Effects of Neurally Adjusted Ventilatory Assist (NAVA) levels in non-invasive ventilated patients: titrating NAVA levels with electric diaphragmatic activity and tidal volume matching

BACKGROUND: Neurally adjusted ventilatory assist (NAVA) delivers pressure in proportion to diaphragm electrical activity (Eadi). However, each patient responds differently to NAVA levels. This study aims to examine the matching between tidal volume (Vt) and patients' inspiratory demand (Eadi), and to investigate patient-specific response to various NAVA levels in non-invasively ventilated patients. METHODS: 12 patients were ventilated non-invasively with NAVA using three different NAVA levels. NAVA100 was set according to the manufacturer's recommendation to have similar peak airway pressure as during pressure support. NAVA level was then adjusted ±50% (NAVA50, NAVA150). Airway pressure, flow and Eadi were recorded for 15 minutes at each NAVA level. The matching of Vt and integral of Eadi (ʃEadi) were assessed at the different NAVA levels. A metric, Range90, was defined as the 5-95% range of Vt/ʃEadi ratio to assess matching for each NAVA level. Smaller Range90 values indicated better matching of supply to demand. RESULTS: Patients ventilated at NAVA50 had the lowest Range90 with median 25.6 uVs/ml [Interquartile range (IQR): 15.4-70.4], suggesting that, globally, NAVA50 provided better matching between ʃEadi and Vt than NAVA100 and NAVA150. However, on a per-patient basis, 4 patients had the lowest Range90 values in NAVA100, 1 patient at NAVA150 and 7 patients at NAVA50. Robust coefficient of variation for ʃEadi and Vt were not different between NAVA levels. CONCLUSIONS: The patient-specific matching between ʃEadi and Vt was variable, indicating that to obtain the best possible matching, NAVA level setting should be patient specific. The Range90 concept presented to evaluate Vt/ʃEadi is a physiologic metric that could help in individual titration of NAVA level.Peer reviewe

Effects of increased afterload on left ventricular performance and mechanical efficiency are not baroreflex-mediated

peer reviewedObjective: To assess baroreflex intervention during increase in left ventricular afterload, we compared the effects of aortic banding on the intact cardiovascular system and under hexamethonium infusion. Methods: Six open-chest pigs, instrumented for measurement of aortic pressure and flow, left ventricular pressure and volume, were studied under pentobarbital-sufentanil anesthesia. Vascular arterial properties were estimated with a four-element windkessel model. Left ventricular contractility was assessed by the slope of end-systolic pressure-volume relationship. Results: The effects of aortic banding on mechanical aortic properties were unaffected by autonomic nervous system inhibition. However, increase in peripheral arterial vascular resistance and in heart rate were prevented by hexamethonium. Aortic banding increased left ventricular contractility and stroke work. Left ventricular-arterial coupling remained unchanged, but mechanical efficiency was impaired. These ventricular changes were independent of baroreflex integrity. Conclusions: Our results demonstrate that an augmentation in afterload has a composite effect on left ventricular function. Left ventricular performance is increased, as demonstrated by increase in contractility and stroke work, but mechanical efficiency is decreased. These changes are observed independently of baroreflex integrity. Such mechanisms of autoregulation, independent of the autonomic nervous system, are of paramount importance in heart transplant patients. (C) 2003 Elsevier B.V. All fights reserved

Expiratory model-based method to monitor ARDS disease state

INTRODUCTION: Model-based methods can be used to characterise patient-specific condition and response to mechanical ventilation (MV) during treatment for acute respiratory distress syndrome (ARDS). Conventional metrics of respiratory mechanics are based on inspiration only, neglecting data from the expiration cycle. However, it is hypothesised that expiratory data can be used to determine an alternative metric, offering another means to track patient condition and guide positive end expiratory pressure (PEEP) selection. METHODS: Three fully sedated, oleic acid induced ARDS piglets underwent three experimental phases. Phase 1 was a healthy state recruitment manoeuvre. Phase 2 was a progression from a healthy state to an oleic acid induced ARDS state. Phase 3 was an ARDS state recruitment manoeuvre. The expiratory time-constant model parameter was determined for every breathing cycle for each subject. Trends were compared to estimates of lung elastance determined by means of an end-inspiratory pause method and an integral-based method. All experimental procedures, protocols and the use of data in this study were reviewed and approved by the Ethics Committee of the University of Liege Medical Faculty. RESULTS: The overall median absolute percentage fitting error for the expiratory time-constant model across all three phases was less than 10 %; for each subject, indicating the capability of the model to capture the mechanics of breathing during expiration. Provided the respiratory resistance was constant, the model was able to adequately identify trends and fundamental changes in respiratory mechanics. CONCLUSION: Overall, this is a proof of concept study that shows the potential of continuous monitoring of respiratory mechanics in clinical practice. Respiratory system mechanics vary with disease state development and in response to MV settings. Therefore, titrating PEEP to minimal elastance theoretically results in optimal PEEP selection. Trends matched clinical expectation demonstrating robustness and potential for guiding MV therapy. However, further research is required to confirm the use of such real-time methods in actual ARDS patients, both sedated and spontaneously breathing.Peer reviewe

Performance of lung recruitment model in healthy anesthetised pigs

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Mathematical modeling of extracorporeal CO2 removal

Extra¬cor¬poreal CO2 removal devices (ECCO2R) can be used in clinics to decarboxylate blood externally for patients suffering from pulmonary insufficiencies like acute respiratory distress syndrome. In this work, a model of the respiratory system coupled with such a device is proposed to analyze the decrease of CO2 partial pressure in blood as a function of blood flow through the device. This model provides a mathematical tool which could help clinicians to choose the optimal settings of ECCO2R.Mathematical modeling and optimization of the use of cardiopulmonary assistances in intensive care unit

Computer-based monitoring of global cardiovascular dynamics during acute pulmonary embolism and septic shock in swine

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Neurally adjusted ventilatory assist (NAVA) improves patient-ventilator interaction during non-invasive ventilation delivered by face mask

Purpose: To determine if, compared to pressure support (PS), neurally adjusted ventilatory assist (NAVA) reduces patient-ventilator asynchrony in intensive care patients undergoing noninvasive ventilation with an oronasal face mask. Methods: In this prospective interventional study we compared patient-ventilator synchrony between PS (with ventilator settings determined by the clinician) and NAVA (with the level set so as to obtain the same maximal airway pressure as in PS). Two 20-min recordings of airway pressure, flow and electrical activity of the diaphragm during PS and NAVA were acquired in a randomized order. Trigger delay (T d), the patient's neural inspiratory time (T in), ventilator pressurization duration (T iv), inspiratory time in excess (T iex), number of asynchrony events per minute and asynchrony index (AI) were determined. Results: The study included 13 patients, six with COPD, and two with mixed pulmonary disease. T d was reduced with NAVA: median 35ms (IQR 31-53ms) versus 181ms (122-208ms); p=0.0002. NAVA reduced both premature and delayed cyclings in the majority of patients, but not the median T iex value. The total number of asynchrony events tended to be reduced with NAVA: 1.0events/min (0.5-3.1events/min) versus 4.4events/min (0.9-12.1events/min); p=0.08. AI was lower with NAVA: 4.9 % (2.5-10.5 %) versus 15.8 % (5.5-49.6 %); p=0.03. During NAVA, there were no ineffective efforts, or late or premature cyclings. PaO2 and PaCO2 were not different between ventilatory modes. Conclusion: Compared to PS, NAVA improved patient ventilator synchrony during noninvasive ventilation by reducing T d and AI. Moreover, with NAVA, ineffective efforts, and late and premature cyclings were absen

Detection of decreased glomerular filtration rate in intensive care units: serum cystatin C versus serum creatinine

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Comparison between single-beat and multiple-beat methods for estimation of right ventricular contractility.

OBJECTIVE: It was investigated whether pharmacologically induced changes in right ventricular contractility can be detected by a so-called "single-beat" method that does not require preload reduction. DESIGN: Prospective animal research. SETTING: Laboratory at a large university medical center. SUBJECTS: Eight anesthetized pigs. INTERVENTIONS: End-systolic elastance values obtained by a recently proposed single-beat method (Eessb) were compared with those obtained using the reference multiple-beat method (Eesmb). MEASUREMENTS AND MAIN RESULTS: Administration of dobutamine increased Eesmb from 1.6 +/- 0.3 to 3.8 +/- 0.5 mm Hg/mL (p =.001), whereas there was only a trend toward an increase in Eessb from 1.5 +/- 0.2 to 1.7 +/- 0.4 mm Hg/mL. Esmolol decreased Eesmb from 1.7 +/- 0.3 to 1.1 +/- 0.2 mm Hg/mL (p =.006), whereas there was only a trend for a decrease in Eessb from 1.5 +/- 0.2 to 1.3 +/- 0.1. CONCLUSIONS: The present method using single-beat estimation to assess right ventricular contractility does not work as expected, since it failed to detect either increases or decreases in right ventricular contractility induced by pharmacologic interventions.Peer reviewe