Neurally adjusted ventilatory assist decreases work of breathing during non-invasive ventilation in infants with severe bronchiolitis.

Dear Editor,

Though neurally adjusted ventilatory assist (NAVA) is known to improve patient-ventilator interactions in infants with bronchiolitis [1, 2], its impact on respiratory muscles unloading has not previously been studied.

We conducted a secondary analysis (ethics committee approval CE_SRLF_18-48) of a prospective physiological study [3] which evaluated the impact of body positioning on work of breathing (WOB) in infants with severe bronchiolitis. Seven of the children included (median age 35 [27-63] days) had a respiratory recording during the transition from nasal continuous positive airway pressure (nCPAP; set at 7cmH2O [4]) to NAVA. Esophageal (Peso), gastric (Pga), and airway (Paw) pressures, as well as Electrical activity of the diaphragm (Edi), and flow were recorded simultaneously. Median NAVA level was set at 0.7 [0.7–0.9] cmH2O/μV and median positive end expiratory pressure at 5 [4-7] cmH2O. Twenty-five breaths during the last 2 min in nCPAP then during the first 2 min in NAVA were analyzed off-line. Metabolic cost of breathing was estimated by the Peso (PTPeso) and diaphragmatic (PTPdi) pressure time product, inspiratory effort by the Peso (ΔPeso) and diaphragmatic (ΔPdi) pressure swings, and respiratory drive by the Edi swing (ΔEdi). Data were expressed as median [IQR] and compared using Wilcoxon two-sample paired sign test. A p value < 0.05 was considered significant.

As detailed in Table 1 and illustrated in Fig. 1, all indices of WOB (PTPeso, PTPdi, ΔPeso, ΔPdi, Edi swing, and inspiratory time to total time ratio (Ti/Ttot)) decreased significantly in every child with NAVA as compared to nCPAP (p < 0.05 in all instances), while the mean Paw was increased (p < 0.05).

Table 1

Comparison of physiological parameters between nasal continuous positive airway pressure and neutrally adjusted ventilatory assist

	nCPAP	NAVA	p*
Ti/Ttot (%)	0.47 [0.45–0.49]	0.40 [0.37–0.45]	0.02
Respiratory rate (/min)	71 [64–84]	65 [57–80]	0.31
Mean airway pressure (cmH2O)	7.0 [6.9–7.1]	10.6 [9.4–11.9]	0.02
ΔEdi (μV)	19 [17–25]	16 [10–19]	0.03
Swing Peso (cmH2O)	14 [12–18]	8 [8–13]	0.01
Swing Pdi (cmH2O)	14 [13–15]	10 [9–10]	0.02
PTPeso/breath (cmH2O s)	4.7 [3.4–6.1]	2.1 [1.9–3.7]	0.02
PTPdi/breath (cmH2O s)	4.2 [3.9–4.4]	2.6 [2.5–2.8]	0.02
PTPeso/min (cmH2O s/min)	365 [237–429]	162 [139–226]	0.02
PTPdi/min (cmH2O s/min)	298 [256–354]	157 [151–199]	0.02

Data are expressed as median [interquartile range]

nCPAP nasal continuous positive airway pressure, NAVA neutrally adjusted ventilatory assist, PEEP positive end expiratory pressure, Ti inspiratory time, Ttot total time, Peso esophageal pressure, Pga gastric pressure, Edi electrical activity of the diaphragm, PTP pressure time product

*Wilcoxon two-sample paired sign test

Fig. 1

Decrease of esophageal and trans-diaphragmatic pressure swing and Edi amplitude after switching to neurally adjusted ventilatory assist. The red arrow indicates the switch from nCPAP to NAVA. nCPAP, nasal continuous positive airway pressure; NAVA, neurally adjusted ventilatory assist; PEEP, positive end expiratory pressure; Paw, airway pressure; Peso, esophageal pressure; Pga, gastric pressure; EAdi, electrical activity of the diaphragm

In this physiological study, we report an improvement of respiratory unloading by adding a second level of pressure with NAVA in infants with severe bronchiolitis. WOB decreased immediately after switching to NAVA (Fig. 1), as reported previously in adults with obstructive lung diseases [5], and was associated with a lower neural drive and Ti/Ttot ratio.

This study has several limitations, including the small sample size, the short study period, the non-randomized order of recordings, and the non-standardized NAVA settings. However, the consistent, rapid, and large improvement in WOB-related indices observed in every infant is an important finding, especially considering the number of infants with severe bronchiolitis who may benefit from an improvement in non-invasive support. The findings support the need for further evaluation of the potential interest of NAVA to improve the efficiency of non-invasive support in infants with bronchiolitis.