A NEW multicenter trial has found that proportional-assist ventilation with load-adjustable gain factors (PAV+) does not reduce the time to successful liberation from mechanical ventilation compared to conventional pressure-support ventilation (PSV) in critically ill adults.
The study, conducted across 23 centers in seven countries, randomized 573 patients who had been mechanically ventilated for at least 24 hours but were not yet ready for extubation. Participants were assigned to receive either PAV+, which targets a normal work of breathing, or PSV, which focuses on achieving a normal respiratory rate and tidal volume. The trial aimed to determine whether PAV+ could accelerate liberation from mechanical ventilation, a key clinical goal that reduces complications and improves outcomes.
Median time to successful liberation was 7.3 days in the PAV+ group versus 6.8 days in the PSV group, a difference that was not statistically significant (P = 0.58). Secondary outcomes, including ventilator-free days, reintubation rates, tracheostomy incidence, and 90-day mortality, were also similar between groups. Mortality by day 90 was 29.6% with PAV+ and 26.6% with PSV.
Although PAV+ was associated with a modest reduction in sedative use, as reflected by a greater decrease in midazolam-equivalent dosing by day 28, this did not translate into improved clinical outcomes. The incidence of serious adverse events was comparable between the two arms (10.8% for PAV+ vs. 9.8% for PSV).
The findings suggest that PAV+, while theoretically advantageous by better matching ventilatory support to patient effort, may offer no practical benefit in reducing mechanical ventilation duration in this patient population. Clinicians should continue to weigh the complexity of implementing PAV+ against its lack of demonstrated superiority in time to extubation.
Reference:
Bosma KJ et al. Proportional-Assist Ventilation for Minimizing the Duration of Mechanical Ventilation. N Engl J Med. 2025. doi: 10.1056/NEJMoa2505708. [Online ahead of print]
