Neurally Adjusted Ventilatory Assist vs Pressure Support Ventilation for Noninvasive Ventilation During Acute Respiratory Failure: A Crossover Physiologic Study

doi:10.1378/chest.12-0424

Chest

Volume 143, Issue 1, January 2013, Pages 30-36

https://doi.org/10.1378/chest.12-0424 Get rights and content

Background

Patient-ventilator asynchrony is common during noninvasive ventilation (NIV) with pressure support ventilation (PSV). We examined the effect of neurally adjusted ventilatory assist (NAVA) delivered through a facemask on synchronization in patients with acute respiratory failure (ARF).

Methods

This was a prospective, physiologic, crossover study of 13 patients with ARF (median PaO₂/FIO₂, 196 [interquartile range (IQR), 142-225]) given two 30-min trials of NIV with PSV and NAVA in random order. Diaphragm electrical activity (EAdi), neural inspiratory time (TIn), trigger delay (Td), asynchrony index (AI), arterial blood gas levels, and patient discomfort were recorded.

Results

There were significantly fewer asynchrony events during NAVA than during PSV (10 [IQR, 5-14] events vs 17 [IQR, 8-24] events, P = .017), and the occurrence of severe asynchrony (AI > 10%) was also less under NAVA (P = .027). Ineffective efforts and delayed cycling were significantly less with NAVA (P < .05 for both). NAVA was also associated with reduced Td (0 [IQR, 0-30] milliseconds vs 90 [IQR, 30-130] milliseconds, P < .001) and inspiratory time in excess (10 [IQR, 0-28] milliseconds vs 125 [IQR, 20-312] milliseconds, P < .001), but TIn was similar under PSV and NAVA. The EAdi signal to its maximal value was higher during NAVA than during PSV (P = .017). There were no significant differences in arterial blood gases or patient discomfort under PSV and NAVA.

Conclusion

In view of specific experimental conditions, our comparison of PSV and NAVA indicated that NAVA significantly reduced severe patient-ventilator asynchrony and resulted in similar improvements in gas exchange during NIV for ARF.

Trial registry

ClinicalTrials.gov; No.: NCT01426178; URL: www.clinicaltrials.gov.

Section snippets

Materials and Methods

This study was performed in the ICU of the Estaing Hospital (University of Clermont-Ferrand, France) from July 2011 to September 2011. The Institutional Review Board (Comité de Protection des Personnes Sud-Est I, Clermont-Ferrand, France) approved the protocol (reference number 2010-A01197-32), and each patient or next of kin provided written informed consent. This study followed CONSORT recommendations regarding the report of randomized trials.¹¹

Results

Sixteen consecutive patients with ARF were enrolled initially. Three of these patients were excluded, two because a worsening of ARF required tracheal intubation, and one because of an inappropriate EAdi signal. A total of 13 patients completed the study protocol (Table 1). There was no patient with COPD. On admission, all patients needed oxygen therapy (mean FIO₂, 50% ± 26%).

Table 2 shows the ventilatory settings under PSV and NAVA. No relevant clinical problems occurred during any procedure,

Discussion

With respect to specific experimental conditions, the results of the current study indicate that the use of NAVA instead of PSV for NIV in patients with ARF improves patient-ventilator interaction. In particular, NAVA delivered through a facemask improved patient-ventilator interaction by reducing the total number of asynchrony events, severe patient-ventilator asynchrony (AI > 10%), the Td, and TIexe.

Our results agree with those of previous studies that showed that NAVA can improve

Acknowledgments

Author contributions: Drs Bertrand, Futier, and Constantin are guarantors of the paper and take responsibility for the integrity of the work as a whole, from inception to published article.

Dr Bertrand: contributed to the study design and protocol and recording and analysis of the data.

Dr Futier: contributed to the study design and protocol and writing and revision of the manuscript.

Dr Coisel: contributed to the study design and protocol and writing and revision of the manuscript.

Dr Matecki:

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Asynchronies, characterized by the lack of synchronization between the moments when the patient performs neural inspirations and those programmed in the ventilator, are common in patients requiring ventilatory support. Although esophageal monitoring is considered the most accurate method for detection, diagnosis, and intervention, it proves impractical in the clinical evaluation context. Monitoring through various curves and loops, however, facilitates the identification of asynchronies and allows for the assessment of the response to established interventions. This review focuses on differentiating stimuli to the respiratory center and mechanical responses, thereby easing the diagnosis and interventions necessary for their control.
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No study has compared neurally adjusted ventilator assist (NAVA) with adaptive support ventilation (ASV) during non-invasive ventilation (NIV) in subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).
In this randomized controlled trial, we compared NAVA-NIV with ASV-NIV for delivering NIV in consecutive subjects with AECOPD. The primary outcome was NIV failure rate (invasive mechanical ventilation). The key secondary outcomes were number of NIV manipulations, asynchrony index, and 90-day mortality.
We enrolled 76 subjects (NAVA-NIV, n = 36, ASV-NIV, n = 40; 74% males) with a mean ± SD age of 61.4 ± 8.2 years. We found no difference in NIV failure rates between the two arms (NAVA-NIV vs. ASV-NIV; 8/36 [22.2%] vs. 8/40 [20%]; p = 0.83). The median physician manipulations for NIV were significantly less in the ASV-NIV arm than in the NAVA-NIV arm (2 [0.8–4] vs. 3 [2–5]; p= 0.014) during the initial 24-h. We found no difference in median asynchrony index (NAVA-NIV vs. ASV-NIV, 16.6% vs. 16.4%, p = 0.5) and 90-day mortality (22.2% vs. 17.5%, p = 0.67).
The use of NAVA-NIV was not superior to ASV-NIV in reducing NIV failure rates in AECOPD. Both NAVA-NIV and ASV-NIV had similar asynchrony index and 90-day mortality.
www.clinicaltrials.gov (NCT04414891).
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Funding/Support: The authors have reported to CHEST that no funding was received for this study.

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Chest

Original ResearchCritical CareNeurally Adjusted Ventilatory Assist vs Pressure Support Ventilation for Noninvasive Ventilation During Acute Respiratory Failure: A Crossover Physiologic Study

Background

Methods

Results

Conclusion

Trial registry

Section snippets

Materials and Methods

Results

Discussion

Acknowledgments

Lancet

Chest

Chest

Chest

Noninvasive ventilation in acute respiratory failure

Crit Care Med

Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial

Am J Respir Crit Care Med

Physiologic effects of noninvasive ventilation during acute lung injury

Am J Respir Crit Care Med

Patient-ventilator interaction

Am J Respir Crit Care Med

Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study

Intensive Care Med

Neural control of mechanical ventilation in respiratory failure

Nat Med

Neurally adjusted ventilatory assist improves patient-ventilator interaction

Intensive Care Med

Patient-ventilator interaction during pressure support ventilation and neurally adjusted ventilatory assist

Crit Care Med

CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials

BMJ

Enhancement of signal quality in esophageal recordings of diaphragm EMG

J Appl Physiol

Evaluation of the catheter positioning for neurally adjusted ventilatory assist

Intensive Care Med

Performance of noninvasive ventilation algorithms on ICU ventilators during pressure support: a clinical study

Intensive Care Med

Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure

Intensive Care Med

Neurally adjusted ventilatory assist in patients recovering spontaneous breathing after acute respiratory distress syndrome: physiological evaluation

Crit Care Med

Original Research
Critical Care
Neurally Adjusted Ventilatory Assist vs Pressure Support Ventilation for Noninvasive Ventilation During Acute Respiratory Failure: A Crossover Physiologic Study