| Critical Care | Case Report: NAVA |

Case contributed by Professor Saïd Hachimi-Idrissi, University Hospital of Brussels - Jette, Belgium.

PATIENT CASE REPORT. CATEGORY: NEONATALDETERMINING THE NAVA LEVEL IN PRETERM INFANT WITH APNOEA AND POOR PERIPHERAL PERFUSION.

Clinical Background and Situation:A preterm infant weighing 1090 g was born after caesarean because of placenta abruption at the gestational age of 27

weeks. The Apgar scores were 6 and 8 after 5 and 10 minutes respectively. The newborn had developed a respiratory

distress syndrome for which mechanical ventilation was needed as well as surfactant, which was administered

endotracheally. The mechanical ventilation was stopped after 9 days, 3 days on non-invasive ventilation and on oxygen

for another 60 days because of bronco-pulmonary dysplasia. Further neonatal period was without major incident and the

patient was discharge after a period of 78 days with body weight of 2402 g.

Figure 1 Edi catheter positioning to obtain Edi signal by means of ECG.

Figure 2 Following reduction of sedation the patient was switched to NAVA.

Interventions and course of ventilation therapy:Two weeks after discharge from the neonatal intensive care,

the infant was brought to the hospital because of recurrent

apnea on the cardiorespiratory home monitoring.

On admission the infant showed central cyanosis with

gasping. The patient was first ventilated with bag-valve

mask and high oxygen concentration together with chest

compression for very poor peripheral perfusion and

bradycardia less than 40/min, and this was sustained for a

10 minute period followed by endotracheal intubation and

artificial ventilation. The subsequent day two, the infant

was on Pressure Regulated Volume Control (PRVC) mode

and despite high pressure, the PaCO2 remained very high

and the patient was switched to high frequency ventilation

(VDR® IV). The patient had also a very low systemic pressure

requiring Inotrop and Vasopressor as well as several fluid

challenges. An antibiotics therapy was started because of

aspiration pneumonia on admission. On day 10 after the

collapse, the infant’s condition improved considerably and

the high frequency ventilation was switched to the PRVC

mode with a TV of 45 ml; I/E: 1:2, at frequency of 33/min

with a flow trigger of 3, PEEP of 4 cm H2O and FiO2 of 35%

with an arterial pH of 7.39, PaCO2 of 45, PaO2 of 120 and

Bicarbonate of 27 and a saturation of 98%. At that time an

8 Fr NAVA Edi catheter was inserted via the nostril and was

placed according the formula at 26.5 cm. The appropriate

location was obtained by the Edi signal (figure 1).

The patient sedation was reduced and the Edi signal was

detected and the patient was switched to the NAVA mode

with a NAVA level of 0.5 (figure 2).

Case contributed by Professor Saïd Hachimi-Idrissi, University Hospital of Brussels - Jette, Belgium.

| Critical Care | Case Report: NAVA |

Figure 4 Curve during PRVC mode.

Figure 3 Increase of NAVA level to 3.8.

Weaning process and results:The patient became tachypneic up 60 breaths /min and

the NAVA mode switched more frequently to the back up

pressure support mode with a deterioration of the blood

gas analysis ( pH:7.26; PaCo2:63; PaO2: 80, Bicarbonate: 29

and saturation was 94%). After a 4 hour trial we switched to

the PRVC mode with an improvement of the arterial blood

gas analysis. A second trial next day was performed with

frequent switch to the back-up mode Pressure Support and

even to Pressure Control mode.

On the 3 day of our trial on NAVA we decided to start with a

higher NAVA level at 3.8 (Figure 3). This level of NAVA was

to obtain a similar pressure curve as when the patient was

on PRVC (Figure 4). The patient’s conditions improved, he

became less tachypneic and the blood gas analysis improved

(pH: 7.4; PaCo2: 60; PaO2: 132; bicarbonate: 32, saturation: 98%)

Case contributed by Professor Saïd Hachimi-Idrissi, University Hospital of Brussels - Jette, Belgium.

| Critical Care | Case Report: NAVA |

Figure 5 Trends for PRVC, followed by NAVA prior to weaning.

On the end of the day 3, the patient was able to be weaned

from the machine as well from NAVA, and started to breathe

spontaneously with passive oxygen flow (Figure 5).

One week after weaning from the ventilator, the patient was

sent to the general ward with physiotherapy as treatment

and feeding gavages plus oral feeding in order to improve

the body weight. The patient was discharged from the

general ward 6 days later in good condition, without obvious

neurological problem and having a body weight of 2.730 g.

Case summary:A preterm infant was admitted with apnoea and poor

peripheral perfusion, successfully resuscitated without

neurological sequelae. First he had high ventilatory

parameters and later on we switched to the NAVA with a

low NAVA level. Initially, he remained tachypneic and had

abnormal blood gas analysis, but when the NAVA level was

increased to obtain similar pressure that the patient had on

PRVC, he improved rapidly, allowing us to reduce the NAVA

level and weaning the patient from the ventilator.

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The views, opinions and assertions expressed in the patient cases

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