My lecture: "Benefits and insights 2 years after implementation of NAVA and NIV NAVA as a standard of care…" at the NAVA-symposium "A review of the experience and evidence so far..." West Suffolk Hospital, Sept. 12th 2016

1. NAVA-Symposium Cambridge 2016-09-12 Torben Steensgaard Andersen 1
Benefits and insights 2 years after implementation
of NAVA and NIV NAVA as a standard of care…
Torben Steensgaard Andersen, MD, MHIT, Consultant

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Conflict of interest
Maquet Critical Care has defrayed my expenses of hotels, flights etc for this lecture
Maquet Critical Care has granted the Dept. of Anaesthesiology at Vejle Hospital for time
used for hospital record reviews in connection with the study

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• PRESENTATION
• IMPLEMENTATION STRATEGIES (what we did)
• RESULTS (if any !!)
• A FEW CASES
• WHAT’S NEXT IN NAVA? or
• If I could wish

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Vejle

5. Vejle Hospital
- a part of Lillebaelt Hospital
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Facts and Figures
KEY FIGURES
• App. 62,000 inpatients with a mean length of stay of 3,7 days
• 463,800 outpatient attendances
• App. 700 beds
• App. 4,500 members of staff (full time)
• 2 ICUs with a total of 24 beds

7. Vejle Hospital
Specialized in diagnostics, treatment and care of cancer
KEY FIGURES
22.000 ward patients
250.000 outpatients
21.000 visits in ER
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8. Key specialities
• Cardiology
• General Surgery
• Haematology
• Oncology
• Orthopedic surgery
• Neurology
• Ear, Nose and Throat Surgery
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9. Intensive Care Unit
• 9 beds
• 6 beds (intermediary/’step-up-step-down’)
Staff
• 3 Senior Consultants
• 1 Head Nurse
• 70 nurses
• Fellows/Senior Registrars/RMO/Interns
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10. Key figures
• 1000 admissions per year
• 400 admissions for intermediary
• 200 treatments with ventilator
• 250 treatments with NIV
• 35 treatments with CRRT
• Nurse-Patient Ratio
• 1 : 1 daytime
• 0.8 : 1 nighttime and weekends
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PHILOSOPHY SINCE 2004:
• Actively participating patient
• Low sedation strategy
• Early mobilization
• Spontaneous breathing

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• PRESENTATION
• IMPLEMENTATION STRATEGIES (what we did)
• RESULTS (if any !!)
• A FEW CASES
• WHAT’S NEXT IN NAVA? or
• If I could wish

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• IMPLEMENTATION
”Step-by-step”
The goal is known, but the order
established during implementation

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The start

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PREPARATION AND EDUCATION TIME:
2 MONTHS
FROM FEBRUARY 1st TO APRIL 1st 2014

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HOW DID WE EDUCATE?
• 2-3 hours theoretical education for all staff
• Constantly bed-side training for juniors and nurses
• A ”Weekly Focus” patient
• Repeatedly discussed on weekly staffmeetings

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Since April 1st 2014:
ALL patients with respiratory insufficiency shall have an Edi
catheter
EXCEPT
Patients who are expected to be without need for support
within 12-24 hours
Patients with known hiatal/esophageal hernia
Patients with known bleeding disorders in oesophagus
Patients who are treated with therapeutic hypothermia

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PHILOSOPHY SINCE 2014:
• Monitor respiratory capacity with Edi
• Ventilate with NAVA if possible
 (invasive or non-invasive)

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• PRESENTATION
• IMPLEMENTATION STRATEGIES (what we did)
• RESULTS (if any !!)
• A FEW CASES
• WHAT’S NEXT IN NAVA? or
• If I could wish

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• RETROSPECTIVE ANALYSIS
• A QUESTIONNAIRE
• SEMI-STRUCTURED INTERVIEWS

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1 8 m o n t h s
1 8 m o n t h s
versus
A
B
NO NAVA (n = 114) NAVA (n = 43)
NO NAVA (n = 86) NAVA (n = 68)

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A Bversus
No differences in:
• Speciality (medical/surgical/neurology/cardiology/haematology)
• Gender
• Age
• Diagnoses
• Reintubation
• BMI
• Initial bloodgases

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NO NAVA (n = 114) NAVA (n = 43)
Time ( AVG hours)
Mechanical ventilation 31 112
Sedation with remifentanil 19 85
Use of norepinephrine 24 33
A
NO NAVA (n = 86) NAVA (n = 68)
23 76
21 49
23 44
B
Mortality n (%) n (%)
Dead in the ICU 20 (18) 13 (30)
Dead in 30 days 20 (18) 6 (14)
Dead in 90 days 8 (7) 6 (14)
Alive at 90 days 66 (58) 18 (42)
n (%) n (%)
10 (12) 19 (28)
12 (14) 15 (22)
3 (3) 1 (1)
61 (71) 33 (48)
Scores
APACHE II 23 25
SAPS II 45 51
21 27
41 49

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PATIENT CHARACTERISTICS COMPARED FOR 3 GROUPS
COMBINING THE 2 TIME PERIODS:
• PATIENTS WITHOUT ANY NAVA-TREATMENT
• PATIENTS RECEIVING NAVA FOR MORE THAN 50% OF VENTILATOR TIME
• PATIENTS RECEIVING NAVA FOR LESS THAN 50% OF VENTILATOR TIME

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NO NAVA (n = 200) NAVA < 50% (n =51) NAVA ≥ 50% (n =60)
Time (hours AVG)
Mechanical ventilation 42 79 79
Sedation with remifentanil 20 71 65
Use of norepinephrine 24 36 42
p
< 0.001
< 0.001
0.02
Mortality
Dead in the ICU 30 (15%) 19 (37%) 13 (22%)
Dead in 30 days 32 6 15
Dead in 90 days 11 2 5
Alive at 90 days 127 24 27
0.007
ns
ns
ns
Scores
APACHE II 22 28 25
SAPS II 43 51 49
< 0.001
< 0.01
LOS ICU 68 134 139 < 0.001

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STAFF EXPERIENCES - A QUESTIONNAIRE
52 nurses and 18 physicians completed the survey
Majority > 10 years’ of experience as a professional

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STAFF EXPERIENCES - A QUESTIONNAIRE
RESULTS
Advantages
• Faster correction of respiratory insufficiency (58%)
• Monitoring of respiratory capacity (42%)
• Decreased ventilator time (29%)
• Increased patient comfort (80%)
• Increased patient involvement (33%)
• Other (8%)
Disadvantages
• Applying a particular nasogastric tube (40%)
• Need for training in the NAVA modus (35%)
• Troublesome to adjust correctly (15%)
• Demands more in regard to collaboration with the patient (25%)
• Other (25%)
• (this included the heaviness of the NG tube and short cabling)

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STAFF EXPERIENCES - A QUESTIONNAIRE
RESULTS
84% found to a high or very high degree that NAVA is an excellent
therapy option
79% experienced no barriers in regard to NAVA therapy
Those experiencing barriers found that the main ones were
• Lack of experience for both nurses and physicians
• Difficulties interpreting the alarms
• The lack of control of most respiratory parameters

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STAFF EXPERIENCES - semi-structured interviews
3 senior and 1 junior physician
2 senior nurses and 1 junior nurse
Advantages of NAVA
• Increased patient comfort
• Increased synchrony with the ventilator
• Improved opportunities for monitoring patient respiratory performance
The implementation
• The implementation had overall been very succesful
• With a united commitment from physicians and nurses to move forward with
NAVA the implementation proces accelerated

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STAFF EXPERIENCES - semi-structured interviews
The main barriers
• Lack of knowledge
• Uncertainty about NAVA
• Lack of courage to skip the control over the patients ventilation
• The time and effort needed to find the right setting for the individual patient
• (the triangle between patient, physician and ventilator)
Suggestions for improving implementation
• Educating more ”Super-NAVA-nurses and -doctors”
• Ensure expert knowlegde in the ICU 24/7
• Structured peer-to-peer training in practice
• More education to especially senior physicians used to traditional respiratory
therapy (!)

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• PRESENTATION
• IMPLEMENTATION STRATEGIES (what we did)
• RESULTS (if any !!)
• A FEW CASES
• WHAT’S NEXT IN NAVA? or
• If I could wish

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Female
70 years old
COPD - now pneumonia with hypoxia and hypercapnia. pH 7.19
Initially and for 18 hours ventilated with NIV-PS/PC without
correcting her blodgasses
Placing af Edi catheter
CASE I

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Female
70 years old
COPD - now pneumonia with hypoxia and hypercapnia. pH 7.19
Initially and for 18 hours ventilated with NIV-PS/PC without
correcting her blodgasses
Placing af NAVA catheter.
After 8 minutes there is a perfect patient-ventilator synchronisation
followed by rapid correction of blodgasses and normalization of pH.

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Male
60 years old
COPD. Skizophrenia. Found unconscious. pH 7.29 PaCO2 12 kPa.
Initially ventilated with NIV-PS for several hours without correction
of bloodgases
Placing af Edi catheter
CASE II
Demonstrating asynchrony

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Male
60 years old
COPD. Skizophrenia. Found unconscious. pH 7.29. PaCO2 12 kPa
Initially ventilated with NIV-PS
Asynchrony
Placing af NAVA catheter
Immediate synchronisation.
Correcting pH in 1 hour to 7.34 and PaCO2 9 kPa

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Male 57 yo Weight 120 kg (BMI 39)
Skizophrenia and COPD.
Found laying on the floor - probably for the last 24 hours.
Severe pneumonia and septic shock
CASE III

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FiO2 = 0.6
PaO2/FiO2 = 170
pH = 7.18
PaCO2 = 8.7

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FiO2 from 0.6 to 0.35
PaO2/FiO2 from170 to 225
pH from 7.18 to 7.43
PaCO2 from 8.7 to 5.4

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Male 57 yo Weight 120 kg (BMI 39)
Skizophrenia and COPD.
Found laying on the floor - probably for the last 24 hours. Severe
pneumonia and septic shock
Rapid correction of blood gases, reduction of FiO2, improvement of
P/F-fraction and ready for extubation or NIV

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Male 80 yo Previously fit and healthy
Subdural hematoma Evacuated Pneumonia
Respiratory insufficiency Ventilator weaning
CASE IV

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Just before tracheostomy

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Part of procedure - given 40 mg propofol at 13.40
Note the reduction in Edi peak from 11 to 2.6 and the patients
ability to breath with very little diaphragmatic effort ….
..perfectly breathing with PS/CPAP ?

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Male 80 yo Previously fit and healthy
Subdural hematoma Evacuated Pneumonia
Respiratory insufficiency Ventilator weaning
Think about:
Spontaneously breathing patient but without diaphragmatic effort
Monitor your sedation by means of the Edi-signal

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CASE V
Male 72 yo
Known with diabetes, aortic stenosis, cerebral shunt(hydrocephalus).
Intracerebral hemorrhage -> Evacuated -> Pneumonia
Respiratory insufficiency
Transferred from University Hospital to our ICU at day 6 with a report
saying that:
“The patient is unable to breath sufficiently when we have tried to
let him breath spontaneously”

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Initial screen

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• Placing a Edi catheter
• Changing the mode to PC/PS
• “Starving” the patient by reducing Pressure Control

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Primary result:
Spontaneously breathing without any work from the diaphragm

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“Starving” the patient even more by reducing pressure support to 4:

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50 minutes later perfectly and spontaneously breathing

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Male 72 yo
Known with diabetes, aortic stenosis, cerebral shunt(hydrocephalus).
Intracerebral hemorrhage -> Evacuated -> Pneumonia
Respiratory insufficiency
Transferred from University Hospital to our ICU at day 6 with a report
saying that he couldn’t breath sufficiently when they tried to let him
breath spontaneously
Think about:
Hyperventilated patients often don’t breath spontaneously.
Monitor your ventilation by means of the Edi-signal
CASE V

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CASE VI
Male 73 yo
Previously fit and healthy Was still working as a teacher
Sudden aphasia and lack of motor control. Rushed to thrombolytic
therapy but proved ineffective.
Thrombectomy was attempted but was abandoned due to bilateral
stenosis in aa. vertebrae

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9 days after insult and tracheostomy transferred to center for neural
rehabilitation and ventilator weaning.
7 days after the transferral without need for ventilator in daytime
and ventilator was discontinued.
The following night cardiac arrest probably due to ventilatory
arrest/insufficiency and hypoxaemia.
2 weeks later transferred to Vejle ICU - still in need of respiratory
support at a low level (PS 11 cmH2O, PEEP 7 cmH2O, FiO2 0.28)

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An Edi catheter was applied and detected normal diaphragmatic
activity in the awake patient.

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Normal diaphragmatic activity while the patient is awake -
ventilated with PS/CPAP

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During sleep however, all innervation of the diaphragm ceased,
testifying that the patient's respiratory drive was exclusively relying
on voluntary muscle contractions.

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An MRI was performed, which revealed sequelae after a massive
ischemic event near the brainstem of recent date confirming the
suspicion evoked during ventilator therapy.

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Male 73 yo
Previously fit and healthy Was still working as a teacher
Sudden aphasia and lack of motor control. Rushed to thrombolytic
therapy but proved ineffective.
Thrombectomy was attempted but was abandoned due to bilateral
stenosis in aa. vertebrae
The Edi-signal as a diagnostic tool
Detection of Acquired Central Hypoventilation Syndrome (Ondine’s
Curse) in an elderly male by means of monitoring with neurally
adjusted ventilatory assist.
CASE VI

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A few keypoints:
• Implement as a ”Big Bang”
• Be sure that the staff is (very) well educated
• Be sure you have NAVA-expertise 24/7/365
• Speed up the implementation by a united commitment from physicians and nurses
• More education to especially senior physicians used to traditional respiratory
therapy!
• If you need proving your results
• Design a prospective trial
• Use NAVA for
• Correcting asynchrony
• Monitoring sedation
• Rapid correction of ventilatory parameters
• Monitoring your patients diaphragmatic activity
• NAVA is
• ”Driving a car by looking out the front window instead of by looking in the rear
mirror”
• A supplementary diagnostic tool in neurological diseases such as ”Ondine’s Curse,
ALS, critical illness polyneuropathy

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Some other insights
• For both nurses and doctor has this high level
technology changed focus to basal, human
physiology
• Personalized and spontaneous breathing is alpha
and omega for better comfort, reduced ventilator
days and very fast weaning

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• PRESENTATION
• IMPLEMENTATION STRATEGIES (what we did)
• RESULTS (if any !!)
• A FEW CASES
• WHAT’S NEXT IN NAVA? or
• If I could wish

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• If I could wish

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• If I could wish

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