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Objective:To explore the prognostic effect and safety of neurally adjusted ventilatory assist (NAVA) mode on the patients with severe neurological cerebrovascular disease undergoing mechanical ventilation.Methods:A prospective study was conducted. Fifty-four patients with cerebrovascular disease undergoing mechanical ventilation admitted to the neurosurgery intensive care unit (NSICU) of the First Affiliated Hospital of Wannan Medical College (Yijishan Hospital) from December 2020 to May 2022 were enrolled. They were divided into NAVA group and pressure support ventilation (PSV) group by computer random number generator with 27 patients in each group. The ventilation time of the two groups was ≥72 hours. The general basic data of the two groups were recorded. The time without mechanical ventilation 28 days after enrollment, total length of mechanical ventilation, survival rate of 90 days after enrollment, length of NSICU stay, total length of hospital stay, NSICU mortality, in-hospital mortality, Glasgow outcome score (GOS), complications related to mechanical ventilation, and changes of respiratory mechanics indexes, arterial blood gases, vital signs, and diaphragm function indexes were observed.Results:The time without mechanical ventilation 28 days after enrollment in the NAVA group was significantly longer than that in the PSV group [days: 22 (15, 26) vs. 6 (0, 23), P < 0.05]. However, there were no significant differences in the total length of mechanical ventilation, 90-day survival rate, length of NSICU stay, total length of hospital stay, NSICU mortality, in-hospital mortality, GOS score, and incidence of mechanical ventilator-related complications between the two groups. In terms of respiratory mechanics parameters, the expiratory tidal volume (VTe) on 3 days after mechanical ventilation of patients in the NAVA group was significantly lower than that on 1 day and 2 days, and significantly lower than that in the PSV group [mL: 411.0 (385.2, 492.6) vs. 489.0 (451.8, 529.4), P < 0.01]. Minute ventilation (MV) at 2 days and 3 days in the NAVA group was significantly higher than that at 1 day, and significantly higher than that in the PSV group at 2 days [L/min: 9.8 (8.4, 10.9) vs. 7.8 (6.5, 9.8), P < 0.01], while there was no significant change of MV in the PSV group. At 1 day, peak airway pressure (Ppeak) and mean airway pressure (Pmean) in the NAVA group were significantly lower than those in the PSV group [Ppeak (cmH 2O, 1 cmH 2O≈0.098 kPa): 14.0 (12.2, 17.0) vs. 16.6 (15.0, 17.4), Pmean (cmH 2O): 7.0 (6.2, 7.9) vs. 8.0 (7.0, 8.2), both P < 0.05]. However, there was no significant difference in the Ppeak or Pmean at 2 days and 3 days between the two groups. In terms of arterial blood gas, there was no significant difference in pH value between the two groups, but with the extension of mechanical ventilation time, the pH value at 3 days of the two groups was significantly higher than that at 1 day. Arterial partial pressure of oxygen (PaO 2) at 1 day in the NAVA group was significantly lower than that in the PSV group [mmHg (1 mmHg≈0.133 kPa): 122.01±37.77 vs. 144.10±40.39, P < 0.05], but there was no significant difference in PaO 2 at 2 days and 3 days between the two groups. There was no significant difference in arterial partial pressure of carbon dioxide (PaCO 2) or oxygenation index (PaO 2/FiO 2) between the two groups. In terms of vital signs, the respiratory rate (RR) at 1, 2, and 3 days of the NAVA group was significantly higher than that of the PSV group [times/min: 19.2 (16.0, 25.2) vs. 15.0 (14.4, 17.0) at 1 day, 21.4 (16.4, 26.0) vs. 15.8 (14.0, 18.6) at 2 days, 20.6 (17.0, 23.0) vs. 16.7 (15.0, 19.0) at 3 days, all P < 0.01]. In terms of diaphragm function, end-inspiratory diaphragm thickness (DTei) at 3 days in the NAVA group was significantly higher than that in the PSV group [cm: 0.26 (0.22, 0.29) vs. 0.22 (0.19, 0.26), P < 0.05]. There was no significant difference in end-expiratory diaphragm thickness (DTee) between the two groups. The diaphragm thickening fraction (DTF) at 2 days and 3 days in the NAVA group was significantly higher than that in the PSV group [(35.18±12.09)% vs. (26.88±8.33)% at 2 days, (35.54±13.40)% vs. (24.39±9.16)% at 3 days, both P < 0.05]. Conclusions:NAVA mode can be applied in patients with neuro-severe cerebrovascular disease, which can prolong the time without mechanical ventilation support and make patients obtain better lung protective ventilation. At the same time, it has certain advantages in avoiding ventilator-associated diaphragm dysfunction and improving diaphragm function.
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Objective:To investigate the clinical effect of neurally adjusted ventilatory assist (NAVA)on weaning from prolonged mechanical ventilation (PMV) in pediatrics and its influence on related parameters of respiratory mechanics.Methods:A retrospective analysis was conducted on 12 children in the pediatric intensive care unit (PICU) of Children′s Hospital, Capital Institute of Pediatrics from July 2014 to July 2020.All the cases adopted NAVA for weaning from PMV, and the type of NAVA included invasive NAVA and non-invasive neurally adjusted ventilatory assist with NAVA.The main diagnosis, etiology, oxygenation index (OI), pediatric critical illness score (PCIS), treatment of mechanical ventilation(MV), respiratory mechanics indexes, length of stay in PICU and prognosis were recorded.Besides, the complications that happened after transition to NAVA were evaluated.The rank sum test was used for comparison of respiratory mechanics indexes and blood gas values before and after NAVA ventilation. Results:Among the 12 children, 11 cases had basic diseases.There were 8 premature infants complicated with chronic lung diseases.Two cases had Wilson-Mikity syndrome.One case had congenital omphalocele, 1 case had Prader-Willi syndrome (PWS), 1 case had spinal muscular atrophy (SMA). The main diagnosis of 8 children was acute respiratory distress syndrome (ARDS). The median duration of MV and PICU stay was 32.0 (25.0, 39.0) days and 39.5(29.5, 48.5) days.The median duration of invasive NAVA and non-invasive-NAVA was 5.5 (3.8, 6.3) days and 7.0(5.0, 9.5) days.All cases were successfully weaned from MV(100%), and the survival-to-discharge rate was 100%.There were no complications related to NAVA.After ventilation for 6 hours, no significant difference was observed in respiratory mechanical parameters between synchronized intermittent mandatory ventilation (SIMV) and NAVA (all P>0.05). However, compared with SIMV, NAVA significantly decreased the arterial partial pressure of carbon dioxide[43.50 (41.75, 46.00) mmHg vs.48.50 (45.25, 56.00) mmHg, 1 mmHg=0.133 kPa] ( Z=-2.253, P=0.024), increased the arterial partial pressure of oxygen[68.00 (65.00, 72.25) mmHg vs.62.00 (59.00, 64.75) mmHg] ( Z=-2.733, P=0.006), and reduced the value of OI[3.70 (3.38, 5.60) vs.5.90 (4.58, 7.08)]( Z=-2.272, P=0.023). Conclusions:NAVA is a safe and effective approach to weaning from PMV in children.Compared to SIMV, NAVA can greatly improve ventilation and oxygenation.NAVA is strongly recommended to PMV infants with chronic lung diseases who have failed to wean from ventilation.
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Objective To compare the trigger delay and work of trigger between neurally adjusted ventilatory assist (NAVA) and pressure support ventilation (PSV) in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) patients with intrinsic positive end-expiratory pressure (PEEP) during mechanical ventilation. Methods AECOPD patients with intrinsic PEEP (PEEPi) greater than or equal to 3 cmH2O (1 cmH2O=0.098 kPa) were enrolled during invasive mechanical ventilation. Subjects were ventilated with low, medium and high pressure under either NAVA or PSV mode. Servo Tracker software continuously recorded the waveform of ventilator and respiratory mechanics indexes (including respiratory frequency, inspiratory tidal volume (Vti), minute ventilation volume (VE), peak airway pressure (PIP), inspiratory time), and calculated trigger and expiratory conversion delay time, work of trigger and total work of breath. Results A total of 14 AECOPD patients were enrolled with the average PEEPi (4.3±1.3) cmH2O. PSV inspiratory trigger delay time was positively correlated with PEEPi (r=0.913, P<0.05). Compared with PSV, NAVA significantly decreased trigger delay time in low, medium and high pressure level groups [(48±17) ms vs. (167±86) ms, (63±65) ms vs. (247±240) ms, (63±49) ms vs. (342±192) ms,respectively all P<0.05]. Similar results were shown as to work of trigger [(0.92±0.36) μV?s vs. (1.22±0.70) μV?s, (1.08±0.51) μV?s vs. (1.62 ± 1.25) μV?s, (1.20 ± 0.96) μV?s vs. (2.29 ± 1.02) μV?s, all P<0.05]. Trigger delay time increased according to the increase of pressure level in PSV mode.Conclusion The presence of PEEPi in AECOPD patients leads to obvious trigger delay under PSV mode, which is positively correlated with PEEPi level. NAVA significantly reduces trigger delay time and work of trigger compared with PSV mode.
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RESUMO Objetivo: Relatar um caso raro de síndrome posterior do tronco cerebral em um lactente após um episódio hipóxico-isquêmico devido a sepse grave, e o uso da ventilação assistida ajustada neuralmente no auxílio diagnóstico e no desmame da ventilação mecânica. Descrição do caso: Lactente masculino de 2 meses de idade, previamente hígido, apresentou sepse grave que evoluiu para síndrome posterior do tronco encefálico, entidade que pode ocorrer após lesão hipóxico-isquêmica em neonatos e lactentes e que apresenta imagens de ressonância magnética muito particulares. Devido à lesão neurológica, permaneceu em ventilação mecânica. Optou-se por iniciar ventilação assistida ajustada neuralmente para verificar a patência da condução do nervo frênico ao diafragma e auxiliar no desmame da ventilação mecânica. Comentários: A síndrome posterior do tronco cerebral é uma entidade rara que deve ser considerada em lactentes após evento hipóxico-isquêmico.
ABSTRACT Objective: To report a rare case of dorsal brainstem syndrome in an infant after hypoxic-ischemic episode due to severe sepsis and the use of neurally adjusted ventilatory assist (NAVA) to aid in diagnosis and in the removal of mechanical ventilation. Case description: A 2-month-old male infant, previously healthy, presented with severe sepsis that evolved to dorsal brainstem syndrome, which usually occurs after hypoxic-ischemic injury in neonates and infants, and is related to very specific magnetic resonance images. Due to neurological lesions, thei nfant remained in mechanical ventilation. A NAVA module was installed to keep track of phrenic nerve conduction to the diaphragm, having successfully showed neural conduction and helped removing mechanical ventilation. Comments: Dorsal brainstem syndrome is a rare condition that should be considered after hypoxic-ischemic episode in infants.
Subject(s)
Humans , Male , Infant , Brain Stem , Hypoxia-Ischemia, Brain/therapy , Interactive Ventilatory Support , SyndromeABSTRACT
Neurally adjusted ventilatory assist ( NAVA ) and non-invasively-NAVA are safe and feasible mode of ventilation in both the pediatric and the neonatal populations. NAVA mode has excellent synchrony and is superior over conventional mode at improving patient-ventilator interaction. NAVA is least vulnerable to changes in airway disease or airway resistance patterns. Non-invasively-NAVA delivers synchro-nized ventilation independent of leaks. NAVA offers maintenance of physiologic variability in breathing. NAVA can effectively avoid excessive ventilation,assist the weaning and has a lung protective function. Bed-side monitoring of Edi is a useful tool for evaluating diaphragm function,central apnea,clinical interventions, and decision support. Further high-quality studies are required to evaluate the long-term clinical prognosis for NAVA mode utilizing in pediatric patients.
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Neurally adjusted ventilatory assist(NAVA)is a mode of ventilation in which both the timing and degree of ventilatory assist are controlled by the patient.Since NAVA uses the diaphram electrical activity (Edi)as the controller signal,it is possible to deliver synchronized non-invasive NAVA(NIV-NAVA)regardless of leaks and to monitor continuously patient respiratory pattern.Advantages of NIV-NAVA over conventional modes include improved patient-ventilator interaction,reliable respiratory monitoring and self-regulation of re-spiratory support.In theory,these characteristics make NIV-NAVA an ideal mode to provide effective,appropri-ate non-invasive support to newborns with respiratory insufficiency.NIV-NAVA has been successfully used clini-cally in neonates as a mode of ventilation to prevent intubation,to allow early extubation,and as a novel way to deliver nasal continuous positive airway pressure.
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Neurally ajd usted ventilatory assist( NAVA) uses the electrical activity of the diaphragm as a neural trigger to synchronize mechanical ventilatory breaths with the patient′s neural respiratory drive. Some studies have shown that compared with pressure-support ventilation,NAVA can improve patient-venti-lator synchrony while maintaining spontaneous breathing,unload respiratory musculaturei n term adn prte erm i nfants.Further studies are needed to determ ine whether NA VA will have significant impact on the overall outcomes of neonates.
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Objective To observe the correlation between neutrally adjusted ventilatory assist (NAVA) mode and improvement of inflammation and oxidative stress in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD),and as well as to investigate the effects of NAVA mode versus pressure support ventilation (PSV) mode on improving the success rate of weaning advantages.Methods A total of 40 patients with AECOPD-Ⅲ supported by mechanical ventilation treatment admitted from November 2012 to January 2014 into intensive care unit (ICU) were enrolled for prospective study.The patients were randomly divided into PSV mode (n =20) and NAVA mode (n =20) according to gender,age,APACHE Ⅱ score,medical history,PaCO2 of five factors and adopting the principle of minimum distribution of the imbalance index.The comparisons of the successful rate of weaning,48 h re-intubation rate and length of ICU stay were made between two groups.The level of C-reactive protein (CRP),serum amyloid A (SAA),human cartilage glycoprotein 39 (YKL-40) in serum were measured by enzyme-linked immunosorbent assay (ELSIA) on the 1st day,3rd day,5th day and 7th day after initiation of mechanical ventilation,and results of these laboratory tests in patients were compared with those in healthy subjects of control group.And simultaneously,the broncho-alveolar lavage fluid (BALF) was collected with Gibot method by employment of optic fiber bronchoscope on the given days for detection of YKL-40,and levels of YKL-40 were compared between NAVA mode and PSV mode.Enumeration data were analyzed with x2 test,measurement data were analyzed with t test or repeated measures analysis of variance,and P ＜ 0.05 was considered to be significant.Results (1) There were no significant differences in leukocyte count and neutrophils percentage between NAVA mode and PSV mode (P ＞ 0.05).The magnitudes of decrease in concentrations of blood CRP and SAA in NAVA mode were significantly greater than those in PSV mode (P ＜ 0.01),but there was no significant difference in blood YKL-40 between NAVA mode and PSV mode (P ＞ 0.05).The magnitude of reduction in concentration of BALF YKL-40 in NAVA mode was significantly greater than that in PSV mode (P ＜0.01).(2) There was on significant difference in rate of final weaning between NAVA mode and PSV mode,but the rate of direct weaning was higher in NAVA mode than that in PSV mode (P =0.046),and the 48 h re-intubation rate was lower in NAVA mode than that in PSV mode (P =0.032).The length of ICU stay was shorter in NAVA mode than that in PSV mode (P =0.031).The peak of EAdi (electric activated diaphragma trigger) in 8 patients failing in direct weaning before first attempt was significantly higher than that in other patients with successful weaning patients (P =0.002).Conclusions NAVA mode can attenuate inflammation and oxidative stress in patients with AECOPD,and ultimately improve the rate of direct weaning and shorten the length of ICU stay.Further research is necessary to confirm the capability of NAVA mode for improving the ultimate rate of weaning in AECOPD patients.
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During the treatment of pediatric critical cases,the mechanical ventilation support is one of the most important factors.Neonatologists are trying to find a better mode of ventilation support.Neurally adjusted ventilatory assist (NAVA) is a new mode of mechanical ventilation controlled by diaphragmatic electrical signals.Because the mechanism of ventilation support is different from the conventional ventilators,NAVA provides a different effect of respiratory support varying with the needs of the newborn.Pediatric studies had been review to provide more information of NAVA to pediatrics.