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In individuals with acute exacerbation of chronic obstructive pulmonary disease (AECOPD), adaptive support ventilation (ASV) performed as well as pressure support ventilation (PSV) during noninvasive ventilation (NIV), according to the results of an exploratory study published in COPD: Journal of Chronic Obstructive Pulmonary Disease.1
Traditionally, NIV has been delivered using the PSV mode, which allows the patient to influence the breathing pattern. However, the ventilator cycling criteria and the inability of pressure support to vary with changing lung mechanics are significant limitations of this mode.2 ASV is a closed loop mode of ventilation that maintains an operator-preset target minute ventilation, independent of the patient’s activity. By matching the patient’s respiratory demand, it can potentially improve the ventilator success rates.3-6
Whether the use of ASV during NIV is as effective as PSV is unknown; therefore, researchers compared the delivery of NIV with PSV vs ASV in a single-center, randomized controlled trial (ClinicalTrials.gov Identifier: NCT02877524). A total of 74 consecutive participants with AECOPD were randomly assigned to receive NIV with either mode (PSV n=38 and ASV n=36).1
The researchers found that the overall NIV failure rate was 28.4% and was similar in participants who received PSV (34.2%) and those who received ASV (22.2%; P =.31). In addition, there was a 9% reduction in the intubation rate with ASV, and there were 6 deaths (PSV n=2 and ASV n=4; P =.311).
In terms of secondary outcomes, the time to intubation and duration of ventilation (both noninvasive and invasive) were similar between the PSV and ASV groups. NIV-related complications were similar between the 2 groups. The most common complications were mask intolerance, skin ulceration from the mask, and gastric distension.
The limitations of the study included the small sample size, which may have contributed to a lack of generalizability. The results are applicable only to patients with AECOPD and not other forms of respiratory failure. Therefore, these results should be confirmed in a larger multicenter trial.
“In conclusion, ASV mode performs as well as PSV during NIV of [participants] with AECOPD,” the researchers wrote.1 “There was a trend towards lower intubation rates with the use of ASV during NIV.”
References
1. Sehgal IS, Kalpakam H, Dhooria S, Aggarwal AN, Prasad KT, Agarwal R. A randomized controlled trial of noninvasive ventilation with pressure support ventilation and adaptive support ventilation in acute exacerbation of COPD: a feasibility study [published online June 4, 2019]. COPD. doi:10.1080/15412555.2019.1620716
2. Vignaux L, Vargas F, Roeseler J, et al. Patient-ventilator asynchrony during non-invasive ventilation for acute respiratory failure: a multicenter study. Intensive Care Med. 2009;35(5):840-846.
3. Arnal JM, Wysocki M, Nafati C, et al. Automatic selection of breathing pattern using adaptive support ventilation. Intensive Care Med. 2008;34(1):75-81.
4 Jaber S, Sebbane M, Verzilli D, et al. Adaptive support and pressure support ventilation behavior in response to increased ventilatory demand. Anesthesiology. 2009;110(3):620-627.
5. Tassaux D, Dalmas E, Gratadour P, Jolliet P. Patient-ventilator interactions during partial ventilatory support: a preliminary study comparing the effects of adaptive support ventilation with synchronized intermittent mandatory ventilation plus inspiratory pressure support. Crit Care Med. 2002;30(4):801-807.
6. 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 patients in the ICU. CHEST. 2015;147(6):1503-1509.
