Journal Pre-proof

Automated weaning from mechanical ventilation: Results of a

Bayesian network meta-analysis

Arthur Neuschwander, Vibol Chhor, Amélie Yavchitz, Matthieu

Resche-Rigon, Romain Pirracchio

PII: S0883-9441(20)30746-2
DOI: https://doi.org/10.1016/j.jcrc.2020.10.025
Reference: YJCRC 53692

To appear in: Journal of Critical Care

Please cite this article as: A. Neuschwander, V. Chhor, A. Yavchitz, et al., Automated
weaning from mechanical ventilation: Results of a Bayesian network meta-analysis,
Journal of Critical Care (2020), https://doi.org/10.1016/j.jcrc.2020.10.025

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© 2020 Published by Elsevier.

 Journal Pre-proof 1

Automated weaning from Mechanical Ventilation: Results of a

Bayesian network meta-analysis.

Arthur Neuschwander, MD1, Vibol Chhor, MD, PhD1, Amélie Yavchitz, MD, PhD1, Matthieu Resche-
Rigon, MD PhD2, Romain Pirracchio, MD PhD1,3
1
Service d’Anesthésie Réanimation, Hôpital Européen Georges Pompidou, Université Paris Descartes,

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Sorbonne Paris Cité, Paris, France.

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2
Service de Biostatistiques et Information Médicale, Hôpital Saint Louis, Unité INSERM UMR-1153,

Université Paris Diderot, Sorbonne Paris Cité, Paris, France.

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Department of Anesthesia and Perioperative Medicine, San Francisco General Hospital and Trauma
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Center, University of California, San Francisco, CA, USA
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Corresponding author

Pr Romain Pirracchio
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Department of Anesthesia & Perioperative Medicine

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Zuckerberg San Francisco General Hospital and Trauma Center

University of California San Francisco

1001 Potrero avenue, CA94110, San Francisco, U.S.A.

Email : Romain.Pirracchio@ucsf.edu

ABSTRACT
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Purpose: Mechanical ventilation (MV) weaning is a crucial step. Automated weaning modes reduce

MV duration but the question of the best automated mode remains unanswered. Our objective was to

compare the major automated modes for MV weaning in critically ill and post-operative adult patients

Material and Methods: We conducted a network Bayesian meta-analysis to compare different

automated modes. We searched MEDLINE, EMBASE and Cochrane central registry for randomized

control trials comparing automated weaning modes either to another automated mode or to standard-

of-care. The primary outcome was the duration of MV weaning extracted from the original trials.

Results: 663 articles were screened and 26 trials (2097patients) were included in the final analysis. All

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automated modes included in the study (ASV°, Intellivent ASV, Smartcare, Automode°, PAV° and

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MRV°) outperformed standard-of-care but no automated mode reduced the duration of mechanical
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ventilation weaning as compared to others in the network meta-analysis
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Conclusion: Compared to standard weaning practice, all automated modes significantly reduced the

duration of MV weaning in critically ill and post-operative adult patients. When cross-compared using
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a network meta-analysis, no specific mode was different in reducing the duration of MV weaning.
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The study was registered in PROSPERO (CRD42015024742)

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KEYWORDS
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- Ventilator weaning

- Critical care

- Post-operative period

- Automated closed loop modes

- Network meta-analysis

- Mechanical ventilation

LIST OF ABBREVATION
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ASV° = Adaptative support ventilation

ICU = Intensive care unit

MD = Mean difference

MRV° = Mandatory rate ventilation

MRR = Mean relative reduction

PAV° = Proportional assist ventilation

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INTRODUCTION
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Weaning mechanical ventilation (MV) is a critical step in a patient’s trajectory in the intensive care
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unit (ICU) [1] and can sometimes be challenging following surgery [2]. If more than 50% of ICU
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patients require less than 48h hours of MV, the weaning process may take much longer in others [3].

While its impact on ICU mortality remains controversial [4,5], the duration of MV is known to be
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strongly associated with the risk of ventilator-associated adverse events [6,7] such as ventilator-

associated pneumonia [8]. In turn, ventilator-associated events which occur with an incidence of 10-15
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events per 1000 ventilation days [9] are associated with increased morbidity, mortality and ICU-
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related costs [10]. Many clinical trials have reported a benefit of reducing the amount of sedation or

performing systematic spontaneous breathing trials [11,12]. In addition, the availability of a

standardized MV weaning protocol is also associated with a reduction in the duration of MV [13].

Over the past decades, several automated weaning modes were developed to adjust ventilator settings

more frequently and in a standardized manner and thereby reduce inter-practitioner variability in the

weaning process [14] and thus to allow for an earlier identification of the readiness to be weaned from

the ventilator [15]. A recent meta-analysis has reported a reduction in the duration of MV when using

an automated weaning mode as compared to a non-automated mode [16]. However, the question of the

best automated mode remains unanswered as studies comparing several automatic modes are lacking.
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Network meta-analysis allow for indirect comparison of multiple interventions across different trials

based on a common comparator. The objective of this network meta-analysis was to compare the

performance of different specific automated weaning modes in reducing the duration of MV in

critically ill and post-operative adult patients.

MATERIAL AND METHODS

This network meta-analysis was performed and is reported according to the PRISMA guidelines[17].

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The study was registered in PROSPERO (CRD42015024742)

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Identification of trials
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Search strategy
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We searched electronic databases MEDLINE and EMBASE via OvidSP and Cochrane central register

of controlled trial (CENTRAL) for published trials without language restriction and clinicaltrials.gov
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registry for ongoing and unpublished trials. The last searched was performed on July 1st 2019. Our

search strategy was based on the medical sub headings (MeSH) used in the last Cochrane meta-
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analysis on automated weaning in order to maximize comparability and reproducibility of results [16].
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The following MeSH were used to identify relevant studies: weaning, mechanical ventilation,

intensive care units, critical care units, post-operative, automated weaning, Smartcare°, Automode°,

Proportional assist ventilation, PAV°, Mandatory rate ventilation, MRV°, adaptative support

ventilation, ASV° and Intellivent ASV°. Details on the search strategy are available in the

supplemental material (Additional file 1).

Study selection

Inclusion criteria were 1) randomized controlled trials, 2) comparing an automated weaning mode

either to another automated mode or to standard-of care (including weaning according to a written

protocol and nurse / physiotherapist driven protocols), 3) in adult patients receiving mechanical
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ventilation in the ICU or during post-operative care. Two authors (AN, VC) independently examined

the titles and abstracts of all articles retrieved though electronic and manual searches to determine

eligibility. Full-texts were obtained and examined for eligibility.

Type of interventions

The automated weaning modes considered in this study were the modes that are the most frequently

encountered in clinical practice and that were evaluated in at least one clinical trials [16] : Automode°,

Smartcare°, ASV°, Intellivent ASV°, the PAV° and MRV°. The Automode° (Maquet Critical Care,

Solna, Sweeden) is a mode that automatically switches from controlled to assisted ventilation as soon

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as the patient performs two consecutive triggering efforts. It may switch back to a controlled mode if

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the patient becomes apneic after a predetermined apnea duration. The Smartcare° (Dräger, Lübeck,
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Germany) is a pressure support mode that uses a proprietary algorithm to adjust the inspiratory

pressure level every 2 to 5 minutes based on the tidal volume (Vt), the respiratory rate (RR), and the
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end tidal carbon dioxide (EtCO2). It also automatically performs spontaneous breathing trials and
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concludes as to whether or not the patient is ready to be separated from the ventilator. The Adaptative

support ventilation (ASV°, Hamilton Medicals, Bonadul, Switzerland) is a pressure mode that uses
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the physician-supplied targeted minute volume to adjust its support setting at every cycle. It also

automatically switches from controlled to assisted ventilation depending on the presence of

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spontaneous breathing efforts and performs spontaneous breathing trials. The Intellivent ASV°
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(Hamilton Medical, Rhäzüns, Switzerland) is an extension of the ASV that uses closed loop control to

adjust minute ventilation based on the EtCO2 and oxygenation by automatically adjusting the fraction

of inspired oxygen (FiO2) and the positive end-expiratory pressure (PEEP) using the acute respiratory

distress syndrome network (ARDSnet) PEEP-FiO2 table. The Proportional assist ventilation (PAV°)

adjusts the airway pressure based on the estimated compliance and resistance. There are no set targets

for pressure, volume or flow. The Mandatory rate ventilation (MRV°, Taema-Horus, Air Liquide,

France) adjusts pressure support based on a respiratory rate target. The ventilator compares the

average respiratory rate over four respiratory cycles and increase/decrease the level of pressure

support by 1 cm H20.
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Data extraction and risk of bias assessment

For each included study, data were extracted from published reports (AN, VC). Whenever needed, we

contacted the authors by email to obtain additional data. The risk of bias was assessed independently

by two investigators (AN and VC) using the items defined by the Cochrane Collaboration [18]:

random sequence generation; allocation concealment; blinding; missing data; selective reporting; risk

of other bias. In case of discordance, a third party assessment (RP) was involved until consensus was

reached. Multi-arm studies were treated as multiple independent two-arm studies.

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Outcome measures
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The primary outcome measure was the duration of mechanical ventilation weaning in hours, defined
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as the time between randomization and successful extubation.
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Statistical analysis

Outcome measure
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All durations were converted into hours. Means and variances were extracted from original published
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reports. Whenever the duration was expressed as a median with an inter-quartile range, the mean and

the variance were obtained using the method proposed by Wan [19]. All data were log transformed

according to the formulae proposed by Higgins et al. for meta-analysis of skewed data [20].

Standard Meta-analyses

We first performed pairwise random effect meta-analyses to compare each mode and the control, i.e.,

standard-of-care. In pairwise meta-analyses, heterogeneity between studies was quantified using the

degree of inconsistency (I2), and the p-value from the Cochrane Q statistic (Metafor R-package,

version 2.0-0). Heterogeneity was deemed acceptable with one chi-square p-value above 0.10. For
 Journal Pre-proof 7

statistical reasons, automated modes that included 2 or less studies were pooled in an “other modes”

group (Automode, PAV° and MRV°).

Network Meta-analyses

We first analyzed the pattern of the 2-by-2 comparisons between automated weaning modes

and produced network graphs where each node represents a competing weaning mode. In these graphs,

the presence of an edge between 2 nodes means there is at least one trial comparing the two

corresponding weaning modes (Additional file 2)

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Methods for indirect and mixed comparisons

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A Bayesian random effect network meta-analysis was then carried out to compare the weaning modes

using a Bayesian hierarchical model (gemtc R-package, version 0.8-2 [21,22]). Pooled mean
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differences of log transformed times together with their 95% credibility intervals (CrI) were estimated
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from the mean of the posterior distribution obtained from the Bayesian analysis.
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Mean relative reduction (MRR) together with their 95% credibility intervals (CrI) were calculated. In

the present case, MRR can be interpreted as log relative reduction of the weaning time, e.g., MRR of
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0.22, 0.69 and 2.30 correspond respectively to a reduction 20%, 50% and 90% in the weaning time.

For each automated weaning mode, the posterior probability to be the best mode, the second ranked
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mode, the third ranked mode and the worst mode were calculated and illustrated using cumulative rank
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curves.

Subgroup analyses

Prespecified subgroups analyses were performed in the post-operative population and in ICU patients.

The statistical analysis was performed using R 3.6.0 [23] and rjags [24] .

Funding source

There was no funding source for this study.

 Journal Pre-proof 8

RESULTS

Identification and characteristics of the studies

Among the 663 identified citations, 60 randomized controlled trials were selected for full text

screening. One additional study of 33 patients comparing Smartcare° to standard-of-care was declared

on clinical trial.gov registry (NCT00606554) but terminated before completion for insufficient

recruitment. The results were declared in the registry and therefore included in the analysis. In total,

26 trials corresponding to a total of 2097 ventilated patients were included in the systematic review.

All included studies reported the primary outcome and were included in the quantitative analysis

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(figure 1).

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Table 1 summarizes the characteristics of the 25 trials, excluding the unpublished study. The
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automated weaning modes under investigation were ASV° in 12 studies (n=940), Smartcare° in 7
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studies (n=767), Intellivent ASV° in 3 studies (n=160), Automode° in 2 studies (n=60) and PAV°

(n=50) and MRV° (n=87) in one study. No study investigating several automated modes was
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identified. Thirteen of the 25 studies (763 patients) were performed in the post-operative period while

the 12 others were conducted in 1301 ICU patients. Standard-of-care included the use of a written
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weaning protocol in 22 studies (88%). In 8 ICU studies (66%), sedation was administered using a
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written protocol based on sedation score. None of the 12 ICU studies used daily sedation interruption.
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Risk of bias

Table 2 reports the assessment of the risk of bias. In all studies, due to the lack of blindness, the risk of

detection and performance bias was high. For random sequence generation, incomplete outcome data

and selective reporting, all but one studies were considered at low risk of bias.

Synthesis of results

First, each automated weaning mode was separately compared to standard-of-care (figure 2). ASV or

Intellivent ASV, mean difference (MD) =-0.31; 95% Credibility Interval (CrI) (-0.48, -0.14)
 Journal Pre-proof 9

corresponding to a mean relative reduction (MRR) of 0.73 (0.62;0.86) and Smartcare (MD=-0.19, (-

0.35;-0.03), corresponding to a MRR of 0.83 (0.70;0.97)) were found to be superior to standard-of-

care. The other modes were not different than standard-of-care: MD=-0.24, (-0.58; 0.10), MRR=0.79

(0.56;1.10). Funnel plots of individual meta-analysis are available in the supplemental material

(Additional file 4).

Secondly, the automated weaning modes were compared to each other using a Bayesian random effect

network meta-analysis. Differences in the log-duration of MV weaning between ASV° or Intellivent

ASV and standard-of-care was MD=-0.31, 95% CrI (-0.48;-0.14), MRR=0.73 (0.62;0.86); between

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other modes and standard-of-care MD=-0.24 (-0.58;0.11), MRR=0.78 (0.55;1.09); between Smartcare

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and standard-of-care MD=-0.20 (-0.46;0.07), MRR=0.81 (0.62;1.06). This corresponds to a decrease

in the MV weaning duration of 27%, 22% and 19% with the ASV°, the Other modes and the
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Smartcare° respectively when compared to standard-of-care. Mean differences in the log-duration of
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MV weaning between ASV° or Intellivent ASV and Other modes, ASV° or Intellivent ASV and
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Smartcare° were MD=-0.08, 95% CrI (-0.46;0.31) MRR=0.91 (0.62;1.33); and MD=-0.12 (-

0.43;0.20), MRR=0.88 (0.64;1.20), respectively. The mean difference in the duration of MV weaning
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between Other modes and Smartcare° was MD=-0.04 (-0.48; 0.40), MRR=0.94 (0.61;1.44). Figure 3

displays the cumulative probabilities to be the first ranked, the second ranked, the third ranked, and the
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forth ranked weaning mode.

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Subgroup analyses were performed in the ICU and the post-operative population (Additional file 3). In

ICU patients, the individual meta-analysis revealed that ASV° or Intellivent ASV, Smartcare° and

PAV° significantly reduced the duration of MV weaning when compared to standard-of-care: MD=-

0.36, 95% CrI (-0.64,-0.09), MRR=0.70 (0.53;0.91); MD=-0.19 (-0.35, -0.03), MRR=0.82 (0.70;0.97)

and MD=-0.84 (-1.37,-0.31) MRR=0.43 (0.25;0.73) respectively. In Bayesian random effect network

meta-analysis, ASV° or Intellivent ASV, PAV° and Smartcare° probabilities to be the best automated

weaning mode in ICU patients were 0.11, 0.87 and 0.02 respectively. In the post-operative population,

the standard meta-analysis revealed that ASV° or Intellivent ASV but not the Other modes

significantly reduced the duration of MV weaning when compared to standard-of-care: MD=-0.29,

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95% CrI(-0.51-.07), MRR=0.75 (0.60;0.93) and MD=-0.14 (-0.34,-0.06), MRR=0.87 (0.71;0.94)

respectively. In Bayesian random effect network meta-analysis, ASV° or Intellivent ASV and Other

Modes probabilities to be the best automated weaning mode in post-operative patients were 0.78 and

0.21 respectively.

DISCUSSION

As compared to standard-of-care weaning practices, all automated weaning modes included in this

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network meta-analysis significantly reduced the duration of mechanical ventilation weaning. When

cross-compared using a network meta-analysis, no specific mode was different in reducing the

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duration of MV weaning. -p
These results are in accordance with a recent meta-analysis comparing the usefulness of automated
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weaning modes for reducing the duration of MV in critically ill adults. Although Rose et al. [16]
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studied the total duration of MV weaning while we focused on the duration of MV weaning, the

magnitude of the reduction associated with automated weaning modes observed in our study was
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similar to what was previously reported. We estimated that overall, the 3 automated weaning modes

are associated with an average decrease of approximately 23% of the weaning duration when
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compared to the standard-of-care. Furthermore, the population included in our study encompassed
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both post-operative and critically ill patients, thereby increasing the generalizability of the results to a

wide range of clinical settings. However, whether this reduction is associated with substantial clinical

benefits remains however to be evaluated.

Although the ASV° or Intellivent ASV° seemed associated with reduced duration of mechanical

ventilation weaning when compared to other weaning modes, this difference was not statistically

significant. Similarly, Morato et al. performed a bench study comparing the performance of several

automated modes (Smartcare°, Adaptative Support Ventilation (ASV°) and Mandatory Rate

Ventilation (MRV°)) and showed similar performance but more frequent pressure support level

adjustments with the ASV° [25]. In our study, the heterogeneity induced by pooling together critical
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care and postoperative patients may have contributed to the lack of difference between automated

modes. Indeed, in the post-operative period, the main challenge is to detect spontaneous breathing as

soon as possible, while in the ICU, it is to optimize the level of pressure support in a personalized

manner. Each automated mode has specific features that may make it more suitable for critical care of

for the postoperative period. For instance, ASV° or Intellivent ASV° can identify, without any human

intervention, spontaneous breathing and then automatically switches to spontaneous ventilation.

Automode° also recognizes patient triggering efforts but does not seem to be associated with the same

the results in terms of MV weaning duration reduction in the subgroup of postoperative patients. ASV°

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or Intellivent ASV° works as a closed-loop mode that adjusts inspiratory pressure and respiratory rate

on a breath-by-breath basis to maintain a predefined minute ventilation and thus optimizes the

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respiratory pattern according to a proprietary algorithm. This represents a major difference with
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Automode° but also with Smartcare° that adjusts its setting over several minutes. Noteworthy, PAV°
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also adjusts the level of pressure support at each respiratory cycle and was associated with the best

performance in the subgroup of ICU patients. Also, one possible explanation for the lack of significant
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difference between automated modes could be that mechanical ventilation weaning is not limited to
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evaluating and optimizing respiratory mechanics. Many information (e.g. cardiovascular or

neurological data) are not accounted for in the algorithm used by the automated modes at stake,
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thereby limiting their ability to differentiate themselves. In the future, this specific point may be better

addressed by the development of artificial intelligence driven weaning tools that will have the
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possibility to integrate many more physiological parameters.

Our study suffers some limitations. First, there was some heterogeneity across studies in the definition

of the weaning period, especially in the weaning starting time. This could have contributed to some

degree of evaluation bias and heterogeneity that need to be considered when interpreting the study

results. The definition of the weaning period was much more homogeneous within the two predefined

subgroups. In addition, the definition of a successful weaning was similar across studies and based on

international guidelines [26]. Second, sedation practices varied across studies. The impact of sedation

on mechanical ventilation is well described and thus any discrepancy in the sedation regimen may
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have impacted the results [27,28]. However, in most of the ICU studies, the sedation protocol was

based on a sedation scale and none reported systematic daily sedation interruption. Third, the

importance of a written MV weaning protocol on reducing the duration of mechanical ventilation was

recently emphasized [13]. The fact that a vast majority of controls included in the meta-analysis

benefited from written MV weaning protocol further underlines the benefit of automated weaning

modes. Fourth, the lack of collected data in our study design on other relevant clinical outcomes such

as the overall duration of MV, the rate of ventilator associated pneumonia, the length of ICU stay and

ICU mortality rate is a limitation to further conclude on the clinical relevance of the observed

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reduction in the MV weaning duration. No secondary outcome was collected in this study as our

objective was not to replicate previously published results on automated modes for mechanical

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ventilation weaning but to compare their individual performance. Fifth, because of a limited number of
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studies, we had to pool several modes with insufficient trials in and Other mode group. This limits our
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ability to conclude on these specific automated weaning modes. We also excluded neurally adjusted

ventilation (NAVA°, Maquet Critical Care, Solna, Sweeden) from our population as it cannot be
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considered as a closed loop automated mode since this mode does not include any automatic
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adaptation of the ventilation settings. Sixth, we decided to pool together studies on ICU and on post-

operative patients. Although this choice is likely to have contributed to a higher heterogeneity in our
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primary analysis, we believe that the gain in terms of generalizability outweighs the risks, especially

since we were able to conduct subgroup meta-analyses in the 2 specific subpopulations. Finally,
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although we are confident that our search strategy allowed us to screen all published or registered

trials relevant to our research questions, we nevertheless were not able to conduct an extensive

exploration of the grey literature. However, funnels plots did not show any evidence of substantial

publication bias.

CONCLUSION

As compared to a standardized weaning protocol, all major automated weaning modes significantly

reduced the duration of MV weaning in critically ill and in post-operative adult patients. When cross-
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compared using a network meta-analysis, no specific mode was different in reducing the duration of

MV weaning.

ACKNOLEDGMENT

Ethics approval and consent to participate: Not applicable

Competing interests: The authors declare that they have no competing interests

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Funding: No funding
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Authors' contributions
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AN contributed to the design of the work, acquisition of data and drafted the manuscript
VC contributed to the design of the work and acquisition of data
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AY revised the work for important intellectual content

MRR performed the analysis and revised the work for important intellectual content
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RP contributed to the design of the work, analysis, interpretation of data and revised the work for
important intellectual content
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All authors approved the submitted version of the manuscript

The authors declare no conflict of interest and no funding source for this study

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ADDITIONAL FILES

Additional File 1

Details on the search strategy on electronic databases MEDLINE and EMBASE via OvidSP and
Cochrane central register of controlled trial (CENTRAL) for published trials
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Additional File 2

Network graphs where each node represents a competing weaning mode. In these graphs, the presence
of an edge between 2 nodes means there is at least one trial comparing the two corresponding weaning
modes

Additional File 3:

Detailed subgroup analyses in the ICU and the post-operative population

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Additional File 4:

Funnel plots of the included trials

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Table 1 –Individual Trials Characteristics.
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Fisrt author Year Setting Modes Sample size Primary Outcome

Agarwal [29] 2013 ARDS ICU ASV° vs control 23 vs 25 Duration of mechanical
ventilation
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2012 ASV° vs control 41 vs 40 Duration of mechanical

Aghadavoudi[30] PO cardiac surgery ventilation
2018 IntelliventASV° vs 30 vs 30 Number of manual
Arnal[31] control ventilator settings
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ICU all patients

Bosma[32] 2016 ICU all patients PAV° vs control 27 vs 23 Not defined
2013 Smartcare° vs 48 vs 43 Weaning protocol
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Burns[33] ICU all patients control compliance

Celli[34] 2014 PO liver transplant ASV° vs control 10 vs 10 Duration of intubation
2009 ASV° vs control 60 vs 61 Time until tracheal
Dongelmans[35] PO cardiothoracic extubation
2017 IntelliventASV° vs 20 vs 20 Duration of mechanical
Fot[36] PO cardiac surgery control ventilation
Gruber[37] 2008 PO cardiac surgery ASV° vs control 23 vs 25 Duration of intubation
2006 Automode° vs 10 vs 10 Not defined
Hendrix[38] PO cardiac surgery control
Kirakli - 2015 ASV° vs control 114 vs 115 Mechanical ventilation
Chest[39] ICU duration
Kirakli - 2010 ASV° vs control 49 vs 48 Weaning duration
ERJ[40] ICU COPD patients
Lellouche – 2006 Smartcare° vs 74 vs 70 Time to successful
AJRCCM [14] ICU all patients control extubation

Lellouche - 2013 IntelliventASV° vs 30 vs 30 Duration of MV within

ICM[41] PO cardiac surgery control predefined range
Mohamed[42] 2014 ICU COPD ASV° vs control 25 vs 25 Not defined
Moradian[43] 2017 PO cardiac surgery ASV° vs control 57 vs 58 Not defined
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2003 ASV° vs control 18 vs 16 Duration of tracheal

Petter[44] PO cardiac surgery intubation
2008 Smartcare° vs 51 vs 51 Time to separation
Rose[45] ICU all patients control

Article Randon Allocation Blinding Incomplete Selective Other

sequence concealment outcome reporting bias
generation data

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2001 Automode° vs 20 vs 20 Total weaning time

Roth[46] PO neurosurgery control
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2012 Smartcare° vs 150 vs 150 Overall ventilation time

Schadler[47] ICU all patients control
2009 Smartcare° vs 30 vs 30 Duration of ventilator
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Stahl[48] ICU all patients control weaning

2001 ASV° vs control 16 vs 20 Duration of tracheal
Sulzer[49] PO cardiac surgery intubation
Taniguchi – 2009 MRV° vs control 38 vs 49 Duration of the
CC09[50] PO all patients weaning process
Taniguchi – 2015 Smartcare vs 35 vs 35 Duration of weaning
CC15[51] ICU all patients physiotherapist
2015 ASV° vs control 30 vs 31 Duration of mechanical
Zhu[52] PO cardiac surgery ventilation

PO: post-operative, ICU: Intensive Care Unit, COPD: Chronic Obstructive Pulmonary Disease, Auto: automated mode, ASV: Adaptive

Support Ventilation, MRV: Mandatory Rate Ventilation, PAV: Proportional Assist Ventilation

Table 2 – Assessment of the risk of bias

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Agarwal + + - + + +
Aghadavoudi + + - + + +
Arnal + + - + + +
Bosma + + - + + +
Burns + + - + + +
Celli + - - + + -
Dongelmans + + - + + +
Fot
Gruber + + - + + +
Hendrix ? ? - + + +
Kirakli –ERJ + + - + + +
Kirakli – Chest + + - + + +
Lellouche - + + - + + +
AJRCCM
Lellouche - + + - + + +

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ICM
Mohamed + - - + - -
Moradian + - - + ? ?

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Petter + + - + + +
Rose + + - -p + + +
Roth ? ? - + + +
Schadler + + - + + +
Stahl + + - + + ?
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Sulzer + + - + + +
Taniguchi - + + - - - +
2009
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Taniguchi - + + - + + +
2015
Zhu + + - - + +
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Figure 1. Flow chart

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Figure 2. Individual meta-analysis comparing each automated mode to the control group

Figure 3. Cumulative rank curves – probability to be the best, second, third and worst for each

treatment.

HIGHLIGHTS

 Mechanical weaning is a crucial step in critically ill and post-operative patients

 Automated modes reduces the duration of MV weaning when compared to controls

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 No specific mode was significantly superior in reducing the duration of MV weaning in the

network meta-analysis

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Figure 1
Figure 2
Figure 3