Noninvasive ventilation with neurally adjusted ventilatory assist (NIV-NAVA) outperforms nasal continuous positive airway pressure (NCPAP) post-extubation in preterm infants

1. In a randomized controlled trial of 70 infants born before 30 weeks’ gestation, rates of extubation failure within 72 hours were 20% lower in infants placed on neurally adjusted ventilatory assist (NAVA) than infants on nasal continuous positive airway pressure (NCPAP).

2. Peak and swing electrical activity of the diaphragm values were also significantly lower in the NAVA group than the CPAP group.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Nasal continuous positive airway pressure (NCPAP) is widely used after extubation for infants requiring invasive ventilatory support. Extubation failure, or need to re-intubate, is common during this weaning process. Other noninvasive ventilation (NIV) strategies based on intermittent positive pressure ventilation have been reported to provide benefit over NCPAP. Neurally adjusted ventilatory assist (NAVA), which detects the electrical activity of the diaphragm (Edi), is one strategy for triggering positive pressure ventilation. This study aimed to assess the benefit of NIV-NAVA over NCPAP using a randomized design. 70 infants with average gestational age approximately 27 weeks were randomized. NIV-NAVA significantly reduced extubation failure within 72 hours; the failure rate was 8.6% compared to 28.6% for the NCPAP group. The difference in extubation failure rate within 7 days was similar but did not reach statistical significance. Rates of severe bronchopulmonary dysplasia, time to reach full feeds, and length of hospital stay did not significantly differ between groups. Peak and swing Edi values were lower at 4, 12, and 24 hours after extubation in the NIV-NAVA group, suggesting decreased work of breathing. This study adds convincing evidence to a growing body of work suggesting that NIV-NAVA outperforms NCPAP in supporting durable extubation for infants born preterm. This is consistent with the mechanism of NIV, which decreases work of breathing, and NAVA, which aims to optimize synchronous delivery of breaths.

Click to read the study in the Journal of Pediatrics

Relevant Reading: Nasal intermittent positive pressure ventilation in the newborn: Review of literature and evidence-based guidelines

In-Depth [randomized controlled trial]: Infants born before 30 weeks’ gestation between 2015 and 2020 at a single hospital in South Korea who were intubated and ventilated for at least 48 hours starting within 48 hours of birth were included. Infants with congenital anomalies, anomalies involving the airway, and neuromuscular diseases were excluded. Subjects were randomized just after extubation by blocks of 2 and 4, with groups balanced for birth before or after 26 weeks. Edi was measured for both groups using a catheter inserted through the ventilatory tube before extubation. Infants were extubated after meeting criteria of peak inspiratory pressure (PIP) of 16 cmH₂O or lower, respiratory rate of 25/minute or lower, and FiO₂ of 0.35 or lower for at least 6 hours. Positive end expiratory pressure and FiO₂ settings were based on predefined criteria in each group initially, then adjusted for target oxygen saturation of 88-95% and partial pressure of carbon dioxide <70 mmHg. Infants were reintubated for respiratory acidosis, severe apnea events, FiO₂requirement >0.6, or frequent desaturations.

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