• Domenico Luca Grieco, Maria Maddalena Bitondo, Hernan Aguirre-Bermeo, Stefano Italiano, Francesco Antonio Idone, Antonia Moccaldo, Maria Teresa Santantonio, Davide Eleuteri, Massimo Antonelli, Jordi Mancebo, and Salvatore Maurizio Maggiore.
• Department of Anesthesiology and Intensive Care, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Largo Agostino Gemelli, 8, 00168 Rome, Italy.
• J Crit Care. 2018 Dec 1; 48: 203-210.

PurposeOptimizing pressure support ventilation (PSV) can improve patient-ventilator interaction. We conducted a two-center, randomized cross-over study to determine whether automated PSV lowers asynchrony rate during difficult weaning from mechanical ventilation.MethodsThirty patients failing the first weaning attempt were randomly ventilated for 2 three-hour consecutive periods with: 1)PSV managed by physicians (convPSV); 2)PSV managed by Smartcare® (autoPSV). These 2 periods were applied in the afternoon and overnight, for a 12-h total study time. Two independent clinicians offline analyzed ventilator waveforms to compute asynchrony index(AI).ResultsAI was lower during autoPSV than during convPSV (medians[interquartile ranges] 5.1[2.6-9.5]% vs. 7.3[2.3-13.4]%, p = 0.02), without changes in the proportion of patients with AI>10%(p = 0.31). Pressure support (PS) variability was higher during autoPSV (p < 0.001), but average PS did not vary. In patients with baseline PS > 12 cmH2O (n = 15), PS and tidal volume were lower with autoPSV (12 [10-15]cmH2O vs. 15 [14-18]cmH2O,p = 0.003; 7.2[6.2-8.3]ml/Kg vs. 8.2[7.1-9.1]ml/Kg, p = 0.02) and AI reduction was driven by lower tidal volume (p = 0.03). In patients with baseline PS ≤ 12 cmH2O, AI reduction during autoPSV was mediated by increased PS variability (p = 0.04).ConclusionDuring difficult weaning, autoPSV improves patient-ventilator interaction by lowering tidal volume and enhancing PS variability. In expert centres, however, the size effect of the intervention appears clinically small, likely because physicians themselves adequately limit PS and tidal volume.Copyright © 2018 Elsevier Inc. All rights reserved.

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