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NEURALLY ADJUSTED VENTILATORY ASSIST (NAVA)

DOCUMENT TYPE: PROCEDURESite Applicability

Neonatal Intensive Care Unit (NICU), Neonatal ProgramPediatric Intensive Care Unit (PICU), BC Children’s HospitalEmergency Department (ED), BC Children’s Hospital

Practice Level/Competencies

NAVA set-up, maintenance of respiratory support, and insertion of orogastric (OG) and nasogastric (NG) Edi catheters are Basic Skills of the Registered Respiratory Therapist (RRT) as outlined by the Canadian Society for Respiratory Therapists (CSRT) National Competency Profile.

OG and NG insertion and removal is a Basic Skill of the Registered Nurse (RN) as outlined by the British Columbia College of Nursing Professionals (BCCNP).

Policy Statements The respiratory centre of the brain controls rate and depth of breathing by sending electrical impulses to the diaphragm, the main respiratory muscle. Diaphragm excitation is the earliest signal involved in control of respiration. Neurally Adjusted Ventilatory Assist (NAVA) mode on the Servo® ventilator uses the electrical activity of the diaphragm (Edi signal) to control the assist provided by the ventilator based on the patient's respiratory efforts. A NAVA level is set which determines the level of assistance that the ventilator will provide the patient or the work that will be unloaded from the patient. Based on the Edi signal, and the level of NAVA set, the NAVA mode delivers assistance in proportion to and in synchrony with the patient’s respiratory efforts breath by breath. This translates to the patient receiving the support they demand with the intent of eliminating ventilator asynchrony. This optimizes conservation of energy towards growth and healthy development.

The Edi catheter is a single-use gastric feeding tube and can be used for the administration of nutrition, fluids, and medications. The Edi catheter has an array of 10 electrodes. The first electrode is a reference electrode and the remaining 9 are measuring electrodes which capture the Edi signal. When placed correctly into the esophagus, the Edi catheter sits at the level of the crural diaphragm. Electrodes pick up signals at a rate of 62.5 times per second. The signal between the electrodes is measured and processed by the Servo ventilator which displays 4 ECG waveforms and numeric Edi values. The Edi signal provides objective clinical measurements of the patient’s respiratory drive and synchronicity with the ventilator.

The Edi signal, displayed as a cyclical waveform on the ventilator, uses both the highest (Edipeak) and lowest (Edimin) values numerically (microvolts (μV)). The ventilator uses these values to determine the pressure delivered to the patient in proportion to the patient’s demands based off of the Edi signal. This is calculated by the ventilator as:

Peak Inspiratory Pressure (PIP) (cmH2O) delivered to the patient =NAVA level X (Edipeak - Edimin) + Positive End Expiratory Pressure (PEEP) (cmH2O).

Edi catheter insertion is a two-person procedure and is a shared responsibility between RNs and RRTs. An RRT must be present for Edi catheter insertion and is responsible for confirming Edi catheter positioning via the ECG waveforms displayed on the Servo ventilator. The Edi catheter (and Halyard extension tubing) must be changed every 6 days. Avoid disconnection of the Edi catheter. In the event of disconnection of the Edi catheter, the mode will switch to backup ventilation and the RRT must be called to ensure NAVA ventilation resumes.

The Edi signal may be used for patients that are invasively and non-invasively ventilated via the NAVA and NIV NAVA modes, respectively. Edi Monitoring can also be used in the standby mode or with other modes utilized.

C-0506-12-60407 Published Date: 14-Nov-2019 of 16 Review Date: 14-Nov-2022 This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.


DOCUMENT TYPE: PROCEDUREIndications:

≥ 24 weeks corrected GA as initial or post extubation respiratory support (NIV NAVA maintained for a minimum of 72 hours in neonates < 30 weeks GA unless intubation criteria met)

Criterion of yellow or red status met Acute or chronic stage Ventilator asynchrony (may be clinically evident as increased WOB, increased

sedation/medication dosing in the absence of new lung disease, incongruence of the delivered pressure (Ppeak) waveform and the estimated pressure (Pest) waveform based on the Edi signal with Edi catheter in situ)

Neuromuscular Disorders (Guillain-Barre, Myasthenia Gravis, Muscular Dystrophy) Diaphragmatic atrophy from long-term ventilation in the PICU or NICU Supporting diagnosis of spinal cord injuries

Contraindications: Insufficient/absent respiratory effort (brain abnormality, medications) Phrenic nerve injury Congenital myopathy Magnetic Resonance Imaging (MRI) (Edi catheter electrodes are composed of stainless steel -

the catheter must be removed prior to MRI) Anomaly (esophageal atresia, severe diaphragmatic activity seen with high Edi peak pressures

(e.g. > 20 μV)) Any contraindication to the insertion of an OG or NG tube

Equipment & Supplies Servo-u® or Servo-n® Ventilator (with pre-use check completed and ready for clinical use if not

already used on the patient). Equipped with Fisher & Paykel (F&P) Infant Respiratory Care System Evaqua 2 (RT266) Ventilator Circuit, MR850 Humidifier with heater wire adaptor and temperature probe, neonatal flow sensor and pressure line (if intubated in neonatal category), sterile water for inhalation 1000 milliliter (mL) bag.

Appropriately sized Edi catheter (single-use) NAVA Edi module NAVA Edi cable Sterile water ampule Tape and another securing device (e.g. TegadermTM) for Edi catheter Sterile (clear) disposable glove OG/NG tubing Halyard MIC 6-inch Extension Tubing Date change label x 2

Procedure

SET UP - EDI CATHETER INSERTIONSTEPS RATIONALE1. Verify medical order for the initiation of NAVA. Steps #1-19 completed by the RRT only.2. Collect and set-up the Servo ventilator if the

patient is not currently receiving therapy on this system.

3. Collect the appropriately sized Edi catheter based on the patient’s height and weight.

Check expiration date on the Edi catheter package.

o Weight only is used for Edi catheter size selection in the NICU.

o Height is used for Edi catheter size selection in the PICU and ED.

o Edi catheter sizes range from 6 to 16 French (Fr).



DOCUMENT TYPE: PROCEDUREOnly 12 and 16 Fr Edi catheters have an additional venting lumen.

o An additional 5 Fr OG may be inserted when a 6 Fr Edi catheter is used with NIV NAVA. The Edi catheter is longer which increases resistance and can make venting difficult. Feeding pump versus gravity feed facilitates easier administration with a 6 Fr Edi catheter.

o A catheter size chart is located on each Edi catheter package. It is also displayed on the drop-down menu of the Edi catheter size in the CALCULATION TOOL.

Catheter Selection GuidePatient Length centimeters (cm)

<55 <55 45-85 75-160 >140

Patient Weight kilograms (kg)

0.5-1.5

1.0-2.0

Edi Catheter Size (Fr/cm)

6/49 6/50 8/100 12/125 16/1258/125

4. Wash hands.5. Insert the NAVA module into a free module

compartment on the front panel of the Servo ventilator (if not already present).

6. Connect the black end of the Edi cable into the NAVA module.

7. Disconnect the Edi test plug connector from its insert on the Edi cable.



DOCUMENT TYPE: PROCEDURE

8. Calibrate the Edi cable by connecting the Edi test plug connector to the connector end of the Edi cable.

o Upon connection of the Edi test connector, an automated Edi cable self-test will commence to ensure proper functioning.

9. Select OK when PASSED has displayed on the screen.

10. Disconnect the Edi cable from the Edi test plug.

11. Reconnect the Edi test plug back into the insert on the Edi cable. “No Edi Catheter connected” will display – tap OK.

12. Wash hands.13. Don clean gloves.14. Measure the distance from the bridge of the

Nose (N) via the Earlobe (E) to the distal tip of the Xiphoid process (X) = (NEX).

o Make note of this distance – this number will be entered on the ventilator to calculate Edi insertion depth.

15. Determine the Edi catheter insertion depth: Tap Edi-NAVA from the Quick Menu. Tap CALCULATION TOOL. Tap under Select Edi catheter size and choose

size from the drop-down menu. Tap under Select insertion type to choose Oral

or Nasal Tap under Measure NEX and Input NEX

distance




o The ventilator will calculate the Edi catheter insertion distance based on the catheter size and NEX distance. Once the NEX distance is input into the system, the “Edi catheter insertion distance” will automatically display the Edi catheter insertion depth.

16. Open sterile package of the Edi catheter (do not remove Edi catheter at this time).

o Inspect contents to confirm that there has been no damage to the catheter.

17. Pour contents of a sterile water ampule to the distal end of the Edi catheter. Keep catheter submerged in the water for 5 seconds.

o Sterile water activates the electroconductive dry bond coating of the Edi catheter. Once inserted, this coating interacts with stomach pH to produce a brownish discoloration. Anything other than sterile water can destroy the dry bond coating and should not be used.




18. Don 1 sterile (clear) disposable glove (for primary inserter - RN or second RRT).

o For insertion of the Edi catheter.

19. Insert the Edi catheter into the patient via oral or nasal route to the predetermined insertion depth in short strokes (1-2 cm at a time).

o Provide developmentally supportive care prior to insertion of Edi catheter (e.g. hand hugging).

o Edi catheter insertion is always a 2 person procedure (one of which must be an RRT).

o A second RRT or RN inserts the Edi catheter with a sterile (clear) disposable glove donned.

o Short strokes are used to minimize coiling in the pharynx.

o The RN or second care provider holds placement of the Edi catheter while the RRT proceeds to the next step.

20. Remove Gloves (RRT). o Steps #20-29 completed by the RRT only.21. Wash hands (RRT).22. Disconnect the plastic protective cap from the

Edi catheter.23. Connect the Edi catheter to the Edi cable.



DOCUMENT TYPE: PROCEDURE24. Select Edi CATHETER POSITIONING. o Accessed from Edi-NAVA >> Edi CATHETER

POSITIONING on the Quick Menu or from the last window accessed (CALCULATION TOOL) on the bottom of the window.

25. Confirm proper positioning of the Edi catheter by observing the 4 ECG waveforms displayed on the ventilator monitor:

The electrodes beside the middle 2 ECG waveforms will be illuminated pink when the catheter is correctly positioned at the level of the crural diaphragm.

P and QRS waves are larger on the top leads and progressively become smaller in the bottom leads. The top ECG lead will be the largest as it is measuring electrical activity behind the right atrium. Bottom lead will display no P wave (furthest from the heart).

o Pink illuminated on the electrodes and ECG waveforms indicates where the Edi signal is strongest. If no Edi signal is detected, pink will not be illuminated. Positioning of pink highlights will fluctuate along the electrodes with patient movement.

o The catheter positioning guide will display up or down arrows if the catheter is incorrectly positioned. Reposition the catheter if positioning guide arrows are present by slowly advancing or withdrawing the catheter in 0.5 cm increments.

o If the Edi catheter is coiled, the top and bottom ECG leads will be similar (larger QRS). Correct positioning by slowly withdrawing and reinserting the catheter.

o The bottom window of the Edi CATHETER POSITIONING window will display an Edi waveform (purple) when the ventilator is in STANDBY and also when in NIV NAVA/NAVA.




o If the patient is currently receiving support on another mode (e.g. PRVC) the bottom window of the Edi CATHETER POSITIONING window will display a gray waveform superimposed on a yellow waveform. The grey waveform is the estimated pressure (Pest) waveform based on the Edi signal and the yellow waveform is the delivered pressure waveform. This illustrates how the ventilator is synchronizing with the patient. If the patient is in NAVA mode, this window will show the delivered pressure (yellow) waveform only.




o The Edi signal waveform viewed on the main screen will be present regardless of whether the patient is on the NAVA mode or not.

26. Observe Edipeak ensuring it is consistently > 5 μv.

o If the Edipeak is consistently < 5 μv, consider potential causes of disruption of the neural signal between the brain and the diaphragm (muscle relaxants, spinal cord injury, heavy sedation, or hyperinflation). Correct causes of disruption, if feasible. If Edipeak remains < 5 μv, or no Edi signal is detected, do not initiate NAVA.

27. Input final insertion distance on the left-hand-side of the Edi CATHETER POSITIONING window.

28. Select DONE.29. Tap TRENDS AND LOGS from the Quick

Menu on the ventilator to organize trends. Tap TRENDS. Tap Organize Trends. Select and drag backup

occurrences (∑), Backup %, and Edipeak,Edimin to the top 3 on the list. Tap “X” to return to previous screen.

o Trends are displayed per minute and can be displayed over 1, 3, 6, 12, 24, or 72 hours (select 12 hours).

o Trends are valuable to assess readiness to wean or escalation of therapy.

30. Affix a yellow date change label to the Edi catheter.

On this label, write the date/time catheter was inserted along with the date/time 6 days ahead (when the catheter will need to be replaced).

o The Edi catheter is used for 6 days and then disposed of.

31. Wash hands.32. Secure Edi catheter with tape and other

securing device (e.g. TegadermTM).o Steps #32-37 completed by the RN.o Ensure that the Edi catheter is not secured to the

oral endotracheal tube (OETT) or nasal endotracheal tube (NETT) if present.



DOCUMENT TYPE: PROCEDUREo Edi monitoring is now achieved and NAVA can be

initiated if desired. Edi monitoring can continue without initiating NAVA. This is done by tapping Edi & NAVA on the Quick Menu and selecting Edi MONITORING. The Edi monitoring screen will display Pest and Pdelivered waveforms, Edipeak, Edimin, and Edi trend when on STANDBY. Clinically, this can be used to optimize patient-ventilator synchrony.

33. Confirm catheter position by using pH strips. Aspirate 0.5 mL of gastric fluid.

o See Gastric Tube Placement Procedure (NN.08.02).

34. Connect the MIC extension tubing (6 inches) to extend the connection of Edi catheter to feed via OG/NG tubing.

35. Affix a yellow date change label to the MIC extension tubing.

On this label, write the date/time extension tubing was opened along with the date/time 6 days ahead (when the extension tubing will need to be replaced).

o The MIC extension tubing is used for 6 days and then disposed of. The extension tubing is flushed with sterile water, wrapped in a sterile towel, and placed in the refrigerator between feeds to help reduce bacterial growth.

o The feeding/venting lumen of the Edi catheter is

C-0506-12-60407 Published Date: 14-Nov-2019 of 16 Review Date: 14-Nov-2022

This is a controlled document for BCCH& BCW internal use only – see Disclaimer at the end of the document. Refer to online version as the print copy may not be current.


DOCUMENT TYPE: PROCEDUREcapped off when the MIC extension tubing is not connected for feeds.

36. Remove gloves.37. Wash hands.

NIV NAVA INITIATION – COMPLETED BY RRT ONLYSTEPS RATIONALE1. Select mode. Select NIV NAVA mode for noninvasive

support Select NAVA mode for invasive support

o If the patient is not currently receiving support, tap START. If the patient is being switched from noninvasive to invasive support (or vice versa), tap STANDBY, tap and hold Stop VENTILATION, select desired MODE, and press START.

o See Neurally Adjusted Ventilatory Assist (NAVA): Ongoing Care Algorithm (C-0506-01-60408) and Neurally Adjsuted Ventilatory Assist (NAVA): Weaning Algorithm (C-0506-01-60409).

2. Set Basic settings: NIV NAVA: Oxygen concentration (%)/Fraction of inspired

oxygen (FiO2) PEEP NAVA level Edi trigger NAVA: Oxygen concentration (%)/FiO2

PEEP NAVA Level Edi trigger Trigger (flow, Litres per minute (L/min))

o Set PEEP based on x-ray and oxygenation requirements or to match PEEP on previous ventilation mode.

o Set NAVA level to 2.0. Titrate NAVA to target EdiPeak of 5-20 μv. If EdiPeak is > 20 μv increase NAVA level to provide more support and offload work from the patient. If Edipeak is < 5 μv decrease NAVA level to provide less support.

o Edimin should be < 5 μv. If Edimin is ≥ 5 μv consistently, this indicates the patient has a higher diaphragmatic tonic activity to maintain their FRC. No intervention is needed based on the Edimin providing the patient is stable (PEEP increase can be considered if the patient is unstable evident by increased FiO2 requirements).

o Edi trigger set to 0.5 μv.o NIV NAVA:

o NIV NAVA will be highlighted when the patient is in the NAVA mode.

o NAVA:o NAVA has a pneumatic trigger which acts

as a secondary trigger source. Trigger (Edi or flow) acts on a first-come-first-serve-




DOCUMENT TYPE: PROCEDUREbasis. Set flow trigger at 1 L/min so the ventilator prefers Edi triggering.

o Expiration begins when the Edi decreases below 70 % of the peak value and if the upper pressure limit is exceeded. When the breath cycles off the assist returns to the PEEP level set.

o NAVA will be highlighted when the patient is in NAVA mode.

1. Set Backup settings: NIV NAVA and NAVA: Backup respiratory rate (RR) Backup pressure control (PC) above PEEP Backup Inspiratory Time (Ti) Apnea Time

o Set PC above PEEP to achieve adequate chest rise (approximately 18-22 cmH2O for neonates) or to match previous settings.

o Backup RR: 30-50 breaths/min or to match previous settings.

o Set initial apnea time to 2 seconds (range of 2-10 seconds). When the apnea time is reached, the ventilator will trigger backup ventilation (PC or NIV PC).

o Set Ti to match the previous ventilation mode or as indicated. Optimize level by observing the flow waveform – inspiration reaches zero flow and synchrony is achieved.

o NIV NAVA:o The backup mode for NIV NAVA is NIV PC

mode. NIV PC will be highlighted when the patient is in backup mode.

o NAVA:o The backup mode for NAVA is PC mode.

PC will be highlighted when the patient is not in NAVA and is in backup ventilation.

o When the Edi catheter is disconnected “No Edi catheter connected” will alarm. The patient will automatically be switched to backup ventilation. Backup ventilation will also occur when an Edi Signal is not measured.

3. Select ACCEPT.4. Set appropriate alarms. o Maximum pressure reached is 5 cmH2O below

high peak pressure (Ppeak) alarm in NIV NAVA and NAVA.

o Turn off the No Patient Effort alarm: when set to off, all apnea related alarms will be turned off. Backup ventilation will remain active but the ventilator will never lock in a backup. In invasive NAVA, high and low minute ventilation alarms will be deactivated. This alarm indicates when the patient is switching between NAVA and the backup mode which is not necessary for the clinician to be alerted of each time.

o Turn off the Leakage too high alarm: Edi signal is independent of leakage. Triggering and cycling of




DOCUMENT TYPE: PROCEDUREthe breath rely on the Edi signal.

o Set high peak pressure (Ppeak) alarm to 35-40 cmH2O to allow for recruitment breaths. The patient will receive tidal volumes physiologically appropriate for them due to innate receptors and reflexes such as the Hering-Bruer reflex which protects from overinflation.

5. Select ACCEPT.6. Monitor and document. o Monitor transcutaneous carbon dioxide (TcPCO2)

or end-tidal carbon dioxide (EtCO2) if clinically indicated, in addition to regularly monitored parameters (Heart Rate (HR), Respiratory Rate (RR), Saturation (SpO2).

CLEANING - COMPLETED BY RRT ONLYSTEPS RATIONALE1. Dispose of all single-use equipment. o Single-use equipment includes:

o Fisher & Paykel (F&P) Infant Respiratory Care System Evaqua 2 (RT266) Ventilator Circuit

o Sterile water for inhalation bag.o Neonatal flow sensor and pressure line.o Edi catheter.

2. Remove detachable non-disposable equipment from the ventilator.

3. Clean or send all reusable equipment for sterilization.

o MR850 Humidifier and heater wire adaptor wiped with CaviWipesTM.

o Temperature probe and Servo® exhalation block wiped with CaviWipesTM and placed in the soiled utility room for sterilization.

o NAVA module and Edi cable wiped with




DOCUMENT TYPE: PROCEDURECaviWipesTM and placed in one of the Respiratory Therapy Storage Room. NAVA module may be left inserted into the ventilator.

4. Clean ventilator with CaviWipesTM.Documentation

RN: Document Edi catheter size and insertion depth on the RN Flowsheet. In addition to regularly charted parameters (performed Q1H), NAVA level and average Edipeak/average Edimin must be documented on the RN Flowsheet.

RRT: o Upon initiation, document on the Respiratory Therapy Flowsheet Charting by Exception area the

indication for NAVA, insertion of Edi catheter, and clinical objective findings. Complete a full monitor of parameters on the front of the flowsheet.

o Document Edi catheter size, insertion depth, and date of Edi catheter replacement on the front of the Respiratory Flowsheet.

o Confirmation of Edi catheter positioning must occur with each monitor (Q3H) by accessing Edi CATHETER POISTIONING from NAVA on the Quick Menu of the ventilator.

o In the Charting by Exception area document Q12H the approximate % of time in backup over the previous 12 hours. Screenshots taken Q12H of trend graphs (completed with camera function on the monitor). This is to be used to compare graphical trends of occurrences and % of time in backup day-to-day.

o In addition to regularly charted ventilator parameters (performed Q3H) include all settings chosen (including Backup Settings) on the Respiratory Therapy Flowsheet. The following parameters specific to NAVA ventilation on the Respiratory Therapy Flowsheet must be added: o NAVA levelo Average Edipeak and Edimin ranges (average of values over the previous 30 seconds)o Edi trigger

ReferencesFirestone, K. S., Beck, J., & Stein, H. (2016). Neurally adjusted ventilatory assist for noninvasive support in

neonates. Clinics in Perinatology, 43(4), 707-724. doi: 10.1016/j.clp.2016.07.007Getinge AB. (2018). NAVA(R) basics e-learning module. Retrieved from

https://getinge.training/d/course/1010001711/Getinge AB. (2019). The basic concept of NAVA and edi module 1. Retrieved from

https://elearning.getinge.com/NAVA/NAVA_MODULE1/story_html5.htmlKallio, M., Peltoniemi, O., Anttila, E., Pokka, T., & Kontiokari, T. (2014). Neurally adjusted ventilatory assist

(NAVA) in pediatric intensive Care: A randomized controlled trial. Pediatric Pulmonology, 50(1), 55-62. doi: 10.1002/ppul.22995

Maquet Critical Care AB. (2014a). Superiority of NAVA: The evidence booklet. Critical Care News. Retrieved from http://www.criticalcarenews.com/contentassets/dba2ef730fdf405e8ee69843cd319763/mx-6212---04.00---nava_superiority_of_nava_the_evidence_en_all.pdf

Maquet Critical Care AB. (2014b). Servo education: NAVA in neonatal settings study guide. Retrieved from http://www.criticalcarenews.com/contentassets/0fdfdf915cf94bb2be59fda1033270b7/mx-5734_study_guide_nava_for_neonates_rev04_en_all.pdf

Maquet Critical Care AB. (2016). User’s manual: SERVO-n ventilator system (v2.1). Solna, Sweden: Maquet Critical Care AB.




DOCUMENT TYPE: PROCEDURESinderby, C., & Beck, J. (2009). Neurally adjusted ventilatory assist for infants in critical condition. Pediatric

Health, 3(4), 297-301. doi: 10.2217/phe.09.30Stein, H., & Firestone, K. (2014). Application of neurally adjusted ventilatory assist in neonates. Seminars in

Fetal & Neonatal Medicine, 19(1), 60-69. doi: 10.1016/j.siny.2013.09.005Rahmani, A. Y., Imran, A. A., Boats, U., Chedid, F., Woodworth, S., & Khan, J. (2015). Can utilizing neurally

adjusted ventilatory assist in the ventilation support of critically ill neonates results in shorter hospital stay? Journal of Clinical Neonatology, 4(1), 32-37. doi: 10.4103/2249-4847.15116

Definitions

∑: Occurrences or the number of times the patient switches to backup ventilation every minute. Backup %: Amount of time, as a percent, the patient is in backup ventilation every minute. Edi (µv): Electrical activity of the diaphragm which reflects the patient’s neural respiratory drive. Edi trigger (µv): Edi level above Edimin which must be reached for an assist breath to be delivered. For example, if the Edi trigger is set to 0.5 µv and the Edimin is 0.4, the ventilator will be triggered at 0.8 µv to deliver assist. Edi Peak (µv): Highest Edi value of the Edi Signal waveform. This represents the neural inspiratory effort and is the determinant of size and duration of breaths delivered. Edi min (µv): Lowest Edi value of the Edi signal. This represents the spontaneous tonic activity of the diaphragm which prevents alveolar derecruitment. NAVA level (cmH2O/µv): Amplification factor/proportionality constant. The Servo ventilator converts the Edi signal into a delivered airway pressure by multiplying the set NAVA level with the Edipeak and Edimin.

Developed ByNeonatal Program – Neonatologist; Respiratory Therapy Educator

Version HistoryDATE DOCUMENT NUMBER and TITLE ACTION TAKEN06-Nov-2019 C-0506-12-60407 Neurally Adjusted Ventilatory Assist

(NAVA)Approved at: Neonatal Leadership Committee

DisclaimerThis document is intended for use within BC Children’s and BC Women’s Hospitals only. Any other use or reliance is at your sole risk. The content does not constitute and is not in substitution of professional medical advice. Provincial Health




DOCUMENT TYPE: PROCEDUREServices Authority (PHSA) assumes no liability arising from use or reliance on this document. This document is protected by copyright and may only be reprinted in whole or in part with the prior written approval of PHSA.



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