Adaptive support ventilation: State of the art review

Effectiveness of Adaptive Support Ventilation in Facilitating Weaning from Mechanical Ventilation in Postoperative Patients

OBJECTIVE

This meta-analysis aims to evaluate the effectiveness of adaptive support ventilation (ASV) in facilitating postoperative weaning from mechanical ventilation in cardiac surgery patients.

DESIGN

A systematic review and meta-analysis to assess ASV in weaning postoperative cardiac surgery patients. Outcomes included early extubation, reintubation rates, time to extubation, and lengths of intensive care units and hospital stays.

SETTING

We searched electronic databases from inception to March 2023 and included randomized controlled trials that compared ASV with conventional ventilation methods in this population.

PARTICIPANTS

Postoperative cardiac surgery patients.

MEASUREMENTS AND MAIN RESULTS

A random effects model was used for meta-analysis, and trial sequential analysis (TSA) was conducted to assess result robustness. The meta-analysis included 11 randomized controlled trials with a total of 1027 randomized patients. ASV was associated with a shorter time to extubation compared to conventional ventilation (random effects, mean difference -68.30 hours; 95% confidence interval, -115.50 to -21.09) with TSA providing a conclusive finding. While ASV indicated improved early extubation rates, no significant differences were found in reintubation rates or lengths of intensive care unit and hospital stays, with these TSA results being inclusive.

CONCLUSIONS

ASV appears to facilitate a shorter time to extubation in postoperative cardiac surgery patients compared to conventional ventilation, suggesting benefits in accelerating the weaning process and reducing mechanical ventilation duration.

Six methods to determine expiratory time constants in mechanically ventilated patients: a prospective observational physiology study

BACKGROUND

Expiratory time constant (τ) objectively assesses the speed of exhalation and can guide adjustments of the respiratory rate and the I:E ratio with the goal of achieving complete exhalation. Multiple methods of obtaining τ are available, but they have not been compared. The purpose of this study was to compare six different methods to obtain τ and to test if the exponentially decaying flow corresponds to the measured time constants.

METHODS

In this prospective study, pressure, flow, and volume waveforms of 30 postoperative patients undergoing volume (VCV) and pressure-controlled ventilation (PCV) were obtained using a data acquisition device and analyzed. τ was measured as the first 63% of the exhaled tidal volume (VT) and compared to the calculated τ as the product of expiratory resistance (RE) and respiratory system compliance (CRS), or τ derived from passive flow/volume waveforms using previously published equations as proposed by Aerts, Brunner, Guttmann, and Lourens. We tested if the duration of exponentially decaying flow during exhalation corresponded to the duration of the predicted second and third τ, based on multiples of the first measured τ.

RESULTS

Mean (95% CI) measured τ was 0.59 (0.57-0.62) s and 0.60 (0.58-0.63) s for PCV and VCV (p = 0.45), respectively. Aerts method showed the shortest values of all methods for both modes: 0.57 (0.54-0.59) s for PCV and 0.58 (0.55-0.61) s for VCV. Calculated (CRS * RE) and Brunner's τ were identical with mean τ of 0.64 (0.61-0.67) s for PCV and 0.66 (0.63-069) s for VCV. Mean Guttmann's τ was 0.64 (0.61-0.68) in PCV and 0.65 (0.62-0.69) in VCV. Comparison of each τ method between PCV and VCV was not significant. Predicted time to exhale 95% of the VT (i.e., 3*τ) was 1.77 (1.70-1.84) s for PCV and 1.80 (1.73-1.88) s for VCV, which was significantly longer than measured values: 1.27 (1.22-1.32) for PCV and 1.30 (1.25-1.35) s for VCV (p < 0.0001). The first, the second and the third measured τ were progressively shorter: 0.6, 0.4 and 0.3 s, in both ventilation modes (p < 0.0001).

CONCLUSION

All six methods to determine τ show similar values and are feasible in postoperative mechanically ventilated patients in both PCV and VCV modes.

Using Artificial Intelligence to Predict Mechanical Ventilation Weaning Success in Patients with Respiratory Failure, Including Those with Acute Respiratory Distress Syndrome

The management of mechanical ventilation (MV) remains a challenge in intensive care units (ICUs). The digitalization of healthcare and the implementation of artificial intelligence (AI) and machine learning (ML) has significantly influenced medical decision-making capabilities, potentially enhancing patient outcomes. Acute respiratory distress syndrome, an overwhelming inflammatory lung disease, is common in ICUs. Most patients require MV. Prolonged MV is associated with an increased length of stay, morbidity, and mortality. Shortening the MV duration has both clinical and economic benefits and emphasizes the need for better MV weaning management. AI and ML models can assist the physician in weaning patients from MV by providing predictive tools based on big data. Many ML models have been developed in recent years, dealing with this unmet need. Such models provide an important prediction regarding the success of the individual patient's MV weaning. Some AI models have shown a notable impact on clinical outcomes. However, there are challenges in integrating AI models into clinical practice due to the unfamiliar nature of AI for many physicians and the complexity of some AI models. Our review explores the evolution of weaning methods up to and including AI and ML as weaning aids.

The Effects of Automatic Inspiratory Rise Time and Flow Termination on Operation of Closed-Loop Ventilation

BACKGROUND

Adaptive ventilation mode (AVM) is a automated mode of mechanical ventilation. AVM is comprable to adaptive support ventilation (ASV). Both recommend a tidal volume (VT) and breathing frequency (f) combination based on lung mechanics, but AVM also automatically adjusts rise time and flow termination of pressure support breaths. How these added features of AVM affect VT and f recommendations compared to ASV is not clear. The present study compared these 2 modes in a test lung with obstructive and restrictive mechanics.

METHODS

The experiment was performed in a simulated lung model in which the compliance (C) and resistance (R) could be altered independently. The ventilatory parameters at different minute volumes (MinVol%) in AVM or ASV mode were recorded.

RESULTS

When MinVol% was set at 100%, AVM provided a similar VT and f combination compared to ASV with decreasing compliance or increasing resistance. However, when MinVol% was increased to 250% simulating hyperventilation, for the severely obstructive lung (C60, R70) model, AVM provided a significantly higher f (26 ± 0.6 breaths/min vs 7.00 ± 0 breaths/min in ASV) and lower VT (240 ± 80 mL vs 491 ± 131 mL in ASV).

CONCLUSIONS

The addition of automatic control of rise time and flow termination functions did not affect recommended ventilator settings in AVM in the noncompliant or obstructive lung when minute ventilation (V̇E) was low. At higher V̇E, AVM compared to ASV recommended a ventilatory strategy with lower VT and higher f. These results need to be validated in patients.

Determining respiratory rate using measured expiratory time constant: A prospective observational study

PURPOSE

Potential negative implications associated with high respiratory rate (RR) are intrinsic positive end-expiratory pressure (PEEPi) generation, cardiovascular depression and possibly ventilator induced lung injury. Despite these negative consequences, optimal RR remains largely unknown. We hypothesized that without consideration of dynamics of lung emptying (i.e., the expiratory time constant [RC_EXP]) clinician settings of RR may exceed the frequency needed for optimal lung emptying.

MATERIALS AND METHODS

This prospective multicenter observational study measured RC_EXP in 56 intensive care patients receiving pressure-controlled ventilation. We compared set RR to the one predicted with RC_EXP (RR_P). Also, the subgroup of patients with prolonged RC_EXP was analyzed.

RESULTS

Overall, the absolute mean difference between the set RR and RR_P was 2.8 bpm (95% CI: 2.3-3.2). Twenty-nine (52%) patients had prolonged RC_EXP (>0.8 s), mean difference between set RR and RR_P of 3.1 bpm (95% CI: 2.3-3.8; p < 0.0001) and significantly higher PEEPi compared to those with RC_EXP ≤ 0.8 s: 4.4 (95% CI: 3.6-5.2) versus 1.5 (95% CI: 0.9-2.0) cmH₂O respectively, p < 0.0001.

CONCLUSIONS

Use of RR_P based on measured RC_EXP revealed that the clinician-set RR exceeded that predicted by RC_EXP in the majority of patients. Measuring RC_EXP appears to be a useful variable for adjusting the RR during mandatory mechanical ventilation.

A randomized controlled trial comparing non-invasive ventilation delivered using neurally adjusted ventilator assist (NAVA) or adaptive support ventilation (ASV) in patients with acute exacerbation of chronic obstructive pulmonary disease

PURPOSE

No study has compared neurally adjusted ventilator assist (NAVA) with adaptive support ventilation (ASV) during non-invasive ventilation (NIV) in subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD).

MATERIALS AND METHODS

In this randomized controlled trial, we compared NAVA-NIV with ASV-NIV for delivering NIV in consecutive subjects with AECOPD. The primary outcome was NIV failure rate (invasive mechanical ventilation). The key secondary outcomes were number of NIV manipulations, asynchrony index, and 90-day mortality.

RESULTS

We enrolled 76 subjects (NAVA-NIV, n = 36, ASV-NIV, n = 40; 74% males) with a mean ± SD age of 61.4 ± 8.2 years. We found no difference in NIV failure rates between the two arms (NAVA-NIV vs. ASV-NIV; 8/36 [22.2%] vs. 8/40 [20%]; p = 0.83). The median physician manipulations for NIV were significantly less in the ASV-NIV arm than in the NAVA-NIV arm (2 [0.8-4] vs. 3 [2-5]; p= 0.014) during the initial 24-h. We found no difference in median asynchrony index (NAVA-NIV vs. ASV-NIV, 16.6% vs. 16.4%, p = 0.5) and 90-day mortality (22.2% vs. 17.5%, p = 0.67).

CONCLUSION

The use of NAVA-NIV was not superior to ASV-NIV in reducing NIV failure rates in AECOPD. Both NAVA-NIV and ASV-NIV had similar asynchrony index and 90-day mortality.

TRIAL REGISTRY

www.

CLINICALTRIALS

gov (NCT04414891).

Adaptive Support Ventilation and Lung-Protective Ventilation in ARDS

BACKGROUND

Adaptive support ventilation (ASV) is a partially closed-loop ventilation mode that adjusts tidal volume (V_T) and breathing frequency (f) to minimize mechanical work and driving pressure. ASV is routinely used but has not been widely studied in ARDS.

METHODS

The study was a crossover study with randomization to intervention comparing a pressure-regulated, volume-targeted ventilation mode (adaptive pressure ventilation [APV], standard of care at Beth Israel Deaconess Medical Center) set to V_T 6 mL/kg in comparison with ASV mode where V_T adjustment is automated. Subjects received standard of care (APV) or ASV and then crossed over to the alternate mode, maintaining consistent minute ventilation with 1-2 h in each mode. The primary outcome was V_T corrected for ideal body weight (IBW) before and after crossover. Secondary outcomes included driving pressure, mechanics, gas exchange, mechanical power, and other parameters measured after crossover and longitudinally.

RESULTS

Twenty subjects with ARDS were consented, with 17 randomized and completing the study (median P_aO2 /F_IO2 146.6 [128.3-204.8] mm Hg) and were mostly passive without spontaneous breathing. ASV mode produced marginally larger V_T corrected for IBW (6.3 [5.9-7.0] mL/kg IBW vs 6.04 [6.0-6.1] mL/kg IBW, P = .035). Frequency was lower with patients in ASV mode (25 [22-26] breaths/min vs 27 [22-30)] breaths/min, P = .01). In ASV, lower respiratory-system compliance correlated with smaller delivered V_T/IBW (R² = 0.4936, P = .002). Plateau (24.7 [22.6-27.6] cm H₂O vs 25.3 [23.5-26.8] cm H₂O, P = .14) and driving pressures (12.8 [9.0-15.8] cm H₂O vs 11.7 [10.7-15.1] cm H₂O, P = .29) were comparable between conventional ventilation and ASV. No adverse events were noted in either ASV or conventional group related to mode of ventilation.

CONCLUSIONS

ASV targeted similar settings as standard of care consistent with lung-protective ventilation strategies in mostly passive subjects with ARDS. ASV delivered V_T based upon respiratory mechanics, with lower V_T and mechanical power in subjects with stiffer lungs.

Liberation from Mechanical Ventilation: Established and New Insights

A substantial proportion of critically ill patients require ventilator support with the majority requiring invasive mechanical ventilation. Timely and safe liberation from invasive mechanical ventilation is a critical aspect of patient care in the intensive care unit (ICU) and is a top research priority for patients and clinicians. In this article, we discuss how to (1) identify candidates for liberation from mechanical ventilation, (2) conduct spontaneous breathing trials (SBTs), and (3) optimize patients for liberation from mechanical ventilation. We also discuss the roles for (4) extubation to noninvasive ventilation and (5) newer modes of mechanical ventilation during liberation from mechanical ventilation. We conclude that, though substantial progress has been made in identifying patients who are likely to be liberated (e.g., through the use of SBTs) and management strategies that speed liberation from the ventilator (e.g., protocolized SBTs, lighter sedation, and early mobilization), many important questions regarding liberation from mechanical ventilation in clinical practice remain unanswered.

Capnography and Pulse Oximetry Improve Fast Track Extubation in Patients Undergoing Coronary Artery Bypass Graft Surgery: A Randomized Clinical Trial

Background

Use of capnography as a non-invasive method during the weaning process for fast track extubation (FTE) is controversial. We conducted the present study to determine whether pulse oximetry and capnography could be utilized as alternatives to arterial blood gas (ABG) measurements in patients under mechanical ventilation (MV) following coronary artery bypass graft (CABG) surgery.

Methods

In this randomized clinical trial, 70 patients, who were candidates for CABG surgery, were randomly assigned into two equal groups (n = 35), intervention and control group. In the intervention group, the ventilator management and weaning from MV was done using Etco2 from capnography and SpO2 from pulse oximetry. Meanwhile, in the control group, weaning was done based on ABG analysis. The length of intensive care unit (ICU) stay, time to extubation, number of manual ventilators setting changes, and alarms were compared between the groups.

Results

The end-tidal carbon dioxide (ETCO2) levels in the intervention group were completely similar to the partial pressure of carbon dioxide (PaCo2) in the control group (39.5 ± 3.1 vs. 39.4 ± 4.32, p > 0.05). The mean extubation times were significantly shorter in the intervention group compared to those in the control patients (212.2 ± 80.6 vs. 342.7 ± 110.7, p < 0.001). Moreover, the number of changes in the manual ventilator setting and the number of alarms were significantly lower in the intervention group. However, the differences in the length of stay in ICU between the two groups were not significant (p = 0.219).

Conclusion

Our results suggests that capnography can be used as an alternative to ABG. Furthermore, it is a safe and valuable monitor that could be a good alternative for ABG in this population. Further studies with larger sample sizes and on different disease states and populations are required to assess the accuracy of our findings.

Clinical Trial Registration

Current Controlled Trials, IRCT, IRCT201701016778N6, Registered 3 March 2017, https://www.irct.ir/trial/7192.

Severe Protracted Hypophosphatemia in a Patient with Persistent Vegetative State on Long-Term Assisted Respiratory Support

BACKGROUND Phosphorous is an essential component of cell structure and physiology, and is required for energy conservation and expenditure. Severe hypophosphatemia can lead to profound dysfunction and injury affecting most organs and can be life-threatening. It can also compromise weaning of mechanically ventilated patients. Long-term assisted ventilatory care in ambulatory or inpatient settings is an expanding medical service for patients with various forms of persistent or progressive incapacitating diseases. Hypophosphatemia, caused by respiratory alkalosis, has been reported in critical-care settings, but its occurrence in medically stable patients requiring long-term respiratory support has not been thoroughly investigated. CASE REPORT We report the case of a ventilated patient in a chronic vegetative state displaying progressive hypophosphatemia spanning over 3 months, with plasma levels gradually declining to 0.8 mg/dL. Evaluation did not reveal conditions leading to diminished phosphate absorption or enhanced urinary phosphate excretion, but it identified respiratory alkalosis related to a recent increase in target minute-volume ventilation in the adaptive support ventilation (ASV) mode as the cause of hypophosphatemia. Despite the very low plasma phosphate level, the patient was asymptomatic, probably because this type of hypophosphatemia may not represent physiologically significant intracellular phosphate depletion. The respiratory alkalosis resolved upon decreasing the target minute-volume ventilation settings, and serum phosphate was normalized. CONCLUSIONS Since blood gases are not routinely monitored in respiratory and hemodynamically stable patients on long-term respiratory support, hypophosphatemia may herald the development of significant respiratory alkalosis. Assessment of acid-base balance is thus warranted in patients receiving long-term ventilation, especially in those developing hypophosphatemia.

The Rothman Index Does Not Predict a Successful Extubation in the Neurosurgical Critical Care Unit

Background

Identification of risk factors associated with successful extubation in neurosurgical critical care units (NSICUs) has been elusive due to the complex nature of neurocritical care injuries and patient factors. Traditional risk factors for extubation were shown to have poor predictive value in neurocritical care patients as compared to mixed ICU patients. The aim of this study was to determine if any risk factors, including the Rothman Index, could reliably predict successful extubation in a large sample size of neurocritical care patients.

Methods

We retrospectively analyzed 610 consecutively intubated patients in an NSICU while collecting variables of interest in airway management. Furthermore, Rothman Indices were collected immediately after intubations and extubations. A paired t-test of the immediate changes in Rothman Indices after airway manipulation was compared in patients who needed reintubation. In a smaller cohort of 88 patients, in whom complete data points existed for airway management, we performed a principal component analysis (PCA) to determine which risk factors were associated with extubation success when indexed with the magnitude of the Rothman Index.

Results

In 610 consecutively intubated patients, the mean pre-intubation Rothman Index average was 41.0 compared to the mean post-extubation Rothman Index was 35.4 (p<0.0001). Compared to those who were re-intubated, the Rothman Index did not correlate well with the prediction of extubation (p=0.355). Furthermore, an analysis of the PCA plot showed that a higher respiratory rate, longer length of stay, shorter length of intubation, and smaller cuff leak percentage were identified as risk factors associated with reintubation. Age and change in rapid shallow breathing index (RSBI) did not correlate with reintubation.

Conclusion

The Rothman Index does not predict extubation success in patients in an NSICU. Risk factors associated with reintubation were respiratory rate, length of stay, length of intubation, and cuff leak percentage. Reintubation rates in our single-center NSICU are on par with general critical care populations.

Advanced mechanical ventilation modes: design and computer simulations

In this paper, three different advanced mechanical ventilation modes, pressure regulated volume control ventilation (PRVC), proportional assist ventilation (PAV), and adaptive support ventilation (ASV) are designed and simulated on the computer via MATLAB/Simulink. In the algorithms of advanced ventilation modes, a closed-loop control structure is used and recursive least squares method is considered for the estimation of respiratory mechanics. The designed algorithms are then applied to the human respiratory system model for the active and/or passive patient cases. Simulation results show that such algorithms can be designed and simulated on the computer successfully. In addition, the simulation environment helps us to understand the working principles of the advanced modes and to see the results such as ventilator waveforms, the effect of the parameter changes. Moreover, it also allows us to improve and test the algorithms and strategies quickly and efficiently.

Go with the flow-clinical importance of flow curves during mechanical ventilation: A narrative review

Most clinicians pay attention to tidal volume and airway pressures and their curves during mechanical ventilation. On the other hand, inspiratory–expiratory flow curves also provide a plethora of information, but much less attention is paid to them. Flow curves chronologically show the velocity and direction of inspiration and expiration and are influenced by the respiratory mechanics, the patient’s effort, and the mode of ventilation and its settings. When the ventilator setting does not synchronize with the patient’s respiratory pattern, the patient can easily have worsening breathing effort, patient–ventilator asynchrony, which can lead to prolonged ventilator support or lung injury. The information provided by the flow curves during mechanical ventilation, such as respiratory mechanics, the patient’s effort, and patient–ventilator interactions, are very helpful when adjusting the ventilator setting. If clinicians can monitor and assess the flow curves information appropriately, it can be a useful diagnostic and therapeutic tool at the bedside. There may be association between inspiratory effort and flow, and this may further guide us, especially in the weaning process and when patients are not synchronizing with the ventilator. In this review, we try to gather information about “flow” that is scattered around in the literature and textbooks in one place. We will summarize the different flow waveforms utilized in commonly used ventilator modes with their advantages and disadvantages, information gained by the flow curves (i.e., flow-time, flow-volume, and flow-pressure), how to detect and manage asynchronies, and some ideas for future uses. Flow waveforms shapes and patterns are very beneficial for the management of patients undergoing mechanical ventilatory support. Attention to those waveforms can potentially improve patient outcomes. Clinicians should be familiar with this information and how to act upon them.

Comparisons of Metabolic Load between Adaptive Support Ventilation and Pressure Support Ventilation in Mechanically Ventilated ICU Patients

Purpose

The aim of this study was to compare the metabolic load between adaptive support ventilation (ASV) and pressure support ventilation (PSV) modes in critically ill patients.

Methods

Sequential 20 min ventilation by PSV followed by 20 min ASV in critically ill patients was assessed. ASV was set for full support, i.e., with the minute volume control set at the same level as the minute volume observed during PSV. The trial started from PSV 8 cmH₂O and continued with high (PSV 12 cmH₂O) to low (PSV 0) conditions or low to high conditions, in random order. The oxygen consumption (VO₂), production of carbon dioxide (VCO₂), and energy expenditure (EE) were measured by indirect calorimetry (IC).

Results

Twenty-four patients with critical illness participated in the study. Comparing with the PSV mode, the EE in the ASV mode was lower in the level of PSV 0 cmH₂O (1069 ± 73 vs. 1425 ± 76 kcal), PS 8 cmH₂O (1116 ± 70 vs. 1284 ± 61 kcal), and PS 12 cmH₂O (1017 ± 70 vs. 1169 ± 58 kcal) (p < 0.05). The VO₂, VCO₂, and P0.1 in PSV were significantly higher than those in ASV (p < 0.05). The VO₂, VCO₂, and P0.1 in PSV were significantly higher than those in ASV (.

Conclusion

In patients with critical illness, the application of ASV set for full support was associated with a lower metabolic load and respiratory drive than in any of the studied PSV conditions.

From a small local audit to a regional quality improvement project - Improving lung protective ventilation

Background

Lung protective ventilation with tidal volumes (V_T) of 6-8 ml per kg ideal body weight have been shown to reduce mortality in patients with acute respiratory distress syndrome and reduce post-operative pulmonary complications in major abdominal surgery. Following a local audit on weight recording, the Southcoast Perioperative Audit and Research Collaboration (SPARC) conducted a regional multi-disciplinary survey on the current practice in lung protective ventilation in the Wessex region. This resulted in a quality improvement project improving lung protective ventilation across these intensive care units.

Methods

Over one-week period in January over two consecutive years, lung protective ventilation parameters of mandatory ventilated patients (above the age of 18 years) were audited in intensive care units in the Wessex region.

Results

A total 1843 hours of mandatory ventilation were audited. The quality improvement project led to an improvement of lung protective ventilation with an average of 30% higher duration of ventilation with V_T < 8 ml/kg ideal body weight. There was a suggestion that documentation of height and weight on admission to intensive care units improved compliance with lung protective ventilation.

Conclusions

Adherence to lung protective ventilation is variable across intensive care units but can be improved by recording patient's weight and height accurately and using simple chart to help calculate the appropriate tidal volume. Additionally, this project demonstrates how a regional audit and quality improvement network can help to facilitate regional quality improvement.

The Comparison Effects of Two Methods of (Adaptive Support Ventilation Minute Ventilation: 110% and Adaptive Support Ventilation Minute Ventilation: 120%) on Mechanical Ventilation and Hemodynamic Changes and Length of Being in Recovery in Intensive Care Units

Background:

The conventional method for ventilation is supported by accommodative or adaptive support ventilation (ASV) that the latter method is done with two methods: ASV minute ventilation (mv): 110% and ASV mv: 120%. Regarding these methods this study compared the differences in duration of mechanical ventilation and hemodynamic changes during recovery and length of stay in Intensive Care Units (ICU).

Materials and Methods:

In a clinical trial study, forty patients candidate for ventilation were selected and randomly divided into two groups of A and B. All patients were ventilated by Rafael ventilator. Ventilator parameters were set on ASV mv: 110% or ASV mv: 120% and patients were monitored on pulse oximetry, electrocardiography monitoring, central vein pressure and arterial pressure. Finally, the data entered to computer and analyzed by SPSS software.

Results:

The time average of connection to ventilator in two groups in modes of ASV mv: 110% and 120% was 12.3 ± 3.66 and 10.8 ± 2.07 days respectively, and according to t-test, there was no significant difference between two groups (P = 0.11). The average of length of stay in ICU in two groups of 110% and 120% was 16.35 ± 3.51 and 15.5 ± 2.62 days respectively, and according to t-test, there found to be no significant difference between two groups (P = 0.41).

Conclusion:

Using ASV mv: 120% can decrease extubation time compared with ASV mv: 110%. Furthermore, there is not a considerable side effect on hemodynamic of patients.

Nursing Strategies for Effective Weaning of the Critically Ill Mechanically Ventilated Patient

The risks imposed by mechanical ventilation can be mitigated by nurses' use of strategies that promote early but appropriate reduction of ventilatory support and timely extubation. Weaning from mechanical ventilation is confounded by the multiple impacts of critical illness on the body's systems. Effective weaning strategies that combine several interventions that optimize weaning readiness and assess readiness to wean, and use a weaning protocol in association with spontaneous breathing trials, are likely to reduce the requirement for mechanical ventilatory support in a timely manner. Weaning strategies should be reviewed and updated regularly to ensure congruence with the best available evidence.

Comparing the effects of adaptive support ventilation and synchronized intermittent mandatory ventilation on intubation duration and hospital stay after coronary artery bypass graft surgery

Background:

Different modes of mechanical ventilation are used for respiratory support after coronary artery bypass graft (CABG). This study aimed to compare the effect(s) of using adaptive support ventilation (ASV) and synchronized intermittent mandatory ventilation (SIMV) on the length of mechanical ventilation (intubation duration) and hospital stay after coronary artery bypass graft surgery.

Materials and Methods:

In a randomized control trial, 64 patients were ventilated with ASV as the experiment group or with SIMV as the control group after CABG surgery in Chamran Hospital of Isfahan University of Medical Sciences. The time of tracheal intubation and the length of hospital stay were compared between the two groups. Data were analyzed and described using statistical analysis (independent t-test).

Results:

The mean time of intubation duration was significantly lower in ASV group compared with SIMV group. (4.83 h vs 6.71 h, P < 0.001). The lengths of hospital stay in the ASV and the SIMV groups were 140.6 h and 145.1 h, respectively. This difference was significant between the two groups (P = 0.006).

Conclusions:

According to the results of this study, using ASV mode for mechanical ventilation after CABG led to a decrease in intubation duration and also hospital stay in comparison with the SIMV group. It is recommended to use ASV mode on ventilators for respiratory support of patients undergoing coronary artery bypass graft surgery.

Adaptive support ventilation versus synchronized intermittent mandatory ventilation with pressure support in weaning patients after orthotopic liver transplantation

BACKGROUND

The extubation phase is an extremely critical moment in patients who have undergone orthotopic liver transplantation, who do not always have the advantage of long-lasting positive-pressure ventilation and positive expiratory end pressure; these factors can lead to splanchnic venous congestion, and this is why a rapid extubation can represent a great benefit for the graft.

METHODS

The aim of this study was to compare the adaptive support ventilation (ASV) mode with the standard mode of weaning in our intensive care unit, synchronized intermittent mandatory ventilation with pressure support (P-SIMV), in patients who received orthotopic liver transplantation. ASV is a positive-pressure mode, in which pressure level and respiratory rate are automatically adjusted according to measured lung dynamics at each breath. Eligible patients were assigned to either ASV or P-SIMV group. The weaning protocol was based on the individual respiratory activity and structured in 4 different phases.

RESULTS

The average length of intubation was significantly shorter in the ASV group than in the P-SIMV group (90±13 vs 153±22 minutes, P=.05). The total modifications to the ventilator settings were significantly larger in the P-SIMV group (1.5±1 vs 6±2; P=.003).

CONCLUSIONS

Our results suggest that although both procedures are safe and easy to apply, ASV is superior in terms of weaning times, and it simplifies respiratory management. The better patient-machine interaction in ASV has been highlighted by other authors for different clusters of patients.