Early Noninvasive Neurally Adjusted Ventilatory Assist Versus Noninvasive Flow-Triggered Pressure Support Ventilation in Pediatric Acute Respiratory Failure: A Physiologic Randomized Controlled Trial

Objective: Neurally adjusted ventilatory assist has been shown to improve patient-ventilator interaction in children with acute respiratory failure. Objective of this study was to compare the effect of noninvasive neurally adjusted ventilatory assist versus noninvasive flow-triggered pressure support on patient-ventilator interaction in children with acute respiratory failure, when delivered as a first-line respiratory support. Design: Prospective randomized crossover physiologic study. Setting: Pediatric six-bed third-level PICU. Patients: Eighteen children with acute respiratory failure needing noninvasive ventilation were enrolled at PICU admission. Interventions: Enrolled children were allocated to receive two 60-minutes noninvasive flow-triggered pressure support and noninvasive neurally adjusted ventilatory assist trials in a crossover randomized sequence. Measurements and Main Results: Primary endpoint was the asynchrony index. Parameters describing patient-ventilator interaction and gas exchange were also considered as secondary endpoints. Noninvasive neurally adjusted ventilatory assist compared to noninvasive flow-triggered pressure support: 1) reduced asynchrony index (p = 0.001) and the number of asynchronies per minute for each type of asynchrony; 2) it increased the neuroventilatory efficiency index (p = 0.001), suggesting better neuroventilatory coupling; 3) reduced inspiratory and expiratory delay times (p = 0.001) as well as lower peak and mean airway pressure (p = 0.006 and p = 0.038, respectively); 4) lowered oxygenation index (p = 0.043). No adverse event was reported. Conclusions: In children with mild early acute respiratory failure, noninvasive neurally adjusted ventilatory assist was feasible and safe. Noninvasive neurally adjusted ventilatory assist compared to noninvasive flow-triggered pressure support improved patient-ventilator interaction.