Neurally adjusted ventilatory assist for children on veno-venous ECMO

  • Jana AssyEmail author
  • Philippe Mauriat
  • Nadir Tafer
  • Sylvie Soulier
  • Issam El RassiEmail author
Original Article Artificial Lung / ECMO


NAVA may improve veno-venous ECMO weaning in children. This is a retrospective small series, describing for the first time proof-of-principle for the use of NAVA in children on VV ECMO. Six patients (age 1–48 months) needed veno-venous ECMO. Controlled conventional ventilation was replaced with assisted ventilation as soon as lung compliance improved, and could trigger initiation and termination of ventilation. NAVA was then initiated when diaphragmatic electrical activity (EAdi) allowed for triggering. NAVA was possible in all patients. Proportionate to EAdi (1.8–26 μV), initial peak inspiratory pressures ranged from 21 to 34 cm H2O, and the tidal volume (Vt) from 3 to 7 ml/kg. During weaning, peak pressures increased proportionally to EAdi increase (5.2–41 μV), with tidal volumes ranging from 6.6 to 8.6 ml/kg. ECMO was weaned after a median time of 1.75 days on NAVA. Following ECMO weaning, the median duration of mechanical ventilation, and intensive care unit stay were 4.5 days, and 13.5 days, respectively. Survival to hospital discharge was 100%. In conclusion, combining NAVA to ECMO in paediatric respiratory failure is safe and feasible, and may help in a smoother ECMO weaning, since NAVA allows the patient to drive the ventilator and regulate Vt according to needs.


Extracorporeal membrane oxygenation ECMO Veno-venous ARDS Ventilatory assist NAVA 




Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


  1. 1.
    Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilator support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet. 2009;374:1351–63.CrossRefGoogle Scholar
  2. 2.
    Schmidt M, Pellegrino V, Coombes A, et al. Mechanical ventilation during membrane oxygenation. Crit Care. 2014;18:203–10.CrossRefGoogle Scholar
  3. 3.
    Maslach-Hubbard A, Bratton SL. Extracorporeal membrane oxygenation for pediatric respiratory failure: history, development and current status. World J Crit Care Med. 2013;2:29–39.CrossRefGoogle Scholar
  4. 4.
    Schmidt M, Steart C, Bailey M, et al. Mechanical ventilation management during extracorporeal membrane oxygenation for acute respiratory distress syndrome: a retrospective international multicenter study. Crit Care Med. 2015;43:654–64.CrossRefGoogle Scholar
  5. 5.
    Pediatric Acute Lung Injury Consensus Conference Group. Pediatic acute respiratory distress syndrome: consensus recommendation from the pediatric acute lung injury consensus conference. Pediatr Crit Care. 2015;16:428–439.CrossRefGoogle Scholar
  6. 6.
    Kneyber M, Jouvet P, Rimensberger P. How to manage ventilation in pediatric acute respiratory distress syndrome. Intensive Care Med. 2014;40:1924–6.CrossRefGoogle Scholar
  7. 7.
    Richard C, Argaud L, Blet A, et al. Extracorporeal life support for patients with acute respiratory distress syndrome (adult and paediatric). Consensus conference organized by the French Intensive Care Society. Rev Mal Respir. 2014;31:779–795.CrossRefGoogle Scholar
  8. 8.
    Huh JW. Update on the extracorporeal life support. Tuberc Resp Dis. 2015;78:149–55.CrossRefGoogle Scholar
  9. 9.
    Zhang Z, Gu WJ, Chen K, et al. Mechanical ventilation during extracorporeal membrane oxygenation in patients with acute severe respiratory failure. Can Respir J 2017. (Epub 2017).Google Scholar
  10. 10.
    Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107–16.CrossRefGoogle Scholar
  11. 11.
    Forel JM, Roch A, Marin V, et al. Neuromuscular blocking agents decrease inflammatory response in patients presenting with acute respiratory distress syndrome. Critical Care Med. 2006;34:2749–57.CrossRefGoogle Scholar
  12. 12.
    Powers SK, Kavazis AN, Levine S. Prolonged mechanical ventilation alters diaphragmatic structure and function. Crit Care Med. 2009;37:347–53.CrossRefGoogle Scholar
  13. 13.
    Karagiannidis C, Lubnow M, Philipp A, et al. Autoregulation of ventilation with neurally adjusted ventilatory assist on extracorporeal lung support. Intensive Care Med. 2010;36:2038–44.CrossRefGoogle Scholar
  14. 14.
    Levine S, Nguyen T, Taylor N, et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med. 2008;358:1327–35.CrossRefGoogle Scholar
  15. 15.
    Vassilakopoulos T, Zakynthinos S, Roussos C. Bench-to-bedside review: weaning failure—should we rest the respiratory muscles with controlled mechanical ventilation? Crit Care. 2006;10:204–9.CrossRefGoogle Scholar
  16. 16.
    Schweickert WD, Pohlman MC, Pohlman AS, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009;373:1874–82.CrossRefGoogle Scholar
  17. 17.
    Yoshida T, Rinka H, Kaji A, et al. The impact of spontaneous ventilation on distribution of lung aeration in patients with acute respiratory distress syndrome: airway pressure release ventilation versus pressure support ventilation. Anesth Analg. 2009;109:1892–900.CrossRefGoogle Scholar
  18. 18.
    Putensen C, Mutz NJ, Putensen-Himmer G, et al. Spontaneous breathing during ventilatory support improves ventilation–perfusion distributions in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med. 1999;159:1241–8.CrossRefGoogle Scholar
  19. 19.
    Sinderby C. Ventilatory assist driven by patient demand. Am J Respir Crit Care Med. 2003;168:720–30.CrossRefGoogle Scholar
  20. 20.
    Lellouche F, Brochard L. Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare). Best Pract Res Clin Anaesthesiol. 2009;23:81–93.CrossRefGoogle Scholar
  21. 21.
    Beck J, Reilly M, Grasselli G, et al. Patient–ventilator interaction during neurally adjusted ventilatory assist in very low birth weight infants. Pediatr Res. 2009;65:663–8.CrossRefGoogle Scholar
  22. 22.
    Barwing J, Ambold M, Linden N, et al. Evaluation of the catheter positioning for neurally adjusted ventilatory assist. Intensive Care Med. 2009;35:1809–14.CrossRefGoogle Scholar
  23. 23.
    Colombo D, Cammarota G, Bergamaschi V, et al. Physiologic response to varying levels of pressure support and neurally adjusted ventilatory assist in patients with acute respiratory failure. Intensive Care Med. 2008;34:2010–8.CrossRefGoogle Scholar
  24. 24.
    Bein T, Osborn E, Hofmann HS, et al. Successful treatment of a severely injured soldier from Afghanistan with pumpless extracorporeal lung assist and neurally adjusted ventilatory support. Int J Emerg Med. 2010;3:177–9.CrossRefGoogle Scholar
  25. 25.
    Mauri T, Bellani G, Grasselli G, et al. Patient–ventilator interaction in ARDS patients with extremely low compliance undergoing ECMO: a novel approach based on diaphragm electrical activity. Intensive Care Med. 2013;39:282–91.CrossRefGoogle Scholar
  26. 26.
    Brogan T, Lequier L, Lorusso R, MacLaren G, Peek G. ECMO: extracorporeal cardiopulmonary support in critical care, Red book. 5th ed. Ann Arbor: Extracorporeal Life Support Organization; 2017.Google Scholar
  27. 27.
    Putensen C, Hering R, Muders T, et al. Assisted breathing is better in acute respiratory failure. Curr Opin Crit Care. 2005;11:63–8.CrossRefGoogle Scholar
  28. 28.
    Putensen C, Zech S, Wrigge H, et al. Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med. 2001;164:43–9.CrossRefGoogle Scholar
  29. 29.
    Esteban A, Frutos F, Tobin MJ, et al. A comparison of four methods of weaning patients from mechanical ventilation. Spanish Lung Failure Collaborative Group. N Engl J Med. 1995;332:345–50.CrossRefGoogle Scholar
  30. 30.
    Güldner A, Kiss T, Bluth T, et al. Effects of ultraprotective ventilation, extracorporeal carbon dioxide removal, and spontaneous breathing on lung morphofunction and inflammation in experimental severe acute respiratory distress syndrome. Anesthesiology. 2015;122:631–46.CrossRefGoogle Scholar
  31. 31.
    Hering R, Bolten JC, Kreyer S, et al. Spontaneous breathing during airway pressure release ventilation in experimental lung injury: effects on hepatic blood flow. Intensive Care Med. 2008;34:523–7.CrossRefGoogle Scholar
  32. 32.
    Goto Y, Katayama S, Shono A, Mori Y, Miyazaki Y, Sato Y, Ozaki M, Kotani T. Roles of NAVA in improving gaz exchange in a severe acute respiratory distress syndrome patient after weaning from ECMO: a case report. J Intensive Care. 2016;4:21–31.CrossRefGoogle Scholar
  33. 33.
    De Wit M, Miller KB, Green DA, et al. Ineffective triggering predicts increased duration of mechanical ventilation. Crit Care Med. 2009;37:2740–5.Google Scholar
  34. 34.
    Richard JC, Lefebvre JC, Tassaux D, et al. Update in mechanical ventilation 2010. Am J Respir Crit Care Med. 2011;184:32–6.CrossRefGoogle Scholar
  35. 35.
    Piquilloud L, Vignaux L, Bialais E, et al. Neurally adjusted ventilatory assist improves patient–ventilator interaction. Intensive Care Med. 2011;37:263–71.CrossRefGoogle Scholar
  36. 36.
    Epstein SK. How often does patient–ventilator asynchrony occur and what are the consequences? Respir Care. 2011;56:25–35.CrossRefGoogle Scholar
  37. 37.
    Di Mussi R, Spadaro S, Mirabella L, et al. Impact of prolonged assisted ventilation on diaphragmatic efficiency; NAVA versus PSV. Crit Care. 2016;20:1–12.CrossRefGoogle Scholar
  38. 38.
    Kolobow T, Gattinoni L, Tomlinson TA, et al. Control of breathing using an extracorporeal membrane lung. Anesthesiology. 1977;46:138–41.CrossRefGoogle Scholar
  39. 39.
    Brander L, Sinderby C, Lecomte F, et al. Neurally adjusted ventilatory assist decreases ventilator-induced lung injury and non-pulmonary organ dysfunction in rabbits with acute lung injury. Intensive Care Med. 2009;35:1979–89.CrossRefGoogle Scholar

Copyright information

© The Japanese Society for Artificial Organs 2019

Authors and Affiliations

  1. 1.Department of Anesthesia and Intensive CareHopital Haut-LévêquePessacFrance
  2. 2.Department of PediatricsAmerican University of Beirut Medical CenterBeirutLebanon
  3. 3.Department of SurgeryAmerican University of Beirut Medical CenterBeirutLebanon

Personalised recommendations