Non-invasive neurally adjusted ventilatory assist in preterm infants: a randomised phase II crossover trial

Objective To compare non-invasive ventilation neurally adjusted ventilatory assist (NIV-NAVA) and non-invasive pressure support (NIV-PS) in preterm infants on patient ventilator synchrony. Design A randomised phase II crossover trial. Setting Neonatal intensive care units of two tertiary university hospitals in Korea. Patients Preterm infants born <32 weeks. Intervention NIV-NAVA and NIV-PS were applied in random order after ventilator weaning. Data were recorded for sequential 5 min periods after 10 min applications of each mode. Main outcome measures The electrical activity of the diaphragm (Edi), ventilator flow and pressure curves were compared to examine the trigger delay (primary outcome) and other parameters of patient ventilator interaction (secondary outcomes) for each period. Results Fifteen infants completed the protocol. Trigger delay (35.2+/-8.3 vs 294.6+/-101.9 ms, p<0.001), ventilator inspiratory time (423.3+/-87.1 vs 534.0+/-165.5 ms, p=0.009) and inspiratory time in excess (32.3+/-8.3% vs 294.6+/-101.9%, p=0.001) were lower during NIV-NAVA compared with NIV-PS. Maximum Edi (12.6+/-6.3 vs 16.6+/-8.7 mu V, p=0.003), swing Edi (8.8+/-4.8 vs 12.2+/-8.7 mu V, p=0.012) and peak inspiratory pressure (12.3+/-1.5 vs 14.7+/-2.7 cm H2O, p=0.003) were also lower during NIV-NAVA. The main asynchrony events during NIV-PS were ineffective efforts and autotriggering. All types of asynchronies except double triggering were reduced with NIV-NAVA. Asynchrony index was significantly lower during NIV-NAVA compared with NIV-PS (p<0.001). No significant differences in leakage, expiratory tidal volume or minute ventilation were observed, but the respiratory rate was lower during NIV-PS than during NIV-NAVA. Conclusions NAVA improved patient ventilator synchrony and diaphragmatic unloading in preterm infants during non-invasive nasal ventilation even in the presence of large air leaks.