R. Amin1, M. Arca1 1Medical College of Wisconsin,Milwaukee, WI, USA
Background: Conventional modes of ventilation can result in patient-ventilator asynchrony, which may be overcome using neurally-adjusted ventilator assist (NAVA) methodology. The use of NAVA in congenital diaphragmatic hernia (CDH) patients is controversial, as the trigger for breaths is diaphragmatic muscle activity. We report on our experience in using NAVA in CDH patients.
Methods: We performed an IRB-approved retrospective review of newborns with CDH from 1/1/2012-1/1/2017 at a Level I Children’s Surgery Center who underwent operative repair. Data obtained include demographics, hernia defect, type of repair, pre and post-operative respiratory support, and outcomes.
Results: Thirty-seven patients underwent operative repair. Post-operatively, none required NAVA while on conventional mechanical ventilation (CMV), but 7 were placed on noninvasive-NAVA (NIV-NAVA) after extubation. Three patients were male. Three patients had right sided CDH. Average estimated postmenstrual age and weight at birth were 38 2/3 weeks [range 35 3/7-40/17] and 2.96 kg [2.21-3.5], and 40 2/3 [38 3/7-41 6/7] and 3.08kg [2.21-3.84] at repair. The average initial arterial pCO2 was 72.2 mmHg. High frequency oscillatory ventilation was used in 5 patients preoperatively; six were transitioned to CMV prior to repair. Preoperatively, all required inhaled nitric oxide. Four required extracorporeal life support (ECLS) and one was repaired on ECLS. All patients underwent open repair via abdominal approach, with patch repair in 5 infants. All were on CMV postoperatively.
Specified reasons for using NAVA post-extubation include increased work of breathing after extubation and previous failed extubation requiring reintubation. Five patients were extubated to NAVA directly. Average time on NAVA support was 9.4 days [5-21], with initial NAVA level of 3.1 [1-5], and NAVA level of 2 [0-3] at the end of support.
Four patients were weaned to room air [3-32 days] prior to discharge, and two were weaned to room air within a year. Five patients went home on enteral feeds. One patient had seizure activity, but none had intraventricular hemorrhage or periventricular leukomalacia. There was one hernia recurrence in the patient who was repaired on ECLS. There were no deaths.
Conclusion: This is the first report of NAVA being successfully utilized as an adjunct to wean infants from CMV after CDH repair, even in those who required a patch.
