Neurally Adjusted Ventilatory Assist Is Associated with Greater Initial Extubation Success in Postoperative Congenital Heart Disease Patients when Compared to Conventional Mechanical Ventilation

Shawn Berry Sood; Nasir Mushtaq; Kellie Brown; Vanette Littlefield; Roger Phillip Barton

doi:10.1055/s-0038-1627099

Journal of Pediatric Intensive Care, Inhaltsverzeichnis

J Pediatr Intensive Care 2018; 07(03): 147-158
DOI: 10.1055/s-0038-1627099

Original Article

Georg Thieme Verlag KG Stuttgart · New York

Neurally Adjusted Ventilatory Assist Is Associated with Greater Initial Extubation Success in Postoperative Congenital Heart Disease Patients when Compared to Conventional Mechanical Ventilation

Authors

Shawn Berry Sood

¹Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, United States
Nasir Mushtaq

¹Department of Pediatrics, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma, United States
Kellie Brown

²Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
Vanette Littlefield

²Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States
Roger Phillip Barton

²Division of Pediatric Intensive Care, The Children's Hospital at Saint Francis, 6161 South Yale Avenue, Tulsa, Oklahoma 74136, United States

Abstract

Extubation failure is associated with considerable morbidity and mortality in postoperative patients with congenital heart disease (CHD). The study purpose was to investigate initial extubation success utilizing neurally adjusted ventilatory assist (NAVA) compared with pressure-regulated volume controlled, synchronized intermittent mandatory ventilation with pressure support (SIMV-PRVC + PS) for ventilatory weaning in patients who required prolonged mechanical ventilation (MV). Also, total days on MV, inotropes, sedation, analgesia, and pediatric intensive care unit (PICU) length of stay (LOS) between both groups were compared. This was a non-randomized pilot study utilizing historical controls (SIMV-PRVC + PS; n = 40) compared with a prospective study population (NAVA; n = 35) in a Level I PICU and was implemented to help future trial designs. All patients (n = 75) required prolonged MV ≥96 hours due to their complex postoperative course. Ventilator weaning initiation and management was standardized between both groups. Ninety-seven percent of the NAVA group was successfully extubated on the initial attempt, while 80% were in the SIMV-PRVC + PS group (p = 0.0317). Patients placed on NAVA were eight times more likely to have successful initial extubation (odds ratio [OR]: 8.50, 95% confidence interval [CI]: 1.01, 71.82). The NAVA group demonstrated a shorter median duration on MV (9.0 vs. 11.0 days, p = 0.032), PICU LOS (9.0 vs. 13.5 days, p < 0.0001), and shorter median duration of days on dopamine (8.0 vs. 11.0 days, p = 0.0022), milrinone (9.0 vs. 12.0 days, p = 0.0002), midazolam (8.0 vs. 12.0 days, p < 0.0001), and fentanyl (9.0 vs. 12.5 days, p < 0.0001) compared with the SIMV-PRVC + PS group. NAVA compared with SIMV-PRVC + PS was associated with a greater initial extubation success rate. NAVA should be considered as a mechanical ventilator weaning strategy in postoperative congenital heart disease (CHD) patients and warrants further investigation.

Keywords

neurally adjusted ventilatory assist - mechanical ventilation - NAVA - extubation - congenital heart disease

Volltext

Referenzen

References
1 Harrison AM, Cox AC, Davis S, Piedmonte M, Drummond-Webb JJ, Mee RB. Failed extubation after cardiac surgery in young children: Prevalence, pathogenesis, and risk factors. Pediatr Crit Care Med 2002; 3 (02) 148-152
2 Newth CJ, Venkataraman S, Willson DF. , et al; Eunice Shriver Kennedy National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Weaning and extubation readiness in pediatric patients. Pediatr Crit Care Med 2009; 10 (01) 1-11
3 Harkel AD, van der Vorst MM, Hazekamp MG, Ottenkamp J. High mortality rate after extubation failure after pediatric cardiac surgery. Pediatr Cardiol 2005; 26 (06) 756-761
4 Kurachek SC, Newth CJ, Quasney MW. , et al. Extubation failure in pediatric intensive care: a multiple-center study of risk factors and outcomes. Crit Care Med 2003; 31 (11) 2657-2664
5 Polito A, Patorno E, Costello JM. , et al. Perioperative factors associated with prolonged mechanical ventilation after complex congenital heart surgery. Pediatr Crit Care Med 2011; 12 (03) e122-e126
6 Gupta P, Rettiganti M, Gossett JM. , et al. Risk factors for mechanical ventilation and reintubation after pediatric heart surgery. J Thorac Cardiovasc Surg 2016; 151 (02) 451-8.e3
7 Gaies M, Tabbutt S, Schwartz SM. , et al. Clinical epidemiology of extubation failure in the pediatric cardiac ICU: A report from the pediatric cardiac critical care consortium. Pediatr Crit Care Med 2015; 16 (09) 837-845
8 Edmunds S, Weiss I, Harrison R. Extubation failure in a large pediatric ICU population. Chest 2001; 119 (03) 897-900
9 Baisch SD, Wheeler WB, Kurachek SC, Cornfield DN. Extubation failure in pediatric intensive care incidence and outcomes. Pediatr Crit Care Med 2005; 6 (03) 312-318
10 Breatnach C, Conlon NP, Stack M, Healy M, O'Hare BP. A prospective crossover comparison of neurally adjusted ventilatory assist and pressure-support ventilation in a pediatric and neonatal intensive care unit population. Pediatr Crit Care Med 2010; 11 (01) 7-11
11 Carteaux G, Córdoba-Izquierdo A, Lyazidi A, Heunks L, Thille AW, Brochard L. Comparison between neurally adjusted ventilatory assist and pressure support ventilation levels in terms of respiratory effort. Crit Care Med 2016; 44 (03) 503-511
12 Coisel Y, Chanques G, Jung B. , et al. Neurally adjusted ventilatory assist in critically ill postoperative patients: a crossover randomized study. Anesthesiology 2010; 113 (04) 925-935
13 Piquilloud L, Vignaux L, Bialais E. , et al. Neurally adjusted ventilatory assist improves patient-ventilator interaction. Intensive Care Med 2011; 37 (02) 263-271
14 Clement KC, Thurman TL, Holt SJ, Heulitt MJ. Neurally triggered breaths reduce trigger delay and improve ventilator response times in ventilated infants with bronchiolitis. Intensive Care Med 2011; 37 (11) 1826-1832
15 Spahija J, de Marchie M, Albert M. , et al. Patient-ventilator interaction during pressure support ventilation and neurally adjusted ventilatory assist. Crit Care Med 2010; 38 (02) 518-526
16 Chao DC, Scheinhorn DJ, Stearn-Hassenpflug M. Patient-ventilator trigger asynchrony in prolonged mechanical ventilation. Chest 1997; 112 (06) 1592-1599
17 Thille AW, Rodriguez P, Cabello B, Lellouche F, Brochard L. Patient-ventilator asynchrony during assisted mechanical ventilation. Intensive Care Med 2006; 32 (10) 1515-1522
18 Colombo D, Cammarota G, Bergamaschi V, De Lucia M, Corte FD, Navalesi P. Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure. Intensive Care Med 2008; 34 (11) 2010-2018
19 Vignaux L, Grazioli S, Piquilloud L. , et al. Optimizing patient-ventilator synchrony during invasive ventilator assist in children and infants remains a difficult task*. Pediatr Crit Care Med 2013; 14 (07) e316-e325
20 Levine S, Nguyen T, Taylor N. , et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 2008; 358 (13) 1327-1335
21 Hudson MB, Smuder AJ, Nelson WB, Bruells CS, Levine S, Powers SK. Both high level pressure support ventilation and controlled mechanical ventilation induce diaphragm dysfunction and atrophy. Crit Care Med 2012; 40 (04) 1254-1260
22 Hermans G, Agten A, Testelmans D, Decramer M, Gayan-Ramirez G. Increased duration of mechanical ventilation is associated with decreased diaphragmatic force: a prospective observational study. Crit Care 2010; 14 (04) R127
23 Sinderby C, Beck J, Spahija J. , et al. Inspiratory muscle unloading by neurally adjusted ventilatory assist during maximal inspiratory efforts in healthy subjects. Chest 2007; 131 (03) 711-717
24 Wysocki M, Cracco C, Teixeira A. , et al. Reduced breathing variability as a predictor of unsuccessful patient separation from mechanical ventilation. Crit Care Med 2006; 34 (08) 2076-2083
25 Di Mussi R, Spadaro S, Mirabella L. , et al. Impact of prolonged assisted ventilation on diaphragmatic efficiency: NAVA versus PSV. Crit Care 2016; 20: 1
26 Sassoon CS, Zhu E, Caiozzo VJ. Assist-control mechanical ventilation attenuates ventilator-induced diaphragmatic dysfunction. Am J Respir Crit Care Med 2004; 170 (06) 626-632
27 Dantzker DR. Oxygen delivery and utilization in acute and chronic disease. In: Gutierrez G, Vincent JL. , eds. Tissue Oxygen Utilization. Update in Intensive Care and Emergency Medicine. Vol 12. Springer, Berlin, Heidelberg; 1991
28 Heulitt MJ, Torres Jr A, Carmack J, Anders M. Mechanical ventilators optimized for pediatric use decrease work of breathing and oxygen consumption during pressure-support ventilation. Crit Care Med 1995; 23 (11) 1931-1933
29 Berger D, Bloechlinger S, Takala J, Sinderby C, Brander L. Heart-lung interactions during neurally adjusted ventilatory assist. Crit Care 2014; 18 (05) 499
30 Kallio M, Peltoniemi O, Anttila E, Pokka T, Kontiokari T. Neurally adjusted ventilatory assist (NAVA) in pediatric intensive care–a randomized controlled trial. Pediatr Pulmonol 2015; 50 (01) 55-62
31 de la Oliva P, Schüffelmann C, Gómez-Zamora A, Villar J, Kacmarek RM. Asynchrony, neural drive, ventilatory variability and COMFORT: NAVA versus pressure support in pediatric patients. A non-randomized cross-over trial. Intensive Care Med 2012; 38 (05) 838-846
32 Kress JP, Pohlman AS, O'Connor MF, Hall JB. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342 (20) 1471-1477
33 Esteban A, Alía I, Ibañez J, Benito S, Tobin MJ. ; The Spanish Lung Failure Collaborative Group. Modes of mechanical ventilation and weaning. A national survey of Spanish hospitals. Chest 1994; 106 (04) 1188-1193