NAVA Ventilation in Neonate:

Clinical Guidelines and Management

Strategies

DR. dr. R. Adhi Teguh Perma Iskandar, Sp.A(K)

Medical Faculty University of Indonesia
Ciptomangunkusumo National Referral Hospital
 Aim

• Synchronization
• Neurally Adjusted Ventilatory Assist (NAVA)
• Evidence of Invasive NAVA in Neonate
• Invasive NAVA’s Parameter
• Initial Setting and Adjustment of Invasive NAVA
• Weaning of Invasive NAVA
 Invasive Mechanical
Ventilation Goal
1. Optimization of gas
exchanged
2. Reduced work of
breathing
3. Optimization patient-
ventilator interaction
4. Reduced lung Injury

Van Kaam A.H et al. Pediatric

Research. 2019
Spontaneous Breathing without
lung injury
 Synchronizations
• A way that ventilator is respond to what kind
of breath characteristic that babies want.
• Some challenges for neonatal ventilator
synchronization are :
• Variable Leak problem
• Rapid respiratory rate
• Small tidal volumes
• Short inspiratory time
• Periodic breathing pattern

Keszler M. Perinatol.
2009;29:262‐275.
 Synchronization with
Patient Triger Ventilation
(A/C or SIMV+PS)
Asynchrony in Conventional
Ventilator
 Asynchroni
ze
Breathing

Ventilation
Lung Injury
(VILI)
Clin Chest Med. 2016 December ; 37(4): 633–646.
 Neurally Adjusted Ventilatory
Assist (NAVA)
• Applies pressure to the
patient’s airway in
proportion to the
electrical activity of the
diaphragm (Edi).
• Patient could modified
their own breath
characteristic according to
what they need.
• Ventilator is respond
without delayed to what
breath that babies need
• Can be applied for invasive
NAVA vs. Other mode of
Ventilator

Local operating procedure. Royal Women

Ideal Synchronization
 Contraindication of NAVA
• Absent of respiratory effort
• Brain anomaly
• Medication
• Esophageal atresia
• Diaphragmatic Hernia
• Phrenic nerve injury
• Congenital myopathy
• MRI Scanning
• Please remove Edi Catheter before MRI
Local operating Procedure. Royal women
Hospital : 2017
 Clinical Trial of Invasive
NAVA (1)
Study Design Subjec Outcome Result
Shetty at Cross over 18 subject Arterial NAVA VS AC/PC
a. (2019) NAVA VS AC < 32 weeks oxygenati Oxygen Index 7.9 vs 11.1 (p
/PC , evolving on = 0.007). The FiO2 (0.36 vs
BPD MV 0.45, p = 0.007), PIP (16.7
Parameter vs 20.1 cm H2O, p = 0.017)
and MAP (9.2 vs 10.5 cm H2O,
p = 0.004) . Compliance was
(0.62 versus 0.50
ml/cmH2O/kg, p = 0.005).
Kallio M RCT NAVA 60 Duration NAVA VS AC/PC
at al AC/PC subject MV Duration MV 34.7 h vs 25.8 h
(2016) 28-36 MV (p= 0.21).
weeks with Parameter PIP is lower in NAVA (p =
RDS 0.02)
No diffrences PEEP, mean
Shetty at pressure
airway al. Eur J[MAP],
Pediatr.2017
TV,
Kallio atfrequency
breathing al. Eur Jor
Pediatr.
OI)
 Clinical Trial of Invasive
NAVA (2)
Study Design Subject Outcome Results
Longhini at Cross over 14 infant the Paw peak and VT were greater
al. (2015) PRVC VS 27 -35 physiolog in PRVC (p < 0.01). Blood
NAVA weeks GA ic gases and RR were not
With ARF effects different between modes. The
of NAVA asynchrony index lower in
12 h NAVA (p < 0.001). Less
fentanyl was administered
during NAVA (p < 0.01).
Hunt at al Cross over 18 Arterial There was no significant
(2019) PAV VS subject oxygenati difference in the mean “OI”
NAVA < 32 on between the two modes, but
weeks , the mean “A-a” gradient was
evolving better on NAVA
BPD Longhini et al. Neonatology
2015;107:60–67
Hunt et al. Eur J Pediatr
 Clinical Trial of Invasive
NAVA (3)
Study Design Subject Outcome Result
Lee J et al Cross over 26 infant MV- NAVA VS SIMV+PS
(2012) NAVA VS < 32 weeks Paramete PIP 5,9±3,4 vs 13,5±2,7
SIMV+PS with MV r cmH2O; (p=0,04)
Work of WOB 11,1 (3,9-61)VS
Breathin 8,4(1,6-30) mJ/L; (p=0,02)
g Edi Peak 13,4±5,7 vs
11,4±5,5 µV; (p=0,04)
Rosterman et Cross over 24 Resp NAVA vs SIMV+PS
al (2017) NAVA VS infants > Severity RSS 3,82 vs 3,83 (p=0,950)
SIMV+PS 22 weeks Score PIP 17.8 vs 19.9 cmH2O
with MV (FiO2xMA (P<0.05)
P) Resp Rate (52 vs 39
MV- (P<0.05)), work of
Paramete breathing 0.01 vs 0.04 J/L
Lee.
r at al.J Pediatr.2012;161:808-13
(P<0.05))
Roesterman et alJournal of
How to Use NAVA ?
 Edi Catheter and It’s
Placement

Edi Correct Position Too deep Too

Catheter Shallow
Electrical Activity of
Diagphragm (Edi)
PIP (cmH2O) = PEEP + Nava Level x (edi
peak-edi min)
How to set up invasive NAVA
Ventilation
 NAVA Parameter
(Spontaneous Breathing)
NAVA Parameter Definition Aplication
NAVA Level Represent how much pressured PIP = PEEP + (Edi peak-min
delivered proportional to every x NAVA Level)
microvolt Edi. will dictate spontaneous
tidal volume
Edi Trigger How much Edi potential (micro volt) 0,5 uV
which trigger ventilator to start
giving ventilation
Apnea Time Time for ventilator to wait before Start 2 second
it gives back up ventilation Minimum 1 second
Maximum 4 second
PEEP Positive end expiratory pressure to Correlated with Edi min
keep lung open et the end of Edi min > 3 uV  need
expiration higher PEEP
Trigger (Flow) Minimal flow that trigger which If Edi signal is lost 
 PC Parameter/Back Up
Parameter
(Mandatory Breathing)
NAVA Definition Aplication
Parameter
Back Up RR Ventilator’s breathing frequency start 30x/mnt  no
given when baby’s spontaneous more than 60x/mnt.
breathing is not detected
Apnea Time Time for ventilator to wait Start 2 second
before it gives back up Minimum 1 second
ventilation Maximum 4 second
Back Up PC Driving pressure which PIP mandatory = Back up
above PEEP ventilator give to patient to PC above PEEP + PEEP
produce adequate tidal volume Will dictate Mandatory
Tidal Volume
Inspiratory How long mandatory inspiration 3-5 time constant
Time will be maintain befor (Compliance x
expiration started Resistence)
 Apnea Time and Back Up
Rate
Apnea Time Back Up
(Second) Rate
(Rate/minu
Set the initial te)
apnoea time 4 15
at 2 seconds 3 20
2 30
1,8 33
No spontaneous Breath regularly Irregular
breath Stable SpO2 breath/WOB 1,6 38
unstable SpO2 1,4 43
1,2 50
Longer Apnea Optimal Apnea Shorter Apnea 1 60
Time by 0.2 time Time by 0.2
Optimal NAVA Level (1) : NAVA
Preview • a yellow one, that
represents the actual
pressure delivery
• a grey one that provides an
estimation of the pressure
delivered based on actual
NAVA Level
• Adapt the NAVA level so that
the estimated pressure curve
(grey) resembles the actual
pressure curve (yellow)
Optimal NAVA Level (2):
Titration
NAVA LEVEL
1cmH2O/μV

Edi Peak > 15 μV Edi Peak <5 μV

Increase nava Decrease NAVA

NAVA level 0,2
level 0,2 cmH2O/μV
cmH2O/μV
Edi Peak > Edi Peak 5- 15 μV Edi Peak <
15 μV 5 μV

Keep Optimal NAVA

LEVEL
Optimal NAVA Level (3) :
Titrating NAVA LEVELA B

E F

C D

B C D
A

E F
 Optimizing PEEP Based on Edi
Signal
PEEP 5 cmH2O

Edi Min > 3 μV Edi Min < 3 μV

Consider consistently
splinting,
pain, crying Increase PEEP Keep PEEP 5 cmH2O
etc 1 cmH2O

Edi Min > 3 Edi Min < 3

μV μV
 Edi Triger & Sensitivity

Flow Trigger : air

flow velocity that
marked the beginning of
spontaneous breathing
trigger which detected
by flow sensor
Set : 0.5-1 L/mnt

Edi trigger : the

voltage of diaphragm
electical that marked
the beginning of
spontaneous breathing
which detected by EDI
Edicatheter
Set : 0.5 μV
Alarm Setting
Summary of NAVA Parameter
Trend
Display information about
Respiratory variable
24-72 hours
Should be compared with clinical
condition

Backup %: Amount of time, as a

percent, the patient is in
backup ventilation every minute.

∑: Occurrences or the number

of times the patient switches
to backup ventilation every
minute.
 NAVA Setting Adjustments based
on Edi
15

3
 NAVA Setting Adjustments
pCO2< 35 mmHg or
Mve=TVxRR
Hyperventilation

Long duration in Frequent change Long duration

NAVA ventilation to Back up of back up
& Ventilation ventilation (%
High Tidal Volume time of back up

⬇ Nava Level ⬆ Apnea time ⬇ backup

setting (PIP,
RR)

Modified from Arata Oda, Rundjan L. PICU NICU

 NAVA Setting Adjustment based
on BGA
pCO2 > 45 mmHg
or
Hypoventilation

Long duration in Frequent change Long duration

NAVA ventilation to Back up in Back up
(> 50% ) Ventilation ventilation (>
50% time of
back up
⬆ Nava Level;
Consider to ⬆ ⬇ Apnea time ⬆ backup
Caffein setting (PIP,
RR)
VG; A/C; SMIV
+PS
Modified from Arata Oda, Rundjan L. PICU NICU
Update 2021
Weak or absent Edi
Signal
 NAVA Setting Adjustments
Absent of Edi
signal

Catheter Central Apnea Hyperventilat

malposition ion

Reposition ⬆ Caffein ⬇ ⬇ backup

catheter dose Sedative seting

⬇ Nava ⬆ Apnea
Level time
Arata Oda & Rundjan L. PICU NICU
Update 2021
 Frequent Desaturation

Lack Edi Optimized

Signal NAVA Level

When During Shorter apnea

desaturation Spontaneous time
happen breath

During Back Increase back

Up breath Up setting
(PIP or RR)

Arata Oda, Rundjan L. PICU NICU Up

date 2021
 Weaning
• As patient condition improve, wean down the
NAVA level gradually
• Extubation criteria :
• NAVA level 0,5-1 cmH2O/µV
• Percentage time of apnea time is less < 50%, at
apnea time 2-4 S
• PEEP 5 cmH2O
• Acceptable Blood Gas Analysis
• We can use either NIV NAVA or nCPAP after
extubation.
• Do not pull out Edi catheter  use as lung
monitor
 CO2 within target, No WOB,
Edi Ppeak <20 cmH2O
Weaning Invasive
NAVA

If mostly in Back If mostly in NAVA

Up PC Mode (> 50%) /Spontaneous Mode (>
setting 50%) , Edi Peak 5-
20/uV
Decrease in Back
Up Setting (PIP , Resp Support < 7 Resp Support > 7
RR) days days

Decrease NAVA Decrease NAVA

Level 0,5 cmH2O/uV Level 0,1-0,3
cmH2O/uV

Consider Extubation to NIV NAVA or CPAP

if NAVA Level < 0,5-1 cmH2O/uV
 Non INVASIVE NAVA
• To facilitate early
extubation
• To synchronized non-invasive
ventilation,
• To prevent de-recruitment
• To avoid increased work of
breathing
• to provide back-up support
for apneas
 Non INVASIVE NAVA
Note ventilator parameters on invasive mode prior to
extubation, particularly tidal volume (Vt), peak
inspiratory pressure (PIP), positive end expiratory
pressure (PEEP), effort of breathing and frequency of
apneas.
Recommended Setting NIV NAVA
• NAVA level is 1.0-1.5
cmH2O/uV
• PEEP 6-7 cmH2O
• IT 0.40 second
• backup rate 50 x/mnt cmH2O
above PEEP,
• Apnoea time 2-3 seconds.
 NIV-NAVA

Primary/Initial Post-Extubation Escalation from nCPAP As nCPAP with back-upsupport for

Mode Apnoeas
AIMS
For Infants ≥ 27 wks
Maintain lung AIMS AIM
Currently not practiced
recruitment - Re-recruit the lungs Use device as nCPAP but
in our NICU < 27 weeks.
Maintain baby - Provide NIV provide back-up rate
Surfactant given as MIST
comfort - Reduce WOB when apnoeic
while on NIV-NAVA
Avoid reintubation - Improve gas exchange
Avoid unnecessary - Avoid intubation
lengths on NIV-NAVA
Initial Setting while Edi Place Edi catheter Select NIV-NAVA mode on
catheter is inserted: Before extubation SERVO-n
Initial Settings:
PIP 16-18, PEEP 6-7, IT Check Edi peak &
- NAVA 1.0-2.0
0.35, Backup rate 50, Edi min
- PEEP 6-7, IT 0.40
Backup PC 10 above PEEP, Extubate to NIV- Set Nava at zero, PEEP
sec
Apnoea time 1.2 sec NAVA 6-7, IT 0,50, backup
- Backup rate 50/min
Initial Setting: rate 50/min, backup PC
- Backup PC 10 above
Settings once Edi catheter NAVA 1.0-1.8, PEEP 6-7, 10 above PEEP, Apnea
PEEP,
is in place: IT 0,40 sec Backup rate time 1.2 sec
- Apnoea time 1.2 sec
NAVA level 1.0-1.5 50/min, Backup PC 10
PEEP 6-7, IT 0.35 sec above PEEP, Apnea time Check how much PIP is With these settings, when
Backup rate 50-60/min, 1.2 sec generated at the set infant is breathing
Backup PC 10 above PEEP, NAVA level. spontaneously, nCPAP is
Apnea time 1-1.2 sec Check how much PIP is
delivered, but when
generated at set NAVA Our local experience apnoeic, backup
level. Our local suggests a NAVA level ventilation is triggered
experience suggests a that generates PIP of at rate set
NAVA level that 16-18 cm to begin with
generates PIP of 16-18
 SUMMARY
• NAVA is new ventilation mode that make better
synchronization between ventilated babies and
their ventilator.
• Better synchronization of NAVA reduce PIP and
VT, increased comfort and spontaneous breathing
compared to other volume or pressure targeted
mode.
• More RCT with bigger subject is needed to
clarify the superiority of NAVA regarding
short or long term outcome.
THANK YOU