Neurally adjusted ventilatory assist in infants: A review article
AbstractNeurally adjusted ventilatory assist (NAVA) and non-invasive (NIV)-NAVA are innovative modes of synchronized and proportional respiratory support. They can synchronize with the patients’ breathing and promote patient comfort. Both techniques are increasingly being used these years, however experience with their use in newborns and premature infants in Taiwan is relatively few. Because increasing evidence supports the use of NAVA and NIV-NAVA in newborns and premature infants requiring respiratory assist to achieve better synchrony, the aim of this article is to discuss whether NAVA can provide better synchronization and comfort for ventilated newborns and premature babies. In a review of recent literature, we found that NAVA and NIV-NAVA appear to be superior to conventional invasive and non-invasive ventilation. Nevertheless, some of the benefits are controversial. For example, treatment failure in premature infants is common due to insufficient triggering of electrical activity of the diaphragm (EAdi) and frequent apnea, highlighting the differences between premature infants and adults in settings and titration. Further, we suggest how to adjust the settings of NAVA and NIV-NAVA in premature infants to reduce clinical adverse events and extubation failure. In addition to assist in the use of NAVA, EAdi can also serve as a continuous and real-time monitor of vital signs, assisting physicians in the administration of sedatives, evaluation of successful extubation, and as a reference for the patient’s respiratory condition during special procedures.
Keywords:electrical activity of the diaphragm; neurally adjusted ventilatory assist; NIV-NAVA; premature infants; review
References
1. Beck J., Sinderby C. Neurally adjusted ventilatory assist in newborns. Clin Perinatol. 2021; 48: 783–811.
2. Mortamet G., Larouche A., Ducharme-Crevier L., Flechelles O., Constantin G., Essouri S., et al. Patienteventilator asynchrony during conventional mechanical ventilation in children. Ann Intensive Care. 2017; 7: 122.
3. Jung Y.H., Kim H.S., Lee J., Shin S.H., Kim E.K., Choi J.H. Neurally adjusted ventilatory assist in preterm infants with established or evolving bronchopulmonary dysplasia on high-intensity mechanical ventilatory support: a single-center experience. Pediatr Crit Care Med. 2016; 17: 1142–6.
4. Shi Y., Muniraman H., Biniwale M., Ramanathan R. A review on non-invasive respiratory support for management of respiratory distress in extremely preterm infants. Front Pediatr. 2020; 8: 270.
5. Rong X., Liang F., Li Y.J., Liang H., Zhao X.P., Zou H.M., et al. Application of neurally adjusted ventilatory assist in premature neonates less than 1,500 grams with established or evolving bronchopulmonary dysplasia. Front Pediatr. 2020; 8: 110.
6. Mally P.V., Beck J., Sinderby C., Caprio M., Bailey S.M. Neural breathing pattern and patient-ventilator interaction during neurally adjusted ventilatory assist and conventional ventilation in newborns. Pediatr Crit Care Med. 2018; 19: 48–55.
7. Firestone K., Horany B.A., de Leon-Belden L., Stein H. Nasal continuous positive airway pressure versus noninvasive NAVA in preterm neonates with apnea of prematurity: a pilot study with a novel approach. J Perinatol. 2020; 40: 1211–5.
8. Gibu C.K., Cheng P.Y., Ward R.J., Castro B., Heldt G.P. Feasibility and physiological effects of noninvasive neurally adjusted ventilator assist in preterm infants. Pediatr Res. 2017; 82:650–7.
9. Xiao S, Huang C, Cheng Y, Xia Z, Li Y, Tang W, et al. Application of neurally adjusted ventilatory assist in ventilator weaning of infants ventilator weaning. Brain Behav. 2021; 11: e2350.
10. Lee B.K., Shin S.H., Jung Y.H., Kim E.K., Kim H.S. Comparison of NIVNAVA and NCPAP in facilitating extubation for very preterm infants. BMC Pediatr. 2019; 19: 298.
11. Lecomte F., Brander L., Jalde F, Beck J., Qui H., Elie C., et al. Physiological response to increasing levels of neurally adjusted ventilatory assist (NAVA). Respir Physiol Neurobiol. 2009; 166: 117–24.
12. Patroniti N., Bellani G., Saccavino E., Zanella A., Grasselli G., Isgro S., et al. Respiratory pattern during neurally adjusted ventilatory assist in acute respiratory failure patients. Intensive. Care Med. 2012; 38: 230–9.
13. Stein H., Firestone K. NAVA ventilation in neonates: clinical guidelines and management strategies. Neonatol Today. 2012; 7: 1–10.
14. Firestone K.S., Fisher S., Reddy S., White D.B., Stein H.M. Effect of changing NAVA levels on peak inspiratory pressures and electrical activity of the diaphragm in premature neonates. J Perinatol. 2015; 35: 612–6.
15. LoVerde B., Firestone K.S., Stein H.M. Comparing changing neurally adjusted ventilatory assist (NAVA) levels in intubated and recently extubated neonates. J Perinatol. 2016; 36: 1097–100.
16. Henderson-Smart D.J., Subramaniam P., Davis P.G. Continuous positive airway pressure versus theophylline for apnea in preterm infants. Cochrane Database Syst Rev. 2001; 4: CD 001072.
17. DiBlasi R.M. Nasal continuous positive airway pressure (CPAP) for the respiratory care of the newborn infant. Respir Care. 2009; 54: 1209 –35.
18. Firestone K.S., Beck J., Stein H. Neurally adjusted ventilatory assist for noninvasive support in neonates. Clin Perinatol. 2016; 43: 707 –24 .
19. Stein H., Beck J., Dunn M. Non-invasive ventilation with neurally adjusted ventilatory assist in newborns. Semin Fetal Neonatal Med. 2016; 21:154 –61.
20. Morgan E.L., Firestone K.S., Schachinger S.W., Stein H.M. Effects of changes in apnea time on the clinical status of neonates on NIV-NAVA. Respir Care. 2019; 64: 1096 –100.
21. Nam S.K., Lee J., Jun Y.H. Neural feedback is insufficient in preterm infants during neurally adjusted ventilatory assist. Pediatr Pulmonol. 2019; 54: 1277–83.
22. Protain A.P., Firestone K.S., McNinch N.L., Stein H.M. Evaluating peak inspiratory pressures and tidal volume in premature neonates on NAVA ventilation. Eur J Pediatr. 2021; 180: 167 –75 .
23. Bridier A., Francois T., Baudin F., Emeriaud G. Neural feedback is effective in preterm infants during neurally adjusted ventila tory assist, when using clinically relevant settings. Pediatr Pulmonol. 2019; 54: 1878–9 .
24. Iyer N.P., Dickson J., Ruiz M.E., Chatburn R., Beck J., Sinderby C., et al. Neural breathing pattern in newborn infants pre-and postextubation. Acta Paediatr. 2017; 106: 1928–33 .
25. Amigoni A., Rizzi G., Divisic A., Brugnaro L., Conti G., Pettenazzo A. Effects of propofol on diaphragmatic electrical activity in mechanically ventilated pediatric patients. Inten- sive Care Med. 2015; 41: 1860–1.
26. Snow T.M., Brinck M.J. Assessing the response to inhaled albu- terol by monitoring patient effort-related trends with a servo-I ventilator in neurally adjusted ventilatory assist mode: a case presentation. Adv Neonatal Care. 2015; 15: E3–11.
27. Baudin F., Emeriaud G., Essouri S., Beck J., Portefaix A., Javouhey E., et al. Physiological effect of prone position in children with severe bronchiolitis: a randomized cross-over study (BRONCHIO-DV). J Pediatr. 2019; 205: 112–9 .
28. Lee J., Parikka V., Lehtonen L., Soukka H. Parent einfant skin-to- skin contact reduces the electrical activity of the diaphragm and stabilizes respiratory function inpreterm infants. Pediatr Res. 2022; 91: 1163–7.