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2017-10-05
1
NAVA-korzyści dla noworodka
Jan Mazela
Poznan University of Medical Sciences
Poznan, Poland
DISCLOSURE
• No conflict of interest related to this topic
POZNAŃ POZNAŃ andandWIELKOPOLSKAWIELKOPOLSKA REGIONREGION
EUROPE POLAND
WIELKOPOLSKA
REGION
POZNAŃ
••4 4 mlnmln level III center (7 level II and 24 level I)level III center (7 level II and 24 level I)••773300 deliveries00 deliveries••400 400 outbornoutborn admissionsadmissions••900 NICU admissions900 NICU admissions••337 NICU beds7 NICU beds
Poznan Poznan UnivUniv of Med Sciences NICUof Med Sciences NICU
2017-10-05
2
• Intro/basics
• How it looks/how it works?
• Status quo in the literature
• How to tune-up NAVA ventilation
• Ventilation Induced Diaphragm Dysfunction
Comparison of TriggeringMethods
Method Advantages Disadvantages
Impedance No added dead space, noninvasive Poor sensitivity, many artifacts
Pneumatic Capsule Rapid response, no extra dead
space, leak tolerant
Positioning is critical, no longer
commercially available
Pressure No added dead space, leak
tolerant
Poor sensitivity, long trigger
delay, high WOB
Airflow Very sensitive, rapid response Added dead space, leak
sensitive
Diaphragm EMG - Edi Sensitive, most rapid
response, leak tolerant
Requires careful positioning
of probe
State of the art in mechanical ventilation, Keszler, J of Perinatology (2009) 29, 262-75
NAVA
neurally adjusted
ventilatory assist
How NAVA works
The ventilator generates the peak inspiratory pressure
based on the amount of electrical activity generated
by the diaphragm
The PIP is generated until the electrical activity
decreases by 40 to 70% and then the breath is
terminated
The baby therefore determines the peak inspiratory
pressure, the inspiratory and termination time for
each breath and the respiratory rate
2017-10-05
3
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 (Allo
2006, Emeriaud, Beck 2008)
Edi trigger – the change in Edi needed to trigger the ventilator to deliver a breath
NAVA Terminology
NAVA level - Conversion factor that translates the Edi from an electrical signal to a peak inspiratory pressure (PIP)
Calculated by:
PIP = NAVA level x(Edi peak – Edi min) + PEEP
NAVA Terminology
PIP = NAVA level x(Edi peak – Edi min) + PEEP
NAVA level 2 Edi peak 12 Edi min 2 PEEP 5
PIP = 2 x (12 – 2) + 5 = 2 x (10) + 5 = 25 mmHg
Brainstem senses decreased pH or increased pCO2 – wants to increase tidal volume – increases the electrical signal to the diaphragm
NAVA level 2 Edi peak 15 Edi min 2 PEEP 5
PIP = 2 x (15 - 2) + 5 = 2 x (13) + 5 = 31 mmHg
NAVA Terminology
PIP = NAVA level x (Edi peak – Edi min) + PEEP
NAVA level 3 Edi peak 12 Edi min 2 PEEP 5
PIP = 3 x (12 – 2) + 5 = 3 x (10) + 5 = 35 mmHg
Brainstem senses increased pH or decreased pCO2 – wants to decrease tidal volume – decreases the electrical signal to the diaphragm
NAVA level 3 Edi peak 8 Edi min 2 PEEP 5
PIP = 3 x (8 - 2) + 5 = 3 x (6) + 5 = 23 mmHg
2017-10-05
4
Conventional Ventilation
Patient Controls using Flow Trigger:
Initiation of Breath Rate (in some modes)
Ventilator Controls:
Peak Pressure or Tidal VolumeInspiratory TimeTermination of BreathPEEPMinimum RateFiO2
Synchrony:
Only for Initiation of BreathAsynchronous for Many BreathsFalse Triggering
NAVA Ventilation
Patient Controls using Neural Trigger:
Initiation of BreathInspiratory TimeRatePeak PressureTermination of Breath
Ventilator Controls:
FiO2
PEEP
Synchrony:
Initiation of BreathSize of BreathTermination of Breath
Edi
VT
Health Disease
Neuroventilatory coupling
μV μV μV
ml ml ml
NAVA is not only about triggering Neural Control of Ventilatory Assist (NAVA)
Neu
ro-V
enti
lato
ry C
ou
pli
ng Central Nervous System
↓↓↓↓Phrenic Nerve
↓↓↓↓Diaphragm Excitation
↓↓↓↓Diaphragm Contraction
↓↓↓↓Chest Wall and Lung
Expansion↓↓↓↓
Airway Pressure, Flow and Volume
New
Technology
Ideal
Technology
Current
Technology
Ventilator
Unit
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Edi Catheter
Fr (French) = circumference of the catheter in mm
1. Connection to Edi cable
2. Nutrition feed
3. Evacuation (only 12 and 16 Fr)
4. Reference electrode
5. Electrodes (9)
6. Holes for nutrition/evacuation
7. Inter Electrode Distance (IED)
8. Lumen for electrodes
9. Sump lumen (only 12 and 16 Fr)
10. Feeding lumen
11. Barium strip for X-ray identification
12. Coating for easier insertion and better
electrical conductivity (indicated in the
picture with light blue)
13. Scale in centimeters from the tip
Edi catheter preparation
Ventilator set-up Catheter positioning
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Catheter positioning 2 NAVA ventilation tuning
NAVA ventilation tuning
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How does it work in real life? Status quo in the literature• 235 peer reviewed manuscripts
• Latest systematic review: Beck J, et al.
Minnerva Anestesiologica 2016; 82(8):874
• Clinical studies on newbrons:
– Invasive NAVA: 6 studies (n=106 baies);
GA=24weeks, bw=728g
– Non-invasive NAVA: 2 studies (n=17 babies);
GA=24 weeks, bw=812g
• Results:
– Limits PIP and TV
– Superior patient-ventilator interaction
Electrode Array in Neurally Adjusted Ventilatory
Assist (NAVA)
Sinderby et al, Nature Medicine 1999; 5(12):1433-1436
2017-10-05
8
Mechanical ventilation induces
prolonged neural expiratory time
• 14 patients with ARDS
• Draeger Babylog 8000– Trigger setting @1
– Flow 10 L/min
• Eadi measured with esophageal electrodes
• CONCLUSIONS:– No reflex deactivation of the diaphragm during SIMV
– 53% infant-ventilator asynchrony of the total breath
– Asynchrony associated predominantly with expiratory asynchrony
– Online monitoring of diaphragm activation during IMV
Beck, J., et al., Pediatr Res, 2004. 55(5): p. 747-754.
Mechanical ventilation induces
prolonged neural expiratory time
Beck, J., et al., Pediatr Res, 2004. 55(5): p. 747-754.
NAVA improves synchrony and
respiratory unloading
• 12 New Zealand rabbits
– (ARDS lung lavage model)
– Servo I (VT=6 mL/kg, RR=20, FiO2=0.5, PEEP=2 cmH2O)
– Incremental PSV and NAVA run for each animal
• CONCLUSIONS:
– NAVA requires small increase in airway pressure to unload the
diaphragm
– NAVA interferes less with natural breathing pattern than PSV
Beck, J., et al., Pediatr Res, 2007. 61(3): p. 289-294. Beck, J., et al., Pediatr Res, 2007. 61(3): p. 289-294.
NAVA improves synchrony and respiratory unloading
NAVA lo NAVA hi PSV lo PSV hi
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NAVA in LBW infants
• 7 premature infants < 36 weeks ga– 5F oro-gastric tube
– Conventional ventilation group: Babylog Draeger, PSV
– NAVA group: Servo300 with NAVA:• Intubated – ET tube, NAVA matched PIP
• Non-intubated – SNP tube, NAVA adjusted to reach this same delta IP
• CONCLUSIONS:– Patient-ventilator synchrony not affected by the presence
of leak
– Interface with less leak would increase the efficiency of non-invasive ventilation with NAVA
Beck, J., et al., Pediatr Res, 2009. 65(6): p. 663-668.
NAVA in LBW infants
Beck, J., et al., Pediatr Res, 2009. 65(6): p. 663-668.
PSV+VG NAVANIV NAVA
NAVA NIV NAVA
PSV+VGPSV
Synchrony is not affected by leaks
during non-invasive ventilation
Beck, J., et al., Pediatr Res, 2009. 65(6): p. 663-668.
Patient-ventilator synchrony in children
Beck J, et al. Minnerva Anestesiologica 2016; 82(8):874
2017-10-05
10
Edi Catheter positioning procedure
Edi Catheter positioning window
• Four ECG waveforms
for Edi catheter
position
• Edi waveform
• Scale and sweep
speed settings
• Freeze function
• Numerical values of
Edi peak and Edi min
Fine-tune the settings in Pressure Support
Trigger Edi
• Trigger Edi zawsze na 0.5 uV
NAVA estimation
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2017-10-05
12
NAVA titration
• Starting at NAVA=0.5 => every 3 minutes increases
until NAVA=4
Edi from 1 premie Edi from all premies
Firestone KS, et al. J Perinatol 2015;35:612e6.
Edi Peak and Minimum
Neonates > 37 weeks with no active respiratory problems and feeding
normally
**
* P < 0.05
Stein ,Wilmoth and Burton 2010
Beck J, et al. Minnerva Anestesiologica 2016; 82(8):874
NAVA optimization
• Optimize the NAVA level according to Edi max, which
should be targeted between 5-15 μV.
- If Edi max is < 5 μV, decrease the NAVA level.
- If Edi max is > 15 μV, increase the NAVA level.
• The changes in NAVA level should be 0.1-0.2 cmH2O/μV
at a time. The changes in NAVA level are mediated in a
few breaths to Edi max. The usual NAVA level is 0.5 – 2.0
cmH2O/μV.
2017-10-05
13
Setting up PEEP
• Initially, set the same PEEP as in the previous
ventilator settings. If Edi min is constantly > 1
μV (as a sign of tonic diaphragmatic activity to
maintain FRC), increase PEEP.
Setting up apnea time
• Set the initial apnea time at 5 seconds. If
breathing is irregular and the patient unstable,
you may decrease apnea time down to 2
seconds. This will result in backup breaths after
each 2-second apnea until next spontaneous
breath indicated by Edi signal occurs. However,
make sure that the backup ventilation does not
hyperventilate the patient preventing
spontaneous breathing efforts (which would
keep the patient unnecessarily on backup
ventilation).
Back-up settings
• A shorter apnea time (<5 seconds ) increases
the significance of backup ventilation, as there
is a risk for hyperventilation. This does not
usally occur with NAVA ventilation.
• Adjust the backup settings appropriately
taking into account the pre-NAVA settings and
the recovery process of the patient.
Weaning patients from NAVA
• Decrease the NAVA level as the patient’s
pulmonary status improves. Usually, the
patient is ready to be extubated when the
NAVA level is ≤ 0.5 cmH2O/μV.
2017-10-05
14
NIV NAVA in practice
• The NAVA levels in NIV NAVA are usually lower
than in invasive NAVA (0.5 – 1.0 μV/cmH2O).
Higher NAVA levels may increase the amount of
gas entering the stomach/intestine and cause
abdominal distention.
- If Edi max is < 5 μV, decrease the NAVA level.
- If Edi max is > 20 μV, increase the NAVA level.
• The changes in NAVA level should be 0.1-0.2
μV/cmH2O at a time. Usually, patient can be
switched to nCPAP, when the NAVA level is < 0.5
cmH2O/μV.
NIV NAVA
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15
NIV NAVA
NIV NAVA
NIV CPAP
When using nCPAP NAVA set-up NAVA=0
2017-10-05
16
2d of life, 750g, 1 dose of SurvantaPIP decreases when on NAVA
0
5
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:00P
ea
k a
irw
ay p
res
su
re
[cm
H₂₂ ₂₂O
]
0
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30
35
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:00P
ea
k a
irw
ay p
res
su
re
[cm
H₂₂ ₂₂O
]
0
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30
12
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00
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Pe
ak
air
wa
y p
res
su
re
[cm
H₂₂ ₂₂O
]
0
10
20
30
40
50
18
:00
19
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23
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00
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:00
Pe
ak
air
wa
y p
res
su
re
[cm
H₂₂ ₂₂O
]
32 weeks, 2140 gm, CLD , NAVA 533 weeks, 2260 gm, RDS , NAVA 2.5
30 weeks, 1150 gm, RDS and
pneumothorax, NAVA 2
3 month old ex 28 week infant with
pulmonary hypoplasia, NAVA 2
Dynamic Compliance improves on
NAVA
0
0,5
1
1,5
2
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:…
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:…
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00
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01
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02
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:…
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:…
06
:…
Dyn
am
ic c
om
plia
nc
e
[ml/c
mH₂₂ ₂₂O
]
0
0,2
0,4
0,6
0,8
1
1,2
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:…
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Dyn
am
ic c
om
plia
nc
e
[ml/c
mH₂₂ ₂₂O
]
0
0,3
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1,2
1,5
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:…
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:…
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00
:…
Dyn
am
ic c
om
plia
nc
e
[ml/c
mH₂₂ ₂₂O
]
0
0,5
1
1,5
2
2,5
3
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:00
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00
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:00
Dyn
am
ic c
om
plia
nc
e
[ml/c
mH₂₂ ₂₂O
] **
**
Neonates with Acidosis - on
SIMV/PC and then on NAVA
7,05
7,1
7,15
7,2
7,25
7,3
7,35
7,4
7,45
SIMV/PC NAVA
pH < 7.38
7.29
35
45
55
65
75
85
pCO2 > 45SIMV/PC NAVA
7.32
P = 0.018
P = 0.0008
55.9
49.5
2017-10-05
17
Neonates with Alkalosis - on
SIMV/PC and then on NAVA
7,3
7,35
7,4
7,45
7,5
7,55
SIMV/PC NAVA
pH > 7.42
10
20
30
40
50
SIMV/PC NAVA
pCO2 < 35
7.47
7.39
P = 0.004
34.5
29.9
P = 0.05
Neonates with normal pH and pCO2
- on SIMV/PC and then on NAVA
20
30
40
50
60
SIMV/PC NAVA
pCO2 35 - 45
7,3
7,35
7,4
7,45
7,5
SIMV/PC NAVA
pH 7.38 - 7.42
7.39
7.38
39.5 40.8
P = 0.82P = 0.45
0
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Pe
ak
air
wa
y p
res
su
re
[cm
H₂₂ ₂₂O
]
NAVA 2.2
NAVA allows neonates to wean
their own PIP over time
0
5
10
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02
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Pe
ak
air
wa
y p
res
su
re
[cm
H₂₂ ₂₂O
]
NAVA 0.5
0
5
10
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20
25
30
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:00
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Pe
ak
air
wa
y p
res
su
re
[cm
H₂₂ ₂₂O
]
0
5
10
15
20
25
30
35
40
06
:00
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:00
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:00
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:00
14
:00
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:00
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:00
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:00
22
:00
00
:00
02
:00
04
:00
06
:00
Pe
ak a
irw
ay p
res
su
re
[cm
H₂₂ ₂₂O
]
NAVA 2 NAVA 3.2
Improved Compliance over time on NAVA
0,5
0,8
1,1
1,4
1,7
2
2,3
06
:00
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:00
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:00
Dyn
am
ic c
om
plia
nc
e
[ml/c
mH₂₂ ₂₂O
]
0
0,5
1
1,5
2
2,5
02
:00
03
:00
04
:00
05
:00
06
:00
07
:00
08
:00
09
:00
10
:00
11
:00
12
:00
13
:00
14
:00
Dyn
am
ic c
om
plia
nc
e
[ml/c
mH₂₂ ₂₂O
]
0,5
1
1,5
2
2,5
3
19
:00
20
:00
21
:00
22
:00
23
:00
00
:00
01
:00
02
:00
03
:00
04
:00
05
:00
06
:00
Dyn
am
ic c
om
plia
nc
e
[ml/c
mH₂₂ ₂₂O
]
0
0,3
0,6
0,9
1,2
1,5
06
:00
08
:00
10
:00
12
:00
14
:00
16
:00
18
:00
20
:00
22
:00
00
:00
02
:00
04
:00
06
:00
Dyn
am
ic c
om
plia
nc
e
[ml/c
mH₂₂ ₂₂O
]
2017-10-05
18
Diaphragm activity
2017-10-05
19
Summary
• Neonates appear to have intact neuro-ventilatory coupling with functional feedback pathways.
• Patient selection is important – not all neonates are candidates for NAVA and, some may not be candidates all the time (sedation, PPHN, IVH, CNS)
• Many neonates ventilate on NAVA with lower PIP (TV) and FiO2 then on conventional ventilation.
Summary
• Many neonates improve their blood gases on NAVA despite ventilating with lower pressures.
• Many neonates decrease their own PIP (TV) over time while on NAVA – “auto weaning”
• Many neonates have improved compliance on NAVA.
• In this small number of patients no significant complications or side effects were noted while on NAVA.
• Large multi-center trials are needed to answer questions if: – NAVA decreases time on ventilators?
– NAVA decreases the incidence of chronic lung disease?
– Is it helpful for MIST/INSURE?
But does it make a difference to outcomes?
NAVA WORKS IN
NEONATES!Thank you