Innovations in Neonatal Ventilation NAVA Neurally Adjusted Ventilatory Assist Howard Stein, M.D. Director Neonatology, Promedica Toledo Children s Hospital Clinical Professor of Pediatrics, University of Toledo Health Science Campus Toledo, Ohio Dr Stein: Disclosures 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 Breathing Easy Respiratory Management in the Modern Era San Antonio, August 8, 16 NAVA Terminology EADi Electrical Activity of the Diaphragm Abbreviated as Edi Edi Peak - peak electrical activity tells you about the neural inspiratory effort Edi Min tonic electrical activity believed to play a role in preventing de-recruitment of the lung SIMV (pressure control) with EDI superimposed shows the lack of synchrony on the flow triggered breaths Pvent Flow Volume Edi Peak Edi Min Edi 1
Apnea - Failure to trigger Conventional Ventilation Patient Controls using Flow Trigger: Rate (in some modes) NAVA Ventilation Patient Controls using Neural Trigger: Inspiratory Time Rate Peak Pressure Ventilator Controls: Peak Pressure or Tidal Volume Inspiratory Time PEEP Minimum Rate FiO2 Synchrony: Only for Ventilator Controls: FiO2 PEEP Apnea time (minimum rate) Peak Inspiratory pressure alarm Synchrony: Size of Breath Conventional Ventilation Flow Trigger: Based on patient s effort NAVA Ventilation Neural Trigger: Based on patient's drive Clinical Guidelines When breathing: Ventilator synchronous for: Breath initiation only When apneic: Ventilates in pressure (or volume) control When breathing: Ventilator synchronous for: Breath initiation, size, and termination When apneic: Ventilates in pressure control Ventilator settings in NAVA: Apnea time Peak Inspiratory pressure alarm How to set the NAVA level Apnea Time 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 3 breaths/min Apnea alarm Minimum rate 1 sec breaths/min 1 sec 6 breaths/min sec 12 breaths/min sec 1 breaths/min 3 sec breaths/min 2 sec 3 breaths/min This is different from the backup rate: RR when the neonate is apneic and getting pressure control 2
Peak Inspiratory Pressure Alarm Peak Inspiratory Pressure Alarm Prevents High Pressures Peak Inspiratory pressure alarm Case presentation: 1 8 6 1 2 3 ph 7. ph 7.1 ph 7.2 pco2 98 pco2 8 pco2 6 BE -8 BE - BE - ph 7.3 pco2 BE -3 Respiratory Rate 32 weeks gestation Primary C-section for maternal PIH 1.8 kg Apgars 7/8 8 minutes developed grunting and retractions placed on CPAP CXR showed mild to moderate RDS Edi Peak Peak Pressure 3:18 :18 :18 6:18 7:18 8:18 9:18 1:18 11:18 1 - CPAP 2 - NIV PC 1/, 3 - NIV NAVA 2 - NIV NAVA 2 rate PEEP PEEP PIP Limit PIP Limit Stein H, Firestone K: Neonatology Today, 12, 7(), 1-8. 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 Edi Titration Study to determine the optimal NAVA level. 1 1. 2 3 6 9 12 1 18 21 2 Time (minutes) 2. 3 3. 3
Edi Titration Study to determine the optimal NAVA level 3 Change in Breakpoint from NAVA to NIV NAVA NAVA 1 1 Breakpoint Peak Inspiratory Pressure (cmh) Peak Pressure (cm H 2 O) 2 1 1 Edi Peak (mcv). 1 1. 2 2. 3 3. BrP-1 BrP-. BrP NAVA BrP+. BrP+1 BrP+1. BrP+2 LoVerde, Stein and Firestone, - in submission Change in Breakpoint from NAVA to NIV NAVA 3 NAVA NIV NAVA Pressure and Volume Distribution in Premature Neonates Peak Pressure (cm H 2 O) 2 1 1 1.2 1.6 16 Variable (+ SD) NAVA NIV NAVA # Neonates 2 12 Birth weight grams 87 (362) 83 (179) Study weight grams 862 (361) 8 (16) Gestational age weeks 26. (2.3) 26.8 (1.) Study age - days 8 (9) 13 (12) Ave # Breaths /neonate 29,66,3 NAVA BrP-1 BrP-. BrP NAVA BrP+. BrP+1 BrP+1. BrP+2 NIV NAVABrP-1. BrP-1 BrP-. BrP NIV NAVA BrP+. BrP+1 BrP+1. Total breaths 711,98,361 Stein, Firestone 1 - in submission
Adult Infant NAVA Improves Synchrony (Courtesy of Dr. Beck, revised October 1) Asynchrony Index NAVA Asynchrony Index Conventional Number of Patients Type INV or NIV? (%) (%) AUTHOR/Year Mauri 12 1 Adult ARDS and ECMO INV 7 Piquilloud ICM 11 22 Adult mixed INV. 12 Bertrand 12 13 Adult mixed NIV 2 12 Spahija 1 9 Adult mixed INV 26 vaschetta 1 Adult mixed INV 22 Wu Zhonghua Jie He He Hu Xi Za Zhi 9 18 Adult ARDS INV 22 Terzi CCM 1 11 Adult ARDS INV 2 11 Colombo 8 1 mixed adult INV Delisle Sleep 11 1 mixed adult INV Piquilloud ICM 12 13 Adult mixed NIV.9 1.8 schmidt Dres ccm 12 17 Adult mixed NIV 1.8 26.3 Camarotta ICM 11 1 helmet adult NIV 2 Doorduin 1 12 Adult COPD niv 21 Moerer ICM 8 7 helmet healthy NIV 8 Beck Ped Res 9 7 NICU INV and NIV Clement 11 23 PICU INV Bentsson 1 21 PICU INV zhu 1 1 PICU INV 22 Vignaux pccm 13 19 PICU INV 3.8 29 Bordessoule 12 1 PICU mixed INV 11 2 De la Oliva 12 12 PICU mixed INV 2 12 Breatnach 1 16 PICU NICU INV Alander 11 18 PICU NICU INV 8.7 27. Chen 13 1 NICU INV Ducharme-Crevier 1 13 PICU NIV 8 27 Houtekie 1 1 PICU post cardiac NIV Longhini 1 12 NICU INV 22 Vignaux pccm 13 6 PICU NIV 2.3 Baudin 1 11 PICU NIV 3 38 Lee 1 1 NICU NIV 19.7 73 TOTAL (ALL STUDIES) 2 TOTAL when AI reported 272.26 28.3 Edi monitoring is essential for: quantifying the strength of spontaneous breathing, unloading of the diaphragm Detecting patient-ventilator asynchrony detecting central apnea and its therapy Detecting over-assist/sedation Accurate respiratory metrics AI = Asynchrony Index 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 NAVA often provides lower PIPs and may be lung protective NAVA provides equivalent or improved ABGs and FIO2 NAVA Appears safe PIP and TV are mostly below typical range for CV To date no adverse outcomes reported (23 peer reviewed publications, are in pediatric patients) NAVA improves comfort, incidence of central apnea (2 trials) NAVA reduces sedation requirements (1 trial) NAVA reduces length of stay in infants (2 trials) 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