Advanced closed loops during mechanical ventilation (PAV, NAVA, ASV, SmartCare)

New modes of mechanical ventilation with advanced closed loops are now available, and in the future these could assume a greater role in supporting critically ill patients in intensive care units (ICUs) for several reasons. Two modes of ventilation - proportional assist ventilation and neurally adjusted ventilatory assist - deliver assisted ventilation proportional to the patient's effort, improving patient-ventilator synchrony. Also, a few systems that automate the medical reasoning with advanced closed-loops, such as SmartCare and adaptive support ventilation, have the potential to improve knowledge transfer by continuously implementing automated protocols. Moreover, they may improve patient-ventilator interactions and outcomes, and provide a partial solution to the forecast clinician shortages by reducing ICU-related costs, time spent on mechanical ventilation, and staff workload. Preliminary studies are promising, and initial systems are currently being refined with increasing clinical experience. A new era of mechanical ventilation should emerge with these systems. (C) 2008 Elsevier Ltd. All rights reserved.