Heart-lung interactions during neurally adjusted ventilatory assist

Introduction: Assist in unison to the patient's inspiratory neural effort and feedback-controlled limitation of lung distension with neurally adjusted ventilatory assist (NAVA) may reduce the negative effects of mechanical ventilation on right ventricular function. Methods: Heart-lung interaction was evaluated in 10 intubated patients with impaired cardiac function using esophageal balloons, pulmonary artery catheters and echocardiography. Adequate NAVA level identified by a titration procedure to breathing pattern (NAVAal), 50% NAVAal, and 200% NAVAal and adequate pressure support (PSVal, defined clinically), 50% PSVal, and 150% PSVal were implemented at constant positive end-expiratory pressure for 20 minutes each. Results: NAVAal was 3.1 +/- 1.1cmH(2)O/mu V and PSVal was 17 +/- 2 cmH(2)0. For all NAVA levels negative esophageal pressure deflections were observed during inspiration whereas this pattern was reversed during PSVal and PSVhigh. As compared to expiration, inspiratory right ventricular outflow tract velocity time integral (surrogating stroke volume) was 103 +/- 4%, 109 +/- 5%, and 100 +/- 4% for NAVAlow, NAVAal, and NAVAhigh and 101 +/- 3%, 89 +/- 6%, and 83 +/- 9% for PSVlow, PSVal, and PSVhigh, respectively (p < 0.001 level-mode interaction, ANOVA). Right ventricular systolic isovolumetric pressure increased from 11.0 +/- 4.6 mmHg at PSVlow to 14.0 +/- 4.6 mmHg at PSVhigh but remained unchanged (11.5 +/- 4.7mmHg (NAVAlow) and 10.8 +/- 4.2 mmHg (NAVAhigh), level-mode interaction p= 0.005). Both indicate progressive right ventricular outflow impedance with increasing pressure support ventilation (PSV), but no change with increasing NAVA level. Conclusions: Right ventricular performance is less impaired during NAVA compared to PSV as used in this study. Proposed mechanisms are preservation of cyclic intrathoracic pressure changes characteristic of spontaneous breathing and limitation of right-ventricular outflow impedance during inspiration, regardless of the NAVA level.