MINERVA ANESTESIOL 2002;68:365-8

Adaptive Support Ventilation (ASV)

J. X. BRUNNER, G. A. IOTTI*

Adaptive Support Ventilation is a novel ventilation mode, a closed-loop control mode that may switch automatically from a PCV-like behaviour to an SIMV-like or PSV-like behaviour, according to the patient status. The operating principles are based on pressure-controlled SIMV with pressure levels and SIMV rate automatically adjusted according to measured lung mechanics at each breath. ASV provided a safe and effective ventilation in patients with normal lungs, restrective or obstructive diseases. In cardiac surgery tracheal extrubation was faster in ASV patients then in controls. In the early weaning phase of acute ventilatory insufficiency the need of resetting ventilator parameters was decreased, suggesting potential benefit for patient care. Key words: Adaptive support ventilation Respiration, artificial - Critical care.

From the Hamilton Medical AG Rhzns, Switzerland and *Rianimazione 1 I.R.C.C.S. Policlinico S. Matteo, Pavia, Italy

uring conventional ventilatory support, clinicians choose the ventilation mode and adapt the ventilator controls to the different characteristics and changing conditions of their patients. When the patient is not actively breathing, clinicians normally choose a controlled mode, either volume control ventilation (CMV), or pressure control ventilation (PCV). In both cases clinicians formulate a target for minute ventilation and tidal volume, and set
Address reprint requests to: J. X. Brunner, Hamilton Medical AG, Via Nova, CH-7403 Rhzns, Switzerland. Email: jbrunner@hamilton-medical.ch

a respiratory frequency and an I:E ratio. The initial target is usually based on patient body weight and an assumption about CO2 production and later adjusted according to the results of arterial blood gas measurements. When the patient has resumed spontaneous respiratory activity, most clinicians choose either SIMV mode with pressure support or simply pressure support ventilation (PSV). During PSV, weaning is accomplished through a progressive decrease in the pressure support level. Pressure support is decreased stepwise as long as the patient workload for ventilation and ventilatory pattern remain clinically acceptable. In case of excessive workload and/or rapid shallow breathing, pressure support is increased again to a level that yields a better clinical condition. Adaptive Support Ventilation (ASV) is a novel ventilation mode designed to automatically accomplish most of the tasks outlined above. ASV is a closed-loop control mode that may switch automatically from a PCV-like behavior to an SIMV-like or PSVlike behavior, according to the patient status. However, unlike for PCV, SIMV, or PSV, ASV always maintains control of ventilation volume and it guarantees:

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TABLE I.Function of ASV explained as a command to a hypothetical agent within a ventilator.1

Maintain at least a pre-set minute ventilation Take spontaneous breathing into account Prevent tachypnea Prevent AutoPEEP Prevent excessive dead space ventilation Fully ventilate in apnea or low drive Give control to patient in case brearhing activity is OK, and do all this without exceeding a plateau pressure of 10 mbar below the upper pressure limit

a minimum minute ventilation set by the user, an effective tidal volume, well above the theoretical dead space of the patient, and a minimal breath rate. ASV can be compared to the users servant or agent, executing the commands given in Table I. Operating principles The basic principle of ASV, described elsewhere,1, 2 largely follows the initial idea of Adaptive Lung Ventilation.3 In brief, pressure-controlled SIMV (PC-SIMV) is employed, but with automatically adjusted pressure levels and SIMV rate based on measured lung mechanics. Adjustments are made with each breath. The user is asked to set just two main controls, the Ideal Body Weight (IBW) and the minimum Minute Ventilation (MinVol), plus the controls for oxygenation (FiO2), PEEP, and trigger sensitivity. Hence, the control panel of ASV is very simple. Based on the user settings for IBW and MinVol, ASV calculates optimal targets for tidal volume (Vt) and respiratory frequency (f), thus automatically selecting the target ventilatory pattern. This target ventilatory pattern corresponds to the best combination of Vt and f, from the energetic standpoint,4, 5 and is calculated primarily from: user-set MinVol, theoretical dead space (calculated from user-set IBW), and

respiratory system expiratory time constant (RCe, monitored on a breath-bybreath basis). The parameter RCe, obtained from simplified analysis of the expiratory flow-volume curve,6 is a measure of the actual status of the passive respiratory mechanics of the patient. A low RCe, typical of restrictive respiratory disease i.e., stiff lungs, results in the selection of a ventilatory pattern with low Vt and high f. On the other hand, a long RCe, typical of airway obstruction and/or lung emphysema, results in the selection of a ventilatory pattern with higher Vt and low f. The parameter RCe is also used to calculate the inspiratory time (Ti) of mandatory breaths: Ti will be longer when RCe is short (restrictive disease), and shorter when RCe is long (obstructive disease), thus allowing a longer expiratory time when exhalation is slower and intrinsic PEEP is more likely to develop. The theoretical dead space is used also to calculate a minimum Vt level, in order to avoid ineffective alveolar ventilation. For each breath, targets for Vt and f are compared with the actual achieved values, and decisions are automatically made for: the time to start the next mandatory breath (i.e., the mandatory frequency) and the inspiratory pressure above PEEP to be applied in the next breath. In practice, when the actual frequency is higher than the target frequency (for instance due to spontaneous respiratory activity), the mandatory frequency is lowered. The mandatory frequency may decrease even to zero, but it will promptly increase should the patient stop breathing. Simultaneously, the inspiratory pressure is adapted, breath by breath, to gently drive the tidal volume towards the Vt target. This means that when passive mechanics improve and/or patient activity increases, the patient tends to be automatically weaned from pressure. On the contrary, when passive mechanics worsen and/or patient activity decreases, the ventilator automatically increases machine support.

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24 22 20 18 16 14 12 10 8 6 4

10 15 20 25 30 35 40 45 50 55 Rrs (cm H2O/l/s)

24 22 20 18 16 14 12 10 8 6 4

f (b/min)

f (b/min)

20

40

60 80 100 Crs (ml/cm H2O)

120

140

160

Fig. 1.Relationship between respiratory frequency (f) as automatically applied by ASV vs respiratory system resistance (Rrs, A) and compliance (Crs, B) in a group of paralyzed patients with different respiratory system mechanics.

With ASV, the patient has a high degree of breathing freedom within each breath, since the controller works by controlling the inspiratory pressure and never by forcing a given inspiratory flow. With ASV, the user-set minimum minute ventilation is always guaranteed, with a theoretically optimal ventilatory pattern, while the patient always maintains the freedom of increasing his minute ventilation above the user-set target. Clinical results ASV has been developed and studied on ventilators controlled by external computers and recently implemented in the GALILEO and RAPHAEL ventilators (Hamilton Medical, Rhzns, Switzerland). Up to now, few published studies about the clinical use of this novel ventilation mode are available. ASV has been shown to provide a safe and effective startup of ventilation,7, 8 When ASV was used on passive patients with different respiratory system mechanics (normal lungs, restrictive disease, or obstructive disease), the ventilatory pattern applied by the automatic controller was markedly different: frequency (Fig. 1) and I:E ratio were adapted as expected, according to the type and severity of the respiratory disease.9 In cardiac surgery postoperative patients, ASV was successfully used for fast tracheal extubation, with minimum need for user

manipulation of the ventilator.10 The duration of mechanical ventilation was shorter in the ASV group than in the control group (3.2 vs 4 hours, median values). In a nonhomogeneous group of patients in the early weaning phase after acute respiratory insufficiency, ASV was further compared to SIMV with pressure support. At comparable levels of ventilation, central respiratory drive and sternocleidomastoid activity were markedly reduced during ASV.11 Furthermore, ASV was used in postoperative cardiac surgery patients to assess effects on respiratory management, i.e., number of operator interventions. 12 The results suggest that, indeed with ASV, the need to readjust ventilator parameters is clearly decreased, resulting in potential benefits for patient care. These studies confirm that the key features of ASV are ease of operation for the user and adaptation to the different and variable characteristics and needs for the patient. Riassunto
Adaptive Support Ventilation (ASV) Adaptive Support Ventilation una nuova metodica ventilatoria, un controllo a circuito chiuso che pu passare automaticamente da una ventilazione simile alla PCV a una ventilazione simile alla SIMV o PSV in accordo con lo stato del paziente.

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Il principio del funzionamento quello di una SIMV a pressione controllata con livelli pressori e frequenza di SIMV regolati sulla meccanica respiratoria rilevata ad ogni respiro. ASV ha garantito una ventilazione sicura ed efficace in pazienti con polmoni normali e in pazienti con malattie polmonari ostruttive o restrittive. In cardiochirurgia ha consentito unestubazione pi rapida che nel gruppo controllo. Nella fase precoce di svezzamento in pazienti affetti da insufficienza respiratoria acuta, il numero di volte nelle quali stato necessario cambiare i parametri del ventilatore stato inferiore, ci suggerisce un potenziale beneficio per il paziente. Parole chiave: Ventilazione meccanica - Adaptive support ventilation - Terapia intensiva.

References
1. Hamilton Medical AG. Adaptive Support Ventilation Users Guide. Switzerland: Hamilton Medical AG, 1999. 2. Campbell RS, Branson RD, Johannigman JA. Adaptive support ventilation. In: Branson RD, MacIntyre NR, editors. Respiratory Care Clinics of North America. Philadelphia: WB Saunders, 2001;7(3):425-40. 3. Laubscher TP, Heinrichs W, Weiler N, Hartmann G, Brunner JX. An adaptive lung ventilation controller. IEEE Trans Biomed Eng 1994;41(1):51-9.

4. Otis AB, Fenn WO, Rahn H. Mechanics of breathing in man. J App Physiol 1950;2:592-607. 5. Mead J. Control of respiratory frequency. J Appl Physiol 1960;15:325-36. 6. Brunner JX, Laubscher TP, Banner MJ, Iotti GA, Braschi A. A simple method to measure total expiratory time constant based on the passive expiratory flowvolume curve. Crit Care Med 1995;23:1117-22. 7. Campbell RS, Sinamban RP, Johannigman JA. Clinical evaluation of a new closed loop ventilation mode: adaptive support ventilation. Respir Care 1998; 43:A856. 8. Laubscher TP, Frutiger A, Fanconi S, Brunner JX. The automatic selection of ventilation parameters during the initial phase of mechanical ventilation. Intensive Care Med 1996;22:199-207. 9. Belliato M, Maggio G, Neri S, Via G, Fusilli N, Olivei M et al. Evaluation of the Adaptive Support Ventilation (ASV) mode in paralyzed patients. Intensive Care Med 2000;26(Suppl 3):S327. 10. Sulzer CF, Chiolro R, Chassot PG, Mueller XM, Revelly JP. Adaptive support ventilation (ASV) for fast tracheal extubation after cardiac surgery. A randomized controlled study. Anesthesiology 2001;95:1339-45. 11. Tassaux D, Dalmas E, Gratasour P, Chevrolet JC, Jolliet P. Comparison between SIMV and adaptive support ventilation (ASV) during early weaning from mechanical ventilation. Intensive Care Med 2000;26(Suppl 3):S368. 12. Revelly JP, Petter A, Chassot PG, Mueller XM, Chiolro R. A simplified weaning protocol based on Adaptive Support Ventilation: effect on duration of intubation and respiratory management. Intensive Care Med 2001;27(Suppl 2):P136.

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