Effect of proportional assist ventilation plus versus pressure support ventilation on successful weaning in critically ill adults: a systematic review, meta-analysis, and trial sequential analysis

TL;DR

This study compares two ventilator modes for weaning critically ill adults and finds that proportional assist ventilation plus improves weaning success.

Contribution

The study provides robust evidence that proportional assist ventilation plus enhances weaning success compared to pressure support ventilation.

Findings

Proportional assist ventilation plus improved weaning success with a relative risk of 1.12.

The benefit of proportional assist ventilation plus remained significant in sensitivity analyses excluding spontaneous breathing trials.

No significant differences were found in reintubation, mortality, or ICU length of stay between the two ventilation modes.

Abstract

Proportional assist ventilation plus (PAV+) and pressure support ventilation (PSV) are commonly employed ventilatory modes during the weaning process from mechanical ventilation in critically ill adult patients. Proportional assist ventilation plus delivers assistance proportional to the patient’s inspiratory effort, thereby enhancing patient–ventilator synchrony and reducing the work of breathing. However, the efficacy of proportional assist ventilation in facilitating successful weaning remains a matter of debate.

A comprehensive search was conducted in CENTRAL, PubMed, MEDLINE, Web of Science, Embase, and ClinicalTrials.gov from inception to October 1, 2025 We included randomized controlled trials comparing proportional assist ventilation plus with pressure support ventilation in adult patients (≥18 years) who underwent invasive mechanical ventilation for at least 24 h prior to weaning. The primary outcome was the rate of successful weaning, while secondary outcomes included reintubation rate, ICU and hospital mortality, ICU length of stay and duration of weaning. Trial sequential analysis and subgroup analyses based on clinical intent (spontaneous breathing trial vs. continuous weaning) were integrated to enhance the robustness of the findings.

In seven RCTs (n = 1, 214), proportional assist ventilation plus improved weaning success (RR = 1.12, 95% CI: 1.02–1.23). Consistently, this result remained significant in sensitivity analyses excluding spontaneous breathing trial studies. No significant differences were observed in reintubation, mortality, weaning duration, or ICU length of stay.

Proportional assist ventilation plus improved weaning success compared with pressure support ventilation. This benefit remained robust in sensitivity analyses excluding spontaneous breathing trial studies. These findings suggest Proportional assist ventilation plus is a promising weaning mode, but further research is needed to optimize its implementation.

PROSPERO, CRD420251170692.

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