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Hot Topics in Neonatal/Pediatric Respiratory Care

Emilee Lamorena, MSc, RRT, RRT-NPS

Clinical Manager, Respiratory Care I do not have any conflicts of interest to disclose.

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Objectives

1. Neurally Adjusted Ventilatory Assist (NAVA)

2. High Frequency Oscillatory Ventilation

3. Respiratory Therapist-Driven Protocols

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Review recent and relevant literature about the clinical effectiveness and use of:

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Date #1:Mr. NAVA

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I am so intuitive, I can give you exactly what your

brain wants.

The most interesting ventilator mode in the world

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NAVANeurally Adjusted Ventilatory Assist

Nature 1999

Potential Problems:• Over/under sensitivity• Delay in breath delivery• Air leaks

NAVA: The Basics• The patient (specifically the brain) decides when

and how to breathe

• Electrical activity of the diaphragm (Edi signal) is measured with specialized NG tube connected to the ventilator

– Triggers based on electrical activity of the diaphragm

– Provides support to a patient’s spontaneous breaths in proportion to the electrical activity of the diaphragm

• Volume and duration of breath varies according to patient’s demand

• Servo-I and Servo-U

• Invasive and Non-invasive modes8

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Why monitor the Edi Signal?

Ch8

Ch7

Ch6

Ch5

Ch4

Ch3

Ch2

Ch1

Phasic

Tonic

Noise level

Edi signal is averaged 62.5 times per second & transferred to Servo-i.

Edi Peak

Edi Min

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SIMV PC & PS with NAVA Preview

Patient – Ventilator Asynchrony

11Beck J, Emeriaud G, Liu Y, Sinderby C. Neurally-adjusted ventilator assist (NAVA) in children: a systematic review.

Minerva Anestesiologica 2016; 82(8) 874-83.

Patient – Ventilator Asynchrony

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Patient – Ventilator Asynchrony

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Peak Pressures and Tidal Volume• Several studies have

demonstrated that pediatric patients spontaneously choose lower peak inspiratory pressures (PIPs), MAPS, and tidal volumes during NAVA, compared to clinician-targeted settings

• Why?

– Reflex control of brain

– Improved comfort due to better synchrony

• Reduction of pressures observed were associated with reduction of PaCO2, improvement of P/F ratio, and the time of weaning – without hemodynamic impact

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What is the NAVA Level?

Estimated Ppeak (Pest) in NAVA:

= NAVA Level x (Edi peak – Edi min) + PEEP

• Provides support in proportion to the signal from the diaphragm

• The ventilator becomes a “respiratory muscle”– Titrating the NAVA Level just transfers work from the diaphragm to the ventilator

• Prospective case series study

• NICU at Toledo Children’s Hospital and Akron Children’s Hospital between Febuary 2012-June 2012

• Subjects: 21, Infants <30 weeks gestation, birth weight <1500 g

• Invasive and Non-invasive NAVA

• Titration Studies:– 24 minutes

– Started at NAVA 0.5

– Increased incrementally by 0.5 every 3 minutes to a maximum of 4

– Recorded HR, SpO2, and MB 16

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Break point

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Invasive NAVA

Non-Invasive NAVA

Tidal Volumes

Clinical Outcomes?

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• N=170 pediatric patients: full-term infants to 16 years old

• PICU of Oulu University Hospital in Holland – September 2009 to May 2012

• Primary Outcomes:

– Duration of invasive ventilation

– Amount of sedation needed

• Secondary Outcomes:

– LOS in PICU

– Sedation level

– Vent Parameters: FiO2, Vt, Airway Pressures, RR

– Vitals: HR, BP, SpO2

– ABG20

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Time on Ventilator

PICU LOS

NAVA: 3.3 hoursControl: 6.6 hours

P=0.17

NAVA: 49.5 hoursControl: 72.8 hours

P=0.03

Sedation Agitation Scale (SAS)• SAS scores were

similar for the two groups

• Tendency toward lower doses of sedation in NAVA patients

• When post-operative patients were excluded, amount of sedation needed was significantly lower in the NAVA group (P=0.03)

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PIP

FiO2

• Higher levels of PaCo2 in NAVA patients up to 32 hours lower risk of hypocapnia

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CONCLUSIONS:• Edi is a direct measure of patient’s

own breathing drive: valuable tool for assessing level of sedation reduces risk of sedation overdose

• Lower PIPs and FiO2, with improved OI NAVA patients equally able to transfer oxygen to their tissues, while their lungs were less stressed

• NAVA more successful at achieving protective lung strategy?

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Should we utilize NAVA more?

• Long-term role is still uncertain– duration of MV

– LOS

– mortality

• Theoretical/unconfirmed concepts in large studies

• High cost

• While it is great to have to have continuous monitoring of Edi signal, we have little understanding of the impact of this monitoring and the ventilatory strategy on clinical outcomes.

• Institutional barriers to competence and confidence

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• Safe and feasible as a primary mode for use in pediatric critical care

• Neural ventilation in infants and children is better tolerated compared to conventional ventilator modes– Better patient-ventilator interaction

– Provides comfort

– Requires lower level of sedation

• Improves oxygenation even with lower airway pressures

• Continuous information provided by Edi signal

We need more, large, randomized controlled trials to understand its impact on clinical outcomes.

Why? Why not?

Date #2:HULKY HFOV

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I am so strong that I can pick you up if you collapse, but I will always be gentle

and protective.

The Gentle Giant

High Frequency Oscillation (HFOV): Why?

• High frequency, low tidal volume strategy

• Maintains constant alveolar recruitment

• Prevents “inflate-deflate” cycle reduced VILI

• Improved oxygenation

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HFOV: When Do We Use It?

• Indications:

– Rescue therapy for patients with severe respiratory failure who are

• failing conventional ventilation

• Ventilation settings are approaching harmful parameters

– Second-line therapy for managing bronchopleural fistulas

– Lung protective ventilation for ARDS and VILI

– NICU:

• Air leaks

• PPHN

• MAS

– Adults:

• Air leaks

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• Hazards:

– Less effective with obstructive disease: can lead to air trapping or hyperinflation air leaks

– Cardiovascular effects:

• Decreased venous return

• Decreased cardiac output

• IVH

• Increased intrathoracic pressures

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HFOV in ARDS?

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Hospital or 30-Day Mortality

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P/F Ratio

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• 29 different hospitals in England, Wales, and Scotland from 2009-2012

• N: 795 patients

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• 38 different centers in Canada, Saudi Arabia, U.S, Saudi Arabia, Chile, and India from 2007-2012

• Prematurely stopped after 500 patients

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Design:– 5 tertiary care PICUs

– Prospective, randomized, clinical study with crossover

Subjects – 70 patients with either diffuse alveolar disease and/or airleak syndrome

Intervention:– HFOV Strategy: Aggressive increases in MAP to attain ideal lung volume,

SpO2≥ 90%, with FiO2 ≤0.6

– Conventional: increases in PEEP and I-time to increase MAP and limit increases in PIP

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• Results:– In HFOV group:

• PaO2/PAO2 ratio increased significantly

• OI decreased significantly over time

– No differences in:

• Duration of mechanical ventilation

• Frequency of airleak

• 30-day survival

– Significantly fewer patients treated with HFOV required supplemental oxygenation at 30 days compared with patients managed with conventional ventilation

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p<0.001

P=0.001

• Compared outcomes between early use of HFOV or CMV in patients with PARDS

• 200 patients over 5 years

• Results:– Significant improvement in P/F ratio and OI after 24 hours of

enrollment

– No difference in 30-day mortality, length of stay, or ventilation days

HFOV has superior advantage in improving oxygenation, yet with no significant mortality improvement. 38

www.PROSpect-network.org

PROSpect: PRone and OScillation PEdiatric Clinical Trial

Phase III Clinical Trial

UG3 HL141736-01

U24 HL141723-01

Design

Supine Prone

CMV CMV & Supine CMV & Prone

HFOV HFOV & Supine

HFOV & Prone

• 2x2 factorial, response-adaptive, randomized controlled clinical trial of supine/prone positioning and CMV/HFOV

• Consecutive subjects with severe PARDS will be randomized to one of four groups – Randomization stratified by age group(<1; 1-7; 8+)

and direct/indirect lung injury

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Purpose

To provide the field of pediatric critical care evidence to support best practices in critically ill children with severe PARDS

Specific Aims• To compare the effects of prone positioning with supine positioning on

ventilator-free days

• To compare the effects of HFOV with CMV on ventilator-free days

• To compare the impact of these interventions on nonpulmonary organ failure-free days

Exploratory1. To explore the interaction effects of prone positioning with HFOV on VFD

2. To investigate the impact of these interventions on:

• 90-day in-hospital mortality

• Among survivors, the duration of mechanical ventilation

• PICU and hospital length of stay

• Trajectory of post-PICU functional status and HRQL42

Date #3:

Oprah RT-Drive Protocol

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I will empower you and trust you to make the best

decisions! Be your best self!

The Empowering Soul

RT-Driven Protocols: Who Cares?

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RT-Driven Protocols: Topics

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Bronchial HygieneAirway Clearance

Inhaled Nitric OxideVentilator

Management/Weaning

Extubation ReadinessHigh Flow Nasal Cannula Weaning Bronchodilator

Pathways

RT-Driven Protocols: Why?• More objective, consistent, evidence-based approach to

decision making

• Respiratory Therapist-managed protocols are effective in– patient assessment

– ventilator management and liberation

– arterial blood gas sampling

– oxygen titration

– Many interventions inside and outside the ICU

• When comparing physician-directed orders to therapist-driven orders, RT-driven protocols resulted in:– Decreased hospital LOS

– Decreased PICU LOS

– Decreased ventilator days

– Decreased time spent on therapies/modalities

• Provides Respiratory Therapists more flexibility and autonomy

• Elevates status and increases value of Respiratory Therapists 46

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Save one life, and you’re a

superhero.

Save hundreds of lives … and you’re

an RT. 48

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References

1. El-Nawawy A, Moustafa A, Heshmat H, Abouahmed A. High frequency oscillatory ventilation versus conventional mechanical ventilation in pediatric acute respiratory distress syndrome: A randomized controlled study. Turk J Pediatr 2017; 59: 130-143.

2. Arnold JH, Hanson JH, Toro-Figuero LO, et al. Prospective, randomized comparison of high-frequency oscillatory ventilation and conventional mechanical ventilation in pediatric respiratory failure. Crit Care Med 1994; 22: 1530-1539.

3. Beck J, Emeriaud G, Liu Y, Sinderby C. Neurally-adjusted ventilator assist (NAVA) in children: a systematic review. Minerva Anestesiologica 2016; 82(8) 874-83.

4. Ferguson ND, Cook DJ, Guyatt GH, et al. High-frequency oscillation in early acute respiratory distress syndrome. N Engl J Med 2013;368:795-805.

5. Firestone KS, Fisher S, Reddy S, White DB, Stein HM. Effect of changing NAVA levels on peak inspiratory pressures and electricalactivity of the diaphragm in premature neonates. Journal of Perinatology (2015) 1-5

6. Kallio M, Peltonleml O, Anttla E, Pokka T, Kontlokarl T. Neurally adjusted ventilator assist (NAVA) in pediatric intensive care – a randomized controlled trial. Pediatric Pulmonology (2015) 50:55-62

7. Maquet Manual.

8. Napolitano, N. PROSpeCT Training Slides. 2019.

9. Young D, Lamb SE, Shah S, et al. High-frequency oscillation for acute respiratory distress syndrome. N Engl J Med 2013;368:806-13.

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