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ORIGINAL ARTICLE

Adaptive support ventilation for complete ventilatory support in

acute respiratory distress syndrome: A pilot, randomized
controlled trial
RITESH AGARWAL, ARJUN SRINIVASAN, ASHUTOSH N. AGGARWAL AND DHEERAJ GUPTA
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India

ABSTRACT
Background and objective: Low tidal volume ventilation has been shown to improve survival in acute respiratory distress syndrome (ARDS). Adaptive support
ventilation (ASV), a closed-loop ventilatory mode, can
minimize the work of breathing, and thus potentially
improve the outcomes in ARDS. The aim of this pilot,
randomized clinical trial was to compare the outcomes
of ASV versus volume-cycled ventilation (VCV) in
ARDS.
Methods: Patients with ARDS were randomly allocated to either ASV or VCV. The primary outcomes were
duration of mechanical ventilation, new-onset organ
dysfunction and hospital length of stay. The secondary
outcomes were ease of use of the ventilator mode
(assessed using the visual analogue scale (VAS)),
number of daily arterial blood gas analyses, daily
requirements of sedative and neuromuscular blockers,
and mortality.
Results: Forty-eight patients (28 males, 20 females)
with ARDS were randomized to receive either ASV
(n = 23) or VCV (n = 25) during the study period. The
baseline characteristics were almost similar in the two
groups. The duration of mechanical ventilation, delta
sequential organ failure assessment scores, intensive
care unit and hospital stay were comparable in the two
groups. The mortality (VCV-36% vs ASV-34.7%), ease of
use of mechanical ventilation, daily midazolam and
vecuronium doses, and the number of arterial blood
gas analyses performed were also similar in the two
groups.
Conclusions: There was no significant difference in
the outcomes of patients with ARDS ventilated with
either VCV or ASV in this study.
Key words: acute lung injury, acute respiratory distress syndrome, adaptive support ventilation, mechanical ventilation.

Correspondence: Ritesh Agarwal, Department of Pulmonary

Medicine, Postgraduate Institute of Medical Education and
Research,
Sector-12,
Chandigarh-160012,
India.
Email:
riteshpgi@gmail.com; agarwal.ritesh@pgimer.edu.in
Study is registered at clinicaltrials.gov (NCT01165528)
Received 11 December 2012; invited to revise 23 January and
23 February 2013; revised 3 and 25 February 2013; accepted 28
February 2013 (Associate Editor: Amanda Piper).
2013 The Authors
Respirology 2013 Asian Pacific Society of Respirology

SUMMARY AT A GLANCE
Adaptive support ventilation (ASV), a closed-loop
ventilatory mode, can improve outcomes in ARDS
by minimizing the work of breathing. This study
analyzed the outcomes of ASV versus low tidal
volume ventilation in ARDS, and found no significant differences in the outcomes between the two
patient groups.

Abbreviations: ARDS, acute respiratory distress syndrome;

ASV, adaptive support ventilation; fR, respiratory rate; ICU, intensive care unit; MV, minute ventilation; PEEP, positive end expiratory pressure; Pinsp, inspiratory pressure on ASV; Pplat, plateau
pressure; VAS, visual analogue scale; VCV, volume-cycled ventilation; Vt, tidal volume.

INTRODUCTION
Acute respiratory distress syndrome (ARDS) is a
disease characterized by acute inflammation and
increased permeability of pulmonary parenchyma
caused by varying aetiologies, in the absence of left
atrial hypertension.1 Since its initial description,2
ARDS has been associated with significant mortality.3,4 There is no specific pharmacological treatment
of ARDS. As ventilator-associated lung injury is an
important cause of poor clinical outcomes in ARDS,
ventilatory strategies are aimed at reducing the incidence and severity of ventilator-associated lung
injury. Newer ventilatory modes utilize algorithms
that perform breath-to-breath calculation of respiratory mechanics, thereby ensuring adequate minute
ventilation with least possible airway pressures,5
thereby decreasing the risk of ventilator-associated
lung injury.
Adaptive support ventilation (ASV) is a closedloop mode introduced in 1994 by Laubscher and
coworkers that automatically switches from pressure control ventilation to pressure-control synchronized intermittent mandatory ventilation or pressure
support ventilation, depending on the patients status.6,7 ASV works as per the Otis equation, thereby
Respirology (2013) 18, 11081115
doi: 10.1111/resp.12126

ASV in ARDS

minimizing the work of breathing.8 Unlike pressure

control ventilation (or pressure-control synchronized intermittent mandatory ventilation) or pressure support ventilation, ASV guarantees preset
minute ventilation with an optimal breathing
pattern, independent of patient activity or effort.
With ASV, the clinician sets the desired minute ventilation, and the ventilator algorithm calculates the
best respiratory rate (fR) and tidal volume (Vt) combination for the spontaneous and mandatory
breaths according to the patients respiratory
mechanics.9 The ventilator calculates the minute
ventilation based on the patients ideal body weight
and the estimated dead space volume (2.2 mL/kg).
This represents 100% minute volume, and the clinician can set minute volumes greater than 100% in
those with increased requirements as in ARDS or less
than 100% as in weaning. The use of ASV could lead
to potential improvement in patientventilator synchrony and pattern of breathing, thereby decreasing
ventilator-associated lung injury, as it is now
debated that the asynchrony can theoretically
amplify ventilator-associated lung injury.10 ASV can
deliver complete or partial ventilatory support
during the initial stages or the weaning phase of ventilatory support.
Theoretically, ASV could improve the outcomes of
patients with ARDS. However, studies evaluating
ASV in ARDS have examined only the physiological
parameters.1114 No study has reported the clinical
outcomes (such as ventilator days, hospital length of
stay, mortality), or has utilized ASV for complete ventilatory support in ARDS. We have previously reported
our experience in managing patients with ARDS
using both invasive and non-invasive mechanical
ventilation.1517 We hypothesized that ASV would be as
effective as conventional low Vt ventilation in ventilating patients with ARDS. The objectives of this study
were to assess the duration of mechanical ventilation
and hospital length of stay in patients ventilated with
ASV versus conventional ventilatory protocol. In this
pilot, randomized controlled trial, we compare the
outcomes of ASV versus volume-cycled ventilation
(VCV) in managing ARDS.

METHODS
This was a prospective randomized clinical trial conducted between 1 July 2009 and 30 June 2011 in the
respiratory intensive care unit of our institute. The
respiratory intensive care unit is an eight-bedded,
closed intensive care unit (ICU) with five on-call consultants, five pulmonary fellows posted during a 24-h
shift and a nurse-to-patient ratio of 1:2.5. The study
was approved by the ethics review committee
(PGIMER, Chandigarh), and informed consent was
obtained from all patients (or next of kin). The
trial is registered with http://www.clinicaltrials.gov
(NCT01165528).

Patient selection
Patients with ARDS requiring invasive mechanical
ventilation were eligible for inclusion in the study if
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Respirology 2013 Asian Pacific Society of Respirology

1109
they met all the following:1 (i) acute onset dyspnoea
(<7 days); (ii) PaO2/FIO2 <200 mm Hg; (iii) bilateral
opacities on chest radiograph; and (iv) no clinical
evidence of left atrial hypertension. Patients were
excluded from the study if they demonstrated any of
the following: failure to provide informed consent,
age <12 years, pregnancy, chronic lung disease
and contraindications to permissive hypercapnea.
Patients meeting the inclusion criteria were randomized to either VCV or ASV group (Fig. 1). The randomization sequence was computer-generated, and
the assignments were placed in sealed opaque envelopes. The assignment to each arm was made on
admission by the attending physician. Blinding of
treatment was not possible.

Study procedure
Initially, all patients were passively ventilated (completely sedated and paralyzed) with low Vt strategy
(6 mL/kg predicted body weight) with FIO2/positive
end expiratory pressure (PEEP) as per the ARDSnet
protocol to determine the appropriate minute ventilation (MV).18,19 In patients randomized to VCV, the
same strategy was continued. The aim was to achieve
a SpO2 of 8892%, with the lowest FIO2 at a plateau
pressure (Pplat) of 3035 cm H2O and pH >7.3. The
Vt could be reduced to 4 mL/kg predicted body
weight and fR increased to 35/min to achieve these
goals if necessary.
In the ASV group, the minute ventilation attained
with initial VCV was used to guide the initial setting
of percentage MV (%MV). FIO2/PEEP was set according to ARDSnet protocol to maintain SpO2 of 8892%
at minimum possible FIO2. The peak pressure alarm
was set at 45 cm H2O to avoid Pplat from exceeding
35 cm H2O. Subsequent manipulation of %MV was
guided by interpretation of the following parameters:
Pinsp, spontaneous respiratory frequency while on
ASV (fspont) and target respiratory frequency (ftarget)
calculated by the ASV algorithm. If the fspont was
greater than ftarget by 10 breaths and/or associated
was hypoxaemia (PaO2 <55 mm Hg or SpO2 <88%) or
hypercapnic acidosis (pH <7.25), then the %MV was
escalated by 20%. If the fspont was similar to ftarget
without any hypercapnea or hypoxaemia, then the
%MV was de-escalated by 10%. The pressurization
slope (percentage of the inspiratory time taken to
reach the peak pressure) was maintained at 25% for
all subjects. All patients were ventilated with Galileo
Gold ventilators (Hamilton Medical, Bonaduz,
Switzerland).

Sedation protocol
A standard protocol was used in all patients. During
the first 48 h, all patients received intravenous midazolam infusion titrated to a Richmond AgitationSedation Scale (RASS) score of 0 to -2. Pain was
assessed using behavioural pain scale and managed
with intravenous fentanyl/morphine boluses.
Patients received vecuronium only if the fR was >35/
min or if there was significant patientventilator
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1110

R Agarwal et al.

Figure 1 Algorithm depicting the entire protocol, from randomization of the patient to implementation of the two methods of
ventilation in patients with ARDS admitted to the respiratory ICU. ARDS, acute respiratory distress syndrome; ASV, adaptive support
ventilation; FIO2, fraction of inspired oxygen; fR, respiratory rate; VCV, volume-cycled ventilation; MV, minute ventilation; PBW,
predicted body weight, PEEP, positive end expiratory pressure; Pinsp, inspiratory pressure on ASV; Pplat, plateau pressure; PSVmax,
pressure support equal to the maximal plateau pressure while on VCV; SBT, spontaneous breathing trial; Vt, tidal volume.

dyssynchrony (based on the physicians assessment

of ventilator tracings, as well as clinical assessment).
After 48 h, patients were administered intravenous
midazolam boluses of 24 mg only if fR exceeded
35/min or in the presence of significant patient
ventilator dyssynchrony. However, the patient was
started on continuous infusion of midazolam if
there was requirement of frequent midazolam
boluses (2/h).

Weaning protocol
Patients in the VCV arm were shifted to pressure
support (PS) ventilation once the PEEP and FIO2
Respirology (2013) 18, 11081115

requirements decreased to 8 cm H2O and 0.4, respectively (Fig. 1), according to our previously published
protocol.20 The PS used was the Pplat recorded during
the VCV mode (PSmax). PS was gradually decreased
by 2 cm H2O every 6 h (or earlier) until PS of 7 cm H2O.
Subsequently, the patient was given a spontaneous
breathing trial with T-piece (off ventilator) for 1 h. If
the patient tolerated the spontaneous breathing
trial,20 he or she was extubated. In the ASV arm,
weaning was initiated by monitoring the trends for
Pinsp, total fR and spontaneous/control fR. Once
deemed fit, weaning was achieved by sequential
decrease in %MV every 2 h (or earlier). Spontaneous
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1111

ASV in ARDS

Figure 2 CONSORT diagram demonstrating the flow of participants through each stage of the study. ARDS, acute respiratory distress
syndrome; ASV, adaptive support ventilation; VCV, volume-cycled ventilation; RICU, respiratory intensive care unit.

breathing trial was considered once %MV was 70%

and Pinsp was 8 cm of H2O. Patients were extubated
if they were able to tolerate the spontaneous breathing trial for 60 min (Fig. 1).

End-points and definitions

We collected the following data: clinical history and
physical examination, age, gender, and duration of
illness. The severity of the underlying illness was
scored using the acute physiology and chronic health
evaluation II and the sequential organ failure assessment scores.21,22 The ventilatory parameters, including Vt, FIO2 and PEEP settings, peak and Pplat, %MV,
and peak inspiratory pressure on ASV (Pinsp), were
monitored continuously and documented every 12 h
or after any change by the attending physician. The
ease of ventilator mode was broadly assessed using
the visual analogue scale (VAS). The VAS is a measurement instrument for subjective characteristics or attitudes that cannot be directly measured. The VAS is
measured on a scale from 0 to 100 mm, with 0 being
extremely easy to use and 100 being extremely complicated. The physicians specified their level of agreement by indicating a position along a continuous line
between two end-points. The VAS was measured
during every shift of the ICU physician, and then an
average was calculated. Sedative and neuromuscular
blockers were administered using the abovementioned protocol, and the cumulative daily dose
was calculated. Arterial blood gas analysis was performed when indicated.
The primary outcome measures were the duration
of mechanical ventilation, new-onset organ dysfunction (assessed by delta sequential organ failure
assessment score),16 and hospital and ICU length of
stay. The secondary outcome measures were mortality, ease of use of the ventilator mode assessed by VAS,
number of arterial blood gas analysis per day, and
daily requirements of sedative and neuromuscular
blocking agents.
Sample size
Assuming a mortality rate of 31% in the VCV arm and
decline in mortality by 5% in the ASV arm, we would
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Respirology 2013 Asian Pacific Society of Respirology

require 1751 patients in each arm (confidence level

(1-a) 95%, power level (1-b) 90%) to detect these differences. Assuming a mean (standard deviation)
duration of mechanical ventilation of 10 (7) days in
the VCV arm and decrease by 2 days in the ASV arm,
we would require 194 patients in each group. As it was
not feasible to perform such a large study, a pilot
study was performed.

Statistical methods
Statistical significance was assumed at a P-value
<0.05. The categorical variables were analyzed using
chi-square test, while the continuous variables were
analyzed using MannWhitney U-test. The change in
variables over time was analyzed with repeated measures analysis of variance using the mixed linear
model.23 Survival curves were constructed to study
the effect of ventilator strategy on respiratory intensive care unit stay using KaplanMeier analysis, and
group differences were analyzed using the log-rank
test.

RESULTS
There were 352 respiratory intensive care unit admissions (227 patients received invasive ventilation, 43
patients received non-invasive ventilation (NIV), and
82 received oxygen therapy and ICU care for various
indications) during the study period. Seventy-three
(20.7%) patients were admitted with a diagnosis of
ARDS. Of these, seven patients had a duration of
illness of more than 7 days, six had contraindications
to permissive hypercapnea, and 12 had underlying
chronic lung disease and were excluded prior to randomization (Fig. 2). Forty-eight patients met the
inclusion criteria and were enrolled in the study.
There were 28 males and 20 females with mean
(standard deviation) age of 30 (13) years. Twenty-five
patients were randomized to the VCV arm and 23 to
the ASV group. Sepsis (29.2%) and communityacquired pneumonia (22.9%) were the most common
cause of ARDS (Table 1). A total of seven (14.5%)
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Table 1

R Agarwal et al.
Baseline characteristics of patients with acute respiratory distress syndrome (ARDS) included in the study

Demographic and disease severity

Age (year)
Male gender, No. (%)
Length (cm)
PBW (kg)
APACHE II score
SOFA score
Aetiology of ARDS, No. (%)
Sepsis
CAP
Tropical infections (TB, malaria, leptospirosis)
H1N1 influenza
HAP
Ventilatory parameters
Vt, mL/kg
PEEP, cm H2O
Ppeak, cm H2O
Pplat, cm H2O
Arterial blood gases
pH
PaO2/FIO2
PaCO2, mm Hg

VCV (n = 25)

ASV (n = 23)

Total (n = 48)

P-value

29.7 (11.6)
13 (52)
162.6 (11)
58.4 (11.4)
17 (9.7)
8.2 (4.4)

31.4 (14.9)
15 (65.2)
163.8 (9)
59.4 (9.5)
17 (8.9)
7.4 (4.0)

30.5 (13.1)
28 (58.3)
163.2 (9.9)
58.9 (10.4)
17 (9.2)
7.8 (4.4)

0.67
0.35
0.66
0.74
1
0.47

6 (26.1)
5 (21.7)
3 (13.1)
5 (21.7)
4 (17.4)

14 (29.2)
11 (22.9)
10 (20.8)
7 (14.6)
6 (12.5)

0.65
0.85
0.36
0.35
0.59

8 (32)
6 (24)
7 (28)
2 (8)
2 (8)
5.6 (0.8)
12.1 (3.8)
30.9 (4.4)
26.5 (4.1)

6.6 (1.4)
12.6 (4.9)
30.5 (5.7)
26.6 (8.7)

6.1 (1.2)
12.4 (4.3)
30.7 (5)
26.5 (6.6)

0.005
0.70
0.79
0.95

7.27 (0.12)
96.6 (34.5)
44.3 (15.9)

7.29 (0.14)
107.3 (41.9)
40.7 (14.1)

7.28 (0.13)
101.8 (38.2)
42.6 (14.9)

0.50
0.34
0.41

APACHE, acute physiology and chronic health evaluation; ASV, adaptive support ventilation; CAP, community-acquired pneumonia;
HAP, hospital-acquired pneumonia; VCV, volume-cycled ventilation; PEEP, positive end expiratory pressure; PBW, predicted body
weight; Ppeak, peak pressure; Pplat, plateau pressure; SOFA, sequential organ failure assessment; TB, tuberculosis; Vt, tidal volume.

Table 2

Primary and secondary outcomes of the study

VCV (n = 25)

Primary outcome measures

Duration of mechanical ventilation (days)
Duration of ICU stay (days)
Hospital stay (days)
Delta SOFA
Secondary outcome variables
Ease of ventilator use by VAS (mm)
Midazolam requirement (mg/day)
Vecuronium requirement (mg/day)
Average ABGs (number/day)

6 (3.511.5)
9 (4.515.5)
11 (6.518.5)
1 (02.5)
15 (12.525)
18.3 (7.232.1)
6.2 (3.215.7)
1.4 (1.31.7)

ASV (n = 23)

5 (311)
8 (614)
11 (816)
2 (05)
25 (2030)
15 (8.925)
8.8 (5.218.8)
1.3 (1.11.5)

Total (n = 48)

P-value

5 (3.311)
8.5 (514.8)
11 (7.318)
1 (03.8)

0.51
0.9
0.97
0.54

20 (1525)
17.7 (7.827.3)
8.6 (3.315.9)
1.4 (1.21.6)

0.04
0.54
0.39
0.2

All values are represented as median (interquartile range) unless otherwise stated.
ABG, arterial blood gases; ASV, adaptive support ventilation; ICU, intensive care unit; VCV, volume-cycled ventilation; SOFA,
sequential organ failure assessment; VAS, visual analogue scale.

patients received a trial of NIV prior to intubation,

with a significantly higher number in the VCV (n = 6)
compared with the ASV arm (n = 1). The baseline
characteristics of the study group were similar except
for Vt, which was higher in the ASV group (Table 1).
The baseline disease severity assessed by acute physiology and chronic health evaluation II and sequential
organ failure assessment scores was not different in
the two groups. Figure 3 shows the change in Vt, PEEP,
Pplat, static compliance, pH and PaO2/FIO2 scores
over time. The tidal volume delivered significantly
increased with time and was different between the
two groups until 10 days. The PEEP used gradually
Respirology (2013) 18, 11081115

decreased over time and was similar in the two

groups. There was gradual decline in the Pplat and
was significantly different between the groups only on
days 4 and 5. The PaO2/FIO2 ratio, pH and static compliance also gradually increased and were not different between the two groups.

Primary and secondary outcomes

There was no difference in any primary outcome of
the study (Table 2). The delta sequential organ failure
assessment (signifying the occurrence of new-onset
organ dysfunction) was similar in the two groups.
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ASV in ARDS

1113

Figure 3 Time course of tidal volume, plateau pressures (peak inspiratory pressure in the ASV group), PEEP levels, static compliance,
pH and PaO2/FIO2 scores from baseline until day 14 in the two groups of patients. The dark circles represent patients in the
volume-controlled ventilation (VCV) group, while the hollow circles demarcate the adaptive support ventilation (ASV) group (*P < 0.05
between the two groups). RICU, respiratory intensive care unit.

Similarly, the duration of mechanical ventilation and

the ICU and hospital length of stay were not different
in the two groups. The requirement of sedatives and
neuromuscular blocking agents was also equivalent
in the two groups. The VAS rated daily by the ICU
physician was lower in the VCV group; however, the
VAS scores were low in both groups. The requirement
of arterial blood gases was similar in the two groups
(Table 1).
Three patients (two in ASV arm, one in VCV arm)
required NIV pre-emptively. There were 17 (35%)
deaths in the study with no difference in median stay
(Fig. 4) and mortality between the two groups (9/25
(36%) in the VCV arm; 8/23 (34.7%) in the ASV arm).

DISCUSSION
The results of this study suggest that clinical outcomes with ASV are similar to VCV in managing
patients with ARDS. ASV was comparable to VCV in
2013 The Authors
Respirology 2013 Asian Pacific Society of Respirology

Figure 4 Respiratory intensive care unit (RICU) stay in patients

receiving volume-cycled ventilation (VCV, solid line) versus
adaptive support ventilation (ASV, dotted line). The median
intensive care unit stay was similar in the two groups.

Respirology (2013) 18, 11081115

1114
maintaining Pplat below 30 cm of H2O.18 This is the
first trial to report ARDS outcomes in patients solely
ventilated with ASV. In fact, the majority of evidence
regarding the use of ASV is for weaning postoperative patients2429 or chronic obstructive pulmonary
disease patients.30 The use of ASV in ARDS is conceptually appealing because it is a pressure-targeted
form of closed-loop ventilation that optimizes the
relationship between Vt and respiratory frequency
based on lung mechanics.8 ASV automatically determines the best Vt and fR that maintains the peak
pressure below the target level. Further, ASV by automatically adjusting airway pressure prevents the
adverse effects of excessive Pplat than a fixed tidal
volume.12 In a physiological study of total ventilatory
support in respiratory failure, ASV was found superior to conventional ventilation with regard to
haemodynamic, ventilatory and gas exchange
parameters, except for excessive Vt in few patients
with obstructive lung disease.31
In this study,Vt delivered by ASV were slightly higher
compared with VCV, albeit the Pplat was comparable
on most days and so were the other end-points. In the
ASV mode, we measured only the Pinsp and not the
Pplat. In ASV, the alveolar pressure can be considered
equal to Pinsp only when inspiratory time is adequate
for inspiratory flow to reach zero, in which circumstance there is no pressure gradient between proximal
airway pressures and alveolar pressure. However, such
a setting is not possible with ASV; as such, the Pplat
may actually be lower in the ASV group.
Studies designed specifically to compare ASV with
VCV have suggested conflicting results with the ASV
strategy.12,13 In a study comparing ASV with VCV, the
inspiratory and expiratory Vt and expiratory resistance were higher, while the total fR and maximum
pressure were lower with ASV. No changes in the arterial blood gases, heart rate or mean arterial pressure
were observed.13 In contrast, another study found ASV
to deliver lower Vt compared with VCV.12 Earlier
studies have also reported higher VtfR ratios in
patients ventilated with ASV.11,32,33 In a study that
evaluated only the breathing pattern, ASV was found
to deliver Vt at a range of 4.810 mL/kg in patients
with restrictive lung disease.31 As ASV manipulates the
ventilator with each breath, the number of interventions by the physician and the alarms are likely to be
lesser, although this was not particularly evaluated in
the current trial.
ASV reopens the debate of pressure versus volume
ventilation in the management of ARDS, although
data supporting the use of either approach are
equivocal.3438 The ARDS network trial used volume
ventilation in both arms.18 Studies comparing the
effects of pressure versus volume ventilation have
not been well designed.39 However, the advent of
closed-loop mechanical ventilation now combines
the best characteristics of both pressure and volumecontrolled ventilation.19 Regardless of the mode used,
the emphasis of ventilation has shifted to supportive
care and prevention of aggravation of lung injury
rather than cure of ARDS. This study suggests that
ASV could be a viable alternative to VCV in the management of ARDS.
Respirology (2013) 18, 11081115

R Agarwal et al.

The strength of the current study includes its randomized nature, ASV as a primary mode of ventilation
and the comparison of clinical outcomes for up to 2
weeks following randomization. The limitations
include the small study sample, conducted at a single
centre and the unblinded nature of the study. Further,
we collected only hospital mortality and not 28-day or
90-day survival, which are better descriptors of
outcome. Although the attending physicians found
VCV easier to use than ASV, this difference reflects
mere statistical significance as the scores were low in
both the groups. The other reason could be the unfamiliarity, as the mode was in practice only for 1 year
prior to this trial. Specific training of the intensivists
on how to best set the ASV is an important issue,
which should be considered in any future trial involving ASV.
In conclusion, this study found no difference in the
outcomes in patients with ARDS ventilated with
either ASV or VCV with regard to the duration of
medical care, morbidity or mortality. Larger clinical
studies are warranted to clarify the role of ASV as a
primary mode for ventilation in ARDS.

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