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Gentler ventilation strategies for newborns

Topic

Intensive Care

Innovation

NAVA in NICU

Topic

Intensive Care

Innovation

Individually personalized ventilation

Respiratory failure is one of the main reasons for admission to neonatal and pediatric intensive care units. Many patients experience complications related to mechanical ventilation.

Therefore, there is a general trend toward a gentler ventilation approach that can reduce adverse effects such as ventilator-associated pneumonia (VAP) and ventilator-induced lung injury (VILI).

Non-invasive ventilation (NIV) aims to minimize these complications while supporting the patient's own breathing. However, it is particularly challenging to adapt NIV to the needs of infants and children: small tidal volumes and high respiratory rates, especially in the presence of leaks, disrupt the synchrony between the patient and the ventilator. Leaks also lead to unreliable monitoring of respiratory drive and respiratory rate.

To address these challenges, Edi monitoring and the concept of neurally adjusted ventilatory assist (NAVA) were developed. With NAVA, the patient’s own neural respiratory drive is used to control the ventilator.

The advantages of neurally controlled ventilation

With NAVA and NIV NAVA, newborns can control their own ventilation. By using the neural respiratory drive, it is not the ventilator but the patient who determines the initiation and termination of each breath, as well as the breath size, inspiratory time, respiratory rate, and peak pressure. The result is improved synchronisation between the ventilator and the patient, both during invasive and non-invasive ventilation with nasal masks or nasal prongs (NIV NAVA).

Studies demonstrate that newborns supported with NAVA and NIV-NAVA show:

Improved synchronisation^[1]
Reduced work of breathing WOB^[2]
Protective tidal volumes and inspiratory pressures^[3]
Better gas exchange^[4]
Less sedation^[5]
Fewer apneas^[6]
Shortened ventilation time^[5],^[8] and ICU stay^[7],^[9]

Learn more about NAVA.

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All references

1. Lee J, Kim HS, Jung YH, Shin SH, Choi CW, Kim EK, Kim BI, Choi JH. Non-invasive neurally adjusted ventilatory assist in preterm infants: a randomised phase II crossover trial. Arch Dis Child Fetal Neonatal Ed. 2015 Nov;100(6):F507-13.
2. Parikka V, Beck J, Zhai Q, Leppäsalo J, Lehtonen L, Soukka H. The effect of caffeine citrate on neural breathing paern in preterm infants. Early Hum Dev. 2015 Oct;91(10):565-8.
3. Soukka H, Grönroos L, Leppäsalo J, Lehtonen L. The effects of skin-to-skin care on the diaphragmatic electrical activity in preterm infants. Early Hum Dev. Sep. 2014;90(9):531-4.
4. Gibu CK, Cheng PY, Ward RJ, Castro B, Heldt GP. Feasibility and physiological effects of noninvasive neurally adjusted ventilatory assist in preterm infants. Pediatr Res. Oct. 2017;82(4):650-657.
5. Kallio M, Peltoniemi O, Anila E, Pokka T, Kontiokari T. Neurally Adjusted Ventilatory Assist (NAVA) in Pediatric Intensive Care – A Randomized Controlled Trial. Pediatr Pulmonol. Jan. 2015;50(1):55-62.
6. Mally PV, Beck J, Sinderby C, Caprio M, Bailey SM. Neural Breathing Paern and Patient-Ventilator Interaction During Neurally Adjusted Ventilatory Assist and Conventional Ventilation in Newborns. Pediatr Crit Care Med. Jan. 2018; 19(1):48-55.
7. Stein H, Howard D. Neurally Adjusted Ventilatory Assist (NAVA) in Neonates less than 1500 grams: a retrospective analysis. J Pediatr 2012;160:786e9.
8. Piastra M, De Luca D, Costa R, Pizza A, De Sanctis R, Marzano L, Biasucci D, Visconti F, Conti G. Neurally adjusted ventilatory assist vs pressure support ventilation in infants recovering from severe acute respiratory distress syndrome: Nested study. J Crit Care. 2013 Oct 24.
9. Piastra M, De Luca D, Marzano L, Stival E, Genovese O, Pietrini D, Conti G. The number of failing organs predicts non-invasive ventilation failure in children with ALI/ARDS. Intensive Care

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