cambridge september-12-09

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


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


• PRESENTATION

• IMPLEMENTATION STRATEGIES (what we did)

• RESULTS (if any !!)

• A FEW CASES

• WHAT’S NEXT IN NAVA? or

• If I could wish


Vejle

Vejle Hospital

- a part of Lillebaelt Hospital



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

Vejle Hospital

Specialized in diagnostics, treatment and care of cancer

KEY FIGURES 22.000 ward patients 250.000 outpatients 21.000 visits in ER


Key specialities • Cardiology • General Surgery • Haematology • Oncology • Orthopedic surgery • Neurology • Ear, Nose and Throat Surgery


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


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



PHILOSOPHY SINCE 2004: • Actively participating patient • Low sedation strategy • Early mobilization • Spontaneous breathing


• PRESENTATION



• A FEW CASES


• If I could wish


• IMPLEMENTATION

”Step-by-step” The goal is known, but the order

established during implementation


The start


PREPARATION AND EDUCATION TIME:

2 MONTHS

FROM FEBRUARY 1st TO APRIL 1st 2014


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


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


PHILOSOPHY SINCE 2014: • Monitor respiratory capacity with Edi • Ventilate with NAVA if possible

(invasive or non-invasive)


• PRESENTATION



• A FEW CASES


• If I could wish


• RETROSPECTIVE ANALYSIS

• A QUESTIONNAIRE

• SEMI-STRUCTURED INTERVIEWS


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)


A B versus

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


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


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


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


STAFF EXPERIENCES - A QUESTIONNAIRE

52 nurses and 18 physicians completed the survey

Majority > 10 years’ of experience as a professional



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)



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


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


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 (!)


• PRESENTATION



• A FEW CASES


• If I could wish


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


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.


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


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


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


FiO2 = 0.6

PaO2/FiO2 = 170

pH = 7.18

PaCO2 = 8.7


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


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


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

CASE IV


Just before tracheostomy


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 ?


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


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”


Initial screen


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


Primary result: Spontaneously breathing without any work from the diaphragm


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


50 minutes later perfectly and spontaneously breathing


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


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


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)


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


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


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


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.


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


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


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


• PRESENTATION



• A FEW CASES


• If I could wish


• If I could wish

cambridge september-12-09

Healthcare