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Randomized Controlled Trial
. 2025 Oct;168(4):912-923.
doi: 10.1016/j.chest.2025.03.024. Epub 2025 Apr 4.

Effect of Ventilator Mode on Ventilator-Free Days in Critically Ill Adults: A Randomized Clinical Trial

Kevin P Seitz  1 , Bradley D Lloyd  2 , Li Wang  3 , Matthew S Shotwell  3 , Edward T Qian  4 , Amelia L Muhs  5 , Roger K Richardson  6 , J Craig Rooks  6 , Vanessa Hennings-Williams  6 , Claire E Sandoval  6 , Whitney D Richardson  6 , Tracy L Morgan  6 , Amber N Thompson  6 , Pamela G Hastings  6 , Terry P Ring  6 , Joanna L Stollings  7 , Erica M Talbot  8 , David J Krasinski  8 , Bailey R DeCoursey  8 , Tanya K Marvi  9 , Stephanie C DeMasi  2 , Kevin W Gibbs  10 , Wesley H Self  11 , Amanda S Mixon  12 , Todd W Rice  13 , Matthew W Semler  5 , Jonathan D Casey  5 ; Pragmatic Critical Care Research Group
Affiliations
Randomized Controlled Trial

Effect of Ventilator Mode on Ventilator-Free Days in Critically Ill Adults: A Randomized Clinical Trial

Kevin P Seitz et al. Chest. 2025 Oct.

Abstract

Background: Whether the choice of ventilator mode affects outcomes for critically ill patients is unknown.

Research question: What are the effects of 3 common ventilator modes (volume control vs pressure control vs adaptive pressure control) on death and duration of mechanical ventilation among critically ill adults?

Study design and methods: We conducted a pragmatic, cluster-randomized, crossover pilot trial among adults receiving invasive mechanical ventilation in a medical ICU between November 1, 2022, and July 31, 2023. Each month, patients in the participating unit were assigned to receive volume control, pressure control, or adaptive pressure control during continuous mandatory ventilation. The primary outcome was ventilator-free days through 28 days.

Results: Among 566 patients included in the primary analysis, the median proportion of ventilator mode assessments in the assigned mode during the first 72 hours was 100% in each group. The median number of ventilator-free days was 23 days (interquartile range [IQR], 0-26 days) in the volume control group, 22 days (IQR, 0-26 days) in the pressure control group, and 24 days (IQR, 0-26 days) in the adaptive pressure control group (P = .60). The median tidal volume was similar among the 3 groups, but the percentage of breaths > 8 mL/kg of predicted body weight differed among the volume control (median, 4.0% [IQR, 0.0%-14.1%]), pressure control (median, 10.6% [IQR, 0.0%-31.5%]), and adaptive pressure control (median, 4.7% [IQR, 0.0%-19.2%]) groups.

Interpretation: This pilot trial established the feasibility of conducting a cluster-randomized crossover trial of ventilator mode among critically ill adults receiving invasive mechanical ventilation and demonstrated differences in intermediate outcomes that warrant further investigation in a larger trial.

Clinical trial regristation: ClinicalTrials.gov; No.: NCT05563779; URL: www.

Clinicaltrials: gov.

Keywords: clinical trial; critical illness; respiration, artificial; respiratory failure.

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Conflict of interest statement

Financial/Nonfinancial Disclosures The authors have reported to CHEST the following: E. T. Q. reports speaking honoraria from Karl Storz Endoscopy. T. W. R. reports personal fees from Cumberland Pharmaceuticals, Cytovale, and Sanofi. M. W. S. reports consulting fees for Baxter International, Inc. J. D. C. reports receiving a travel grant from Fisher & Paykel Healthcare to speak at conference. None declared (K. P. S., B. D. L., L.W., M. S. S., A. L. M., R. K. R., J. C. R., V. H.-W., C. E. S., W. D. R., T. L. M., A. N. T., P. G. H., T. P. R., J. L. S., E. M. T., D. J. K., B. R. D., T. K. M., S. C. D., K. W. G., W. H. S., A. S. M.).

Figures

None
Graphical abstract
Figure 1
Figure 1
Flow diagram showing participant progression through the trial.
Figure 2
Figure 2
Graphs showing the percentages of ventilator breaths in each trial group that were in volume control mode (red), pressure control mode (blue), and adaptive pressure control mode (gray) for the 72 hours after enrollment. Ventilator mode was assessed approximately every 1 minute. This figure displays data on breaths for which the patient was receiving a continuous mandatory mode of ventilation. Also shown is the number of patients who were alive and receiving continuous mandatory ventilation in each group during each interval. The percentage of breaths in a continuous mandatory mode and in a spontaneous mode (eg, pressure support) were 86.4% and 13.6% on day 1, 78.7% and 21.3% on day 2, and 75.7% and 24.3% on day 3. Ventilator mode is reported for 545 of 566 patients on study day 1. A total of 18 patients did not receive a continuous mandatory mode (ie, they received only spontaneous modes) on day 1, 5 of whom received a continuous mandatory mode on study days 2 or 3. Three patients were missing data on the ventilator modes received. Additional data on ventilator modes are in e-Figures 2-4 and e-Table 7.
Figure 3
Figure 3
Graph showing the proportion of patients alive and not receiving invasive mechanical ventilation. The proportions of patients who were alive (solid lines) and breathing without invasive mechanical ventilation (dotted lines) during the 28 days after enrollment in each ventilator mode group are shown. In a proportional-odds model, the number of days that patients were alive and free of invasive mechanical ventilation through day 28 did not differ significantly among the 3 study groups (P = .60).
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References

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