Neurally adjusted ventilatory assist (NAVA) ventilation mode in adult critical care

Neurally adjusted ventilatory assist (NAVA) is a form of partial ventilatory support where the machine applies adjusted support based on the patients own respiratory drive. NAVA assesses the electrical activity of the diaphragm through a specialised nasogastric feeding catheter. It estimates the respiratory drive, and the patient maintains full control over the breathing pattern.

Reading time approx. 7 minutes Published: April 3, 2024 Publication type:

SBU Enquiry Service

Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Question

What systematic reviews have been published regarding use of NAVA mode in adult critical care?

Method

A systematic literature search was performed using the following databases: MedLine (Ovid) and Scopus. Two authors independently assessed the abstracts of all identified studies. Risk of bias in relevant systematic reviews was assessed using an assessment tool based on AMSTAR.

Identified literature

Two relevant systematic reviews with low to moderate risk of bias were identified [1] [2]. Since the reviews used the same primary studies, only the results and conclusions of the most recent are presented in Table 1. In 6 relevant systematic reviews, the risk of bias was considered to be high, therefore the results and conclusions are not reported [3] [4] [5] [6] [7].

Table 1 Systematic reviews with moderate risk of bias.
Included studies	Population, Intervention, Control	Outcome and Results
RCT = Randomized Controlled Study; MV = Mechanical Ventilation; NAVA = Neurally Adjusted Ventilatory Support; PSV = Pressure Support Ventilation; A/C = Assist/Control; PRVC = Pressure-Regulated Volume Vontrol; OR = Odds Ratio; CI = Confidence Interval; MD = Mean Difference; ICU = Intensive Care Unit
Yuan et al, 2021 [2] Neurally adjusted ventilatory assist as a weaning mode for adults with invasive mechanical ventilation: a systematic review and meta-analysis
Included studies: 6 RCT 1 randomized crossover trial Setting: France, Taiwan, Brazil, Egypt, UK, Spain, China: 1 study each	Population: Adults (aged 18 years or older) with respiratory failure from various etiologies who received invasive MV for least 24 h. Intervention: NAVA mode Comparison: Partial support modes (PSV, A/C, or PRVC)	Weaning success, overall the absence of the requirement for ventilatory support, without reintubation, a cardiac arrest event, or mortality within 48 h after extubation or withdrawal (4 studies, n=512): OR=1.93 (95% CI 1.12 to 3.33) P=0.02, in favour of NAVA Grade: moderate certainty Weaning success, difficult weaning Weaning success for studies containing only patients classified as hard to wean (2 studies, n=129): OR=2.31 (95% CI 1.13 to 4.73) P=0.02, in favour of NAVA Grade: moderate certainty Weaning success, mixed weaning Weaning success of studies containing a mix of patients classified as simple, difficult or prolonged (2 studies, n=383): OR=1.50 (95% CI 0.64 to 3.51) P=0.34 Duration of MV (6 studies, n= 673): MD=− 2.63 (95% CI −4.22 to −1.03) P=0.001, in favour of NAVAGrade: moderate certainty Ventilator-free days at day 28 (VFDs) (4 studies, n=566): MD=3.48 (95% CI 0.97 to 6.00) P=0.007, in favour of NAVA Grade: moderate certainty Hospital mortality (5 studies, n = 555): OR=0.58 (95% CI 0.40 to 0.84) P=0.004, in favour of NAVA Grade: moderate certainty ICU mortality, length of hospital stay, adverse events, and tracheostomy: No difference.
Authors' conclusion: “Ventilation with the NAVA mode may improve the rate of weaning success compared to other partial support modes for difficult to wean patients. The evaluation of duration of MV, ventilator-free days at day 28, hospital mortality, and successful extubation were in favor of NAVA.”

References

Kataoka J, Kuriyama A, Norisue Y, Fujitani S. Proportional modes versus pressure support ventilation: a systematic review and meta-analysis. Annals of Intensive Care. 2018;8(1). Available from: https://doi.org/doi:10.1186/s13613-018-0470-y
Yuan X, Lu X, Chao Y, Beck J, Sinderby C, Xie J, et al. Neurally adjusted ventilatory assist as a weaning mode for adults with invasive mechanical ventilation: a systematic review and meta-analysis. Critical Care. 2021;25(1). Available from: https://doi.org/doi:10.1186/s13054-021-03644-z
Chen C, Wen T, Liao W. Neurally adjusted ventilatory assist versus pressure support ventilation in patient-ventilator interaction and clinical outcomes: a meta-analysis of clinical trials. Annals of Translational Medicine. 2019;7(16). Available from: https://dx.doi.org/10.21037/atm.2019.07.60
Kampolis CF, Mermiri M, Mavrovounis G, Koutsoukou A, Loukeri AA, Pantazopoulos I. Comparison of advanced closed-loop ventilation modes with pressure support ventilation for weaning from mechanical ventilation in adults: A systematic review and meta-analysis. Journal of Critical Care. 2022;68. Available from: https://doi.org/doi:10.1016/j.jcrc.2021.11.010
Pettenuzzo T, Aoyama H, Englesakis M, Tomlinson G, Fan E. Effect of Neurally Adjusted Ventilatory Assist on Patient-Ventilator Interaction in Mechanically Ventilated Adults: A Systematic Review and Meta-Analysis. Critical Care Medicine. 2019;47(7). Available from: https://doi.org/doi:10.1097/CCM.0000000000003719
Pinto CB, Leite D, Brandão M, Nedel W. Clinical outcomes in patients undergoing invasive mechanical ventilation using NAVA and other ventilation modes - A systematic review and meta-analysis. Journal of Critical Care. 2023;76. Available from: https://doi.org/doi:10.1016/j.jcrc.2023.154287
Wu M, Yuan X, Liu L, Yang Y. Neurally Adjusted Ventilatory Assist vs. Conventional Mechanical Ventilation in Adults and Children With Acute Respiratory Failure: A Systematic Review and Meta-Analysis. Frontiers in Medicine. 2022;9. Available from: https://doi.org/doi:10.3389/fmed.2022.814245

Search strategies

Medline via OvidSP 31 Januari 24

Title: NAVA
Search terms		Items found
/ = Term from the MeSH controlled vocabulary; .sh = Term from the MeSH controlled vocabulary; exp = Term from MeSH including terms found below this term in the MeSH hierarchy; .ti,ab = Title or abstract; .tw = Title or abstract; .kf = Keywords; .kw = Keywords, exact; .bt = Book title. NLM Bookshelf.; .pt = Publication type; .ja = Journal abbreviation; .af = All fields; adjn = Adjacent. Proximity operator retrieving adjacent words, adj3 retrieves records with search terms within two terms from each other.; * or $ = Truncation; “ “ = Citation Marks; searches for an exact phrase ^a. Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity- and precision-maximizing version (2008 revision); Ovid format. The Cochrane Collaboration; 2008. Available from: https://training.cochrane.org/handbook/current/chapter-04-technical-supplement-searching-and-selecting-studies#section-3-6-1. with modifications: the following terms are added: clinical trial, phase iii.pt. ; randomised.ab. ; ("Phase 3" or "phase3" or "phase III" or P3 or "PIII").ti,ab,kw.
Population:
1.	(ventilator adj3 weaning).ti,ab,kf,bt.	1173
2.	(respirator adj3 weaning).ti,ab,kf,bt.	124
3.	exp Ventilator Weaning/	4545
Intervention:
4.	nava.ti,ab,kf,bt.	369
5.	neural* adjust* ventilat* assist*.ti,ab,kf,bt.	415
Study types: systematic reviews and meta-analysis / randomized controlled trials^a
6.	((Systematic Review/ or Meta-Analysis/ or Cochrane Database Syst Rev.ja. or ((systematic adj4 review) or "meta analys" or metaanalys).ti,bt,ab.) not (editorial/ or letter/ or case reports/))	467 956
Limits:
7.	Publication Year 2014-2024
Combined sets:
8.	1 or 2 or 3 or 4 or 5	5714
9.	6 and 8	208
Final result
10.	9 AND 7	137

Scopus via scopus.com 31 Januari 24

Title: NAVA
Search terms		Items found
TITLE-ABS-KEY = Title, abstract or keywords (including indexed keywords and author keywords); ALL = All fields; W/n = Within. Proximity operator retrieving terms within n words from each other.; PRE/n = Precedes by. Proximity operator, the first term in the search must precede the second by n words.; LIMIT-TO (X) = Includes only results of specified type, e.g., publication type or time range.; DOCTYPE = Publication type; “re” = review; “le” = letter; “ed” = editorial; “ch” = book chapter; “cp” = conference proceedings; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Population:
1.	TITLE-ABS-KEY ((ventilator W/3 weaning) OR (respirator W/3 weaning))	7618
Intervention:
2.	TITLE-ABS-KEY ( ( "neural* adjust* ventilat* assist*" ) OR ( nava ) ) )	945
Study types: systematic reviews and meta-analysis / randomized controlled trials
3.	TITLE-ABS-KEY ( ( systematic W/2 review ) OR "meta analy" OR metaanaly ) AND (EXCLUDE (DOCTYPE, “le”) OR EXCLUDE (DOCTYPE, “ed”) OR EXCLUDE (DOCTYPE, “ch”) OR EXCLUDE (DOCTYPE, “cp”))	693 397
Limits:
4.	PUBYEAR > 2013 AND PUBYEAR < 2025
Combined sets:
5.	1 OR 2	8460
6.	5 AND 3	331
Final result
7.	6 AND 4	268

Page published April 3, 2024