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Neurally adjusted ventilatory assist improves patient–ventilator interaction

Lise Piquilloud| Laurence Vignaux| Emilie Bialais| Jean Roeseler| Thierry Sottiaux| Pierre-François Laterre| Philippe Jolliet| Didier Tassaux
Original
Volume 37, Issue 2 / February , 2011

Pages 263 - 271

Abstract

Purpose

To determine if, compared with pressure support (PS), neurally adjusted ventilatory assist (NAVA) reduces trigger delay, inspiratory time in excess, and the number of patient–ventilator asynchronies in intubated patients.

Methods

Prospective interventional study in spontaneously breathing patients intubated for acute respiratory failure. Three consecutive periods of ventilation were applied: (1) PS1, (2) NAVA, (3) PS2. Airway pressure, flow, and transesophageal diaphragmatic electromyography were continuously recorded.

Results

All results are reported as median (interquartile range, IQR). Twenty-two patients were included, 36.4% (8/22) having obstructive pulmonary disease. NAVA reduced trigger delay (ms): NAVA, 69 (57–85); PS1, 178 (139–245); PS2, 199 (135–256). NAVA improved expiratory synchrony: inspiratory time in excess (ms): NAVA, 126 (111–136); PS1, 204 (117–345); PS2, 220 (127–366). Total asynchrony events were reduced with NAVA (events/min): NAVA, 1.21 (0.54–3.36); PS1, 3.15 (1.18–6.40); PS2, 3.04 (1.22–5.31). The number of patients with asynchrony index (AI) >10% was reduced by 50% with NAVA. In contrast to PS, no ineffective effort or late cycling was observed with NAVA. There was less premature cycling with NAVA (events/min): NAVA, 0.00 (0.00–0.00); PS1, 0.14 (0.00–0.41); PS2, 0.00 (0.00–0.48). More double triggering was seen with NAVA, 0.78 (0.46–2.42); PS1, 0.00 (0.00–0.04); PS2, 0.00 (0.00–0.00).

Conclusions

Compared with standard PS, NAVA can improve patient–ventilator synchrony in intubated spontaneously breathing intensive care patients. Further studies should aim to determine the clinical impact of this improved synchrony.

Keywords

References

  1. Carson SS, Cox CE, Holmes GM, Howard A, Carey TS (2006) The changing epidemiology of mechanical ventilation: a population-based study. J Intensive Care Med 21:173–182
    • View reference on publisher's website
    • View reference on PubMed
  2. Needham DM, Bronskill SE, Sibbald WJ, Pronovost PJ, Laupacis A (2004) Mechanical ventilation in Ontario, 1992–2000: incidence, survival, and hospital bed utilization of noncardiac surgery adult patients. Crit Care Med 32:1504–1509
    • View reference on publisher's website
    • View reference on PubMed
  3. Needham DM, Bronskill SE, Calinawan JR, Sibbald WJ, Pronovost PJ, Laupacis A (2005) Projected incidence of mechanical ventilation in Ontario to 2026: preparing for the aging baby boomers. Crit Care Med 33:574–579
    • View reference on publisher's website
    • View reference on PubMed
  4. Esteban A, Anzueto A, Alia I, Gordo F, Apezteguia C, Palizas F, Cide D, Goldwaser R, Soto L, Bugedo G, Rodrigo C, Pimentel J, Raimondi G, Tobin MJ (2000) How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 161:1450–1458
    • View reference on PubMed
  5. Rose L, Presneill JJ, Johnston L, Nelson S, Cade JF (2009) Ventilation and weaning practices in Australia and New Zealand. Anaesth Intensive Care 37:99–107
    • View reference on PubMed
  6. Girard TD, Kress JP, Fuchs BD, Thomason JW, Schweickert WD, Pun BT, Taichman DB, Dunn JG, Pohlman AS, Kinniry PA, Jackson JC, Canonico AE, Light RW, Shintani AK, Thompson JL, Gordon SM, Hall JB, Dittus RS, Bernard GR, Ely EW (2008) Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (awakening and breathing controlled trial): a randomised controlled trial. Lancet 371:126–134
    • View reference on publisher's website
    • View reference on PubMed
  7. Kress JP, Pohlman AS, O’Connor MF, Hall JB (2000) Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 342:1471–1477
    • View reference on publisher's website
    • View reference on PubMed
  8. Schweickert WD, Gehlbach BK, Pohlman AS, Hall JB, Kress JP (2004) Daily interruption of sedative infusions and complications of critical illness in mechanically ventilated patients. Crit Care Med 32:1272–1276
    • View reference on publisher's website
    • View reference on PubMed
  9. Larsson L, Li X, Edstrom L, Eriksson LI, Zackrisson H, Argentini C, Schiaffino S (2000) Acute quadriplegia and loss of muscle myosin in patients treated with non depolarizing neuromuscular blocking agents and corticosteroids: mechanisms at the cellular and molecular levels. Crit Care Med 28:34–45
    • View reference on publisher's website
    • View reference on PubMed
  10. Garnacho-Montero J, Madrazo-Osuna J, Garcia-Garmendia JL, Ortiz-Leyba C, Jimenez-Jimenez FJ, Barrero-Almodovar A, Garnacho-Montero MC, Moyano-Del-Estad MR (2001) Critical illness polyneuropathy: risk factors and clinical consequences. A cohort study in septic patients. Intensive Care Med 27:1288–1296
  11. Levine S, Nguyen T, Taylor N, Friscia ME, Budak MT, Rothenberg P, Zhu J, Sachdeva R, Sonnad S, Kaiser LR, Rubinstein NA, Powers SK, Shrager JB (2008) Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 358:1327–1335
    • View reference on publisher's website
    • View reference on PubMed
  12. Futier E, Constantin JM, Combaret L, Mosoni L, Roszyk L, Sapin V, Attaix D, Jung B, Jaber S, Bazin JE (2008) Pressure support ventilation attenuates ventilator-induced protein modifications in the diaphragm. Crit Care 12:R116
    • View reference on publisher's website
    • View reference on PubMed
  13. Vassilakopoulos T, Petrof BJ (2004) Ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 169:336–341
    • View reference on publisher's website
    • View reference on PubMed
  14. Putensen C, Zech S, Wrigge H, Zinserling J, Stuber F, Von Spiegel T, Mutz N (2001) Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 164:43–49
    • View reference on PubMed
  15. Yamada Y, Du HL (2000) Analysis of the mechanisms of expiratory asynchrony in pressure support ventilation: a mathematical approach. J Appl Physiol 88:2143–2150
    • View reference on PubMed
  16. Tobin MJ, Jubran A, Laghi F (2001) Patient–ventilator interaction. Am J Respir Crit Care Med 163:1059–1063
    • View reference on PubMed
  17. MacIntyre N, Nishimura M, Usada Y, Tokioka H, Takezawa J, Shimada Y (1990) The Nagoya conference on system design and patient–ventilator interactions during pressure support ventilation. Chest 97:1463–1466
    • View reference on publisher's website
    • View reference on PubMed
  18. Thille AW, Rodriguez P, Cabello B, Lellouche F, Brochard L (2006) Patient–ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med 32:1515–1522
  19. Kondili E, Prinianakis G, Georgopoulos D (2003) Patient–ventilator interaction. Br J Anaesth 91:106–119
    • View reference on publisher's website
    • View reference on PubMed
  20. Chao DC, Scheinhorn DJ, Stearn-Hassenpflug M (1997) Patient–ventilator trigger asynchrony in prolonged mechanical ventilation. Chest 112:1592–1599
    • View reference on publisher's website
    • View reference on PubMed
  21. Sinderby C, Navalesi P, Beck J, Skrobik Y, Comtois N, Friberg S, Gottfried SB, Lindstrom L (1999) Neural control of mechanical ventilation in respiratory failure. Nat Med 5:1433–1436
    • View reference on publisher's website
    • View reference on PubMed
  22. Piquilloud L, Vignaux L, Tassaux D, Jolliet P (2009) Can neurally adjusted ventilatory assist (NAVA) improve patient–ventilator interaction? A preliminary study. Intensive Care Med 35(Suppl 1):S21
  23. Barwing J, Ambold M, Linden N, Quintel M, Moerer O (2009) Evaluation of the catheter positioning for neurally adjusted ventilatory assist. Intensive Care Med 35:1809–1814
  24. Vignaux L, Vargas F, Roeseler J, Tassaux D, Thille AW, Kossowsky MP, Brochard L, Jolliet P (2009) Patient–ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med 35:840–846
  25. Colombo D, Cammarota G, Bergamaschi V, De Lucia M, Corte FD, Navalesi P (2008) Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure. Intensive Care Med 34:2010–2018
  26. Spahija J, de Marchie M, Albert M, Bellemare P, Delisle S, Beck J, Sinderby C (2010) Patient–ventilator interaction during pressure support ventilation and neurally adjusted ventilatory assist. Crit Care Med 38:518–526
    • View reference on publisher's website
    • View reference on PubMed
  27. Tassaux D, Gainnier M, Battisti A, Jolliet P (2005) Impact of expiratory trigger setting on delayed cycling and inspiratory muscle workload. Am J Respir Crit Care Med 172:1283–1289
    • View reference on publisher's website
    • View reference on PubMed
  28. Breatnach C, Conlon NP, Stack M, Healy M, O’Hare BP (2010) A prospective crossover comparison of neurally adjusted ventilatory assist and pressure-support ventilation in a pediatric and neonatal intensive care unit population. Pediatr Crit Care Med 11:7–11
    • View reference on publisher's website
    • View reference on PubMed
  29. Whitelaw WA, Derenne JP, Milic-Emili J (1975) Occlusion pressure as a measure of respiratory center output in conscious man. Respir Physiol 23:181–199
    • View reference on publisher's website
    • View reference on PubMed
  30. Sassoon CS, Gruer SE (1995) Characteristics of the ventilator pressure- and flow-trigger variables. Intensive Care Med 21:159–168
  31. Nava S, Bruschi C, Fracchia C, Braschi A, Rubini F (1997) Patient–ventilator interaction and inspiratory effort during pressure support ventilation in patients with different pathologies. Eur Respir J 10:177–183
    • View reference on publisher's website
    • View reference on PubMed
  32. Nava S, Bruschi C, Rubini F, Palo A, Iotti G, Braschi A (1995) Respiratory response and inspiratory effort during pressure support ventilation in COPD patients. Intensive Care Med 21:871–879
  33. MacIntyre N (2010) Talk to me! Toward better patient–ventilator communication. Crit Care Med 38:714–715
    • View reference on publisher's website
    • View reference on PubMed
  34. Jubran A, Van de Graaff WB, Tobin MJ (1995) Variability of patient–ventilator interaction with pressure support ventilation in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 152:129–136
    • View reference on PubMed
  35. Parthasarathy S, Jubran A, Tobin MJ (1998) Cycling of inspiratory and expiratory muscle groups with the ventilator in airflow limitation. Am J Respir Crit Care Med 158:1471–1478
    • View reference on PubMed
  36. Stewart TE, Meade MO, Cook DJ, Granton JT, Hodder RV, Lapinsky SE, Mazer CD, McLean RF, Rogovein TS, Schouten BD, Todd TR, Slutsky AS (1998) Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk for acute respiratory distress syndrome. Pressure- and volume-limited ventilation strategy group. N Engl J Med 338:355–361
    • View reference on publisher's website
    • View reference on PubMed

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