or Morbidity in neonates < 1500 grams NAVA OPQC NIV NAVA Death or morbidity 50% 75%

44 % Survival without Morbidities in neonates < 1500 grams NAVA OPQC NIV NAVA NAVA OPQC NIV NAVA VON 50% VON 75%

45 % Survival without Morbidities in neonates < 1500 grams NAVA OPQC NIV NAVA NAVA OPQC NIV NAVA Survival without morbidities VON 50% VON 75%

46 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? NAVA decreases the incidence of chronic lung disease? NAVA improves outcomes? NAVA decreases costs

47 NAVA Graduate to Halloween Hotdog????????????