Standard Care - Quick Guide
Everything You
Need to Know
Guidance if allocated 'Standard Care'
UK NAVA randomises eligible patients 1:1 to either Standard Care or Neural Monitoring-NAVA Pressure Support. If allocated 'standard care' then a NAVA catheter must not be placed and instead the patient should be fed through a standard nasogastric or orogastric tube. All other aspects of supportive respiratory care and general critical care should be provided. This includes appropriate PEEP settings; treatment of sepsis and optimsation of cardiovascular/fluid status.
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Please note - this guidance is not designed to be used outside the UK NAVA trial.
Using Pressure Support in Standard Care Arm
As with NAVA, there is a very limited evidence base, for using pressure support to wean patients from ventilatory support. It is important to ensure there is daily consideration of both sedation and potential liberation from ventilation ('Spontaneous breathing trial').
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In general one of two strategies are used, although they not mutully exclusive
1. The pressure support level is gradually reduced over time, adjusting the rate of reduction according to patient tolerance and physiology [eg respiratory rate, minute ventilation, heart rate, comfort (dyspnoea)].
2. The patient is asked to work hard over 'sprint' blocks with resp periods between and at night. As the patient improves the ratio of sprints: rest is increased.
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Weaning can be calibrated by reviewing the patient clinically, using blood gas trends and using objective measures such as the Rapid Shallow Breathing Index or P 0.1.
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It is also important that all aspects of patient pathophysiology are optimised including cardiac support; fluid balance, nutrition, analgesia and psychology.
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The bottom line is that weaning of pressure support should be structured, agreed and communicated across the whole inter-professional team and involve optimisation of all aspects of patient pathophysiology and supportive care. These core principles should be applied whether the patient is in Neural Monitoring - NAVA Pressure Support or conventional Pressure Support.
Setting the initial Pressure Support
Adjusting the pressure support
There is a risk of double triggering if the end inspiration is set too short as the patient will want a longer breath.
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In other words, double triggering does not necessarily mean the absolute level of pressure support is set too low, and may just indicate that end inspiration is too short.
