Paediatric Respiratory Reviews - SPLFsplf.fr/wp-content/uploads/2019/04/ModesHybrides-CoursRabec.pdf · To discuss the most recent advances in ventilatory modes and features available

Paediatric Respiratory Reviews xxx (2015) xxx–xxx

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YPRRV-1095; No. of Pages 12

Review

New modes in non-invasive ventilation

Claudio Rabec 1,2,*, Guillaume Emeriaud 3, Alessandro Amadeo 4,5,6, Brigitte Fauroux 4,5,6,Marjolaine Georges 1,2

1 Pulmonary Departement and Respiratory Critical Care Unit, University Hospital Dijon, France2 Inserm U 866, University of Burgundy, School of Medicine, Dijon, France3 Pediatric Intensive Care Unit, Saint Justine Hospital, Universite de Montreal, Montreal, Canada4 AP-HP, Hopital Necker, Pediatric Noninvasive Ventilation and Sleep Unit, Paris, France5 Paris Descartes University, France6 Inserm U 955, Team 13, Creteil, France

A R T I C L E I N F O

Keywords:

Respiratory failure

Non invasive ventilation

Ventilatory modes

Central sleep apnea

Neuro Adjusted Ventilatory Assist

Adaptative Servo Ventilation

S U M M A R Y

Non-invasive ventilation is useful to treat some forms of respiratory failure. Hence, the number of

patients receiving this treatment is steadily increasing. Considerable conceptual and technical progress

has been made in recent years by manufacturers concerning this technique. This includes new features

committed to improve its effectiveness as well as patient-ventilator interactions. The goal of this review

is to deal with latest advances in ventilatory modes and features available for non-invasive ventilation.

We present a comprehensive analysis of new modes of ventilator assistance committed to treat

respiratory failure (hybrid modes) and central and complex sleep apnea (adaptive servo ventilation), and

of new modes of triggering and cycling (neurally adjusted ventilatory assist). Technical aspects, modes of

operation and settings of these new features as well as an exhaustive review of published data, their

benefits and limits, and the potential place of these devices in clinical practice, are discussed.

� 2015 Elsevier Ltd. All rights reserved.

EDUCATIONAL AIMS

This paper serves:

� To discuss the most recent advances in ventilatory modes and features available to provide non-invasive ventilation.� To provide a comprehensive analysis of new modes and features.� To illustrate technical aspects and modes of operation and settings of these new features, as well as their benefits and limits.� To provide an exhaustive review of published data,� To illustrate the potential place of these devices in clinical practice.

Contents lists available at ScienceDirect

Paediatric Respiratory Reviews

Since the first studies in the early 1990s showing the usefulnessof non-invasive ventilation (NIV) in the management of someforms of respiratory failure [1], the number of patients receivingthis treatment is steadily increasing. This is explained by a growingnumber of indications in which the effectiveness of NIV has been

* Corresponding author. Service de Pneumologie et Soins Intensifs Respiratoires,

Centre Hospitalier Universitaire de Dijon, 14 rue Paul Gaffarel, 21079 Dijon, France

and Universite de Bourgogne, UFR Sciences de Sante Medecine et Pharmacie,

21033 Dijon, France.

E-mail address: [email protected] (C. Rabec).

Please cite this article in press as: Rabec C, et al. New modes in non-in10.1016/j.prrv.2015.10.004

http://dx.doi.org/10.1016/j.prrv.2015.10.004

1526-0542/� 2015 Elsevier Ltd. All rights reserved.

proved, but also because the technique of application has beengreatly refined. Most important advances include the developmentof interfaces able to deal with different facial morphologies, theavailability of powerful built-in monitoring systems and finallysome innovative developments in terms of ventilatory modes andfeatures. The goal of this paper is to deal with recent advances inventilatory modes and features.

For that, we will successively discuss the following topics:

- New modes of ventilatory assistance- committed to treat respiratory failure: hybrid modes

vasive ventilation. Paediatr. Respir. Rev. (2015), http://dx.doi.org/


mailto:[email protected]



http://www.sciencedirect.com/science/journal/15260542


C. Rabec et al. / Paediatric Respiratory Reviews xxx (2015) xxx–xxx2

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- committed to treat central and complex sleep apnea: adaptiveservo ventilation (ASV)

- A new mode of triggering and cycling: neurally adjustedventilatory assist (NAVA)

NEW MODES OF VENTILATORY ASSISTANCE

Modes committed to treat respiratory failure

Most initial studies concerning NIV used volume-targetedmodes (VTM) [1]. However, pressure-targeted modes (PTM)surpassed VTM at the end of the ‘1990s. Single circuit pressure-targeted ventilators provided with a calibrated leak have becomethe most commonly used devices nowadays. These devices cyclebetween an inspiratory positive airway pressure (IPAP) and anexpiratory positive airway pressure (EPAP). Additionally, a backuprespiratory rate (BURR) can be added. These settings need to beindependently titrated on an individual basis. EPAP needs to betitrated to stabilise the upper airway, whereas IPAP and BURR mustbe adjusted to deliver appropriate ventilatory support.

Recently, manufacturers proposed innovative modes supposedto facilitate NIV adjustments. These modes, also called ‘‘hybridmodes,’’ use intelligent algorithms to automatically adjust one ormore settings to achieve predefined targets. Table 1 shows thecharacteristics of these modes.

The first of these modes, target volume with variable pressuresupport, combines features of pressure and volume ventilation. InVTM, the ventilator delivers a fixed volume during a given timespan. Its advantage is the strict delivery of the preset volume. Itsdisadvantages are that that the effective volume falls withincreasing leaks and that this mode is not able to take intoaccount the patients’ varying requirements. In PTM, airflow isadjusted to generate a constant positive pressure during a giventime span. The volume delivered depends on the interactionbetween the preset pressure, the inspiratory effort and therespiratory mechanics. PTM improves synchronisation since flowcan vary on a breath-by-breath basis. Another advantage is itsability to compensate for leaks. Moreover, PTM generates lowerairway pressures for a given tidal volume (Vt), allowing less masktightness. A limitation of PTM is that it cannot guarantee a Vt,which may lead to insufficient ventilation. Hybrid modes, alsocalled volume targeting pressure ventilation (VTPV), combinecharacteristics of both modes and are supposed to overcome theselimitations. These modes provide a predetermined target volume(TV) while maintaining the physiological benefits of PTM. Theventilator measures or estimates each single expired volume andautomatically adjusts inspiratory pressure within a predetermined

Table 1Summary of different devices providing hybrid modes and their characteristics

Characteristics

Target volume with variable pressure support Automatically adjust IPAP level (i

pressure rang) to achieve a stable

target Vt

Target volume with both variable pressure

support and back-up respiratory rate

Automatically adjust both IPAP an

predefined pressure rang) to achi

predetermined minute ventilation

Target volume with variable pressure

support, back-up respiratory rate

and autoadjusted EPAP

Automatically adjust both IPAP (i

pressure range) to achieve a stabl

level (in a predefined pressure ran

patency Additionally, provides ‘‘a

match the awake spontaneous pa

IPAP: inspiratory airway positive pressure, EPAP: expiratory airway positive pressure,

IVAPS: Intelligent volume assured pressure support.


range to ensure a stable TV. Ventilators provide VTPV either with asingle-limb circuit with an intentional leak or with single or doublecircuit-limb with an expiratory valve. Moreover, some new devicesgive the possibility to also set a variable BURR. They automaticallyadjust both IPAP and BURR level (in a predefined range) to achievea target ventilation [2]. These devices also include a ‘‘learn’’ modein which the ventilator ‘‘copies’’ the patient’s breathing pattern anddetermines target ventilation. Finally, the newest devices combineVTPV with an auto-adjusted EPAP level committed to maintainairway patency. Additionally, they provide an ‘‘automatic’’ BURR.By automatically adjusting IPAP, EPAP and BURR, these devices arefeatured as being able to provide a ‘‘full automatic’’ mode.Examples of different settings automatically adjusted by ‘‘intelli-gent’’ algorithms may be seen in Figure 1.

Theoretical advantages

The first advantage of these newer modes is their ability to ensurea relatively constant Vt whatever the changes in respiratorymechanics while providing the physiologic benefits of PTM[3]. The delivery of an appropriate Vt is crucial in critically illpatients requiring mechanical ventilation. VTPV is able to fulfill thisgoal by generating lower airway pressures than VTM, with improvedcomfort and synchronization. Initial studies evaluating these modesin intubated patients suggested a reduction in muscle workload andan improvement in patient-ventilator synchrony [4]. However,Battisti was unable to show any beneficial effect of VTPV ascompared to PTM in acutely ill patients treated with NIV [3].

When applying NIV in patients with chronic respiratory failure,NIV is applied mainly during the night. Sleep induces ventilatorychanges in the respiratory system that modify ventilatory control,lung mechanics, respiratory muscle recruitment and upper airwaypatency. In healthy subjects, minute ventilation falls 15-20% fromwakefulness to sleep [5]. This phenomenon is further exaggeratedduring the different sleep stages, in particular during rapid eyemovement sleep (REM) sleep. In addition, changes in respiratoryimpedance may be observed during changes in body position, inparticular in overweight patients, which may lead to a fall in Vt[6,7]. Fixed settings do not allow adaptation to these physiologicalchanges. A second theoretical advantage of VTPV is its ability torespond to changes in respiratory mechanics, ensuring relativelyconstant ventilation throughout the night. This is accomplished byincreasing the level of pressure support (but also EPAP and/or BURRwhen possible) when needed, and by reducing it when the support isexcessive. By preventing over- or under-ventilation, these modes aresupposed to ensure more stable ventilation with a lower meaninspiratory pressure. Therefore, VTPV may be beneficial in patientsunable to tolerate high IPAP levels [8].

Brands

n a predefined

predetermined

AVAPSTM (A40TM, Trilogy 100TM and 200TM Philips)

Target volume pressure support (VivoTM 50 and 60,

Breas; VentilogicTM, Weinmann, Monnal T50TM,

ALMS; ElyseeTM 150, 250, 350, Resmed)

d BURR level (in a

eve a stable target

IVAPSTM (VPAP S9TM, StellarTM 100 and 150, LumisTM

AstralTM, Resmed)

n a predefined

e target Vt, and EPAP

g) to maintain airway

utomatic’’ BURR to

tient respiratory rate

Avaps AETM (A40TM, TrilogyTM 100 and 200 Philips)

BURR: backup respiratory rate. AVAPS: Average volume assured pressure support.




Figure 1. Examples of different settings automatically adjusted by ‘‘intelligent’’ algorithms provided by new devices. In each picture: at the top: 1 minute page (raw data), at

the bottom: overnight trend. a) automatically-adjusted inspiratory pressure, b) automatically adjusted back-up respiratory rate, c) automatic adjustment of both expiratory

pressure and pressure support.

C. Rabec et al. / Paediatric Respiratory Reviews xxx (2015) xxx–xxx 3

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A third theoretical advantage is a supposed ‘‘simplification’’ ofventilator adjustments. However, during VTPV, the physician hasto adjust more parameters than during a conventional mode,which makes this mode in fact more complex. In one study, thenumber of adjustments to optimise ventilation was greater duringVTPV compared to PTM [9]. This may be aggravated by the fact thatthe terminology describing these modes and their settings issomewhat confusing. Moreover, the level of knowledge orexperience in understanding the algorithm may be insufficientin non-experienced centres, which may lead to inappropriate andharmful settings.


Finally, in patients with rapidly progressive diseases, serial NIVadjustments may be required to adapt to a declining respiratoryfunction. In these patients, VTPV might theoretically reduce thefrequency of adjustments over time.

Limits

Problems related to optimal settings

The optimal method for setting VTPV is not known. Firstly, thereis no agreement about optimal TV values. Published studies showa large variability of TV used and titration modalities (Table 2)




Table 2Summary of published studies evaluating hybrid modes

Reference Study Design Population Devices and modes Settings Ventilatory status Outcomes Main Results (VTPV vs ST)

Storre [13] RCT

6-weeks

cross-over

Stable OHS (n=10) SynchronyTM

AVAPS TM

vs ST

ST : IPAP 20,

AVAPS: Vt 7-10 ml/IBW

IPAP set between EPAP and 30 mb

Naive (« CPAP non

responders »)

tcPCO2, Sleep quality (PSG),

ABG, HRQL (SRI score)

Greater reduction in tcPCO2

with AVAPS No differences in

sleep or HRQL

Janssens [12] RCT

1-night

cross-over

Stable OHS (n=12) Synchrony TM

AVAPSTM

vs ST

ST : usual ventilator settings,

AVAPS: Vt: 8-12 ml/kg IBW Minimal

IPAP set between usual level minus

3, and 30 mb

Still ventilated

(> 3 months)

Nocturnal SpO2 and TcPCO2

Subjective and objective

quality of sleep (St Mary

Hospital Questionnaire/ PSG),

subjective comfort of

ventilation

Greater reduction in tcPCO2

with AVAPS at the expense of

decrease in objective and

subjective quality of sleep

and comfort. Mean IPAP

higher with AVAPS.

Ambroggio [7] RCT

1-night

cross-over

Stable mixed

population (n=

39, most OHS)

Synchrony TM

AVAPSTM

vs ST

ST: usual ventilator settings,

(confirmed to be adequate during

previous sleep study) AVAPS: Vt

110% of baseline during 6 mb CPAP

or 8 ml/kg IBW (whichever associate

with less dyspnea)

Still ventilated

(> 2 months)

Objective sleep quality (PSG),

ABG, VE, Vt

Greater increase of VE and Vt

with AVAPS. Mean IPAP

higher with AVAPS.

No differences in sleep

quality or ABG

Crisafulli [11] RCT 5-days

cross-over

Stable COPD (n=9) Synchrony TM

AVAPSTM

vs ST

ST : IPAP at maximal tolerated (up to

30 mb), AVAPS: Vt 8 ml/ideal body

weigh

IPAP set between EPAP and 30 mb

Naives to NIV ABG, Subjective quality of

sleep, subjective comfort of

ventilation, compliance

Greater improvement in

subjective quality of sleep

with AVAPS. No differences in

ABG, comfort or compliance

Oscroft [18] RCT 8-weeks

cross-over

COPD (n=25) VPAP 3 STATM

IVAPSTM

vs ST


IVAPS: Target Vt as obtained by

applying ST ventilation at previous usual

settings. Maximal IPAP set up 25 mb

Still ventilated

(> 3 months)

ABG, mean nocturnal SaO2

and tcPCO2, HRQL

(St Georges and SF-36),

compliance

No differences in studied

outcomes

Murphy [17] RCT 3-month

Parallel groups

OHS (n=46) SynchronyTM

AVAPSTM

vs ST

Initial settings: for ST IPAP at

18-22 mb, for AVAPS: target Vt 8-10 ml/

IBW and I IPAP set between EPAP +

4 and 30 mb. Setting were then

progressivelyre adjusted by

increasing IPAP (in ST) and target

volume (in AVAPS) to achieve mean

nocturnal SpO2 > 88% and a fall or

rise < 0.5 kpa in tcpCO2

Naive to NIV ABG, SpO2, tcPCO2, Physical

activity, body composition,

HRQL (SRI score), actigraphy-based

sleep quality.


outcomes

Ekkernkamp [2] RCT 6-weeks

crossover

COPD (n=14) Stellar 150TM

IVAPSTM vs

PAC (HINIPPV)

PAC: stepwise increases in IPAP and

RR in order to achieve controlled

ventilation and maximally decrease

PaCO2, IVAPS: target alveolar

ventilation and target RR as

obtained by applying PAC settings

during daytime ventilation. IPAP

range set between -5 and + 5 from

the PAC pressure support (IPAP

minus EPAP)

Still ventilated

(> 2 months)

Quality of sleep and sleep

efficiency (first night on ST

and IVAPS), perceived

subjective sleep quality and

comfort (VAS) and

compliance at 6 weeks, ABG

Reported sleep better with

IVAPS at 6 weeks but pressure

discomfort higher. No

difference neither in quality

of sleep, sleep efficiency, nor

in ABG

Ekkernkamp [15] Open-label

prospective

study

physiologic

study

COPD (n=22)

(obese and

non obese)

Stellar 150TM

IVAPSTM vs

PAC (HINIPPV)

PAC: previous usual settings. IVAPS

IVAPS: target alveolar ventilation

and target RR as obtained by

applying PAC settings during

daytime ventilation. Pressure

support rang (IPAP minus EPAP) set

between 10 and 30 mb

Still ventilated

(> 2 months)

Minute ventilation (MV) on

spontaneous breathing, PAC

and IVAPS

Compared to spontaneous

breathing, only PAC

significantly increased MV in

non-obese patients while

both modes increase it in

obese patients with no

significant differences in MV

between both modes

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Storre [8] Open label

2-treatment,

2 period

crossover study

COPD (n=14) Vivo 40 TM

and 50 TM

Target volume

vs PAC (HINIPPV)

ST: usual ventilator settings, Vt

mode 2 arms: 8 ml/kg IBW and 110%

of individual Vt during HINIPPV

Still ventilated

(> 3 months)

Sleep quality (PSG), ventilator

patterns, HRQL, lung

function, exercise capability

No differences between

HINIPPV and both settings of

target volume. Trend to lower

pressures with target volume

Brionnes [10] Prospective

match-controlled

study

COPD exacerbation

with hypercapnic

encephalopathy

(n=22)

SynchronyTM

AVAPSTM vs

ST

ST: initial settings IPAP 12 cm then

increasing levels in increments of

2 mb according to the discretion of

attending physician

AVAPS: Vt 8-12 ml/kg of IBW, once

reaching clinical stability, then

switch to 6-8 ml/kg of IBW,

Pressure support rang (IPAP minus

EPAP) set between 6 and 20 mb

Naıve to NIV ABG, GCS, blood pressure, RR,

at 1, 3 12 hours and then

every 24 hs on NIV,

Greater improvements with

AVAPS for PaCO2, RR, GCS

score and expiratory Vt. Mean

IPAP higher with AVAPS.

Jaye [14] RCT 1- month

cross-over

NMD and CWD

(n=20)

VPAP 4TM

(prototype)

IVAPSTM

vs ST


IVAPS: Target alveolar ventilation

calculated over an awake learn

period while breathing at CPAP 4 mb

Minimum and maximum IPAP set

‘‘to maximize target ventilation’’

Still ventilated

(> 6 months)

Overnight

SpO2 and TcpCO2

parameters, objective sleep

quality and efficiency (PSG)

Mean overnight tcPCO2

better in ST mode

No differences in SpO2, and

sleep parameters

Kelly [9] RCT 1- month

cross-over

Mixed population

(n=18)

VPAP 4 TM

IVAPSTM

vs ST

ST: IPAP set at ‘‘maximally

tolerated’’ pressure, RR just below

spontaneous rate IVAPS: Target

alveolar ventilation and back up RR

calculated over an awake learn

period while breathing at CPAP 4 mb

Naive to NIV Objective quality of sleep

(PSG), adherence and

tolerance, overnight SpO2

and PtcCO2, subjective

tolerance

Better adherence with IVAPS,

no difference in objective

quality of sleep, tolerance,

overnight SpO2 or PtcCO2.

Lower mean delivered PS

with IVAPS

Oscroft [16] RCT 3- month

parallel groups

COPD (n=40) VPAP 4 TM

IVAPSTM

vs ST

ST: stepwise increases in IPAP and

RR in order to achieve controlled

ventilation and maximally decrease

tcPCO2 IVAPS: Target minute

ventilation and back up RR

calculated over 1-hour awake

period on pressure support at

15 mb. Pressure support rang

(IPAP minus EPAP) set between 3 and

22 mb

Naive to NIV Efficacy of ventilation as

assessed by diurnal ABG and

mean nocturnal SpO2,

compliance, ESS, MRC

dyspnea scale, HRQL (SGRQ

ans SF36, mean nocturnal

tcPCO2


outcomes

VTPV: volume-targeted pressure ventilation, NIV: non-invasive ventilation, ST: spontaneous-timed mode, RCT: randomized controlled trial, OHS: obesity-hypoventilation syndrome, COPD: chronic obstructive pulmonary disease,

PSG: polysomnography, ABG: arterial blood gases, tcPCO2: transcutaneous pCO2, IPAP: inspiratory airway positive pressure, EPAP: expiratory airway positive pressure, PS: pressure support, RR: backup respiratory rate, BURR:

backup respiratory rate, AVAPS: average volume- assured pressure support, IVAPS: intelligent volume-assured pressure support, HINIPPV: high intensity non-invasive positive pressure ventilation, PAC: pressure-assisted control

ventilation, CPAP: continuous positive airway pressure, IBW: ideal body weight, NMD: neuromuscular disorders, CWD: chest wall disorders, VE: expiratory volume, Vt: tidal volume, HRQL: health-related quality of life. ESS: Epworth

sleepiness scale. MRC: Medical Research Council, RDI: respiratory disturbance index.

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[2,7–17]. The targeted volume (Vt or minute ventilation), themethod used to estimate TV, and the time to reach the TV differaccording to the device. In addition, the range of lower and higherpressures used varies greatly [2,7–9,11–18]. Not unexpectedly,mean obtained IPAP and TV vary amongst different studies. Thesedifferences may impact outcomes such as NIV tolerance and sleepquality. In addition, some settings may affect the quality ofventilation. By moving the PaCO2 across the apnea threshold,changes in ventilation induced by varying IPAP may lead toventilatory instability and promote periodic breathing [19]. Thismay induce apneas/hypopneas leading to arousals that in turnaggravate ventilatory instability. Moreover, the increase ininspiratory pressure can itself induce repetitive arousals [20]. Faur-oux et al., [21] showed that some devices needed peak IPAPvariations of up to 10 cm H2O to maintain TV. In addition, an Vtovershoot is frequent after resolution of a pathological condition[22,23]. Besides inducing arousals, this abrupt hyperventilationmay decrease inspiratory effort and promote asynchrony. Theseinconveniences are enhanced with faster pressure rises and largerpressure ranges [20–22].

Problems related to the accuracy of estimated and delivered Vt

A single limb circuit with intentional leak is the most commoncircuit used to provide NIV. When using this type of circuit, Vt andleaks are estimated by algorithms and not measured directly.Different ventilators do not estimate Vt and leaks in the same way[24]. The accuracy of Vt estimation is variable, with an underesti-mation of Vt that can reach 20% [21,24,25]. This can lead theclinician to increase the support. The accuracy of Vt estimationmay be further affected by leaks. Sogo showed that, duringinspiratory leaks, VTPV ventilators systematically overestimate Vtwith a bias that may reach 35% [26].

When using a valve-based circuit, Vt estimation depends on thecharacteristics of the circuit. When using a single limb circuit witha valve, expiratory Vt cannot be measured and is estimated fromthe volume delivered by the ventilator. This estimate will becorrect in the absence of leak. However, during leaks, flowincreases to reach the predetermined IPAP, which may lead to anoverestimation of Vt and a paradoxical drop off of the inspiratorypressure, which worsens the fall of actual received Vt. When usinga double limb configuration, the simplest method is to measureexpiratory Vt. Khirani et al. showed that all tested single limbdevices misinterpreted leaks as an increase in Vt, resulting indecreased IPAP to the minimal preset value [22]. Unexpectedly,two ventilators also incorrectly estimated Vt when tested with adouble limb circuit. Similar results were obtained by Carlucci[20]. Physicians should be aware that these findings increase therisk of hypoventilation [22].

The ability of a ventilator to maintain a stable TV is related notonly to the assessment of Vt, but also to pressurisation capabilities.Fauroux demonstrated that most VTPV ventilators were not able toguarantee the preset TV during unintentional leaks [21]. All theseissues question the ability of these modes and devices to deal withtheir primary aim, which is to maintain a stable TV.

Overview of published studies

A few studies have compared these new modes to conventionalmodes in adult patients on long-term NIV (Table 2). There are nopublished data in the paediatric population. Most trials were short-duration, crossover studies including few patients. Only onerandomized controlled trial with parallel groups used a protocolsetup aiming to achieve optimal ventilation [17]. Seven studiesused a device targeting Vt and six used a device targeting minuteventilation. To our knowledge, no trial has evaluated thecombination with auto adjusted EPAP. Published studies arehampered by the heterogeneity in terms of population, ventilators,


TV, pressures range, setup protocols, and outcomes. Six trialsincluded patients naıve to NIV [9–11,13,16,17] while seven othersincluded patients previously ventilated [2,7,8,12,14–16].

Only two studies reported a significantly greater reduction innocturnal PCO2 in favor of VTPV [12,13] but at the expense of agreater respiratory disturbance index [13] or a decrease in qualityof sleep and comfort [12]. Two studies showed a trend for lowermean IPAP with VTPV [8,14] but in three other studies, mean IPAPwas higher in the VTPV group [7,10,12]. A better adherence withVTPV was observed in one study [14] but not in three others[2,11,18]. Finally, no study has shown any differences favouringVTPV in diurnal PCO2, quality of life, sleep parameters or comfort.

Place of hybrid modes in clinical practice

There is no evidenced-based benefit of these modes ascompared to conventional modes. Even if these modes might givethe impression of an improved control of NIV and are proposed bysome manufacturers as powerful ‘‘fully automatic modes’’ thatmay simplify NIV settings, they should not be used as a first linetherapy. Some individual patients may benefit from these modes.Further studies are needed to establish whether effective ventila-tion could really be obtained more easily, and to determine theclinical benefit and cost-effectiveness of these hybrid modes.

Modes committed to treat central and complex sleep apnea

Continuous positive airway pressure (CPAP) has been shown tobe effective in treating obstructive sleep apnea (OSA). However,CPAP usually fails to suppress central sleep apnea (CSA) [27]. Overthe last two decades, adaptive servoventilation (ASV) has beenspecifically designed to treat CSA not suppressed by long-term useof CPAP.

ASV: technical considerations

The main goal of ASV is to effectively treat periodic breathing, orCheyne Stokes respiration (CSR) which is the most commonbreathing pattern in 25 to 40% of patients with chronic heart failure(CHF). CSR consists of repetitive cycles of crescendo-decrescendoVt with superimposed central sleep apneas or hypopneas. The aimof ASV is to counterbalance this ventilatory instability bymodulating the level of inspiratory support (Figure 2). ASV devicesperform a breath-by-breath analysis and automatically adjustpressure support (PS) within a predetermined range to stabilizeventilation within a target of 90 to 95% of average ventilation.During normal breathing, a minimal PS is delivered. When theventilation falls below the target, PS increases up to a maximum PSset by the user. ASV acts as a mirror to the patient’s own breathingby copying the waxing and waning pattern of Vt. To assess theoptimal level of PS, instantaneous airflow is measured in a movingtime window and integrated to calculate ventilation. By using acontinuously updated average weighted minute ventilation orpeak inspiratory flow, the targeted ventilation is calculated toadjust the level of PS

ASV also applies a fixed expiratory pressure to suppressassociated OSA. Some devices can adapt EPAP pressure in responseto variations in upper airway patency. An optional BURR candeliver supplementary controlled breaths. The technical charac-teristics of available ASV devices are summarized in Table 3.

In theory, this algorithm aiming to suppress all varieties ofsleep-disordered breathing (SDB) makes ASV particularly suitablefor the treatment of complex breathing patterns comprising CSAand OSA.

ASV: clinical implications

ASV has been proposed for the management of a large range ofSDB including CSR in CHF patients, CSA related to opioid use or




Figure 2. 5-min epochs showing a) baseline polysomnogram displaying Cheyne-

Stokes respiration and the operation of an ASV device: b) sleep onset, c) ASV

modulation of inspiratory support level counterbalancing ventilatory waxing and

waning, d) stabilised breathing. ‘‘Pressure’’ is sensed at the mask level and

corresponds to that delivered by the device. Note that when the patient’s flow


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neurologic disorders and the so called complex sleep apneasyndrome (CompSA).

Periodic Cheyne-Stokes breathing in CHF patients

Several studies evaluating ASV in patients with CHF-relatedSDB confirmed the additional benefits of this mode in terms ofreduced apnea-hypopnea index [28] and improved nocturnaloxygenation and sleep quality when compared to baseline [29],CPAP [30,31], bi-level ventilation [32] or oxygen [33]. ASVeffectively suppressed both CSA and OSA and often normalisedAHI values [34]. AHI significantly decreased from the first night[32] to 3 [30,31] or 6 months [29,31,34].

Several long-term studies reported a significant improvementin left ventricular ejection fraction (LVEF) and plasma pro brainnatriuretic peptide (prBNP) levels. ASV improved LVEF on averageby 6 to 9% [30,34]. Additionally, an improvement in left diastolicfunction was also suggested [35,36]. Consequently, NYHA class,quality of life scores [30,35,36] and exercise capacity [37]improved in CHF patients treated by ASV.

Some physiological changes observed during long-term ASVtreatment suggest a positive impact on cardiac function with (1) areduction of cardiac overload [35,38] but also of afterload [39],resulting in an increase in cardiac output; (2) left ventricular and leftatrium remodelling [39]; (3) a reduction in ongoing myocardialdamage [35]; (4) a decreased rate of ectopic ventricular complexes[40]; (5) an anti-inflammatory effect with lower levels of pro-inflammatory cytokines [41]; and (6) a decrease in plasma levels ofcatecholamines as a marker of muscle sympathetic nerve activity[41]. However, it remains unclear whether the benefits of ASV areassociated with an improvement in survival. By exposing the failingheart to intermittent hypoxia, increased preload and overload, andsympathetic activation, SDB may promote disease progression andcontribute to mortality [42,43]. Intuitively, optimal SDB correctionwould be beneficial for CHF patients. Some preliminary studiesindicated that ASV therapy significantly reduced mortality in CHF/CSR patients [35,38,44,45]. In an observational study conducted overone year in 85 CHF patients with severe predominantly central SDB,a significant reduction in fatal cardiovascular free-event survivalwas observed in patients using ASV for >4 h per night comparedwith non-adherent patients (p<0.01) [45]. Similar results werereported by Koyama [38] and in two short randomized controlledtrials [46,47]. Yoshihisa [46] included 60 patients with CHF (meanLVEF 37.8%) and CSR. The ASV group showed significant reduction incardiovascular mortality and rehospitalisation at 6 months com-pared with patients treated by optimal pharmacotherapy andcardiac resynchronisation (p<0.01). In a study by Hetland [47], atrend toward survival improvement was observed (p=0.07) in30 severe CHF/CSR patients randomized to ASV.

Nevertheless ASV benefit has been dramatically challenged bythe results of the SERVE-HF trial [48]. This study randomly assigned1325 patients with an LVEF � 45%, an AHI � 15 per hour, and apredominance of central events, to receive medical treatment withASV or medical treatment alone. The median duration of follow-upwas 31 months. In the intention-to-treat analysis, all-cause andcardiovascular mortality were significantly higher in the ASV groupthan in the control group. All-cause mortality was 34.8% vs 29.3%,respectively (p=0.01) and cardiovascular mortality was 29.9% vs24.0%, respectively (p=0.006). There was no significant effect of ASVon the incidence of lifesaving cardiovascular intervention orunplanned hospitalization for worsening CHF. Mortality was higherin patients with a higher proportion of CSR and in those with lower

increases (hyperpnea), the pressure delivered by the device decreases (less

inspiratory pressure) and when the patient’s airflow decreases (hypopnea), the

pressure from the device increases. The device algorithm is, thus, anticyclic to the

patient’s own ventilation.




Table 3Summary of different devices providing adaptive support ventilation (ASV) and their characteristics

S9 AutoSet CS PaceWaveTM System One BiPAP autoSV AdvancedTM Somnovent CRTM

Manufacturer Resmed Respironics, Philips Weinmann

Target Minute ventilation Peak inspiratory flow Relative minute volume

PS range 0 to 20 0 to 20 0 to 20

maximal IPAP 25 25

EPAP range 4 to 15 4 to 15

Auto EPAP Available Default: automatic

Can be set manually

Default: automatic

Can be set manually

Early expiratory

pressure relief

Not available Available Available

BURR Default: 15/min + adaptation in a

moving window. Cannot be

set manually

Default: 15/min + adaptation in a moving

window. Can be manually fixed

Default: 80% of average breathing rate with

highest weight on last breaths. Can be

manually fixed

Smart Card Available Available Available

For legends, see Table 1.


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LVEF, but was not associated with ASV settings, ASV use or residualAHI. This unexpected result raises questions regarding thepathophysiological mechanisms implicated in this increasedmortality. One possible explanation is that the theoretical benefitof positive airway pressure on cardiac function is not true or isoutweighed by adverse side effects. A second possibility is that CSR isa compensatory mechanism and may have beneficial effects[49]. Post-hoc analysis regarding patients who regularly used ASVmore than 4 hours per night with an effective correction of CSA isexpected.

An ongoing study with a different ASV device (ADVENT-HF,NCT01128816) may provide some clues about whether thenegative results identified in SERVE-HF study are limited to aparticular device or algorithm. Until then, we must consider thatASV may have potential deleterious effects in patients with severeCHF (LVEF < 45%) who have predominantly CSR, and recommendthat ASV should not be used in these patients

CSA associated with medical conditions

Chronic opioids use is associated with a large spectrum of SDB[50] including OSA or CSA, alveolar hypoventilation and ataxicbreathing. A study evaluating 392 patients on long term opioidtreatment [51] found a high prevalence of sleep apnea with 36% ofpatients showing an AHI �30/h with a mixed pattern. Severalrecent publications reported efficacy of ASV in these patients[27,52]. In one small, non-randomized trial [27], ASV was betterthan CPAP in improving opioid-related SDB in 20 patients.

CSA can also occur in other diseases, such as Arnold-Chiarimalformation or end-stage renal disease, with studies suggestingthat ASV may be beneficial in these clinical situations [53,54].

CSA emergent under CPAP (CompSA)

Complex sleep apnea (CompSA) is a form of central apneadefined as the emergence or worsening of central apneas orhypopneas upon exposure to CPAP. CompSA prevalence variesfrom 5 to 20% [55–57]. CompSA is generally transient and persistsin only 1.5% of patients on long term CPAP [58]. Risk factors forCompSA includes more severe OSA, a baseline CSA index over 5/h,opioid use and older age [55,56]. As CompSA usually resolves overtime, CPAP remains the first line of treatment. ASV should beproposed if CompSA persists after 8 to 12 weeks of CPAP. Bitteret al. [59] showed that ASV was successful in 33 of 34 patients withpersistent CompSA. ASV also improved sleep fragmentation andovernight oxygenation [60]. In a randomized trial comparing CPAP,bilevel ventilation and ASV [32], ASV seemed to be the mosteffective treatment for CompSA.

ASV may be a promising and useful tool to correct coexistingobstructive and central apnea. However, the paucity of dataavailable on the treatment of CSA syndromes should be emphasized.


There are no published studies concerning the paediatric population.In the particular case of CHF patients, caution should be takenfollowing the SERVE-HF results. There is evidence that conventionaltreatment (CPAP, nocturnal oxygen) is effective and should be usedas the first intention in these cases. Further studies are needed toenable recommendations regarding ASV use.

New modes of triggering and cycling: neurally adjusted ventilatory

assist (NAVA)

During NIV, the achievement of patient-ventilator synchrony isa crucial problem, which limits the efficacy of NIV. ConventionalNIV ventilators detect the patient’s respiratory efforts based on themeasurement of a pressure or flow change in the respiratorycircuit. This detection is complex because of the leaks around theairway interface. In pediatric patients, this problem is exaggeratedbecause the respiratory volumes are small with proportionallyhigh leaks. Essouri [61] reported in infants with upper airwayobstruction that most efforts (64%, range 32-97%) are not detected.In addition, the inspiratory trigger delay lasted 300 ms [range 180-530 ms], which approximated the children’s inspiratory time.More recent studies in critically ill children confirmed that patienteffort and ventilator support are not synchronized in 38 to 65% ofcycles [62,63]. Considering that the addition of non-synchronizedassist has frequently little additional benefit, CPAP is the mostfrequently used NIV mode in the pediatric ICU [64].

The neurally adjusted ventilatory assist (NAVA) has beendeveloped to overcome this synchronization problem. DuringNAVA, the ventilator assist is directly synchronized with thediaphragm electrical activity (EAdi) [65]. The EAdi, which isrecorded using a specific nasogastric tube equipped with electro-des, is a reliable and fast reflection of the respiratory drive[66,67]. The ventilatory assist is triggered when EAdi exceeds athreshold (usually 0.5 mV). Of note, the pneumatic trigger remainson, and can also be activated as in conventional NIV. As illustratedin Figure 3, the magnitude of inspiratory support is continuouslyadapted in proportion to the EAdi, according to the formula:

Airway PressureðcmH2OÞ ¼ DEAdiðmVÞ�NAVA levelðcmH2O=mVÞ

þ PEEPðcmH2OÞ

The DEAdi is the increase in EAdi from the end-expiratorybaseline. The proportionality factor ‘‘NAVA level’’ permits adaptionof the magnitude of respiratory unloading. Inspiratory support isinterrupted when EAdi decreases below 70% of peak EAdi, and PEEPis then applied. NAVA ventilation is available on the ServoIventilator (Maquet Critical Care, Solna, Sweden) for both invasiveand non-invasive ventilation.




Figure 3. Screenshot of the ventilator screen during pediatric non-invasive

ventilation with NAVA, displaying ventilatory pressure (yellow curve, top), flow

(green curve), volume (blue curve), and diaphragmatic electrical activity (EAdi, white

tracing, bottom). Note the synchronization and proportionality of pressure and EAdi

signals, characteristic of the NAVA mode. NAVA, neurally adjusted ventilatory assist;

NIV, non-invasive ventilation; resp, respectively; PSV, pressure-support ventilation;

EAdi, electrical activity of diaphragm; nCPAP, nasal continuous positive airway

pressure;


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Theoretical interest of NIV-NAVA

The major advantage of NIV-NAVA is the improvementof patient-ventilator synchrony. The electrical activation ofthe diaphragm precedes its contraction and the subsequent

Table 4Summary of published studies evaluating Non-Invasive Ventilation with NAVA in pedi

Reference Population Study design, Ai

Beck [81] 5 preterm infants, gestational age 26

(25-29) weeks.

Observational st

(20 min) post-ex

Single nasophary

Vignaux [63] 6 post-operative children, aged

18 (5-27) months old, with post-

extubation respiratory failure.

Randomized cro

NAVA (20 min) v

cycling-off criter

Nasal prongs, Fa

Ducharme-Crevier [68] 13 critically ill children, aged

42 (2-109) months.

Cross-over study

Conventional NIV

(60 min) – Conv

Nasopharyngeal

nasobuccal mask

Houtekie [69] 10 infants, aged 7 (4-9) weeks,

extubated after a cardiac surgery.

Randomized cro

NIV-NAVA (30 m

Nasal prongs

Baudin [62] 11 infants (aged 35�23 days) with

severe bronchiolitis and failure of nCPAP.

Cross-over study

Pressure/assist c

(2 hr) followed b

Nasal masks

Lee [80] 15 preterm infants, gestational age

27 (26-28) weeks, in post-extubation

period.

Randomized cro

NIV-NAVA (15 m

Nasal prongs, na

NAVA, neurally adjusted ventilatory assist; NIV, non-invasive ventilation; resp, respective

nasal continuous positive airway pressure.


modification of airway pressure or flow. Moreover, EAdi triggeringis neither affected by the presence of leaks nor by unfavourablemechanical conditions like over-distension and intrinsic PEEP.Inspiratory triggering and cycling-off can therefore be optimizedwith NAVA as compared to the NIV mode based on pneumatictriggering [62,63,68,69].

The proportional assist in response to the patient drive isanother important feature of NAVA. In contrast to conventionalNIV with constant assist level, the level of support is automaticallyadapted to the patient ‘‘demand.’’ The goal is to better unload thediaphragm during periods of increased respiratory load, and toavoid over-assistance, with a low ventilatory drive automaticallyleading to a reduced assist.

The monitoring of EAdi also provides new important insightsfor clinicians [67]. Observation of EAdi can rapidly indicate achange in ventilatory conditions, and facilitate the detection ofover- or under-assistance [67,70]. EAdi monitoring is crucial todiagnose patient-ventilator asynchrony [71] and it can thereforefacilitate the adaptation and settings of NIV, even when NIV-NAVAis not used. EAdi monitoring can also help to better identifymechanisms of ventilator dependence in children with neuromus-cular and respiratory control disorders [67,72–76].

Limits of NIV-NAVA

The most important limit in long-term practice is that NAVA iscurrently available only on an ICU ventilator. Home ventilationwith NAVA is not possible.

The need of a specific nasogastric tube is usually not a limitationin the pediatric ICU, because gastric tubes are often used forfeeding and gastric emptying. In chronically ventilated patients

atric patients.

rway interface Main findings

udy of NIV-NAVA

tubation.

ngeal prong

NIV-NAVA is feasible and well tolerated in preterm

infants.

Trigger and cycling-off delays were short (76�33 ms,

and 28 �11 ms, resp.) during NIV-NAVA, similar with

delays observed in invasive condition.

ss-over study.

s PSV with 3 different

ia.

cial mask

No ineffective efforts, no late or premature cycling

observed during NAVA.

Asynchrony index was 2% (1-5) in NAVA, as compared

to 65% (42-76) and 40 (28-65) during PSV with initial or

optimized cycling-off setting, resp (p<0.05).

Shorter trigger delays in NAVA (p<0.05).

.

(30 min) – NIV-NAVA

entional NIV (30 min)

tubes, nasal masks,

s.

Inspiratory trigger asynchrony, cycling-off asynchrony,

and wasted efforts were decreased in NAVA (p<0.05,

<0.05, and <0.01, resp.)

Decreased time spent in asynchrony: 8% (6-10) in

NAVA, as compared to 27% (19-56) and 32% (21-38) in

both conventional NIV periods.

ss-over study.

in) vs nCPAP (30 min)

Delayed trigger observed in less than 1% breaths during

NIV-NAVA, despite leakage > 70%.

Lower peak EAdi values during NIV-NAVA.

.

ontrol ventilation

y NIV-NAVA (2 hr)

Lower asynchrony index in NIV-NAVA (3�3%), vs

38�21% in Pressure/assist control.

Decreased trigger delay (p<0.0001) and wasted efforts

(p<0.01).

ssover study.

in) vs PSV (15 min).

sal masks

Decreased trigger delay (p<0.001), cycling-off delay

(p<0.01), autotriggering (p<0.001), and wasted efforts

(p<0.001). Lower asynchrony index in NIV-NAVA (20%

(10-23)) as compared to PSV (74% (71-78)).

Lower inspiratory pressure (p<0.01), higher respiratory

rate (p<0.01) during NAVA.

Lower peak inspiratory EAdi during NAVA (p<0.01).

ly; PSV, pressure-support ventilation; EAdi, electrical activity of diaphragm; nCPAP,




PRACTICE POINTS

� New ventilatory modes and features available to providenon-invasive ventilation include:� New modes of ventilatory assistance

Commited to treat respiratory failure (hybrid modes)Commited to treat central sleep apnea (adaptativeservo ventilation)

� New modes of triggering and cycling (neutrally adjustedventilatory assistance)

� Hybrid modes combine characteristics of volume andpressure targeted modes. Their goal is to provide apredetermined target volume while maintaining thephysiological benefits of pressure targeted ventilation.� Adaptive servo ventilation (ASV) was primary designed to

treat periodic breathing, a particular form of central sleepapnea. Its aim is to provide a variable degree of ventilatorysupport to stabilize ventilation by acting as a mirror to thepatient’s own breathing.� Neuro adjusted ventilatory assist (NAVA) is a mode in

which the ventilator assist is directly synchronized withdiaphragm electrical activity. NAVA has been shown toimprove patient-ventilator synchrony during pediatricNIV. NAVA also provides a proportional assist in responseto the patient drive.

RESEARCH DIRECTIONS

Further trials are needed to evaluate the cost-effective-ness of these new modes and features and the impact oncomfort and patient-ventilator synchronisation as well as onthe success rate of non-invasive ventilation.


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who have a gastrostomy, the insertion of a nasogastric tube can beperceived as invasive and should be balanced against the expectedbenefits.

The adjustment of the level of support to the patient’s demandimplies that this demand is continuously appropriate. Thefeasibility of NAVA may be impaired during profound sedation,which is rare during NIV. Most relevant, significant dysfunction ofrespiratory centres limits the feasibility of NAVA. In patients withneuromuscular disease, EAdi may be recorded even in patientswith a severe condition [28,72,76]; however, the signal quality andmagnitude depend on the severity and phase of the disease, andthe feasibility of NAVA should be individually checked.

Practical aspects of NIV-NAVA

The first step is the insertion of a specific, age-appropriate (from6F to 16F) gastric catheter (Edi catheter, Maquet, Solna, Sweden),which permits recording of EAdi in parallel with gastric feeding orsuctioning. The catheter position is estimated based on a pre-established distance formula and confirmed using a specific screenon the ventilator [67]. Once a correct EAdi signal is displayed, theNAVA level is set, taking into account the observed EAdi, theestimation of EAdi that should be targeted, and the anticipatedlevel of pressure assist. A titration method has also been describedto identify the optimal NAVA level, including in neonates[77]. Whatever the method, the key point is to rapidly reassessthe NAVA level, based on the evolution of respiratory rate,volumes, clinical signs of work of breathing, and EAdi. PEEP andFiO2 management is relatively classical, except that high PEEP isnot needed to overcome the high work of breathing associatedwith triggering over intrinsic PEEP in patients with hyperinflation[78]. Of note, the assist is triggered by the first activated trigger(EAdi or pneumatic) and pressure-support ventilation can beactivated in absence of EAdi signal (in particular, in the case of tubedisplacement). Back-up ventilation is available to prevent apnea.

Evidence regarding NIV with NAVA in children

Beck et al., [79] first demonstrated the feasibility of NIV-NAVAin 5 low birth weight premature infants supported through a singlenasopharyngeal prong. The patient-ventilator synchrony wassuccessfully reached during NIV-NAVA, similar to the synchronyobserved before extubation, despite large leaks. As detailed inTable 4, five clinical crossover studies including a total of 55 infantsand children have subsequently evaluated the short-term perfor-mance of NIV-NAVA [62,63,68,69,80]. All these studies confirmedthe excellent synchrony reached in NAVA, while conventional NIVwas associated with huge asynchrony. A constant finding was thesuppression of wasted efforts in NAVA, and the reduction of triggerand cycling-off asynchrony. However, the duration of NAVA wasshort, and these studies did not assess the impact of NAVA on NIVsuccess. Larger trials are warranted to evaluate if this optimizationof synchrony leads to an improved success rate of NIV or decreasesthe duration of ventilatory assist.

EDUCATION ARTICLE

You can receive 1 CME credit by successfully answering thesequestions online.

(A) Visit the journal CME site at http://www.prrjournal.com.(B) Complete the answers online, and receive your final score upon

completion of the test.(C) Should you successfully complete the test, you may download

your accreditation certificate (subject to an administrativecharge), accredited by the European Board for Accreditation inPneumology.


1. Regarding devices providing hybrid modes

a. Some of these devices may be able to automatically adjustsinspiratory pressure within a predetermined range to ensure astable TV

b. Some of these devices may also be able to automaticallyadjust the backup respiratory rate within a predetermined range

c. Some of these devices may also be able to automatically adjustexpiratory pressure within a predetermined range to maintainairway patency.

d. Some of these devices may be able to also automatically adjustthe sensitivity of the inspiratory trigger.

2. Regarding hybrid modes

a. There is evidence that these modes are more effective thanconventional modes.

b. May be used as a first line therapy to treat patients with chronichypercapnic ventilatory failure.

c. There is evidence that these modes improve quality of life andsleep efficiency compared to conventional modes.

d. Evidence does not suggest a clear benefit of these modes

3. Regarding adaptive servo-ventilation (ASV)

a. Is proposed as a first line therapy for treating obstructive sleepapnea.

b. Is proposed as being more effective than CPAP to treat coexistingobstructive and central apnea.

c. Is useful to treat obstructive sleep apnea and coexistinghypoventilation.


http://www.prrjournal.com/




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d. Is proposed as an alternative to treat nocturnal alveolarhypoventilation.

4. ASV is proposed as an effective treatment:

a. in patients with periodic breathing related to cardiac disease,whatever the left ventricular ejection fraction (LVEF).

b. in patients with periodic breathing related to cardiac diseasewith an LVEF > 45%.

c. in patients with central sleep apnea related to opioid use.d. in patients with central sleep apnea related to neurologic

disorders.

5. Regarding NAVA:

a. The ventilator assist is directly synchronized with the dia-phragm electrical activity.

b. This mode of triggering requires the use of intraesophagealelectrodes.

c. The ventilator is able to vary expiratory pressure.d. This mode is available in home ventilators.

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Paediatric Respiratory Reviews - SPLFsplf.fr/wp-content/uploads/2019/04/ModesHybrides-CoursRabec.pdf · To discuss the most recent advances in ventilatory modes and features available