Children undergoing liver transplantation often face prolonged mechanical ventilation due to various perioperative factors affecting their respiratory and cardiac function. A recent study conducted at Bambino Gesù Children’s Hospital explored the effectiveness of neurally adjusted ventilator assist (NAVA) compared to traditional pressure support ventilation (PSV) during the perioperative period.
This single-center, randomized, controlled trial involved 24 pediatric liver transplant recipients, with 21 patients completing the ventilation studies. The primary goal was to assess how these two ventilation strategies impacted patient-ventilator interaction, particularly focusing on the asynchrony index (AI) and cardiac function measured through tricuspid annular plane systolic excursion (TAPSE).
The findings indicated NAVA significantly reduces patient-ventilator asynchronies, with results showing improved synchronization during mechanical ventilation. Specifically, NAVA reduced the asynchrony index by 6.66%, highlighting its potential advantage over PSV. Yet, there was no measurable improvement on the TAPSE, indicating NAVA does not adversely affect cardiac function during use.
According to the authors of the study, "NAVA compared to PSV: (1) improves patient-ventilator interaction reducing AI (coeff − 6.66 95% CI −11.5 to −1.78, p = 0.008); (2) does not improve TAPSE (coeff 0.62 95% CI −1.49 to 2.74, p < 0.557)." This reduction of asynchronies places NAVA as a preferable mode of assistance, particularly for children recovering from major surgeries like liver transplants.
Mechanical ventilation is commonly required for pediatric liver transplantation due to various complications, including diaphragmatic dysfunction and other cardiac stresses linked to surgery. PSV is widely used among medical practitioners but is associated with higher rates of patient-ventilator asynchronies due to its fixed level of support. By leveraging EAdi (electrical activity of the diaphragm), NAVA enhances synchrony, optimizing patient respiratory efforts and thereby potentially decreasing the length of mechanical ventilation.
The trial showed no significant differences between the two ventilation modes concerning gas exchange and hemodynamic parameters, indicating NAVA's efficacy lies mainly within its ability to reduce asynchronies without compromising the patients' cardiac performance.
The assessments included advanced hemodynamic monitoring and the echocardiographic evaluation of cardiac function, which provided comprehensive insights during the early weaning from mechanical ventilation. The combination of these detailed observational strategies allowed for more accurate evaluations of each ventilation system's impact on pediatric liver transplant recipients.
Discussions surrounding these findings suggest the application of NAVA is particularly valuable for surgical patients undergoing extensive abdominal procedures as it addressed issues of diaphragmatic dysfunction effectively, which is frequently exacerbated post-operation.
"NAVA significantly improves patient-ventilator interaction as evidenced by a reduction in AI, compared to PSV mode," emphasized the authors, indicating strong evidence for its integration as standard practice during pediatric liver transplantation recovery.
Nevertheless, the study also pointed to limitations, including its single-center design and the relatively small patient sample size, which restricts generalizability. The need for extensive multicenter studies has been highlighted to draw comprehensive conclusions on the application of NAVA post-liver transplantation across diverse pediatric patient populations.
Overall, this pivotal research indicates promising advancements for neonatal and pediatric surgeries, aligning with trends toward enhancing patient care by effectively managing mechanical ventilation systems.