Non-invasive neurally adjusted ventilatory assist in preterm infants with RDS: effect of changing NAVA levels

We aimed to examine the effect of changing levels of support (NAVA level) during non-invasive neurally adjusted ventilatory assist (NIV-NAVA) in preterm infants with respiratory distress syndrome (RDS) on electrical diaphragm activity. This is a prospective, single-centre, interventional, exploratory study in a convenience sample. Clinically stable preterm infants supported with NIV-NAVA for RDS were eligible. Patients were recruited in the first 24 h after the start of NIV-NAVA. Following a predefined titration protocol, NAVA levels were progressively increased starting from a level of 0.5 cmH(2)O/µV and with increments of 0.5 cmH(2)O/µV every 3 min, up to a maximum level of 4.0 cmH(2)O/µV. We measured the evolution of peak inspiratory pressure and the electrical signal of the diaphragm (Edi) during NAVA level titration. Twelve infants with a mean (SD) gestational age at birth of 30.6 (3.5) weeks and birth weight of 1454 (667) g were enrolled. For all patients a breakpoint could be identified during the titration study. The breakpoint was on average (SD) at a level of 2.33 (0.58) cmH(2)O/µV. With increasing NAVA levels, the respiratory rate decreased significantly. No severe complications occurred. Conclusions: Preterm neonates with RDS supported with NIV-NAVA display a biphasic response to changing NAVA levels with an identifiable breakpoint. This breakpoint was at a higher NAVA level than commonly used in this clinical situation. Immature neural feedback mechanisms warrant careful monitoring of preterm infants when supported with NIV-NAVA. Trial registration: clinicaltrials.gov NCT03780842. Date of registration December 12, 2018. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s00431-021-04244-3.