Respiratory load compensation during mechanical ventilation-proportional assist ventilation with load-adjustable gain factors versus pressure support

Rationale: In mechanically ventilated patients respiratory system impedance may vary from time to time, resulting, with pressure modalities of ventilator support, in changes in the level of assistance. Recently, implementation of a closed-loop adjustment to continuously adapt the level of assistance to changes in respiratory mechanics has been designed to operate with proportional assist ventilation (PAV+). Objectives: The aim of this study was to assess, in critically ill patients, the short-term steady-state response of respiratory motor output to added mechanical respiratory load during PAV+ and during pressure support (PS). Patients and interventions: In 10 patients respiratory workload was increased and the pattern of respiratory load compensation was examined during both modes of support. Measurements and results: Airway and transdiaphragmatic pressures, volume and flow were measured breath by breath. Without load, both modes provided an equal support as indicated by a similar pressure-time product of the diaphragm per breath, per minute and per litre of ventilation. With load, these values were significantly lower (p < 0.05) with PAV+ than those with PS (5.1 +/- 3.7 vs 6.1 +/- 3.4 cmH(2)O.s, 120.9 +/- 77.6 vs 165.6 +/- 77.5 cmH(2)O.s/min, and 18.7 +/- 15.1 vs 24.4 +/- 16.4 cmH(2)O.s/l, respectively). Contrary to PS, with PAV+ the ratio of tidal volume (V-T) to pressure-time product of the diaphragm per breath (an index of neuroventilatory coupling) remained relatively independent of load. With PAV+ the magnitude of load-induced V-T reduction and breathing frequency increase was significantly smaller than that during PS. Conclusion: In critically ill patients the short-term respiratory load compensation is more efficient during proportional assist ventilation with adjustable gain factors than during pressure support.