ROYAL HOSPITAL FOR WOMEN Approved by

LOCAL OPERATING PROCEDURES Quality & Patient Care Committee

NEONATAL SERVICES DIVISION Date: November 2016

MAQUET SERVO-N VENTILATOR- NURSING CARE FOR INVASIVE MODE

This LOP is developed to guide safe clinical practice in Newborn Care Centre (NCC) at The Royal Hospital for
Women. Individual patient circumstances may mean that practice diverges from this Local Operations Procedure
(LOP).
Using this document outside the Royal Hospital for Women or its reproduction in whole or part, is subject to
acknowledgement that it is the property of NCC and is valid and applicable for use at the time of publication. NCC is
not responsible for consequences that may develop from the use of this document outside NCC.

INTRODUCTION
Neurally Adjusted Ventilatory Assist (NAVA) is a mode of mechanical ventilation intended for use in
spontaneously breathing patients. As with all ventilation it is important to manage the machine and the
patient with skill to ensure effective ventilation is delivered.

1. AIM
 To ensure neonates are given appropriate and safe support on the ventilator.

2. PATIENT
 Neonates

3. STAFF
 Medical and nursing staff

4. EQUIPMENT
 Maquet SERVO-n Ventilator- set up and ready to use (Refer to Maquet Servo-n set up protocol)

5. CLINICAL PRACTICE
1. Airway management
a. ETT:
i. Ensure the ETT is patent at all times. Suction using inline suction PRN using the guide in
the table below. Keep spare suction catheters near to the baby also in case of inline
suction failure. As a guide the suction catheter size should be twice that of the ETT
size (eg. Size 3.0 mm ETT= 6 Fr suction catheter). Use short 10 Fr suction catheters
to suction the mouth and nose (R 1). All secretions should be documented on the
observation chart including amount, viscosity, colour and smell (R 2)

ETT SIZE INSERTION DEPTH

2.0mm Green, 16cms
2.5mm Purple, 17cms
3.0mm Double Red, 20cms
3.5mm Double Yellow, 22cms
4.0mm Double Black, 23cms

ii. Ensure the ETT is secure at all times. Check taping is secure. Re-tape PRN with the help
of another nurse. Inform medical staff if re-taping is required. Check tube placement
at the beginning of your shift and with each turn/movement of the patient.

iii. To calculate approximate ETT length use the formula below.

Oral: Weight +6cms, Nasal: Weight +7cms.
Or use the following “Neonatology Calculator” link on the NCC website:
[Link]
Measure tube length in relation to the documented length on the observation
chart using a tape measure (R 3)

…./2
 2.
ROYAL HOSPITAL FOR WOMEN Approved by
LOCAL OPERATING PROCEDURES Quality & Patient Care Committee
NEONATAL SERVICES DIVISION Date: November 2016

MAQUET SERVO-N VENTILATOR- NURSING CARE FOR INVASIVE MODE cont’d

b. Chest X-Ray: All patients receiving invasive ventilation via an ETT should have a chest x-ray
taken post intubation. ETT should be positioned between T1 and T3. Chest x-ray may then be
used PRN and is not done routinely in this unit (R 4).

c. Air entry: Chest should be auscultated at the beginning of shifts, with cares, with suctioning,
repositioning and as required (R 5).
d. The term ‘DOPE’ can be used to troubleshoot ETT problems: D=Displacement, O=
Obstruction, P= Pneumothorax, E= Equipment failure.

2. Ventilation
a. Check ventilation settings at the beginning of the shift and ensure they match those
documented. Assess whether patient is adequately ventilated and that you
understand the method being used. If you do not, seek advice/assistance from senior
nursing staff, team leader, medical team or the education team (R 6).
b. Consider the need for blood gas analysis (R 7).
c. Ensure patient comfort (eg. analgesia, nesting, comfort holding, non-nutritive
sucking).
d. Change the disposable filter every 48 hours.
e. Change the circuit weekly.
f. Wipe down the ventilator daily with neutral detergent.
g. Internal expiratory block only needs to be changed at the end of treatment when it
has been used on an infected patient (eg. MRSA, Serratia, RSV). At all other times it
can be reused as long as the additional disposable filter has been in situ for the
duration of the treatment (R 8).

3. EDi catheter management

a. Before an EDi catheter is passed use the calculation tool to assess size and length of
tube and the length that it should be passed to. To find this on the screen touch
NAVA and then calculation tool. Work through the steps on the screen. The ECG has
tall P and QRS waves in the top leads and no P waves in the bottom leads. Correct
placement means the P waves are pronounced on the top row of ECG, become less
pronounced on the middle two rows (where the purple signal should be) until there is
no P wave and dampened QRS waves on the bottom ECG row.
If the signal is in the bottom portion of the screen this means the catheter is too
HIGH. If it is at the top then too LOW. The arrow next to the chart will indicate the
movement that needs to occur. If the EDi needs to move down then the arrow will
indicate as so, vice versa for up.
b. Catheters should be changed weekly (R 9) but if they fall out before the 7 day change
they can be cleaned and re-inserted.

4. Observations
All ventilated patients should be on continuous monitoring (R 10).

…./3
 3.
ROYAL HOSPITAL FOR WOMEN Approved by
LOCAL OPERATING PROCEDURES Quality & Patient Care Committee
NEONATAL SERVICES DIVISION Date: November 2016

MAQUET SERVO-N VENTILATOR- NURSING CARE FOR INVASIVE MODE cont’d

5. Troubleshooting

Problem/ alarm Response

EDi Catheter won’t Aspirating the EDi catheter may collapse the bore and this
aspirate may be why no aspirate is obtained. They are, however,
designed to be aspirated and so gentle adjustment should
allow aspiration in the case of aspirate measurement.
Positioning for all other feeds and gastric medication
administration can be determined using the EDi catheter
positioning screen.
EDi Catheter blocked Due to the addition of an electrical wire/probe the EDi
catheter has a smaller diameter lumen than the usual NG
tube. This means that it can become blocked by thick viscous
medications or thickened feeds. In this case it may be
necessary to pass a second NG/OGT for the administration
of these products.
Excessive leak A leak of up to 60% is compensated for by the machine to
100% effectiveness. A leak up to 80% is compensated for by
the machine up to 50% effectiveness. Leaks >80% cannot be
guaranteed to deliver effective ventilation in invasive modes.
No patient effort Ensure EDi is correctly positioned, if so then patient may be
apnoeic in which case the backup rate will begin. Consider
reducing the apnoea time if patient is not adequately
supported in back up mode.
Gaseous Distension Because of the smaller lumen and difficulty in aspiration,
often there may be air trapping in the gut. In this case, it may
be necessary to pass a second NG/OGT for aspiration of gas
and gastric contents

6. Pain and Comfort

Ensure patient is comfortable. Non-pharmacological (non-nutritive sucking, comfort holding and
nesting) or pharmacological (sucrose, morphine, fentanyl, midazolam). Kangaroo care should be
encouraged for ventilated babies.

7. Cares
Cares can be conducted using individual assessment but generally 8 hourly. Resite skin probes
4-6 hourly. Observe for signs of skin breakdown from pressure sores.

8. Weighing and Procedures

Patients can still be weighed whilst ventilated either on the Giraffe internal scales or the outside
scales. Procedures can still be conducted in the crib. Both need to take care to ensure a stable
and secure airway and need to be assessed on an individualised basis.

6. DOCUMENTATION
 Integrated Clinical Notes
 Observation Chart

7. EDUCATIONAL NOTES
 EDi
Electrical Activity of the Diaphragm, measured in microvolts. It can be thought of as a respiratory
vital sign. When the respiratory centre in the brain is stimulated it sends a signal via the phrenic
nerve to the diaphragm muscle to stimulate contraction and subsequent respiration. When the

…./4
 4.
ROYAL HOSPITAL FOR WOMEN Approved by
LOCAL OPERATING PROCEDURES Quality & Patient Care Committee
NEONATAL SERVICES DIVISION Date: November 2016

MAQUET SERVO-N VENTILATOR- NURSING CARE FOR INVASIVE MODE cont’d

muscle is stimulated it produces an electrical signal. The EDi Catheter reads this specific
electrical signal in the diaphragm and we, the practitioners, are then able to assess how much or
how little signal is being sent to the diaphragm to stimulate breathing. Maquet SERVO-n ventilator
displays EDi as peak and minimum. EDi peak (also called EDi max) represents neural respiratory
effort and is responsible for the size and duration of the breath. EDi min represents the
spontaneous tonic (or baseline or resting) activity of the diaphragm in between the inspirations,
which prevents de-recruitment (collapse) of lungs (alveoli) during expiration. Normal EDi Peak is
5-15. If EDi peak is >15, this means, a stronger signal is sent from brain to diaphragm to increase
the size of the breath. This can be seen clinically as baby working harder with more inspiratory
recessions. This means more ventilator support (more NAVA in case of NAVA mode) is required.
If EDi peak is <5, this means weak signal is sent from brain to lungs indicating baby requires less
support. Normal EDi min is probably <3. If EDi min is consistently ≥3, consider increasing PEEP
to reduce the tonic activity of the diaphragm and to maintain FRC.

 EDi Trigger
EDi trigger the minimum increase in electrical activity that triggers the ventilator. EDi trigger is
usually set at 0.5microvaults and when the EDi reaches 0.5, NAVA is triggered to assist with the
breath. If the EDi trigger is set too low, the ventilator responds to small EDi signals and converts
them into small breaths. This prevents neonate from going into backup ventilation and may result
in under-ventilation.

 NAVA Level
Neurally Adjusted Ventilatory Assist. The NAVA supports the baby’s breathing by responding to
the electrical signal (EDi). If the NAVA level is set at 1.0 it will provide 1.0cm/H2O for every
microvolt detected. For example if NAVA is set at 1 and Edi Peak is recorded as 20, ventilator
generates PIP of about 20 cm H2O for that breath. When the EDi reaches a peak the breath and
PIP will be held.
The neonate determines the peak inspiratory pressure, inspiratory and expiratory times for each
breath and respiratory rate.

 Apnoea Time
This determines the amount of time the neonate can be apnoeic before ventilating in the backup
mode. Although apnoea is typically defined as no respiratory effort for 20 seconds, it will be too
long for small preterm infant to be apnoeic for 20 seconds before breath is given. Apnoea time is
the maximum time the neonate will be without any ventilation. This is generally set at 1-5
seconds. Apnoea time of 5 seconds generally guarantees a minimum breaths of 12 breaths per
minute. After 5 seconds of apnoea, neonate goes into back-up ventilation at the back-up rate. The
next EDI signal will restart the 5 second apnoea timer again. Apnoea time can be reduced down
to 1 second (minimum rate of 60 breaths/min). A neonate who remains apnoeic will ventilate at
the pre-set backup rate in a pressure controlled mode. If the neonate is apnoeic and desaturating
consider shortening the apnoea time and ensuring back up ventilation settings are suitable for
individual neonate.

 PRVC
Pressure Regulated Volume Controlled (similar to PCAC+VG or SIPPV+VG).
Combines pressure and volume controls by delivering a pre-set volume, with a decelerating
inspiratory flow, at a pre-set rate. Maintains the lowest possible constant pressure on inspiration
to achieve a set volume. Inspiratory pressure will not exceed 5cm/H2O below the upper pressure
limit (alarm limit).

ALERT: The alarm function is not only an alert that the ventilator is
reaching a top pressure it is also a regulation of the pressure.
Therefore to increase pressure delivery the alarm limit must be
increased.
 5.
ROYAL HOSPITAL FOR WOMEN Approved by
LOCAL OPERATING PROCEDURES Quality & Patient Care Committee
NEONATAL SERVICES DIVISION Date: November 2016

MAQUET SERVO-N VENTILATOR- NURSING CARE FOR INVASIVE MODE cont’d

This is similar to the P Max function in the Drager VN500 Ventilators.

PEEP, Ti. Slope and trigger are set. All breaths are synchronised and the patient’s own breaths
are supported.

 PC
Pressure control. (PCAC without VG)
Pre-set inspiratory pressure is delivered at a pre-set respiratory rate, synchronised with the baby’s
[Link], Slope, Ti, Trigger, Paw are all set. All breaths are synchronised and the patient’s
own breaths are supported.

 SIMV (PRVC)
Synchronised Intermittent Mandatory Ventilation + Pressure Regulated Volume Controlled (similar
to SIMV+VG)
Combines pressure and volume controls by delivering a pre-set volume with a decelerating
inspiratory flow at a pre-set rate. Maintains the lowest possible constant pressure on inspiration to
achieve a set volume. Inspiratory pressure will not exceed 5cm/H2O below the upper pressure
limit (alarm limit). This is similar to the PMax function on the Draeger VN500 Ventilator. PEEP, Ti.
Slope and trigger are set. All breaths are synchronised, patients own breaths are unsupported.

 SIMV (PC)
Synchronised Intermittent Mandatory Ventilation + Pressure Control (similar to SIMV without VG)
Delivers a constant pressure over a pre-set Ti at a pre-set rate. Uses a decelerating flow. Volume
delivery will change with lung compliance and resistance and is not regulated. All beaths are
synchronised, patients own breaths are unsupported.

 PS
Pressure Support
Provides ventilator support for the patient’s own breaths using a preset pressure with a
decelerating flow.
Turn PS to zero to ensure patients own breaths are unsupported in SIMV modes.

 Invasive NAVA
Edi triggers breaths, pressures, volumes, Ti, Slope and adjust based on the neural signal read
from the diaphragm. If there is no signal/ patient effort the ventilator will go into a back-up
pressure controlled mode (PC).

8. RELATED POLICIES/PROCEDURES/CLINICAL PRACTICE LOP

 Maquet SERVO-n set up.
 NAVA Clinical Guidelines

9. RISK RATING
 Low

10. NATIONAL STANDARD

 CC – Comprehensive Care

…./6
 6.
ROYAL HOSPITAL FOR WOMEN Approved by
LOCAL OPERATING PROCEDURES Quality & Patient Care Committee
NEONATAL SERVICES DIVISION Date: November 2016

MAQUET SERVO-N VENTILATOR- NURSING CARE FOR INVASIVE MODE cont’d

11. REFERENCES
 Maquet Getinge Group (2015) SERVO-n Self-Guided Education Presentations. Maquet. Rastatt
(Germany)
 Maquet Getinge Group (2015) Neurally Adjusted Ventilatory Assist (NAVA) - Synchrony
redefined. [online] available from [Link] (Accessed on 3/12/15)
 Maquet Getinge Group (2013) Ventilation Servo-I for Neonates. Synchrony for those who need it
most. Maquet. Solna (Sweden)
 Levene, M.I., Tudehope, D.I., Sinha, S. (2009) Essential Neonatal MEDicine. 4th Ed. Blackwell.
Oxford (U.K.)

12. ABBREVIATIONS AND DEFINITIONS OF TERMS

ETT Endo tracheal Tube PIP Peak inspiratory pressure

ICU Intensive Care Unit PRN As necessary
MRSA Methicillin Resistant Staphylococcus RSV Respiratory Syncytial Virus
Areus
NCC Newborn Care Centre SIPPV Synchroniseed Intermittent Positive
Pressure Ventilation
NG Naso gastric Ti Inspiratory Time
OG Orogastric VG Volume Guarantee

13. RATIONALES

Rationale 1 To maintain airway patency and to minimise trauma to the mucosal areas.
Rationale 2 To observe for respiratory infections
Rationale 3 To prevent accidental extubation.
Rationale 4 To ensure correct tube positioning and chest expansion whilst not exposing patient to
excessive radiation.
Rationale 5 To suction PRN and observe for dislodgement of secretions or ETT
Rationale 6 As a standard safety check and for the purposes of nursing observation
Rationale 7 To ensure adequate ventilatory support
Rationale 8 In accordance with infection control protocol
Rationale 9 To prevent infections.
Rationale 10 To observe and record patients physiological status

14. AUTHOR:
Primary Date: Person: A. Ottaway (ACNE/CNS)
05/12/15
Revised Date Person