Neurally Adjusted Ventilatory Assist: NAVA for Neonates
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1 Neurally Adjusted Ventilatory Assist: NAVA for Neonates Robert L. Chatburn, MHHS, RRT-NPS, FAARC Research Manager Respiratory Institute Cleveland Clinic Professor Department of Medicine Lerner College of Medicine of Case Western Reserve University
2 Disclosure I have affiliations with, special interests, or have conducted business with the following companies that in context with this presentation might possibly constitute a real or perceived conflict of interest: : Breathe Technologies CareFusion Covidien Dräger Hamilton IngMar Newport
3 Overview What is NAVA? How does it compare to other modes? How does it serve the patient s needs?
4 What is NAVA? Neurally Adjusted Ventilatory Assist Inspiratory pressure is controlled by the diaphragmatic EMG, called the Edi signal Edi is measured using a naso-gastiric catheter Ventilatory assistance is proportional to patient inspiratory effort Available only on Maquet Servo-i ventilator
5 NAVA Compared to Other Modes Respir Care 2012;57(12):
6 How Does NAVA Serve Patient Needs? What are a patient s needs in terms of goals of MV? How do we match needs to technical capability? How does NAVA serve the patient s needs?
7 Goals of Ventilation 1. Promote safety (do no harm) Provide adequate gas exchange Optimize V/Q relation Protect the lung Optimize P/V relation ventilation perfusion 2. Promote patient comfort Optimize WOB vent vs WOB patient 3. Liberate as soon as possible Optimize weaning experience
8 AIM Before You ACT Patients Assess Patient Needs Identify Technical Capability Safety Comfort Liberation Match Technology to Patient Needs Modes of Ventilation
9 AIM Before you ACT ASSESS Patient needs (safety, comfort, liberation) IDENTIFY Available technology (modes and their capabilities) MATCH Technology to needs (most appropriate mode) ACT APPLY (appropriate settings) CONSIDERED (monitor patient reaction) TECHNOLOGY (reassess appropriateness of mode)
10 Relate Goals to Ventilator Features A Rational Framework for Selecting Modes of Ventilation. Mireles-Cabodevila E, Hatipoglu U, Chatburn RL. Respir Care 2013;58(2):
11 Comfort Technical Capabilities of Modes All breaths can be spontaneous Trigger/cycle based on chest/diaphragm movement Coordination of mandatory vs spontaneous breaths Automatic limitation of autopeep Unrestricted inspiratory flow Automatic adjustment of flow based on frequency Automatic adjustment of support to maintain specific breathing pattern Automatic adjustment of support to meet demand
12 Comfort
13 Safety
14 Liberation Respir Care 2013;58(2):
15 How Does NAVA Work? Measuring diaphragmatic EMG (the Edi signal) Neuroventilatory coupling Patient-ventilator interactions Literature review
16 The Edi Catheter Clin Perinatol 2012;39:
17 Edi Catheter Features Inter-Electrode Distance
18 Connect the Catheter to the Cable
19 Neurally Adjusted Ventilatory Assist ideal NAVA other modes Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
20 Respiratory Inputs Affecting NAVA Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
21 Origin of Edi Signal two motor units Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
22 Edi Signal Processing Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
23 Facts About the Edi Signal Edi represents diaphragmatic electrical activity Edi signal is measured in microvolts (µv) Edi peak 11 ± 5 µv Edi min 3 ± 2 µv Increased neural input to diaphragm from the brain Increased motor unit firing rate Increased motor unit recruitment Increased Edi amplitude Increased inspiratory effort (Pmus)
24 Ventilator Display
25 Edi Signal Nomenclature Pediatric Research 2011;70(6)
26 Infant vs Adult Edi Signals more variability (phasic Edi) variable baseline (tonic Edi) Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
27 Edi as a Monitoring Tool Increased Edi amplitude on inspiration ( phasic Edi ) indicates greater inspiratory effort Edi amplitude increases with worsening respiratory status reduced ventilator assist reduced sedation increased ventilatory demand (eg, exercise) increased dead space
28 Edi as a Monitoring Tool Neuro-mechanical efficiency Paw/Edi during occlusion inspiratory pressure normalized to neural inspiratory effort Neuro-ventilatory efficiency V T /Edi inspiratory volume normalized to neural inspiratory effort Tonic Edi may indicate response to lung derecruitment might be used to set optimum PEEP
29 Tonic Edi vs PEEP Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
30 Edi as a Monitoring Tool Edi is gold standard for determining asynchrony Trigger asynchronies premature trigger ( auto-trigger ) delayed trigger missed trigger efforts Inspiratory pressure asynchrony assist too high/low Cycling asynchrony premature cycling delayed cycling
31 Examples of Asynchronies gray line predicted NAVA breath yellow line actual PC-IMV+PS breaths Edi signal Clin Perinatol 2012;39:
32 Examples of Asynchronies breath triggered no Edi Clin Perinatol 2012;39:
33 Examples of Asynchronies pressure asynchrony under-assist premature cycling trigger delay Clin Perinatol 2012;39:
34 Examples of Asynchronies pressure asynchrony over-assist delayed cycling trigger ok Clin Perinatol 2012;39:
35 Examples of Asynchronies no breath triggered Edi present Clin Perinatol 2012;39:
36 NAVA PCV PSV good synchrony bad neural synchrony inspiratory time trigger delay delayed cycling bad synchrony trigger delay
37 How Does Edi Control the Ventilator? Diaphragm Ventilator Transrespiratory pressure Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
38 How Does Edi Control the Ventilator? Volume Flow Edi Pressure cycle rise in Edi - sensitivity Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
39 How Does Edi Control the Ventilator? Flow Volume Pressure assist pressure proportional to Edi Edi Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
40 How Does Edi Control the Ventilator? Volume Flow Edi Pressure cycle drop to 70% peak Edi - preset Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
41 How Does Edi Control the Ventilator? inspiratory pressure = NAVA level x Edi cm H 2 O above PEEP cm H 2 O/µV above Edi min Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
42 NAVA Unloads Spontaneous Breaths Volume Control? Pressure Control? NAVA? Ventilator WOB NAVA PC VC, adaptive PC Patient WOB
43 NAVA Is Not Affected by Leaks
44 How Do You Set the NAVA Level?
45 Response to Increasing Edi Phase I at low NAVA level, Edi is highest amplitude increasing NAVA increases inspiratory pressure Phase II increasing NAVA level decreases Edi inspiratory pressure constant in comfort zone assist levels adequate to unload ventilatory muscles Phase III increasing NAVA still decreases Edi Edi not abolished so can still control ventilator irregular breathing pattern
46 Response to Increasing NAVA Level adequate assist Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
47 Response to Increasing NAVA Level Sinderby in: Tobin. Principles and Practice of Mechanical Ventilation 3 rd edition 2012.
48 Weaning NAVA Lower NAVA level in increments of 0.5 while following the Edi peak If the Edi peak increases significantly, then the patient may not be ready for weaning Follow the peak inspiratory pressure trend When at sufficiently low levels, consider extubation Stein H, Bringing NAVA to the NICU, Advance for RC & Sleep Medicine, 2010
49 The Evidence for NAVA in Neonates
50 Advantages of NAVA in Neonates Improves synchrony, even with large leaks Pediatr Res 2009;65:663-8 Pediatr Crit Care Med 2010;11:7-11 Intensive Care Med 2011;37:1826 Pediatr Pulmonol 2012;47(1)76-83 Pediatr Res 2012;72(2): Decreased PIP, variable respiratory rate Crit Care Med 2010;11:253-7 Neonatology Today 2010;5:1-4 Pediatr 2011;11:92 J Pediatr 2012;160:786-9
51 Advantages of NAVA in Neonates Improved or unchanged blood gas results Pediatr Crit Care Med 2010;11:7-11 Crit Care Med 2010;11:253-7 Neonatology Today 2010;5:1-4 Pediatr 2011;11:92 Pediatr Pulmonol 2012;47(1)76-83 J Pediatr 2012;160:786-9 No change in intraventricular hemorrhage, pneumothorax or nectorizing enterocolitis J Pediatr 2012;160:786-9
52 Clinical Findings of NAVA in Neonates Tidal volume ml/kg Considered a lung protective mode Respiratory rate breaths/min Pediatr Res 2009;65:663-8 Crit Care Med 2010;11:253-7 Pediatr Crit Care Med 2010;11:7-11 Pediatr 2011;11:92 Pediatr Pulmonol 2012;47(1)76-83 Pediatr Res 2012;72(2): J Pediatr 2012;160:786-9
53 Clinical Findings of NAVA in Neonates Post-extubation Edi higher in infants who failed extubation (30 vs 11 µv) No differences in heart rate, systolic BP, CVP, PaO 2 /FiO 2 or PaCO 2 Zhongguo Dang Dai Er Ke Za Zhi 2009;11:433-6 Patients ready for extubation had higher V T /Edi (25 vs 21 ml/ µv) Pediatr Crit Care Med 2010;12:e220-4
54 Better Synchrony with NAVA No missed trigger efforts compared to PCV, PSV (0% vs 4% vs 7%) Shorter trigger delays (93 vs 193 vs 135 ms) No premature cycling (0% vs 12% vs 21%) Pediatr Res 2012;72(2):
55 Summary NAVA is a form of pressure control continuous spontaneous ventilation with a servo targeting scheme (PC-CSVr) Servo control is based on diaphragmatic EMG called the Edi signal Edi amplitude proportional to inspiratory effort Phasic Edi increases as lung mechanics worsen Paw = NAVA Level x Edi NAVA was designed to serve the goal of comfort Optimizes patient-ventilator synchrony trigger/cycle close to neural signal (leak independent) pressure delivery in proportion to inspiratory effort
56 Summary Neonates have highly variable phasic Edi plus positive tonic Edi Monitoring Edi is the gold standard for identifying patient-ventilator asynchronies Patients have a bi-phasic response to increasing NAVA first V T increases with NAVA then V T remains relatively constant with increasing NAVA Wean NAVA by gradually decreasing NAVA level and watching to see that phasic Edi remains constant.
57 Summary Improves synchrony even with leaks (NIV) trigger, inspiratory pressure, cycle Decreases peak inspiratory pressure Maintains lung protective tidal volumes May improve blood gases Not associated with adverse events Edi signal analysis may provide predictive indices for success of extubation
58 Assistance in Proportion to Effort
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