NIV-NAVA in Infants With Severe Bronchiolitis, a Pilot Multicenter Randomized Controlled Trial

Severe Bronchiolitis, Pediatric Respiratory Distress

bronchiolitis, pediatric intensive care unit, noninvasive ventilation, NAVA, intubation

Severe bronchiolitis is a common lung infection in babies that can cause serious breathing problems and often leads to hospitalization in pediatric intensive care units (PICUs). Many infants need special breathing support, usually through non-invasive methods like high-flow oxygen or continuous airway pressure. However, these methods don't always work, and about one in four infants end up needing a breathing tube (intubation), which comes with more risks and a longer recovery. A newer breathing support method called NIV-NAVA (non-invasive ventilation with neurally adjusted ventilatory assist) may help. It uses signals from the baby's diaphragm to adjust the support in real-time, making breathing easier and possibly reducing the need for intubation. While early results are promising, no high-quality clinical trial has yet tested if NIV-NAVA is better than standard non-invasive support. This study is a pilot trial - a small-scale version of a larger future study - happening in four PICUs across Canada. It will include 90 babies under 2 years old with severe bronchiolitis who need more support than standard methods provide. Half will receive NIV-NAVA, and half will receive the usual care. The main goal of this pilot is to check if a larger trial is doable: Can we recruit enough babies? Can the PICU teams stick to the treatment plan? Can we collect the right information? The full study will eventually look at whether NIV-NAVA really lowers the number of babies who need intubation and improves recovery. This research is led by a team of pediatric experts and could pave the way for better care for thousands of infants with severe breathing problems.

Goal(s) / Research Aims The primary objective of this multicenter pilot RCT is to determine the feasibility of a definitive multicenter RCT that will evaluate whether NIV-NAVA is superior to conventional NIV in infants with severe bronchiolitis who are not adequately supported by HFNC or CPAP. The primary hypothesis is that the pilot RCT will confirm the feasibility of the final trial. Methods / Approaches This is an investigator-led, multicenter, randomized, controlled, open-label, pragmatic pilot trial conducted in four Canadian pediatric intensive care units (PICUs) with varying levels of experience with NIV-NAVA, supported by the Canadian Critical Care Trials Group (CCCTG). Ninety infants younger than 2 years old who are admitted to the PICU with a clinical diagnosis of bronchiolitis, who require NIV support greater than CPAP/HFNC, and who have no exclusion criteria will be randomized 1:1 between NIV-NAVA and conventional NIV management. The pilot trial's feasibility outcomes are the recruitment rate (the primary outcome), adherence to the intervention, and completion of the definitive trial's outcome measures. The primary outcome of the future definitive RCT is the intubation rate. Secondary outcomes will include respiratory distress evolution, comfort, duration of ventilatory support, PICU and hospital length of stay, nutrition and sedation, complication rates, post-PICU functional outcomes, carbon footprint, and cost-effectiveness analysis. Expertise. An experienced, multidisciplinary team of senior, mid, and early career clinician scientists with unique expertise in pediatric NIV, trial methodology, pediatric respirology, and PICU research is leading this project. Expected Outcomes. We expect this pilot trial to confirm the feasibility of a definitive trial on NIV-NAVA in severe bronchiolitis. As the first RCT in this understudied field, it will provide much-needed evidence on the most effective strategy for reducing intubation rates in infants with severe bronchiolitis.

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