NAVA ventilation mode shortens a

stay in ICU by improved synchrony

Dusan Simovic

Declaration of Interest: Dusan Simovic is employed by The Scientific Group as Product Manager for
MAQUET Critical Care products, which include SERVO-i NAVA technology. The license for patented
neural control of mechanical ventilation belongs to MAQUET Critical Care. Commercial use of this
technology may provide financial benefits to Dusan Simovic. Slides and images made by MAQUET
Critical Care are used throughout this presentation.

NAVA – Neurally Adjusted Ventilatory Assist

 How do we breathe ?
• Sensors

– Chemoreceptors

– Pressure/flow sensors

– Positioning/movement

• Feedback system

• Muscle Activity

• Feedback system

• Breath end

• Variability

NAVA – Neurally Adjusted Ventilatory Assist

 How do we breathe

NAVA – Neurally Adjusted Ventilatory Assist

Mechanical Ventilation in Real Life

Synchrony / Asynchrony
NAVA – Neurally Adjusted Ventilatory Assist
 Challenges of mechanical ventilation
• Described as the most frightening ICU experience
• Lengthy ventilation / weaning due to asynchrony
(Thille (2))
• Lung tissue side effects (Jubran (3))
• Diaphragm muscle side effects (Jubran (3))
• Impaired sleep (Bosma(4))

NAVA – Neurally Adjusted Ventilatory Assist

 Major goal of Mechanical Ventilation
Developments
• Get the patient off the
ventilator quicker!
• Increase Patient-
Ventilator Synchrony:
– Increase Monitoring
capabilities
– Increase Intelligence of
the Response
– Increase Gas Control
capabilities
• No Asynchrony found with
NAVA (Colombo (5))

NAVA – Neurally Adjusted Ventilatory Assist

 Common Screen Information in
Mechanical Ventilator
• Pressure

• Flow

• Volume

NAVA – Neurally Adjusted Ventilatory Assist

 Major Common Developments in
Mechanical Ventilation
• PEEP, humidification and O2
concentration
• Volume Control
• SERVO Feedback
• Pressure Support
• SIMV
• Sigh
• Flow Triggering
• PRVC
• Bi-Level Support
• Alternative Therapies
(HFV, NO, Heliox,
partial liquid ventilation, ECMO)

NAVA – Neurally Adjusted Ventilatory Assist

 2006
NAVA Concept

µV NEURAL SIGNAL
from DIAPHRAGM (EDi) MONITORING and EVALUATION
or

goes via EDi CATHETER, CABLE and

MODULE into SERVO-i ventilator Synchronous NAVA ventilation

NAVA – Neurally Adjusted Ventilatory Assist

 NAVA Workflow
• Select catheter
• Add hardware, perform Pre Use Check (while
ventilating)
• Insert Catheter, verify position and secure
• In Preview, adjust NAVA level to match present
gas delivery pressures (Brander (14) )
• Adjust alarms and other parameters if needed
• Switch to NAVA
• Chart values

NAVA – Neurally Adjusted Ventilatory Assist

 EDi Catheter
• Lumen for gastric feeding
• Electrode array measures
EDi and esophageal ECG
• Hydrophilic coating for
easy insertion
• Barium strip
• Disposable
• NAPPI coded
• Medical grade
polyurethane

NAVA – Neurally Adjusted Ventilatory Assist

 EDi Signal processing

µV raw signal (~10)

(amplified, band-pass-filtered)
Top to bottom
Wiener filtering
Double subtraction
RMS processing
New value every 16ms (62.5/sec)

Filtering clears ECG, motion artefacts, background and mains noise

Sinderby (6) , Aldrich (7), Sinderby (8), Beck (9, 10, 11), Sinderby (12,13)

NAVA – Neurally Adjusted Ventilatory Assist

 EDi Signal shape
Health Disease

μV μV μV

EDi
ml ml ml

VT

NAVA – Neurally Adjusted Ventilatory Assist

Monitoring conventional ventilation – ‘synchrony’

NAVA – Neurally Adjusted Ventilatory Assist

Monitoring conventional ventilation – asynchrony

Breatnach (15)
NAVA – Neurally Adjusted Ventilatory Assist
 EDi Trigger Sensitivity

Trigger level
(μV)
Edi

0.5 μV above Edi min

2 0.6 – later (less sensitive)

1
0.7
0.5
0.2
0.4 – earlier (more sensitive)
Time

NAVA – Neurally Adjusted Ventilatory Assist

 Signal Amplification – NAVA Level

Ppeak (Pest) in NAVA = NAVA Level x (Edi peak – Edi min) + PEEP
NAVA – Neurally Adjusted Ventilatory Assist
NAVA Ventilation – NAVA Synchrony

NAVA – Neurally Adjusted Ventilatory Assist

NAVA Simulation Video

NAVA – Neurally Adjusted Ventilatory Assist

NAVA Level Optimization

“This is correct Vte, I will decrease with more support “

NAVA – Neurally Adjusted Ventilatory Assist
NAVA and Non-Invasive Ventilation
• Leakages most common
problem with NIV
• “It has been very simple
– we had leakages of up
to 80% in patients due to
patient interfaces, but it
did not affect the patient
ventilation in any way at
all and there were no
alarms” (Dr. Nordlund,
Ryhov Hospital, Sweden).

NAVA – Neurally Adjusted Ventilatory Assist

 NAVA Benefits
• SYNCHRONY
• Shorter stay (reduce atrophy, improve
recovery)
• Less sedation
• Improved treatment for challenges
• Independent of pneumatic sensors
• RESPIRATORY MONITORING – VITAL SIGN
• Level of sedation
• Neural condition and reactions
• Improving (conventional) settings
• Recognising pathology
• Progress monitoring
• ECG monitoring

NAVA – Neurally Adjusted Ventilatory Assist

Case example:
Yawn allowed

NAVA – Neurally Adjusted Ventilatory Assist

 References
1. MAQUET Critical Care, “NAVA Training Presentation”, “NIV NAVA Training Presentation”
2. Thille et al: “Patient-ventilator asynchrony during assisted mechanical ventilation” Intensive Care Med, 2006 Oct
3. Jubran et al: “Variability of patient-ventilator interaction with pressure support ventilation in patients with chronic obstructive
pulmonary disease” Am J Respir Crit Care Med 1995
4. Bosma et al: “Patient-ventilator interaction and sleep in mechanically ventilated patients: Pressure support versus proportional
assist ventilation.” Crit Care Med 2007
5. Colombo et al: “Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with
acute respiratory failure” Intensive Care Med. 2008 Nov
6. Sinderby et al: “Voluntary activation of the human diaphragm in health and disease”, J Appl Physiol. 85:2146-2158, 1998
7. Aldrich T et al: “Electrophysiologic techniques for the assessment of respiratory muscle function. ATS/ERS statement on respiratory
muscle testing”. Am J Respir Crit Care Med 2002; 166:518–624
8. Sinderby et al: ”Enhancement of signal quality in esophageal recordings of diaphragm EMG”. J Appl Physiol 1997; 82:1370–1377
9. Beck et al: “Influence of bipolar electrode positioning on measurements of human crural diaphragm EMG”. J Appl Physiol 1996;
81:1434–1449
10. Beck et al: ”Diaphragm interference pattern EMG and compound muscle action potentials: effects of chest wall configuration”. J
Appl Physiol 1997; 82:520–530
11. Beck et al: “Effects of lung volume on diaphragm EMG signal strength during voluntary contractions ”. J Appl Physiol 1998; 85:1123–
1134
12. Sinderby et al: “Diaphragm activation during exercise in chronic obstructive pulmonary disease”. Am J Respir Crit Care Med 2001;
163:1637–1641
13. Sinderby et al: “Changes in respiratory effort sensation over time and its link to diaphragm sarcolemma excitability”. Am J Respir Crit
Care Med 2001; 163:905–910
14. Brander et al : “Titration and Implementation of Neurally Adjusted Ventilatory Assist (NAVA) in Critically Ill Patients” Chest 2008,
Nov 18, 2008
15. Breatnach et al : “A prospective crossover comparison of neurally adjusted ventilatory assist and pressure-support ventilation in a
pediatric and neonatal intensive care unit population” Pediatr. Crit. Care Med 2009

NAVA – Neurally Adjusted Ventilatory Assist

 Thank you !

Questions?
NAVA – Neurally Adjusted Ventilatory Assist
 ANALOGY
NAVA introduces link (EDi)
between patient’s carburettor,
and ‘push truck’s’ accelerator

NAVA Level
Daily metabolic challenges

Pathology

VENTILATOR
Minute
volume
Diaphragm
PATIENT
Accelerator – respiratory centre
Acc. Cable – phrenic nerve
Carburettor throttle opening – EDi
Rusted accelerator cable – neurological problems

If engine works with less than 4 cylinders – diaphragm pathology

NAVA – Neurally Adjusted Ventilatory Assist

NAVA Level Increase Video

Open chest - Increasing Pressure Support vs. Increasing NAVA

NAVA – Neurally Adjusted Ventilatory Assist
 Local Experiences

Breathing through the straw

NAVA – Neurally Adjusted Ventilatory Assist