Abstract
NIV-NAVA mode for respiratory support in preterm infants is not well-studied. This study aimed to describe the diaphragmatic function, diaphragmatic excursion (DE), and thickness fraction (DTF), in preterm infants < 30 weeks’ gestation supported by NIV-NAVA compared to NIPPV using bedside ultrasonography. In this consecutive prospective study, DE, diaphragmatic thickness at end of expiration (DTexp), end of inspiration (DTins), and DTF were assessed using bedside ultrasound. Lung aeration evaluation using lung ultrasound score (LUS) was performed for the two groups. Diaphragmatic measurements and LUS were compared for the 2 groups (NIV-NAVA group versus NIPPV group). Statistical analyses were conducted using the SPSS software version 22. Out of 70 infants evaluated, 40 were enrolled. Twenty infants were on NIV-NAVA and 20 infants on NIPPV with a mean [SD] study age of 25.7 [0.9] weeks and 25.1 [1.4] weeks respectively (p = 0.15). Baseline characteristics and respiratory parameters at the time of the scan showed no significant difference between groups. DE was significantly higher in NIV-NAVA with a mean SD of 4.7 (1.5) mm versus 3.5 (0.9) mm in NIPPV, p = 0.007. Additionally, the mean (SD) of DTF for the NIV-NAVA group was 81.6 (30) % vs 78.2 (27) % for the NIPPV group [p = 0.71]. Both groups showed relatively high LUS but no significant difference between groups [12.8 (2.6) vs 12.6 (2.6), p = 0.8].
Conclusion: Preterm infants managed with NIV-NAVA showed significantly higher DE compared to those managed on NIPPV. This study raises the hypothesis that NIV-NAVA could potentially improve diaphragmatic function due to its synchronization with patients’ own breathing. Longitudinal studies to assess diaphragmatic function over time are needed.
Trial registry: Clinicaltrials.gov (NCT05079412). Date of registration September 30, 2021.
What is Known: • NIV-NAVA utilizes diaphragmatic electrical activity to provide synchronized breathing support. • Evidence for the effect of NIV-NAVA on diaphragmatic thickness fraction (DTF) and excursion (DE) is limited. | |
What is New: • Ultrasonographic assessment of diaphragmatic function (DTF and DE) is feasible. • In preterm infants, DE was significantly higher in infants supported with NIV-NAVA compared to those supported with NIPPV. |
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Introduction
Over the past few decades, avoidance of invasive mechanical ventilation (IMV) and promoting of the use of non-invasive ventilation (NIV) in infants born prematurely has been accepted as a standard of care to reduce lung injury and subsequent development of bronchopulmonary dysplasia (BPD) [1]. Although nasal continuous positive airway pressure (nCPAP) is the most frequently used NIV mode for infants born before 32 weeks gestation, NIPPV was found to decrease the incidence of reintubation within 2–7 days of life compared to nCPAP [2]. Furthermore, synchronized NIPPV is considered the most effective NIV in preventing extubation failure in preterm neonates with respiratory distress syndrome [3]. The advantages of NIPPV over nCPAP include the ability to deliver higher mean airway pressure (MAP) and carbon dioxide (CO2) clearance [4, 5].
Recently, neurally adjusted ventilatory assist (NAVA) for invasive and non-invasive ventilation (NIV-NAVA) has emerged as a new respiratory support mode for preterm infants with respiratory insufficiency. Typically, NAVA mode (invasive and non-invasive) uses the electrical activity (Edi) of the diaphragm to trigger, set the amount of pressure, and cycle off the ventilator which in turn reduces asynchrony during NIV [6, 7]. In comparison to NIPPV, several studies have reported that NIV-NAVA is associated with a higher success rate of preventing reintubation [8,9,10], alongside fewer episodes of bradycardia and apnea of prematurity per day [11]. However, data regarding the effect of NIV-NAVA compared to NIPPV on diaphragmatic function and dimensions in preterm infants remains unknown.
Lung ultrasound (LU) has been increasingly used in neonates as a non-invasive and radiation-free imaging modality to assess lung aeration and diaphragm function. Moreover, there is a growing interest among researchers in using ultrasound to monitor the evolution of diaphragmatic contractility and dimensions during IMV, for clinical and research purposes [41].
We acknowledge our study limitations. First, we had a small sample size that could be attributed to interrupted/low recruitment rate due to the COVID-19 pandemic. Second, the study design was based on consecutive recruitment of all eligible patients but lacked randomization. Thirdly, we did not do a serial ultrasonographic assessment to evaluate the changes of diaphragmatic dimensions and functions over time while infants were supported by these two types of NIV. Another limitation is that infants in the NIV-NAVA group were scanned after short duration post transitioning from NIPPV and the risk of “carryover effect” cannot be ruled out completely. Finally, diaphragm ultrasound is operator dependent; therefore, some variations in the measurements are not uncommon. However, our study results have shown high interobserver reliability which validate, to some degree, the study findings.
Conclusion
In infants born at < 30 weeks’ gestation, NIV-NAVA was associated with significantly higher DE compared to NIPPV reflecting improvement in the diaphragmatic functions. There were no significant differences regarding other measurement such as DTexp, DTins, DTF, and LUS. Further studies, with a larger sample size and serial assessment of the diaphragm are needed to draw a firm conclusion.
Data availability
All data generated or analysed during this study are included in this published article (and its supplementary information files).
Abbreviations
- DE:
-
Diaphragm excursion
- DTexp :
-
Diaphragm thickness at end of expiration
- DTF:
-
Diaphragm thickness fraction
- DTins :
-
Diaphragm thickness at end of inspiration
- ICC:
-
Intraclass correlation coefficient
- IMV:
-
Invasive mechanical ventilation
- LU:
-
Lung ultrasound
- LUS:
-
Lung ultrasound score
- NAVA:
-
Neurally adjusted ventilatory assist
- nCPAP:
-
Nasal continuous positive airway pressure
- NICU:
-
Neonatal intensive care unit
- NIPPV:
-
Nasal intermittent positive pressure ventilation
- NIV:
-
Non-invasive ventilation
- RCT:
-
Randomized control trial
- SD:
-
Standard deviation
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Acknowledgements
We would also like to thank the families, nurses, and respiratory therapists in Mount Sinai Hospital who helped us complete our study.
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ME and LT has equal contribution to the study design, data collection, and manuscript writing. AM had full access to all of the data and takes responsibility for the content of this manuscript, including study design, data, and data analysis. The study design was conducted by LT, ME, JI, NN, and AM; data collection was performed by JI, ME, and AM. Data analysis was performed by NN and AM. The manuscript was prepared by ME and LT then edited by JI, NN, and AM. All authors of this study approved the final draft of the manuscript.
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Portions of this paper were presented at the Pediatric Academic Society (PAS) meeting in Denver, USA, in May 2022 a as poster presentation as well as at the 4th Neonatal Research Day- Toronto, Canada, on April 2022 as an oral presentation.
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Elkhouli, M., Tamir-Hostovsky, L., Ibrahim, J. et al. Ultrasonographic assessment of diaphragmatic function in preterm infants on non-invasive neurally adjusted ventilatory assist (NIV-NAVA) compared to nasal intermittent positive-pressure ventilation (NIPPV): a prospective observational study. Eur J Pediatr 182, 731–739 (2023). https://doi.org/10.1007/s00431-022-04738-8
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DOI: https://doi.org/10.1007/s00431-022-04738-8