0
Correspondence |

Adaptive Support Ventilation From Intubation to Extubation: A Word of Caution FREE TO VIEW

Domenico Luca Grieco, MD; Antonio Maria Dell’Anna, MD; Massimo Antonelli, MD
Author and Funding Information

FINANCIAL/NONFIANCIAL DISCLOSURES: None declared.

CORRESPONDENCE TO: Domenico Luca Grieco, MD, Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, L. go F. Vito, Rome, Italy


Copyright 2016, American College of Chest Physicians. All Rights Reserved.


Chest. 2016;149(1):280-281. doi:10.1016/j.chest.2015.10.061
Text Size: A A A
Published online

In a recent issue of CHEST (June 2015), we read with interest the randomized controlled trial (RCT) by Kirakli et al comparing adaptive support ventilation (ASV) with pressure assist/control ventilation (P-ACV) for the entire duration of mechanical ventilation (MV) in a cohort of 229 patients in the medical ICU. The study showed a shorter duration of the weaning process and total MV in the ASV group. We believe that some aspects of this RCT deserve further discussion.

Various authors have previously shown the benefit of ASV in the weaning phase,,: This is the first study, to our knowledge, that investigates the efficacy of ASV as the unique ventilation mode in patients in the medical ICU. Because ASV was shown to reduce total length of MV, the authors claimed that this additional benefit as an effect of the application of ASV from the beginning of MV. However, the protocol in the control group provided P-ACV for the whole length of MV, and pressure support ventilation (PSV) was contemplated only after the failure of the third spontaneous breathing trial (SBT), despite a general consensus and a strong support of the literature for the use of PSV as a weaning mode after an initial failed SBT. Robust evidence indicates the beneficial effects of PSV in patients able to trigger the ventilator compared with assisted/controlled modes,, and these may be of even greater relevance in patients at risk for scarce patient-ventilator interaction. Interestingly, more than one-half of enrolled patients had COPD and, thus, were prone to the development of asynchronies. Unfortunately, no data on this issue were presented, although a poorer patient-ventilator interaction in the P-ACV group could have seriously affected the results. We believe that the choice of not switching to PSV as soon as patients triggered the ventilator hampers the understanding of to what extent the benefit described in patients receiving ASV is due to the use of an assisted/controlled mode in the control group, notably because patients on ASV received totally assisted ventilation as soon as possible.

In addition, no data were provided regarding sedation during MV, which was possibly different between groups because patients receiving P-ACV could have required more sedation to achieve adequate patient-ventilator interaction. Sedation dosing, discontinuation, or both may have consistently affected the decision to consider weaning for the single patient, even with weaning and extubation done according to physician decision and regardless of a standard protocol. In this sense, we recognize that it is still debated whether the use of systematic protocols for weaning may reduce the duration of MV; nevertheless, we believe that the use of such protocols should be considered mandatory when RCTs regarding duration of MV and weaning success are performed, especially when physician blinding is impossible. Finally, despite that cardiac decompensation and fluid overload are recognized as the most common causes of SBT failure, a standardized fluid protocol was not applied, data on fluid balance and cardiac function were not provided, and perhaps most importantly, data clarifying the reasons of weaning failure were not presented.

In conclusion, we believe that the results of the present RCT should be interpreted with caution. We strongly suggest that in the field of MV, careful clinical judgment should still be considered the best way to treat patients, at least before the initiation of the weaning process.

References

Kirakli C. .Naz I. .Ediboglu O. .Tatar D. .Budak A. .Tellioglu E. . A randomized controlled trial comparing the ventilation duration between adaptive support ventilation and pressure assist/control ventilation in medical ICU patients. Chest. 2015;147:1503-1509 [PubMed]journal. [CrossRef] [PubMed]
 
Sulzer C.F. .Chioléro R. .Chassot P.G. .Mueller X.M. .Revelly J.P. . Adaptive support ventilation for fast tracheal extubation after cardiac surgery: a randomized controlled study. Anesthesiology. 2001;95:1339-1345 [PubMed]journal. [CrossRef] [PubMed]
 
Gruber P.C. .Gomersall C.D. .Leung P. .et al Randomized controlled trial comparing adaptive-support ventilation with pressure-regulated volume-controlled ventilation with automode in weaning patients after cardiac surgery. Anesthesiology. 2008;109:81-87 [PubMed]journal. [CrossRef] [PubMed]
 
Kirakli C. .Ozdemir I. .Ucar Z.Z. .Cimen P. .Kepil S. .Ozkan S.A. . Adaptive support ventilation for faster weaning in COPD: a randomised controlled trial. Eur Respir J. 2011;38:774-780 [PubMed]journal. [CrossRef] [PubMed]
 
Boles J.M. .Bion J. .Connors A. .et al Weaning from mechanical ventilation. Eur Respir J. 2007;29:1033-1056 [PubMed]journal. [CrossRef] [PubMed]
 
Spieth P.M. .Carvalho A.R. .Güldner A. .et al Pressure support improves oxygenation and lung protection compared to pressure-controlled ventilation and is further improved by random variation of pressure support. Crit Care Med. 2011;39:746-755 [PubMed]journal. [CrossRef] [PubMed]
 
Tejeda M. .Boix J.H. .Álvarez F. .Balanzá R. .Morales M. . Comparison of pressure support ventilation and assist-control ventilation in the treatment of respiratory failure. Chest. 1997;111:1322-1325 [PubMed]journal. [CrossRef] [PubMed]
 
McConville J.F. .Kress J.P. . Weaning patients from the ventilator. N Engl J Med. 2013;368:1068-1069 [PubMed]journal
 
Peñuelas Ó. .Thille A.W. .Esteban A. . Discontinuation of ventilatory support: new solutions to old dilemmas. Curr Opin Crit Care. 2015;21:74-81 [PubMed]journal. [CrossRef] [PubMed]
 

Figures

Tables

References

Kirakli C. .Naz I. .Ediboglu O. .Tatar D. .Budak A. .Tellioglu E. . A randomized controlled trial comparing the ventilation duration between adaptive support ventilation and pressure assist/control ventilation in medical ICU patients. Chest. 2015;147:1503-1509 [PubMed]journal. [CrossRef] [PubMed]
 
Sulzer C.F. .Chioléro R. .Chassot P.G. .Mueller X.M. .Revelly J.P. . Adaptive support ventilation for fast tracheal extubation after cardiac surgery: a randomized controlled study. Anesthesiology. 2001;95:1339-1345 [PubMed]journal. [CrossRef] [PubMed]
 
Gruber P.C. .Gomersall C.D. .Leung P. .et al Randomized controlled trial comparing adaptive-support ventilation with pressure-regulated volume-controlled ventilation with automode in weaning patients after cardiac surgery. Anesthesiology. 2008;109:81-87 [PubMed]journal. [CrossRef] [PubMed]
 
Kirakli C. .Ozdemir I. .Ucar Z.Z. .Cimen P. .Kepil S. .Ozkan S.A. . Adaptive support ventilation for faster weaning in COPD: a randomised controlled trial. Eur Respir J. 2011;38:774-780 [PubMed]journal. [CrossRef] [PubMed]
 
Boles J.M. .Bion J. .Connors A. .et al Weaning from mechanical ventilation. Eur Respir J. 2007;29:1033-1056 [PubMed]journal. [CrossRef] [PubMed]
 
Spieth P.M. .Carvalho A.R. .Güldner A. .et al Pressure support improves oxygenation and lung protection compared to pressure-controlled ventilation and is further improved by random variation of pressure support. Crit Care Med. 2011;39:746-755 [PubMed]journal. [CrossRef] [PubMed]
 
Tejeda M. .Boix J.H. .Álvarez F. .Balanzá R. .Morales M. . Comparison of pressure support ventilation and assist-control ventilation in the treatment of respiratory failure. Chest. 1997;111:1322-1325 [PubMed]journal. [CrossRef] [PubMed]
 
McConville J.F. .Kress J.P. . Weaning patients from the ventilator. N Engl J Med. 2013;368:1068-1069 [PubMed]journal
 
Peñuelas Ó. .Thille A.W. .Esteban A. . Discontinuation of ventilatory support: new solutions to old dilemmas. Curr Opin Crit Care. 2015;21:74-81 [PubMed]journal. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543