Adaptive support ventilation as an effective treatment option for central sleep apnea in an older adult with heart failure with preserved ejection fraction: a case report

Background

Adaptive support ventilation (ASV) is a proposed treatment option for central sleep apnea (CSA). Although the effectiveness of ASV remains unclear, some studies have reported promising results regarding the use of ASV in patients with heart failure with preserved ejection fraction (HfpEF). To illustrate the importance of suspecting and diagnosing sleep-disordered breathing (SDB) in older adults unable to recognize symptoms, we discuss a case in which ASV was effective in a patient with CSA and HfpEF, based on changes in the Holter electrocardiogram (ECG).

Case presentation.

An 82-year-old man presented to our hospital with vomiting on April 19, 2021. Approximately 10 years before admission, he was diagnosed with type 1 diabetes mellitus and recently required full support from his wife for daily activities due to cognitive dysfunction. Two days before admission, his wife was unable to administer insulin due to excessively high glucose levels, which were displayed as “high” on the patient’s glucose meter; therefore, we diagnosed the patient with diabetic ketoacidosis. After recovery, we initiated intensive insulin therapy for glycemic control. However, the patient exhibited excessive daytime sleepiness, and numerous premature ventricular contractions were observed on his ECG monitor despite the absence of hypoglycemia. As we suspected sleep-disordered breathing (SDB), we performed portable polysomnography (PSG), which revealed CSA. PSG revealed a central type of apnea and hypopnea due to an apnea–hypopnea index of 37.6, which was > 5. Moreover, the patient had daytime sleepiness; thus, we diagnosed him with CSA. We performed ASV and observed its effect using portable PSG and Holter ECG. His episodes of apnea and hypopnea were resolved, and an apparent improvement was confirmed through Holter ECG.

Conclusion

Medical staff should carefully monitor adult adults for signs of or risk factors for SDB to prevent serious complications. Future studies on ASV should focus on older patients with arrhythmia, as the prevalence of CSA may be underreported in this population and determine the effectiveness of ASV in patients with HfpEF, especially in older adults.

Comparison of advanced closed-loop ventilation modes with pressure support ventilation for weaning from mechanical ventilation in adults: A systematic review and meta-analysis

PURPOSE

To compare neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), adaptive support ventilation (ASV) and Smartcare pressure support (Smartcare/PS) with standard pressure support ventilation (PSV) regarding their effectiveness for weaning critically ill adults from invasive mechanical ventilation (IMV).

METHODS

Electronic databases were searched to identify parallel-group randomized controlled trials (RCTs) comparing NAVA, PAV, ASV, or Smartcare/PS with PSV, in adult patients under IMV through July 28, 2021. Primary outcome was weaning success. Secondary outcomes included weaning time, total MV duration, reintubation or use of non-invasive MV (NIMV) within 48 h after extubation, in-hospital and intensive care unit (ICU) mortality, in-hospital and ICU length of stay (LOS) (PROSPERO registration No:CRD42021270299).

RESULTS

Twenty RCTs were finally included. Compared to PSV, NAVA was associated with significantly lower risk for in-hospital and ICU death and lower requirements for post-extubation NIMV. Moreover, PAV showed significant advantage over PSV in terms of weaning rates, MV duration and ICU LOS. No significant differences were found between ASV or Smart care/PS and PSV.

CONCLUSIONS

Moderate certainty evidence suggest that PAV increases weaning success rates, shortens MV duration and ICU LOS compared to PSV. It is also noteworthy that NAVA seems to improve in-hospital and ICU survival.

Adaptive support ventilation attenuates postpneumonectomy acute lung injury in a porcine model

OBJECTIVES

An optimal ventilation strategy that causes as little mechanical stress and inflammation as possible is critical for patients undergoing pneumonectomy. The aim of this study was to determine whether adaptive support ventilation (ASV) can provide protective ventilation to the remaining lung after pneumonectomy with minimal mechanical stress and less inflammation than volume-control ventilation (VCV).

METHODS

In this study, 15 pigs were randomly allocated to 3 groups (n = 5 for each group): the control group, the VCV group and the ASV group. After left pneumonectomy, the VCV group was treated with the volume-control set to 20 ml/kg, and the ASV group with the mode set to achieve 60% of the minute ventilation of 2 lungs.

RESULTS

The ASV group had lower alveolar strain than the VCV group. The ASV group exhibited less lung injury and greater alveolar fluid clearance than the VCV group (13.3% vs -17.8%; P ≤ 0.018). Ventilator-induced lung injury was associated with changes in the cytokine levels in the exhaled breath condensate, differential changes in plasma and changes in the cytokines in the bronchoalveolar lavage fluid. Expression of 3 microRNAs (miR449b-3p, P ≤ 0.001; miR451-5p, P = 0.027; and miR144-5p, P = 0.008) was increased in the VCV group compared with the ASV group.

CONCLUSIONS

The ASV mode was capable of supporting rapid, shallow breathing patterns to exert lung-protective effects in a porcine postpneumonectomy model. Further investigation of microRNAs as biomarkers of ventilator-induced lung injury is warranted.

A Randomized Controlled Trial of Noninvasive Ventilation with Pressure Support Ventilation and Adaptive Support Ventilation in Acute Exacerbation of COPD: A Feasibility Study

Whether the use of adaptive support ventilation (ASV) during noninvasive ventilation (NIV) is as effective as pressure support ventilation (PSV) remains unknown. In this exploratory study, we compared the delivery of NIV with PSV vs. ASV. We randomized consecutive subjects with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) to receive NIV either with the PSV or the ASV mode. The primary outcome was NIV failure (endotracheal intubation, re-institution of NIV within 48 h of discontinuation or mortality). The secondary outcomes were the duration of mechanical ventilation (invasive and noninvasive), the number of NIV manipulations, the visual analogue score (VAS) for physician's ease of use and patient's comfort, and the complications of NIV use. We enrolled 74 subjects (n = 38, PSV; n = 36, ASV; 78.4% males) with a mean (SD) age of 60.5 (9.5) years. The baseline characteristics were similar between the two groups. The overall NIV failure rate was 28.4% and was similar between the two groups (PSV vs. ASV: 34.2% vs. 22.2%, p = 0.31). There was a 9% reduction in the intubation rate with ASV. There were six deaths (PSV vs. ASV: 2 vs 4, p =0.311). There was no difference in the secondary outcomes. The application of NIV using ASV was associated with a similar success rate as PSV in subjects with AECOPD. Due to the small sample size, the results of our study should be confirmed in a larger trial. Trial registry: ww.clinicaltrials.gov (NCT02877524).

Positive Airway Pressure Therapy for Obstructive Sleep Apnea

Positive airway pressure (PAP) is considered first-line therapy for moderate to severe obstructive sleep apnea and may also be considered for mild obstructive sleep apnea, particularly if it is symptomatic or there are concomitant cardiovascular disorders. Continuous PAP is most commonly used. Other modes, such as bilevel airway pressure, autotitrating positive airway pressure, average volume assured pressure support, and adaptive support ventilation, play important roles in the management of sleep-related breathing disorders. This article outlines the indications, description, and comfort features of each mode. Despite the proven efficacy of PAP in treating obstructive sleep apnea syndrome and its sequelae, adherence to therapy is low. Close follow-up of patients for evaluation of adherence to and effectiveness of treatment is important.

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.

Newer nonconventional modes of mechanical ventilation

The conventional modes of ventilation suffer many limitations. Although they are popularly used and are well-understood, often they fail to match the patient-based requirements. Over the years, many small modifications in ventilators have been incorporated to improve patient outcome. The ventilators of newer generation respond to patient's demands by additional feedback systems. In this review, we discuss the popular newer modes of ventilation that have been accepted in to clinical practice. Various intensive care units over the world have found these modes to improve patient ventilator synchrony, decrease ventilator days and improve patient safety. The various modes discusses in this review are: Dual control modes (volume assured pressure support, volume support), Adaptive support ventilation, proportional assist ventilation, mandatory minute ventilation, Bi-level airway pressure release ventilation, (BiPAP), neurally adjusted ventilatory assist and NeoGanesh. Their working principles with their advantages and clinical limitations are discussed in brief.

Adaptive support ventilation: State of the art review

Mechanical ventilation is one of the most commonly applied interventions in intensive care units. Despite its life-saving role, it can be a risky procedure for the patient if not applied appropriately. To decrease risks, new ventilator modes continue to be developed in an attempt to improve patient outcomes. Advances in ventilator modes include closed-loop systems that facilitate ventilator manipulation of variables based on measured respiratory parameters. Adaptive support ventilation (ASV) is a positive pressure mode of mechanical ventilation that is closed-loop controlled, and automatically adjust based on the patient's requirements. In order to deliver safe and appropriate patient care, clinicians need to achieve a thorough understanding of this mode, including its effects on underlying respiratory mechanics. This article will discuss ASV while emphasizing appropriate ventilator settings, their advantages and disadvantages, their particular effects on oxygenation and ventilation, and the monitoring priorities for clinicians.

Use of Adaptive Support Ventilation (ASV) in Ventilator Associated Pneumonia (VAP) - A Case Report

Prolonged ventilation leads to a higher incidence of ventilator associated pneumonia(VAP) resulting in ventilator dependency, increased costs and subsequent weaning failures. Prevention and aggressive treatment of VAP along with patient friendly newer modes of ventilation like adaptive support ventilation go a long way in successful management of these cases.