No.

22

Multi-disciplinary experience of NAVA

at the University Hospital of Bordeaux
2 | Critical Care News

Professor Olivier Brissaud and colleague examine NAVA and Edi settings on an infant patient in the NICU/PICU

Multi-disciplinary experience of NAVA

at the University Hospital of Bordeaux
Consistently ranked among the top three French reference medical centers, the Bordeaux University
Hospital (Centre Hospitalíer Universitaíre de Bordeaux or CHU Bordeaux) is comprised of a cluster
of three main hospital sites and admitted over 134,000 patients in 2009 to its 3100 hospital beds for
medical and surgical treatments.

The institution was one of the very first in France to implement NAVA – Neurally Adjusted Ventilatory
Assist in 2008, and is now utilizing this ventilation technology in multiple intensive care units. These
intensive care departments also took initiative in arranging and sharing their experience with NAVA at
the first French Annual NAVA Symposium earlier this year.
 Critical Care News | 3

Use of NAVA in Cardiosurgical ICU patients

Critical Care News met with staff
members of the Cardiothoracic ICU,
the Thoracic Surgery and Abdominal
Surgery ICUs, the Neonatal and
Pediatric ICU and the Medical ICU at
the Bordeaux University Hospital to hear
about their experiences with the clinical
application of NAVA in specific patient
categories, and heard about the plan for
implementation of NAVA in the Neuro
ICU in the near future. Members of
various intensive care departments also
discussed their plans for the use of non-
invasive NAVA, and future research within
the area of NAVA and Edi monitoring.

Dr Philippe Mauriat is chief of the

Pediatric Cardiosurgical ICU from
Department of Anesthesia and Critical
Care 2 (Dr Alexandre Ouattara). Dr
Mauriat was formerly chief of pediatric
intensive care at a hospital in Paris,
prior to joining the Bordeaux University
Hospital in 2008. He describes the scope
and size of the operations within his ICU:

“We treat neonates, infants, children and

adults with congenital heart disease. Since
the 70’s the surgeries have expanded
in these indications and increased with
excellent results. For the average patient
population, it is necessary to perform
repeat surgery, for example switching
valves and pacemakers in growing
children as well as older adults. The term
is GUSH – Growing Up Heart disease.
We now have a population of pediatrics
and adults as well as neonates. So for
me it was very interesting to try NAVA,
for the neonates, children and adults”.
NAVA as protective ventilation
in cardiac surgery patients
Dr Mauriat first heard of NAVA in 2004
from Jennifer Beck and Christer Sinderby,
who were guest-lecturers in Paris. He
describes the factors that led him to be
interested in implementing NAVA in the
cardiosurgical ICU: “In cardiac surgery
patients, we are primarily interested in
protective ventilation and less invasive
and less aggressive therapies.”
Dr Philippe Mauriat took the first hospital initiative to use NAVA in the Cardiosurgical ICU,
and has been using it since 2008
“In terms of lung protective ventilation,
you strive for as low pressures as
possible in the pulmonary arteries. In
the past, these patients were sedated
and given muscle relaxants for many
days, so it was a long recovery. Currently
the trend is to put the patient on
assisted modes as soon as possible to
promote spontaneous breathing. So
there was Pressure Support, but now
with NAVA there seems to be a good
strategy for a post-operative course
with fast-tracking. Our objective is to
try to wake up the patient as soon
as possible to wean and extubate”.
“We have had experience of over
60 patients with NAVA in the past
two years. In the beginning of our
experience we used NAVA for 30 or 60
minute intervals, to observe and learn
and to be familiar with it, but in time
we have had some specific patients
on NAVA for over a week or more.”
“We now consider NAVA to be a
routine ventilation mode. Every week
we have at least one or two patients
on NAVA. However we are selective;
we don’t place an Edi catheter on
patients that are expected to be
extubated within hours, but on the
4 | Critical Care News
Colleague of Dr Mauriat and Cardiosurgical ICU infant patient on NAVA
patients where we think there will be a
more challenging recovery process.”
Edi monitoring of cardiosurgery
patients – in conventional ventilation,
in NAVA, and after extubation
Dr Mauriat describes Edi monitoring
as a fascinating and a very interesting
new aspect of treatment and diagnosis
of cardiosurgical ICU patients: “For
the first time we now have monitoring
capabilities of the diaphragmatic activity.
We have seen some patients just before
extubation who have a very nice Edi
signal, and once the endotracheal tube
is removed their Edi signal is increasing,
indicating that the patient is getting
fatigued, and might need reintubation
or another support. In patients where
we see some edema in the larynx, for
example, we can observe the change
of the Edi waveform. If the patient is
becoming fatigued, we try first to give
support in the form of non-invasive
ventilation, and if that does not help
enough, we reintubate. I am waiting
for the new NIV NAVA. It is very
promising and I hope to work with it”.
Monitoring sedation levels in
postop cardiac surgery with
the help of Edi signals
Dr Mauriat also believes that the Edi
signal may be valuable to be able to
detect the level of sedation, and to
minimize the level of sedation:
“We frequently cannot switch the
patient to Pressure Support ventilation
since he is still heavily sedated, and
where we are unsure why switching is
difficult and why the patient does not
respond to Pressure Support. However,
the Edi signal gives the opportunity
to observe diaphragmatic activity
and the return of the diaphragmatic
signal for activity of breathing. If you
look at the Edi signal and it is very
low, you can try to reduce the level of
sedation to increase the Edi signal.”
“We are making a study with our nurses
about the sedation level. In this study
we will adapt the sedation by means
of the Edi signal and the pain scale;
they have a scale to see if the patient
has pain, but don’t have a scale to see
if the patient is too heavily sedated.
But now we can monitor the sedation
level and the return of spontaneous
breathing with the Edi signal.”
“The idea is to titrate the sedation
level according to the Edi signal. And
when the patient has a strong Edi
signal, then you can switch to NAVA.”
Comparing Edi signals in conventional
mechanical ventilation to NAVA
Dr Mauriat regularly monitors Edi in
conventional mechanical ventilation
modes, such as Pressure Support, before
switching over to NAVA. He shares his

Dr Mauriat displays an infant NAVA patient case on video with ventilator screen values
experience: “Of course, we see when
the Edi signal comes back in sedation
washout; it is one of the most interesting
aspects of any mode of ventilation. It
is very interesting to see the change
of the Edi signals. And with NAVA, it is
interesting to see the Edi signal and that
NAVA respond to the patient effort and
demand. We think it is very important to
compare the Edi signal in conventional
ventilation and in NAVA – Edi monitoring
is not only valuable for NAVA – and it is
especially interesting to monitor Edi after
extubation, to see the diaphragmatic
activity of the patient. The patient’s Edi
signal helps us in conventional modes,
once we have strong Edi signals we
switch to NAVA, since NAVA is better
for the patient post-operatively.”
“Some of our patients have been on
ECMO for two weeks, and have had
muscle relaxants during this time with
no diaphragmatic signal, and we lost
the patient diaphragmatic activity and
the diaphragm muscle. Also on these
patients, as soon as we see a small
Edi signal return, we switch to NAVA
to force the patient to work, to train
the diaphragm and for rehabilitation
of the diaphragm. , You don’t make
them work a lot from the beginning,
you start out with a little work and
you can check their work of breathing
and load or unload the diaphragm
with adjusting the NAVA level.”
“We find that NAVA is useful in some
patients without any diaphragm
muscles at all, so we must retrain the
diaphragm and condition and recover
the respiratory muscles. We all have
a big interest in NAVA in our unit,
but especially our physiotherapists,
since they have been working for
rehabilitation of the diaphragm for
many years, but had no way of seeing
the effect of what they were doing.
Now you can see a bedside parameter
with the help of Edi monitoring.”
Dr Mauriat has had several patient cases
where Edi signals provided information
that he was not expecting to see. He
explains: “We have one case on video
of a patient with low Edi signal, in
contrast to other patients. This patient
had diaphragmatic paralysis on one side;
we used x-ray and echo to confirm the
diagnosis, and performed a procedure
to stretch the diaphragm and after that
the Edi behavior was very different. The
Critical Care News | 5
cupola was very different, it was not
moving before, and after surgery we had
an Edi signal so we could extubate.”
Current experience with NAVA
in France, and treatment
opportunities for the future
Dr Mauriat was the primary initiative
taker for the first French NAVA user
symposium earlier this year, and explains
why he identified the need for the
activity: “I work with different national
scientific societies, but sometimes it
is necessary to push something new
as an initiative. As many intensive care
units within the Bordeaux University
Hospital were gaining experience
with NAVA, and as I had already
lectured about NAVA at some national
congresses, I saw an opportunity to
bring together experiences of NAVA from
many different intensive care units in
France. Personally, I believe that NAVA
is part of the future in intensive care”.
“We should start to define groups of
patients in intensive care that might
benefit most from NAVA. With the
specific category of pediatric cardiac
surgery patients, NAVA is very
interesting since it is a protective form
of ventilation; it protects the heart and
gives faster weaning. In the future it
might be interesting to put more types
of patients on NAVA for weaning, as
a standard procedure. From general
experience in the surgical ICU, like
cardiac surgery or after neuro surgery,
there are very few indicators when you
may safely extubate the patient and
be comfortable that he will tolerate
extubation. Edi signals provide a good
indicator parameter to monitor and show
that the patient is ready to wean, or to be
extubated. It is important to make more
clinical studies to define the groups of
patients that might benefit the most.”
“Personally, I think that sedation
levels and titration with NAVA and
Edi monitoring is a main point
of interest, from a physiological
perspective. To me, NAVA and Edi
monitoring are only the beginning
of the story of a new physiological
approach to mechanical ventilation.”
6 | Critical Care News
Gaining experience with NAVA in the neonatal and pediatric ICU
Professor Olivier Brissaud is the chief
of the pediatric and neonatal intensive
care unit at the University Hospital of
Bordeaux, and has been working in that
capacity since 2005. He briefly describes
the current situation in the department:
“We have 18 beds, for mixed pediatric
and neonatal care. We usually have 6
or 7 children and 11 or 12 neonates in
the unit, and over the past year we had
550 patients in total, and it is 50/50 mix
of pediatrics and neonates. It is very
interesting to have this kind of unit,
since we have a dynamic and challenging
situation, but very rewarding. It can be
difficult to treat contrasting patients,
such as an 800 gram neonate to older
children with other types of challenges,
a big contrast but very interesting.”
“When we ventilate neonates it is
always Pressure Control ventilation that
we use, but it depends on the patient
population and pathology too. Usually
we use Pressure Control in neonates
and Volume Control in older children,
since they have different pathologies,
especially bronchial pathologies. We used
to use Volume Control in all the children
but the ventilators are very adaptive now,
and one thing we want to increase is
spontaneous breathing. In my opinion, I
think it will be a real benefit for children
and neonates to use NAVA in invasive
or non-invasive ventilation. It is a big
challenge and this new kind of ventilation
pushes us to learn and to do more. For
earlier weaning, if we go directly to
NAVA ventilation, it is a possibility for us
to go faster and opens doors for us.”
Recent implementation of NAVA
in the neonatal/pediatric ICU
Professor Brissaud first heard of NAVA
about 3-4 years ago at a national ICU
congress in France, at the pediatric
session, but he just recently started
using NAVA. He explains: “In pediatric
and neonatal ICUs, we have a lot of
technology associated with ventilation,
monitoring, sepsis monitoring and we
have to select carefully. I am one of
Professor Olivier Brissaud
those doctors who always said that if
you know Pressure Control and Volume
Control and assisted ventilation very
well, you can make it work in nearly
100% of children and neonates. But
I think this was before NAVA”.
“We have had NAVA on five or six
children in the past two months,
and I can say that this is a very good
experience so far.. It has been very
easy to use, also easy to see the
Edi signal. Our experience is small
so far, the experience of Philippe
Mauriat is different since he has been
using NAVA for 1 or 2 years, and it is
easier for a cardiologist to use new
technologies since there is a higher
homogeneity in that patient category.”
“For us it is different in this respect, we
have neonates and children, from 500
grams to 80 kg, and we have to adapt
ourselves all the time, But the first
feeling I have is it is easy to use, and we
have some benefits to using NAVA. For
example, we can more closely observe
the physiopathology of breathing in
patients, which is very important for us.
We can look at the patient to see if he is
able to breathe or not, we can also look
at the assistance of the ventilation, to
observe if we give too much or too little
support. The first step of our experience
with NAVA means that we are in the
observation phase, and we can capture
some new information in our practice”.
NAVA and Edi monitoring from a 950
gram neonate to pediatric patients
The recent experience of NAVA for
Professor Brissaud ranges from a
neonatal patient to 2 year old patients.
He describes the experience so far: “The
smallest patient on NAVA was 950 gram,
and NAVA worked well in this patient.
Another benefit that we must always
ask ourselves is if we are giving the right
level of sedation, and Edi monitoring
with NAVA can help us in this respect.
When we look at the Edi curve and there
is no signal, we must ask ourselves, if
the sedation can be minimized in this
particular baby. For this reason, it is
interesting for our practice to look at the
ability of children to have diaphragmatic
contractions and activity. We have not
observed Edi signals in patients that
have been extubated yet, but this is also
an interesting area to look at the Edi
signals. We will be monitoring Edi signals
after extubation in the future, maybe
in the baby that has been on NAVA, so
that we can see before and after. It can
help us to observe if the baby is getting
stronger or not, or to avoid intubation.”
Non-invasive ventilation and NAVA
in neonates and pediatrics
Professor Brissaud states that non-
invasive ventilation and NAVA is also a
very interesting future direction, in his
opinion, in neonates and in children. He
looks forward to gaining experience with
NIV NAVA, and explains why: “The real
problem with non-invasive ventilation in
my opinion is always in patients between
6 months old and 7 years old. After that
it is easy to do NIV, since older children,
can communicate more easily and can
be managed better with masks, and so

on. Below 6 months it is easy, since we
have technology for NIV in neonatology,
there has been development in this
area for a long time, and when we have
a young baby, below 6 months it is
easy to use NIV. Between the ages of
6 months and 7 years we have lots of
problems with the interfaces, we use a
lot of masks, different kinds, and they
are not adapted, and the helmets are not
very easy to use in small children, and
one of our problems in addition to the
interfaces is the ability of the children
to be synchronized and it is a very big
problem. The young children between 1-7
years are too young for adult modes in
synchronization and spirometry, and too
old to use what we use in neonatology,
for example the spirometry sensor at
the nose of the children, close to the
tube, since it is a good way to reduce the
time between the patient requirement
and the ability of the machine to deliver
the breath. So in neonatology it is quite
common to insert this sensor at this
place, but if we do it in older children,
there is a lot of auto triggering, since
children are too old for this position of the
sensor, and it is difficult for us to use the
flow as a trigger in this respect. We have
to find something more physiological
and in this way Edi monitoring can really
help us in NIV. Our objective is really
to develop non-invasive ventilation in
this patient population between ages
1 and 7, and if NAVA can help us with
this, it would be a great benefit.
“We have to try a new technology
and, if we want progress with it, we
have to choose a specific population
of patients to develop our experience.
We have to make choices.
With children, it is difficult to wean
and get them off the ventilator. Of
course, if we have a better synchrony
between patient and the ventilator,
the tolerability will be better. But we
need to gain experience in this in order
to prove the theory, which is very
seductive and interesting. We have
to gain practice, and I think it will be
a benefit to patients during weaning,
since it may make a close adaptation
between the ventilation and spontaneous
breathing of the patient. For example,
we observed a a young baby in Pressure
Support ventilation, , and we saw
that he was very uncomfortable and
Professor Brissaud and staff members with infant patient on NAVA
agitated. Our first strategy was to make
some adaptations in the ventilation and
modification of the settings, but it did
not help, the baby remained agitated,
and we saw that the baby was not
so synchronized to the ventilator. We
decided to try NAVA and it was our first
experience. We were very surprised
to see that the baby suddenly became
very calm and comfortable. We were
very surprised in this first case, and we
want to gain more experience to confirm
these first surprising experiences. The
third experience we had with NAVA
was with a baby in the unit that was
difficult to wean. The first answer to
the problem during the night was to
introduce sedation and it worked, the
baby stopped spontaneous breathing,
and for the doctor on call that night, I
think that he went on the easier course,
and said it was very difficult, and the
baby was agitated, and modifications
did not work, so I used Sufentanyl.
This is a rather common situation,
especially at night, but a loss of time
for the baby and us in regard to the
weaning process to spontaneous
breathing. In this example we asked
ourselves if NAVA was an alternative.
I think that we should try NAVA as
an alternative to sedation - a more
physiological philosophy to treatment.
Sedation is good in some specific
circumstances, in patients with very
difficult pathologies, to make ventilation
and maybe in some patients, the solution
is not to sedate or to sedate less, and
Critical Care News | 7
maybe NAVA is a good alternative or
a way perhaps to use less sedation”
Learning about NAVA and
Edi monitoring technology
in the NICU/PICU
Professor Brissaud emphasizes that all
the physicians on the unit have tried and
experienced and are familiar with NAVA
and Edi monitoring. “There is a parallel
to EKG technology – it existed when a
few users tried to do something new and
different, and when it works well, it is
difficult for others to go another way. It is
important that more people experience
the start of something new”, he says
“In terms of NAVA level, we look at the
patient, and we look at Edi tracing first
in conventional mode and in the NAVA
preview screen. We try to adapt the
NAVA level individually for each patient
situation. For some babies it was a NAVA
level of 2, for some 3.6, it depends on
the condition. It is important to look at
the Edi signal, and if we think that the
assistance to the baby is too high when
we observe the Edi signal, we have to
try to make a decrease in assistance,
and look at the signal and see how it is
affected. For NAVA level, we look at the
Edi signal in a conventional ventilation
mode and make an adaptation thereafter.
It seems to vary from baby to baby, but it
is an individual physiological approach.”
8 | Critical Care News
Future potential for NAVA in
neonates and pediatrics, in clinical
and practical perspectives
Professor Brissaud sees several
opportunities for potential benefits of
NAVA in the ICU in future. “First of all,
I think that this technology will help us
to look at sedation. We must choose
the most synchronized ventilation for
the patient, and we must encourage
spontaneous breathing of the patient.
We have to ask ourselves about sedation
and in this respect I think that NAVA may
be very helpful to us. Secondly, I think
in non-invasive ventilation in babies and
small children, it will be very interesting
to use NAVA, maybe even more so than
invasive ventilation. The synchronization
is very important in NIV, and to be
synchronized early in the process is
very interesting and to be non-invasively
ventilated as early as possible. In general
I think that we want to become more
non-invasive practitioners; if we pull
the tube earlier, or use NIV and avoid
the tube altogether, or use NIV in very
premature babies with artificial surfactant
–all the practitioners would like to find
solutions to make the installation of
surfactant without intubation. Today
I am aware of some units that use
gastric tubes to insert to the lung and
to administer surfactant, instead of
a chest tube. We would like to make
ventilation without chest tubes whenever
possible. With NAVA in this respect,
I think that we can push ourselves in
this direction, and open the door.”
“We have a baby on the unit on NAVA
today that was born at 36 weeks of
gestation, with pneumothorax. The baby
was born two days ago and he received
artificial surfactant, and developed alex
syndrome on the left side, we inserted
a tube into the lung and last night the
attending physician gave a high level of
sedation to the patient, since he was
agitated. This morning we decided to
start NAVA to decrease the sedation,
and to see the Edi signal for this baby
and to see if it is possible to extubate
earlier. After a few hours on NAVA he
seems to be doing well. The other end
of this reflection is if we can limit the
hospital stay just one day, it is equal to
4,000 Euros in expense, so this is very
important”, says Professor Brissaud.
Preparing to implement NAVA in the
Bordeaux University Hospital neurosurgical ICU
Dr Boulard is head of the neurosurgical
ICU of Bordeaux University Hospital,
where he has worked 40 years. He briefly
describes the department: “Actually
they are 2 separate neurosurgical ICUs
of 12 beds each which should merge
into one unit of 24 in about 3-4 years. In
our neuro-surgical unit we take care of
patients from conventional neuro-surgery,
such as tumors and hemorrhages,
and the specific pathology which is
severe meningeal hemorrhage.”
Dr Boulard has encountered earlier
revolutions in neuro intensive care during
his long career. He explains: “I have
been working in this field all my life. I
started here in 1973 in the children’s
hospital, the same year I got my degree
in anesthesiology and intensive care.
At this time we were only few people,
maybe 50. The first ICU for neuro-surgery
was created here in 1968, and when I
began in neuro-surgery a few years later,
it was forbidden to give one gram of
sodium to the patients. We were talking
about acute hyponatremy and water
intoxication which were killing patients
and I didn’t understand anything. After
some time, I asked why it was forbidden
and colleague suggested me to read
some books written by Bernard Weil but
after reading I still didn’t understand.
My colleagues and I thought that we
were doing things the wrong way. I
asked the head of the department and
he gives me permission to administer
sodium as a different therapy but with
caution. So I began to give 1 gram of
Sodium in 500 ml of glucose solution.
Nothing happened. After some days
I put 2 grams and nothing happened.
After some weeks we saw our patients
with normal sodium value in blood.
Now in contrast the dogma is sodium,
sodium, sodium,… we were pioneers
and I would like my doctors to be a
little more curious and creative today,
not too much, but a little more.”
With the background of this pioneering
spirit in neuro intensive care, Dr Boulard
Dr Boulard
is very excited about the opportunities
that NAVA may provide, when it is
implemented in the neuro ICU later
this year. He explains: “NAVA seems
to be very interesting because one of
the difficulties after coma is respiratory
concerns with the effects of a prolonged
artificial ventilation and a weak
diaphragmatic muscle. It’s like when you
break a leg and put it in plaster. When
you take out the plaster, the leg has lost
2 to 3 kg of muscle. It’s the same with
the diaphragm. In addition it could also
be another central problem on patient
with acute brain pathology and often
metabolic or functional disorders which
can affect respiratory center and delay
the respiration recovery. So we usually
do weaning by switching from control
to spontaneous ventilation, sometimes
with non invasive ventilation, but we
are always downhill from the problem
which is more central. NAVA gives a
solution because it works with the
phrenic signal and gives a reflection of
the recovering respiratory center. This
is why it seems that neurologic post-
coma patients can be good subjects
for NAVA because it uses what the
respiratory center can still deliver. We
will observe this in the coming months”.

Experiences with NAVA in the Bordeaux University Hospital medical ICU
Professor Castaing is chief of the
Medical ICU in Bordeaux University
Hospital, and started working there
in 1975. He was named Professor
at the same institution in 1992. The
medical ICU currently consists of 4
professors, 4 full time resident doctors,
4 senior intensivists, and 8 interns, and
approximately 100 critical care nurses.
They manage care for a total of 32
ICU beds and 20 sub-acute beds.
Before working in the ICU, his focus
was on physiology, and later on
physiopathology and mostly respiratory
physiopathology. His focus has
influenced other members of the ICU
staff. He explains: “In 1982, I went to
work for many months in the lab of
Professor West in San Diego. This is
why about 50 % of the staff in this unit
work in respiratory physiopathology, like
Gilles Hilbert and Frederic Vargas who
continue what I began many years ago.”
The medical ICU had some similar
challenges that were shared with
other ICUs across the world last year.
Professor Castaing says: “We were
affected by the swine flu epidemic, even
if we didn’t have to treat many patients;
we had about 10 of which 2 needed
ECMO. We had recently renovated
part of our ICU, and 2 patient rooms
are equipped with air locked infection
controlled rooms for immunodepressed
or contagious patients. With swine flu,
patients in those rooms were put on
negative pressure.” From his long base
of experience, Professor Castaing also
shares what he sees as the challenges
of intensive care in the coming years
and the need for more advances in
technology, like NAVA: “I think we will
have to define what we can do because
we have more and older patients in the
ICUs in Europe and administration is
reducing number of beds which force
us to make some choices. Our society
will maybe have to accept that patients
shouldn’t always die in ICU. French
recent law of 2006 allows now staff in
ICU to limit resuscitation procedures to
Professor Castaing
some patients with co-morbidities and
there is no single day where we don’t
discuss some cases which mean there
is a problem that we will have to solve
in the future. It’s a problem which is
more acute today than when I begin to
work in ICU. We spend much more time
with family today to prepare them and
to explain what and why we are doing
in terms of providing care to patients.”
Conventional ventilation therapies
and challenges with non-invasive
ventilation in the medical ICU
Professor Gilles Hilbert of the medical
ICU describes the conventional therapies
used in the medical ICU:”The two main
conventional modes we use today are
Volume Control, and Volume Support,
followed by Pressure Support. We
do a lot of non-invasive ventilation in
the ICU, so we optimize the settings
in Pressure Support for non-invasive
ventilation, which is a challenge for us.”
Professor Frédéric Vargas of the
medical ICU describes the typical mix
of patients and clinical situations in the
medical ICU and the focus on non-
invasive ventilation in the unit: “We
Critical Care News | 9
have all types of patients, but primarily
acute respiratory failure, complex COPD
patients, and hypoxemic respiratory
failure in immunosuppressed patients.
Our team has published on the topic of
immunosuppressed patients and acute
respiratory failure; it is one of the areas
of research we are most interested in.
We have a challenge, in the prognosis
of immunosuppressed patients who
are hematological, as soon as the
patients improve, we try to switch to
non-invasive ventilation, but above all
our main objective is to avoid intubation.
The lower the rate of intubation,
the higher the rate of survival is in
these patients, and if we really must
intubate, we try to extubate as soon
as possible to avoid complications.”
Professor Gilles Hilbert outlines the
patient categories that are of particular
interest for non-invasive ventilation in the
unit: “We use non-invasive ventilation
in all types of acute respiratory failure,
but above all in COPD patients, because
the level of contamination is very high,
but also in patients with pneumonia, or
ARDS, if the level of the contamination is
very low. As recently as 3 or 4 years ago,
there was a French consensus on how
10 | Critical Care News
to manage the patient on non-invasive
ventilation and pneumonia and ARDS.
The data today on hypoxemic respiratory
failure, and three years ago I discussed
this point in a debate with the master
Laurent Brochard, indicates that different
strategies depend on the different types
of patients. For the immunosuppressed
patient if you cannot improve ventilation
after several hours, then you must see
if you can do more, without intubation;
once you intubate the patient there are
at risk. For patients with hypoxemia
without immunosuppression, there is
not really an indication for non-invasive
ventilation, but with well trained staff, like
in this ICU, we try NIV but if the situation
does not improve within 2-4 hours, we
reconsider which strategy we will use.”
Professor Hilbert describes a particularly
challenging situation in regard to non-
invasive ventilation, and a randomized
controlled study that is planned: “Non-
invasive ventilation after extubation is
really a challenge. Two large studies,
by Keenan et al, and Esteban et al,
demonstrated no advantage to using
non-invasive ventilation in patients
Professor Frederic Vargas
after extubation who develop ARF after
extubation, and the study by Esteban
demonstrated a higher mort rate in the
group of patients with NIV. Even if the
skills of the team using NIV were not
sufficient, many teams use NIV only
for one year, and a high level of many
years experience and skills is needed
in using NIV in this patient category.
This is an important point as the results
were disappointing, as it was the first
time that the use of NIV was associated
with worse outcomes. The idea of
our team was to start a randomized
controlled study where Frédéric Vargas
is the main investigator, to use NIV in
patients with criteria of severity.”
Professor Vargas describes the study:
“This includes patients older than 55,
and cardiac pathology with respiratory
disease. One of the specificities of
management is NIV, the sequential mode
used but not continuously, discontinued
support as a mode to support COPD
patients, and we apply this mode in all
types of ARF. We have a protocol in a
study published in 2001 in these types
of immunosuppressed patients.”
How NAVA came to be
implemented in the Medical ICU
Professor Hilbert describes the events
leading to the implementation of NAVA:
“We worked with the staff of Laurent
Brochard during one year, including an
evaluation of how to test modes, how to
obtain Edi signals, how to set the NAVA
level, when it was brand new in France.”
Dr Vargas adds: “In our team, we were
the very first NAVA user in France. We
work together in the respiratory team;
I’ve tested it on myself. In the beginning
we put the NAVA on less complex
patients to see how to obtain Edi
signals and to position the Edi catheter.
The next step was to understand the
treatment and how to understand the
Edi signals of what diaphragmatic activity
is indicating. In the first patient we
wanted to understand how it worked,
about the algorithm and how to optimize
the settings. What is very interesting in
NAVA is that you only have one setting,
which is the NAVA level, compared to
other modes with many settings.”
Experience with NAVA and
interest for non-invasive NAVA
Professor Vargas describes how the
unit is using NAVA and some of the
scope of their experiences with it: “We
saw that when we titrate the NAVA
level from a low level to a high level, at
certain times when you see a plateau
in the Edi, pressure and volumes,
we look at the patient, see how he is
reacting to the setting modification,
and with our objective in frequency
and tidal volumes you usually obtain
the correct settings where you do not
over- nor underassist with NAVA.”
“We have treated between 50 and 100
patients in NAVA in invasive ventilation,
but we do not have experience yet in
non-invasive NAVA. The types of patients
that we most commonly treated with
NAVA are primarily stable patients
with weaning problems, including
COPD etc. In these patients, we also
monitor Edi signals immediately after
extubation as we want to prevent
reintubation. We have recently heard
about the possibility of monitoring Edi
signals in levels of sedation, and we

Professor Gilles Hilbert
are also interested in investigating this
indication when we receive more data.”
General current opinions of
NAVA in the Medical ICU
Professor Vargas shared that generally
extubation occurs about 24 hours after
placement of the Edi catheter and
treatment with NAVA, and that the Edi
catheter is usually kept in place for
48 hours post extubation, to monitor
activity of the diaphragm. He stated that
he and his colleagues are interested
to compare the Edi activity under
Pressure Support in the same routine
and method. He says”We find NAVA
to be very interesting, especially as we
know now that conventional mechanical
ventilation modes are not optimal for
all patients, referring to the scientific
literature, where it is reported that 25%
of patients show asynchrony in Pressure
Support or assist control ventilation.
These asynchronies lead to an increase
of duration of ventilation. In non-invasive
ventilation, we know from the literature
that 40% of patients have a high ratio of
asynchrony.” Professor Hilbert concurs:
“Asynchrony in NIV is one of the factors,
but we know that interface and leakage,
are other important factors. Now that
we have NIV modes on ICU ventilators,
it has improved the situation a lot, for
care of the patient that is already in
NIV. In terms of asynchrony, NAVA
is interesting in the perspective of
invasive and non-invasive ventilation. “
Professor Hilbert and Professor Vargas with staff members
Critical Care News | 11
What is foreseen as the
future for NAVA in the
medical intensive care unit
Both Professor Vargas and Professor
Hilbert see needs and opportunities
with NAVA in the future. Professor
Vargas shares: “We need to have clinical
studies for NAVA in non-invasive and
invasive ventilation. We are planning
a multi-center study about NAVA in
France, where Bordeaux will participate
for invasive ventilation in weaning and
NAVA, with a large group of patients,
and we also need studies for non-
invasive ventilation. Today we have
performed a physiological study, and
we hope to increase these studies to
document the benefits of NAVA.”
Professor Hilbert believes that they will
be treating more types of patients with
NAVA and NIV NAVA in future: “Yes, at
this time we will stick to clinical studies
but in future there will probably be
more patients treated. But for now we
try to match clinical activity to clinical
studies. There are certainly more types
of patients who should benefit from
NAVA. If we were asked the question,
what could be improved on NAVA
from a development perspective, we
really could not answer that. Many
years ago there was a lot of work and
trials on EMG and spectral activity to
indicate fatigue of the diaphragm. At
that time, some people including L
Brochard, were looking at those specific
areas of the spectral signal, but it was
invasive and needed data. Now we
have the Edi catheter, so we can see
the diaphragm of the patient more
clearly, and have even more in depth
monitoring opportunities in the future.”
12 | Critical Care News

Working with NAVA in the intensive care units for thoracic surgery
and abdominal surgery
Dr Hadrien Rozé is working on the
thoracic intensive care unit as well as
the abdominal intensive care unit from
Department of Anesthesia and Critical
Care 2 at the Bordeaux university
hospital, and became interested in using
NAVA after seeing the experiences of
his colleague Dr Philippe Mauriat in
the cardio surgery ICU. He states that
they used it very slowly to begin with,
to see how to manage the settings and
become familiar to find the right way to
use NAVA. He describes the situation
in which NAVA was implemented: “In
the thoracic ICU we have 10 beds,
and we also have a unit for patients
with abdominal disease and surgery,
so there are 12 beds there. We have 3
ventilators with NAVA, and everyone is
familiar with the system throughout the
department, since everyone is on call at
least one night a week, they are familiar
with it and do not change the settings. Dr Hadrien Rozé
In the thoracic ICU, we have very
specific patients: transplantation, very
sick thoracic surgery, very sick COPD Determining the NAVA level – a mechanical ventilation, it was better to
patients that have surgery, emphysema, method evaluated in over 40 patients use a new system of ventilation with
surgery in the bronchus, for tumors and these very sick patients, since we can
so on. In this situation the weaning is During his experiences with NAVA, see by the Edi signals immediately if the
very difficult. It was nice to start NAVA Dr Rozé has developed a method to ventilation is adaptive to them or not.”
in these patients, who frequently are determine the NAVA level in his patients.
very difficult to ventilate in Pressure He describes the background and “After 55 days of mechanical ventilation,
Support with pneumatic triggering, there procedure as such: “I was convinced you can imagine the atrophy and
can be lots of failure. Pressure Support that using the same pressures as the weakened state of the patient,
is our standard mode of conventional patient had in Pressure Support in the sometimes it takes days to help them
ventilation in the ICU” says Dr Rozé. NAVA preview screen was not the right to strengthen their respiratory muscles.
way to use it, since we don’t know if The same is valid for diaphragmatic
“My first experience with NAVA was the level of pressure we use in Pressure paralysis patients, since we have to use
about a year ago. First I had to see how Support is truly adaptive to the individual another muscle. It may take weeks to
I should use it, and then show it to the patient need. So we looked for another wean from Pressure Support. What I
rest of the staff and the physiotherapists. way to start with NAVA, at the right level like about NAVA is that we can use it
During the night shift, if the physician that was truly adaptive to the individual as a way to adapt the pressure to the
is not used to NAVA he will change it patient. So we have evaluated over strength of the patient, and the Edi signal
to something he is familiar with. I didn’t 40 patients right now, including a very is a very good tool to show us where we
really know in the beginning how to set severe ECMO patient over the course of are going, and which level of pressure
the NAVA level, so I needed to study and last winter, who suffered from the swine to use according to the patient needs.”
think about this in the beginning. Lots of data, flu influenza, so with very long periods
seeing what happened during procedures like of controlled ventilation, very weakened Doctor Rozé states that the way he
thorascopies, or in other care situations with patients. We had 4 patients on ECMO sets the NAVA level is not volumetric.
the patient. We wanted to see how NAVA devices, transplants and other reasons, He says: “With NAVA we just see how
was working in these different circumstances very sick, with severe ARF, so we knew much electricity the patient is able to
during the day”, explains Dr Rozé. it would be hard to wean them from generate without Pressure Support, and

Dr Rozé is researching and evaluating methods to establish NAVA level in thoracic patients
then we help him to be under this limit,
to condition him. We check the patient
every day for the maximum of Edi he
is able to generate without Pressure
Support, and then we adapt this NAVA
level in order to be under this value. We
want the patient to have support, but not
too much, so it is a good way to adapt
the pressure to the patient so he will use
his diaphragmatic muscles properly.”
Monitoring the Edi signals in
conventional modes, in NAVA and
after weaning from prolonged
periods of mechanical ventilation
Dr Rozé feels that there are multiple
ways in which monitoring Edi signals
are of value. He says, “In the beginning
I used the screen on patients with
Pressure Support and looked at intrinsic
PEEP, in order to see the data between
start of Edi signal and the start of the
pneumatic trigger, and set the right
level of PEEP to have synchronization
between Pressure Support and the
start of the signal. Even if we stay
in Pressure Support, we use the Edi
signal to improve the way we are using
Pressure Support. With Edi monitoring,
we can see if there is a delay between
the start of the Edi signal and the start
of the pressure delivery. We trend the
data for all of our patients, and most
are able to breathe normally after
weaning and extubation. One patient
had to be reintubated, and in this
patient we monitored and recorded the
Edi signal. He had intermittent non-
invasive Pressure Support, and we could
see the variation of the Edi signal, in
Pressure Support and non-invasive and
in between, and when he had fatigue,
we could see this on his Edi signal.”
“I can say that the Edi signal was decreasing
before increase of respiratory frequency,
or even acidosis so it was interesting
that the signal was the first clinical sign
of respiratory distress”, adds Dr Rozé.
Dr Rozé says that in general patients
are on about 19 days of mechanical
ventilation with Volume Control, and
then are switched to Pressure Support
for one hour, just to see how the
patient is tolerating Pressure Support.
Thereafter the patient is switched
from Pressure Support to NAVA.
They are typically on NAVA for 6 days
for weaning, prior to extubation.
Critical Care News | 13
Edi monitoring can reveal patient
information that the doctor would
not otherwise be aware of
Dr Rozé has had a number of interesting
patient cases, where Edi signals
revealed more than he would have
known otherwise. He explains: “I had
one case of a patient with a lung that
was surgically removed due to cancer.
He had a brain stimulator for Parkinson’s
disease, and we were not sure how it
was affecting him, or if it was working.
When I started NAVA, it did not work at
all, since the stimulator was recording.
So we could not use NAVA since the
brain stimulator was active. We knew
that the brain stimulator was working,
and I tried NAVA during one night, we did
not see how the muscle was contracting,
but it was possible to use it without any
trouble. The shape of the signal was
almost the same as other patients; I
thought there would be two waves, but
for this patient that was not the case”.
“We also had thoracoplasty for a patient
with very severe tuberculosis, we
removed the ribs and tried to ventilate
but there was decompression with just
a part of the lung that was working. We
did not have any problem with NAVA with
this patient either. NAVA is nice to try out
with these types of patients with very
different respiratory physiology – one
lung or two lungs, but the diaphragm
seems to work naturally anyway”.
Patient case report with Cystic
Fibrosis, lung transplant and
NAVA, recently published in the
British Journal of Anesthesia
Dr Rozé frequently encounters a
situation probably familiar to most
ICUs that treat cystic fibrosis patients:
once they arrive in the ICU, they are
ventilated with non-invasive Pressure
Support and are very familiar with it
and using it 23 hours a day, with maybe
only one break a day when they are at
end stage awaiting transplantation. He
describes the situational risks: “When
we absolutely have to intubate them,
sometimes the patient can die within
15 minutes, since we simply have no
way to ventilate them – pressures are
difficult and it is too late, their lungs
14 | Critical Care News
are too diseased. We do anything to
avoid this situation – and if this happens
and the situation improves, we wait
for transplant; we have an emergency
list for allocation of lung transplants.
Even if a donor for transplant becomes
available, we often must wait 4 or 5 days,
and I try to stop mechanical ventilation
with Volume Control ventilation since
I don’t want to stay too long without
using the diaphragmatic muscle. It is
very difficult to use Pressure Support
in these patients, once they have
been intubated and mechanically
ventilated on Volume Control.”
“The case in the British Journal of
Anesthesia was the first case of cystic
fibrosis we had on NAVA, but these
patients are very difficult to ventilate, and
this case was a good example of what
we can do with NAVA when Pressure
Support fails. I tried everything, as
described in this case report, and since
the patient was awake and very familiar
with Pressure Support, we decided to
use NAVA without protocol, and the
patient was ventilated with NAVA the
patient could say if she was comfortable
or not. I was satisfied with her blood
gases, intrinsic PEEP, everything was
working but the first endpoint was
the patient comfort, for her it was
possible to stay on NAVA for 4 days
until we had a suitable lung donor.
After the transplant surgery, the Edi
catheter was in place, so I used NAVA
for a few hours to compare before and
after, everything has changed after
surgery – compliance and resistance
and so on, with Edi monitoring. With
this patient, the compliance was low and
resistance was high with high intrinsic
PEEP, it was easy to believe that the
Edi synchronization would lead to a
completely different situation, which
was the case. It was interesting to note
the maximum electricity the patient
was able to deliver every day, which I
tested with a Edi signal test with 7 cm
H2O Pressure Support every morning to
see the max Edi the patient was able to
do. This max level was increasing every
day, the endpoint was to have muscle
strength and improve it, since she was
intubated for 9 days. By successively
increasing Edi peak every day, we
could see when to decrease the NAVA
level and strengthen the diaphragm.”
20 µV
Mechanical ventilation during NAVA ventilation before and after lung transplantation. From the
top to the bottom, peak pressure (Ppeak) time curve, flow time curve, volume time curve, and Edi
in microvolts. Note the different scales of each curve between pre- and post-transplantation
as published in the British Journal of Anesthesia
Developing research and awareness
of NAVA for the future
Dr Roze has a number of ideas for use
of NAVA in future situations. He outlines
some of the areas he is most interested
in: “We want to use NAVA non-invasively,
for cystic fibrosis patients that are not
intubated and have non-invasive ventilation
all the time. They have nasogastric tubes
since we need to feed them to supplement
their nutrition, so for these patients, who
are in physiotherapy, it will be a good start.
The physiotherapists with these patients
are very interested in NAVA, as a course
of treatment prior to transplantation.”
“Most of our patients that need lung
surgery have emphysema and COPD, and
with the surgery and thoracotomy post-
operatively, they have trouble to breathe.
For non-invasive ventilation there are two
studies showing it will reduce mortality in
these patients, one is hematological and
the other is in post-op thoracic surgery.
Another way to introduce something
other than Pressure Support after
thoracic surgery for treatment of acute
respiratory failure after thoracic surgery,
using non-invasive ventilation will reduce
mortality, so this is a very interesting
area for us to examine the use of NAVA.”
“In the cystic fibrosis case published in
the BJA, there was a challenge to ventilate
12 µV
this patient, but I really wanted to show
in this case how we are using the NAVA
level. The way we use it is very simple
and it is described in that case report.
We used NAVA and titrated the NAVA
level in the same manner in another
patient, who was very severely ill, and had
undergone ECMO for 55 days. We had
very good results of using NAVA in this
patient, to slowly regain his diaphragmatic
muscle strength and function again”.
Education of staff members
from both ICU departments
As familiarity with NAVA has grown,
and Dr Rozé has gained knowledge,
he has been able to share it with staff
members in both the thoracic surgery
ICU and the abdominal surgery ICU
departments. “Sometimes they call me
to look and adjust levels, but I am not
always there, and since the patients are
here for a long time, everyone must be
familiar with NAVA and use it. In the
beginning, I would arrive in the morning
and they would have switched from
NAVA to Pressure Support during the
night?, but after training with all of the
staff, with Edi catheter placement and
NAVA levels, now all 15 physicians are
trained. They were all very interested
to learn. We now even receive contacts

from other departments; maybe if
they have a patient that fails Pressure
Support or has respiratory distress,
they call me sometimes to see if NAVA
would be of use after weaning failure.
Since most of our patients are typically
on mechanical ventilation a very long
time, and are complex, we start NAVA
from the first day, but some of the
patients in abdominal surgery may
return to surgery, and when they ask
me to use NAVA it is almost always
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after failure of Pressure Support, not
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procedure with NAVA for both groups:
“The staff members in thoracic ICU and
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Critical Care News | 15
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patient, and they like NAVA very much,
and are involved in the treatment. A small
team, but everyone has a clinical task
and we all work together. Everybody
is a NAVA believer at bedside.”
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 The views, opinions and assertions expressed in the interviews
are strictly those of the interviewed and do not necessarily reflect
or represent the views of Maquet Critical Care AB.
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MAQUET Critical Care AB The product NIV NAVA may be pending regulatory approvals to be
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