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Equipment and monitoring
Published in Brian J Pollard, Gareth Kitchen, Handbook of Clinical Anaesthesia, 2017
Baha Al-Shaikh, Sarah Hodge, Sanjay Agrawal, Michele Pennimpede, Sindy Lee, Janine MA Thomas, John Coombes
NAVA (Neurally Adjusted Ventilatory Assist). Novel mode of positive pressure ventilation where the ventilator is controlled by the patient’s own neural control of breathing. Electrodes on a nasogastric tube monitor electrical impulses from the phrenic nerve at the level of the diaphragm, and adjust ventilatory parameters accordingly.
Respiratory management in the premature neonate
Published in Expert Review of Respiratory Medicine, 2023
Vikramaditya Dumpa, Indirapriya Avulakunta, Vineet Bhandari
Neurally adjusted ventilatory assist (NAVA) is a diaphragm-triggered ventilation that uses the electrical signal from the diaphragm to proportionally assist the patient’s respiration [98]. NAVA can be provided invasively or non-invasively. The benefits of non-invasive NAVA (NIV-NAVA) include the ability to synchronize ventilator inflations with patient’s spontaneous breaths allowing for decreased work of breathing, improved gas exchange, and earlier extubation [98,99]. There are multiple small studies showing improved outcomes of NIV-NAVA compared to NCPAP or NIPPV, but further data from large RCTs especially in extremely preterm infants is required before its use is routinely recommended [100–103]. Moreover, its widespread use is limited by the ability to deliver NAVA only on the Servo® ventilators. The Diaphragmatic Initiated Ventilatory Assist (DIVA) trial is an ongoing large multicenter RCT evaluating NIV-NAVA vs. NIPPV to prevent post-extubation failure in preterm infants 24 0/7–27 6/7 weeks GA with RDS (ClinicalTrials.gov Identifier: NCT05446272).
Lung and diaphragm protective ventilation: a synthesis of recent data
Published in Expert Review of Respiratory Medicine, 2022
Vlasios Karageorgos, Athanasia Proklou, Katerina Vaporidi
Finally, another tool to facilitate lung and diaphragm protective ventilation is the use of proportional modes of assist [74], like neurally adjusted ventilatory assist, NAVA and proportional assist ventilation, PAV. With these modes, the level of assist is proportional to the patient’s effort, thus enabling the patient’s control-of-breathing system to regulate ventilation and limit over- and under-assist [74], enhancing diaphragm recovery [137]. Moreover, because the duration of inspiration is determined by the patient’s effort, proportional modes are associated with reduced asynchronies [138]. Finally, proportional modes may also contribute to lung-protective ventilation by allowing the operation of the protective feedback mechanisms of the control of breathing system. During un-assisted breathing, inspiratory effort is normally decreasing with increasing lung volumes, as a result of the change in force-length relationship in the diaphragm, and the decrease of respiratory system compliance. Because, in proportional modes, the delivered tidal volume is proportional to inspiratory effort, it decreases at higher lung volumes, thus preventing alveolar over-stretch [14].
Treatment and respiratory support modes for neonates with respiratory distress syndrome
Published in Expert Opinion on Orphan Drugs, 2020
Theodore Dassios, Hemant Ambulkar, Anne Greenough
Surfactant therapy has been well proven to reduce mortality and morbidity in infants with RDS. It is now common practice not to give surfactant prophylaxis to all, but rather stabilize babies on noninvasive respiratory support in the delivery suite and give early selective surfactant to infants with signs of RDS. Increasingly, LISA less invasive surfactant administration is used and endotracheal intubation and ventilation avoided. Whether such practice is effective in the delivery suite has rarely been assessed. There are early promising results from nebulization of surfactant. Systemically administered corticosteroids should not be given in the perinatal period, for although effective in increasing extubation, serious complications occur. Early, inhaled budesonide has been associated with an increased mortality. There is no evidence to support routine use of salbutamol or myo-inositol, but inhaled nitric oxide may be helpful in preterm infants with proven pulmonary hypertension. Caffeine should be routinely administered as it reduces BPD, improves neurodevelopmental outcomes, and reduces motor impairment. Further research is required regarding the safety and efficacy of stem cells before they can be considered as a treatment for RDS. Noninvasive techniques of respiratory support include nasal continuous positive airway pressure (nCPAP), nasal intermittent positive pressure ventilation (NIPPV) and heated, humidified, high-flow cannula (HHFNC). Randomized controlled trials (RCTs) of nCPAP versus ventilation have given mixed results. Meta-analysis demonstrated NIPPV rather than nCPAP provided better support post extubation. After extubation, HHFNC has similar efficacy to CPAP. Invasive techniques which synchronize inflations with the patient’s respiratory efforts lead to a shorter duration of mechanical ventilation. Further studies are required to assess the efficacy of newer synchronized techniques that is PAV proportional assist ventilation and NAVA neurally adjusted ventilatory assist. RCTs of VTV have demonstrated reductions in BPD. Systematic reviews have demonstrated high-frequency oscillatory ventilation (HFOV) does not reduce BPD, but it may be associated with superior longer-term lung function. Closed loop automatic oxygen control looks promising, but the long-term efficacy needs testing in appropriate RCTs.