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Case Report: Neurally adjusted ventilatory assist as an effective rescue treatment for pulmonary interstitial emphysema in extremely low birth weight infants.

ABSTRACT: Pulmonary interstitial emphysema (PIE) is a complication observed in extremely low birth weight (ELBW) infants on mechanical ventilation. Despite various proposed therapeutic interventions, the success rates have shown inconsistency. Neurally adjusted ventilatory assist (NAVA) stands out as a novel respiratory support mode, offering lower pressure and tidal volume in comparison to conventional ventilation methods. In this case report, we present five ELBW infants with refractory PIE who were transitioned to NAVA ventilation. Following the switch to NAVA, all cases of PIE gradually resolved. In contrast to traditional modes, NAVA provided respiratory support with significantly lower fraction of inspired oxygen, reduced peak inspiratory pressure, diminished mean airway pressure, and decreased tidal volume within 7 days of NAVA utilization (p = 0.042, 0.043, 0.043, and 0.042, respectively). Consequently, we propose that NAVA could serve as a valuable rescue treatment for ELBW infants with PIE.

SUBMITTER: Chen CM

PROVIDER: S-EPMC10838975 | biostudies-literature | 2024

REPOSITORIES: biostudies-literature

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Case Report: Neurally adjusted ventilatory assist as an effective rescue treatment for pulmonary interstitial emphysema in extremely low birth weight infants.

Chen Chien-Ming CM Chung Mei-Yung MY Kang Hong-Ya HY Ou-Yang Mei-Chen MC Wang Teh-Ming TM Hsu Chung-Ting CT

Frontiers in pediatrics 20240122

Pulmonary interstitial emphysema (PIE) is a complication observed in extremely low birth weight (ELBW) infants on mechanical ventilation. Despite various proposed therapeutic interventions, the success rates have shown inconsistency. Neurally adjusted ventilatory assist (NAVA) stands out as a novel respiratory support mode, offering lower pressure and tidal volume in comparison to conventional ventilation methods. In this case report, we present five ELBW infants with refractory PIE who were tra ...[more]

PMID: 38318454

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Project description:Assist in unison to the patient's inspiratory neural effort and feedback-controlled limitation of lung distension with neurally adjusted ventilatory assist (NAVA) may reduce the negative effects of mechanical ventilation on right ventricular function.Heart-lung interaction was evaluated in 10 intubated patients with impaired cardiac function using esophageal balloons, pulmonary artery catheters and echocardiography. Adequate NAVA level identified by a titration procedure to breathing pattern (NAVAal), 50% NAVAal, and 200% NAVAal and adequate pressure support (PSVal, defined clinically), 50% PSVal, and 150% PSVal were implemented at constant positive end-expiratory pressure for 20 minutes each.NAVAal was 3.1?±?1.1cmH2O/?V and PSVal was 17?±?2 cmH20. For all NAVA levels negative esophageal pressure deflections were observed during inspiration whereas this pattern was reversed during PSVal and PSVhigh. As compared to expiration, inspiratory right ventricular outflow tract velocity time integral (surrogating stroke volume) was 103?±?4%, 109?±?5%, and 100?±?4% for NAVAlow, NAVAal, and NAVAhigh and 101?±?3%, 89?±?6%, and 83?±?9% for PSVlow, PSVal, and PSVhigh, respectively (p?<?0.001 level-mode interaction, ANOVA). Right ventricular systolic isovolumetric pressure increased from 11.0?±?4.6 mmHg at PSVlow to 14.0?±?4.6 mmHg at PSVhigh but remained unchanged (11.5?±?4.7 mmHg (NAVAlow) and 10.8?±?4.2 mmHg (NAVAhigh), level-mode interaction p?=?0.005). Both indicate progressive right ventricular outflow impedance with increasing pressure support ventilation (PSV), but no change with increasing NAVA level.Right ventricular performance is less impaired during NAVA compared to PSV as used in this study. Proposed mechanisms are preservation of cyclic intrathoracic pressure changes characteristic of spontaneous breathing and limitation of right-ventricular outflow impedance during inspiration, regardless of the NAVA level.Clinicaltrials.gov Identifier: NCT00647361, registered 19 March 2008.

Project description:We aimed to examine the effect of changing levels of support (NAVA level) during non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm infants with respiratory distress syndrome (RDS) on electrical diaphragm activity. This is a prospective, single-centre, interventional, exploratory study in a convenience sample. Clinically stable preterm infants supported with NIV-NAVA for RDS were eligible. Patients were recruited in the first 24 h after the start of NIV-NAVA. Following a predefined titration protocol, NAVA levels were progressively increased starting from a level of 0.5 cmH2O/µV and with increments of 0.5 cmH2O/µV every 3 min, up to a maximum level of 4.0 cmH2O/µV. We measured the evolution of peak inspiratory pressure and the electrical signal of the diaphragm (Edi) during NAVA level titration. Twelve infants with a mean (SD) gestational age at birth of 30.6 (3.5) weeks and birth weight of 1454 (667) g were enrolled. For all patients a breakpoint could be identified during the titration study. The breakpoint was on average (SD) at a level of 2.33 (0.58) cmH2O/µV. With increasing NAVA levels, the respiratory rate decreased significantly. No severe complications occurred.Conclusions: Preterm neonates with RDS supported with NIV-NAVA display a biphasic response to changing NAVA levels with an identifiable breakpoint. This breakpoint was at a higher NAVA level than commonly used in this clinical situation. Immature neural feedback mechanisms warrant careful monitoring of preterm infants when supported with NIV-NAVA.Trial registration: clinicaltrials.gov NCT03780842. Date of registration December 12, 2018. What is Known: • Non-invasive neurally adjusted ventilatory assist (NIV-NAVA) is a safe, feasible and effective way to support respiration in preterm infants. • Intact neural feedback mechanisms are needed to protect the lung from overdistension in neurally adjusted ventilatory assist. What is New: • Preterm infants with acute RDS have a similar pattern of respiratory unloading as previously described. • Neural feedback mechanisms seem to be immature with the risk of insufficient support and lung injury due to overdistension of the lung.

Project description:IntroductionThe objective was to compare the impact of three assistance levels of different modes of mechanical ventilation; neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), and pressure support ventilation (PSV) on major features of patient-ventilator interaction.MethodsPSV, NAVA, and PAV were set to obtain a tidal volume (VT) of 6 to 8 ml/kg (PSV₁₀₀, NAVA₁₀₀, and PAV₁₀₀) in 16 intubated patients. Assistance was further decreased by 50% (PSV₅₀, NAVA₅₀, and PAV₅₀) and then increased by 50% (PSV₁₅₀, NAVA₁₅₀, and PAV₁₅₀) with all modes. The three modes were randomly applied. Airway flow and pressure, electrical activity of the diaphragm (EAdi), and blood gases were measured. VT, peak EAdi, coefficient of variation of VT and EAdi, and the prevalence of the main patient-ventilator asynchronies were calculated.ResultsPAV and NAVA prevented the increase of VT with high levels of assistance (median 7.4 (interquartile range (IQR) 5.7 to 10.1) ml/kg and 7.4 (IQR, 5.9 to 10.5) ml/kg with PAV₁₅₀ and NAVA₁₅₀ versus 10.9 (IQR, 8.9 to 12.0) ml/kg with PSV₁₅₀, P <0.05). EAdi was higher with PAV than with PSV at level₁₀₀ and level₁₅₀. The coefficient of variation of VT was higher with NAVA and PAV (19 (IQR, 14 to 31)% and 21 (IQR 16 to 29)% with NAVA₁₀₀ and PAV₁₀₀ versus 13 (IQR 11 to 18)% with PSV₁₀₀, P <0.05). The prevalence of ineffective triggering was lower with PAV and NAVA than with PSV (P <0.05), but the prevalence of double triggering was higher with NAVA than with PAV and PSV (P <0.05).ConclusionsPAV and NAVA both prevent overdistention, improve neuromechanical coupling, restore the variability of the breathing pattern, and decrease patient-ventilator asynchrony in fairly similar ways compared with PSV. Further studies are needed to evaluate the possible clinical benefits of NAVA and PAV on clinical outcomes.Trial registrationClinicaltrials.gov NCT02056093 . Registered 18 December 2013.

Project description:To assess respiratory changes after neurally adjusted ventilatory assist (NAVA) initiation in preterm infants with evolving or established bronchopulmonary dysplasia (BPD). Premature infants born less than 32 weeks gestation with evolving or established BPD initiated on invasive or non-invasive (NIV) NAVA were included. Respiratory data: PCO₂ and SpO₂/FiO₂ (S/F) ratio before and at 4, 24, 48 h post-NAVA initiation were collected. Eighty-eight infants, median GA 25.1 (range 22.7-30.3) weeks, with 191 NAVA episodes were included. Infants born < 32 weeks with evolving and established BPD showed improvements in PCO₂ and S/F ratio 48 h post-NAVA compared to prior: 7.6 (4.5-11.8) versus 8.1 (4.7-13.1) kPa; p < 0.001 and 285 (118-471) versus 276 (103-471); p = 0.013, respectively. Improvements were observed in invasive NAVA: 7.6 (4.5-11.8) versus 8.5 (4.7-12.4) kPa; p = 0.001, 290 (148-471) versus 271 (103-467); p = 0.002, and NIV-NAVA: 7.5 (4.6-11.7) versus 7.9 (5.2-13.1) kPa; p = 0.001, 283 (128-471) versus 294 (114-471); p = 0.002. Severe BPD infants had reductions in PCO₂ 48 h post-initiation: 7.2 (5.6-9.7) versus 8.0 (5.4-11.7) kPa; p = 0.002, with lower FiO₂ requirements 0.37 (0.21-0.65) versus 0.43 (0.21-0.8); p = 0.011, and improved S/F ratios 263 (146-471) versus 219 (114-457); p = 0.006. On subgroup analysis, similar improvements were noted in; PCO2 levels in invasive NAVA (p = 0.011) and NIV-NAVA (p = 0.002), S/F ratios in invasive NAVA (p = 0.046) and NIV-NAVA (p = 0.002) and FiO₂ in invasive NAVA (p = 0.034) and NIV-NAVA (p = 0.053).Conclusion: NAVA improves CO₂ clearance and oxygenation in infants with evolving or established and severe BPD at 48 h post-initiation. In severe BPD, NAVA also reduced oxygen requirements What is Known: • NAVA has the potential to improve CO2 clearance and oxygenation by optimising alveolar ventilation, adapting to the infant's breathing patterns, and enhancing gas exchange. What is New: • The beneficial effects of NAVA are sustained in infants with evolving or established bronchopulmonary dysplasia (BPD), improving carbon dioxide clearance and oxygenation at 48 hours after initiation.

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Case Report: Neurally adjusted ventilatory assist as an effective rescue treatment for pulmonary interstitial emphysema in extremely low birth weight infants.

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Case Report: Neurally adjusted ventilatory assist as an effective rescue treatment for pulmonary interstitial emphysema in extremely low birth weight infants.

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