Available online 26 March 2024, 151889

Author links open overlay panel, , , ABSTRACT

Patient-triggered modes of ventilation are currently the standard of practice in the care of term and preterm infants. Maintaining spontaneous breathing during mechanical ventilation promotes earlier weaning and possibly reduces ventilator-induced diaphragmatic dysfunction. A further development of assisted ventilation provides support in proportion to the respiratory effort and enables the patient to have full control of their ventilatory cycle. In this paper we will review the literature on two of these modes of ventilation: neurally adjusted ventilatory assist (NAVA) and proportional assist ventilation (PAV), propose future studies and suggest clinical applications of these modes.

Section snippetsINTRODUCTION

Mechanical ventilation has been used for decades in preterm infants to provide respiratory support in patients with respiratory insufficiency. There are multiple modes of conventional ventilation in neonates, which mainly use a flow trigger to synchronize the ventilator with the patient's spontaneous breathing effort. Synchronization is important because asynchrony can cause volutrauma1,2, fluctuations in cerebral blood flow with risk of intraventricular haemorrhage (IVH)3,4, respiratory

NEURALLY ADJUSTED VENTILATORY ASSIST

Neurally adjusted ventilatory assist (NAVA) uses the electrical activity of the diaphragm (Edi) to regulate the applied ventilator pressure. The Edi signal, registered by a nasogastric tube with nine electrodes (Edi catheter) and placed near the diaphragm, is used to trigger inflation and to determine the level of inflation pressure throughout the cycle (Figure 1)8, 9, 10. Stronger inspiratory effort leads to more engagement of the diaphragm and larger electrical activity as sensed by the Edi

PROPORTIONAL ASSIST VENTILATION

Similar to NAVA, proportional assist ventilation (PAV) provides support in proportion to the spontaneous breathing effort, but unlike NAVA, it depends on detection of inspired airflow by a pneumotachometer (PNT) and thus is susceptible to problems with leak around uncuffed endotracheal tubes. Its availability is limited to a single European manufacturer and this modality is not available in North America. The inspired airflow is monitored throughout the entire respiratory cycle and the assist

CONCLUSION

The concept of allowing the patient to control the amount of support provided by the ventilator is very attractive and available with both NAVA and PAV. NAVA has the additional advantage of a diaphragmatic trigger that is not affected by endotracheal leak and has an instantaneous response time. The limitations of both modalities are that they are positive feedback loops that assume the patient's respiratory drive is intact and that the effort is appropriate. A theoretical advantage of PAV over

Disclosure

The authors report no potential conflicts of interest (Authors please confirm complete and correct).

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