Titration and Implementation of Neurally Adjusted Ventilatory Assist in Critically III Patients

Background: Neurally adjusted ventilatory assist (NAVA) delivers assist in proportion to the patient's respiratory drive as reflected by the diaphragm electrical activity (EAdi). We examined to what extent NAVA can unload inspiratory muscles, and whether unloading is sustainable when implementing a NAVA level identified as adequate (NAVAal) during a titration procedure. Methods: Fifteen adult, critically, in patients with a Pao(2)/fraction of inspired oxygen (FIO2) ratio < 300 min Hg were studied. NAVAal was identified based on the change from a steep increase to a less steep increase in airway pressure (Paw) and tidal volume (VT) in response to systematically increasing the NAVA level front low (NAVAlow) to high (NAVAhigh). NAVAal was implemented for 3 h. Results: At NAVAal, the median esophageal pressure time product (PTPes) and EAdi values were reduced by 47% of NAVAlow (quartiles, 16 to 69% of NAVAlow) and 18% of, NAVAlow (quartiles, 15 to 26% of NAVAlow), respectively. At NAVAhigh, PTPes and EAdi values were reduced by 74% of NAVAlow (quartiles, 56 to 86% of NANAlow) and 36% of NAVAlow (quartiles, 21 to 51% of NAVAlow; p <= 0.005 for all). Parameters during 3 h on NAVAal were not different from parameters during titration at NAVAal, and were as follows: VT, 5.9 mL/kg predicted body, weight (PBW) [quartiles, 5.4 to 7.2 in mL/kg PBW]; respiratory rate (RR), 29 breaths/min (quartiles, 22 to 33 breaths/min); mean inspiratory Paw, 16 cm H2O (quartiles, 13 to 20 cm H2O); PTPes, 45% of NAVAlow (quartiles, 28 to 57% of NAVAlow); and EAdi, 76% of NANAlow (quartiles, 63 to 89% of NAVAlow). Pao(2)/FIO2 ratio, PaCO2, and cardiac performance during NANAal were unchanged, while Paw and VT were lower, and RR was higher when compared to conventional ventilation before implementing NAVAal. Conclusions: Systematically increasing the NAVA level reduces respiratory drive, unloads respiratory muscles, and offers a method to determine an assist level that results in sustained unloading, low VT, and stable cardiopulmonary function when implemented for 3 h.