Neurally adjusted ventilatory assist versus pressure support ventilation in patients difficult to wean from mechanical ventilation Running title NAVA may reduce weaning duration from mechanical ventilation ID: 816214
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Slide1
A randomized controlled trial to compare Neurally adjusted ventilatory assist versus pressure support ventilation in patients difficult to wean from mechanical ventilation
Running title: NAVA may reduce weaning duration from mechanical ventilation
Ling Liu1, Xiaoting Xu1, Qin Sun1, Yue Yu1, Feiping Xia1, Jianfeng Xie1, Yi Yang1, Leo Heunks2*, Haibo Qiu1*
Department of Critical Care Medicine,
Zhongda
Hospital, School of Medicine, Southeast University, Nanjing, 210009, Jiangsu, China
2
Amsterdam UMC, location
VUmc
, Amsterdam, the Netherlands
*
Joint corresponding authors
Slide2Prospective Randomized controlled trialOne general ICU, From October 2011 to September 2017Clinicaltrials.gov (NCT01280773)The protocol was approved by Institutional Ethics Committee of Zhongda hospital (Approval Number: 2010ZDLL018.0)
Study designs
PatientPatients receiving acute invasive mechanical ventilation for more than 24h were eligible when meeting all the following criteriaFailing the initial spontaneous breathing trial (SBT) or re-intubated within 48 h after the first extubationable to sustain PSV more than 1h with inspiratory support ≤ 15 cmH2O, hemodynamic stable (heart rate < 140 beats/min, no vasopressors required or ≤ 5 μg.kg-1.min-1 dopamine/ dobutamine, or ≤ 0.2 μg.kg-1.min-1 norepinephrine), Maintain light sedation (RASS ≥ -2) during day time
Slide3Ventilation strategies
PSVsupport level was set to obtain a Vt of 6–8 ml/kg. PBW
flow-trigger- 1 L/mincycle off -30 % NAVA NAVA level was titrated to obtain a Vt of 6–8 ml/kg. PBWEAdi trigger-0.5 μVcycles off -70 % of peak EAdiFiO2 and PEEP were set by the physician in charge to maintain the SpO2 ≥ 90% We reasoned that a ventilator mode that improves patient ventilator interaction and delivers proportional support most likely improves weaning outcome in patients difficult to wean from mechanical ventilation.Hypothesis
Slide4Weaning protocolMaterials and methods
Daily screen at 9:00 AM
A 30-minute SBT Patients were screened once daily for possible SBT from the first day after randomization (day 1)CPAP of 5 cm H2O or PSV with inspiratory pressure of 7 cmH2O and 5 cmH2O of PEEPFailedSuccessRestore to ventilation settings before SBTAdequate cough
Reconnected and ventilated in either NAVA or
PSV mode
Yes
Extubation
No
Decisions related to tracheostomy, post-extubation NIV and reintubation were made by clinical team.
Slide5Primary outcome
The percentage of patients who were never weaned from mechanical ventilation was 17% (8/47) in NAVA group and 33% (17/52) in PSV group
(P = 0.073) PSV (n=52)NAVA (n=47)PPrimary outcome Duration of weaning in weaned patient a, days4.1(1.1-7.7)2.4 (1.1-5.3)
0.041
Duration of weaning
in all patients
b
, days
7.4 (2.0-26.5)
3.0 (1.2-7.9)
0.003
Slide6Conclusions
PSV (n=52)NAVA (n=47)Pother outcomes Invasive ventilator-free days, day 2821 (0-26)25 (20-27)0.034Ventilator-free days, day 70 (0-5.0)
4.0 (0-5.8)
0.061
Ventilator-free days, day 14
6.6 (0-12.0)
11.0 (6.0-12.8)
0.011
Ventilator-free days, day 28
21.0 (0-26.0)
25.0 (20.0-27.0)
0.041
Length of stay in ICU, days
27 (13-40)
19(12-32)
0.330
Length of stay in ICU in survivors, days
19 (10-33)
24 (12-35)
0.326
Length of stay in hospital, days
32 (19-58)
29 (19-44)
0.491
Length of stay in hospital in survivors, days
30 (17-44)
35 (26-47)
0.424
ICU mortality, n (%)
17 (32.7)
8 (17.0)
0.073
28 day mortality, n (%)
14 (26.9)
14 (29.8)
0.752Hospital mortality, n (%)25 (48.1)16 (34.0)0.157
In patients who were difficult to wean, NAVA decreased duration of weaning and increase ventilator-free days. NAVA which improved patient-ventilator asynchrony, is safe, feasible and effective during weaning.
Secondary outcomes