Proportional Assist Ventilation for Minimizing the Duration of Mechanical Ventilation: The PROMIZING Study (PROMIZING)

For adult patients with acute respiratory failure requiring invasive mechanical ventilation, does a ventilation strategy using proportional assist ventilation with load-adjustable gain factors (PAV+) result in a shorter duration of time spent on mechanical ventilation than a ventilation strategy using pressure support ventilation (PSV)?

Study Overview

• Status: Completed
• Conditions: Critically Ill; Acute Respiratory Failure
• Intervention / Treatment: Other: PSV ventilation strategy; Other: PAV+ ventilation strategy

Detailed Description

Patients with acute respiratory failure require mechanical ventilation to help them breathe until they recover from their acute illness. Although mechanical ventilation is necessary to sustain life in such situations, it can induce weakness of the respiratory muscles which may lead to prolonged dependence on the ventilator. Prolonged dependence on mechanical ventilation is associated with increased mortality, morbidity and costs to the healthcare system. Thus, a main goal of assisted mechanical ventilation is to reduce the patient's respiratory distress while maintaining some respiratory muscle activity. To attain this goal, the amount of ventilator assistance should theoretically be adjusted to target normal or reasonable levels of respiratory effort.

Modes of Mechanical Ventilation:

Proportional assist ventilation with load-adjustable gain factors (PAV+) is a mode of mechanical ventilation which delivers assistance to breathe in proportion to the patient's effort. The proportional assistance, called the gain, can be adjusted by the clinician to maintain the patient's respiratory effort or workload within a reasonable range. This is the only mode of ventilation which allows for measurement and targeting of a specific range of respiratory muscle activity by the patient.

Pressure support ventilation (PSV) is a mode of ventilation which is considered the current standard of care for assisting breathing of patients during the recovery phase of acute respiratory failure. Several studies have shown short term advantages of PAV over PSV, including improved patient-ventilator synchronization, improved adaptability to changes in patient effort, and improved sleep quality.

Goal of this Randomized Controlled Trial:

To demonstrate that for patients with acute respiratory failure, ventilation with PAV+, being more physiological, will result in a shorter duration of time spent on mechanical ventilation than ventilation with PSV.

• Study Type: Interventional
• Enrollment (Actual): 575
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Argentina
  • Buenos Aires, Argentina, C1430EFA
    • El Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno"
• Canada
  • Ontario
    • Kingston, Ontario, Canada
      • Kingston General Hospital
    • London, Ontario, Canada, N6A 5A5
      • London Health Sciences Centre - University Hospital
    • London, Ontario, Canada
      • Victoria Hospital
    • Toronto, Ontario, Canada
      • St. Michael's Hospital
    • Toronto, Ontario, Canada
      • North York General Hospital
    • Toronto, Ontario, Canada, M4N 3M5
      • Sunnybrook Hospital - Health Sciences Centre
    • Toronto, Ontario, Canada
      • UHN- Toronto General Hospital
    • Toronto, Ontario, Canada
      • UHN- Toronto Western Hospital
  • Quebec
    • Montréal, Quebec, Canada
      • Royal Victoria Hospital
    • Montréal, Quebec, Canada, GC6R+GW
      • Centre Hospitalier de l'Universite de Montreal (CHUM)
    • Québec, Quebec, Canada
      • Institut Universitaire de cardiologie et de pneumologie de Quebec
• France
  • Angers, France
    • Centre Hospitalier Universitaire (CHU) de Angers
  • Créteil, France, QFW8+H5
    • Centre Hospitalier Intercommunal de Créteil
  • Créteil, France
    • Hôpital Henri Mondor (Assistance Publique-Hôpitaux de Paris)
  • Paris, France
    • Hôpital Universitaire Pitié-Salpêtrière
  • Rouen, France
    • Centre Hospitalier Universitaire (CHU) de Rouen
• Greece
  • Heraklion, Greece
    • University Hospital of Heraklion
• Italy
  • Ferrara, Italy
    • University Hospital Of Ferrara
  • Turin, Italy
    • San Giovanni Battista University Hospital
• Saudi Arabia
  • Riyadh, Saudi Arabia, 11426
    • King Abdulaziz Medical City
• Spain
  • Barcelona, Spain
    • Hospital de Sant Pau

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

A staged enrolment process will be used to identify patients eligible to be enrolled and randomized in the study. At each stage of the enrolment process, a patient must meet inclusion criteria and not meet exclusion criteria in order to pass. To progress to the next stage, patients must continue to pass criteria from the prior stages. After enrolment, there are also specific tests to perform (with pass/fail criteria) to determine eligibility to be randomized.

A. SCREENING INCLUSION CRITERIA:

• A1. Age 18 years or older
• A2. Intubated and receiving any mode of invasive mechanical ventilation ≥ 24 hours

A. SCREENING EXCLUSION CRITERIA:

• A3. Anticipating withdrawal of life support and/or shift to palliation as the goal of care
• A4. Severe central neurologic disorder (eg. Hemorrhage, stroke, tumour) causing elevated intracranial pressure, or impaired control of breathing, or requiring specific ventilator adjustments (i.e. To attain specific CO2 target) or requiring neurosurgical intervention
• A5. Known or suspected severe or progressive neuromuscular disorder likely to result in prolonged or chronic ventilator dependence (eg. Guillain-Barré syndrome, Myasthenia Gravis, ALS, MS, high spinal cord injury, kyphoscoliosis or other restrictive disorder) (Note that obesity hypoventilation syndrome that may be managed with nocturnal non-invasive ventilation is NOT an exclusion under A5)
• A6. Severe COPD: Baseline daytime hypercapnia (pCO2> 50 mmHg) OR GOLD 4 airflow limitation (FEV1<30% predicted) OR MRC class 4 symptoms ("I am too breathless to leave the house" OR "I am breathless when dressing")
• A7. Broncho-pleural fistula
• A8. Tracheostomy present at ICU admission for the purpose of chronic or prolonged mechanical ventilation (>21 days). (Note that a patient who was endotracheally intubated for acute respiratory failure and received a tracheostomy during their ICU admission, prior to enrolment, is not excluded under A8).
• A9. Current enrolment in a confounding study, as assessed by the steering committee
• A10. Previous randomization in the PROMIZING Study
• A11. Severe, end-stage, irreversible respiratory or cardiac disease (e.g. interstitial lung disease, pulmonary fibrosis, cardiomyopathy, valvulopathy) likely to result in prolonged or chronic ventilator dependence /unlikely to wean from mechanical ventilation [Note: patients who are candidates for intervention to treat the underlying respiratory/cardiac disease (e.g. lung transplant, heart transplant, cardiac surgery) may be re-evaluated once intervention is complete and they no longer meet criteria A11.]

B. ENROLMENT INCLUSION CRITERIA:

• B1. Ability or potential ability to trigger ventilator breaths (i.e. not receiving neuromuscular blockade).
• B2. On Assist/Control volume-cycled ventilation: Technically satisfactory plateau pressure ≤ 30 cm H2O (see Operations Manual) OR On Assist/Control pressure-controlled ventilation or similar mode: Pressure control plus PEEP ≤ 30 cm H2O OR On Pressure Support ventilation: Pressure support plus PEEP ≤ 30 cm H2O OR On Proportional Assist ventilation: PAV gain <85%
• B3. PaO2 ≥ 60 mmHg or SpO2 ≥ 90% on FiO2 ≤ 0.60 and PEEP ≤ 15 cm H2O
• B4. Metabolic disorders corrected: pH ≥7.32
• B5. Stable hemodynamic status: stable or decreasing doses of vasopressors for ≥6 hours
• B6. Anticipate ongoing need for ventilation >24 hours

B. ENROLMENT EXCLUSION CRITERIA:

• B7. Extubated
• B8. Died
• B9. Patient has met enrolment inclusion criteria B1-B5 AND has tolerated pressure support of 0-20 cm H2O or proportional assist ventilation of 0-85% for ≥24 consecutive hours (including time on CPAP, t-piece, or tracheostomy mask). (Note (1): that it is acceptable to include a patient who has been tried on pressure support or proportional assist ventilation but has required pressures >20 cmH2O or assistance >85% or has required return to A/C ventilation within the 24 hour time window; Note (2): B9 does not apply to patients on ECMO.)
• B10. Patient transferred to a non-participating centre

B. ENROLMENT DEFERRAL CRITERIA:

• B11. Plan to extubate/discontinue mechanical ventilation within <24 hours (Reassess within 24 hours)
• B12. Patient currently on ECMO (Reassess patient once off ECMO)
• C9: Plan for surgery or complex procedure that will require full ventilation to be done prior to attempting extubation (e.g. Procedure requiring neuromuscular blockade and/or heavy sedation, such that patient would be apneic, or not be able to trigger ventilator) (Reassess after surgery/procedure complete)

C. PRESSURE SUPPORT TRIAL INCLUSION CRITEIRA:

• C2. Upon review of Screening and Enrolment criteria (A and B), the patient still passes.
• C3. Treating physician has provided verbal consent to proceed with standardized tests and randomization if eligibility criteria are met.

C. PRESSURE SUPPORT TRIAL DEFERRAL CRITERIA:

• C6. High dose vasopressor requirements (i.e. epinephrine or norepinephrine >0.5 ug/kg/min or equivalent) OR patient requiring an increase in dose of vasopressor within 6 hrs
• C7. Active cardiac ischemia (dynamic ST changes on monitor or ECG within 6 hours)
• C8. Unstable arrhythmias (HR>140 or <50) with clinical signs of low cardiac output or or SBP<80 mmHg
• C10. Receiving a "strict lung protective" ventilation strategy for ARDS (eg. Order on chart to keep Vt ≤6 mL/kg PBW)

C. PRESSURE SUPPORT TRIAL EXCLUSION CRITERIA:

• C12. Treating physician has declined consent

D. WEANING CRITERIA:

• D1. SpO2≥ 90% on FiO2 ≤0.40 and PEEP ≤8 cmH2O
• D2. pH ≥7.32
• D3. Vasopressor requirements no higher than norepinephrine 0.1 ug/kg/min or equivalent.

In the final stage (E), patients will be considered eligible for randomization if the following criteria are met.

E. RANDOMIZATION INCLUSION CRITERIA:

• C1. Patient/SDM has provided consent OR Plan to obtain deferred consent as Patient incapable and no SDM available to provide consent within the randomization window
• E1. Upon review of Criteria A, B, and C, the patient still passes and the patient has passed the PST.
• E2. Does not meet Weaning Criteria OR Fails the ZERO CPAP Trial OR Fails the SBT

E. RANDOMIZATION EXCLUSION CRITERIA:

• B9. Patient has met enrolment inclusion criteria B1-B5 AND has tolerated pressure support of 0-20 cm H2O or proportional assist ventilation of 0-85% ≥24 consecutive hours (including time on CPAP, t-piece, or tracheostomy mask). Note (1): It is acceptable to include a patient who has been tried on pressure support or proportional assist ventilation but has required pressures >20 cmH2O or assistance >85% or has required return to A/C ventilation within the 24 hour time window; Note (2): B9 does not apply to patients while on ECMO
• C4. Patient/SDM has declined consent
• C5. Patient incapable and no SDM available to provide consent (not applicable if plan to obtain deferred consent)
• E3. Passed SBT on t-piece, FiO2 0.40 for 30-120 minutes
• E4. Approval withdrawn (by physician or patient/SDM)

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Supportive Care
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: PSV ventilation strategy; The control is the standard of care PSV ventilation strategy, designed to adjust the level of support according to usual clinical parameters.	Other: PSV ventilation strategy; An algorithm for adjusting the level of pressure support according to usual clinical parameters; patients not tolerating PSV will be switched to Assist/Control mode according to predefined criteria
Active Comparator: PAV+ ventilation strategy; The intervention is a PAV+ ventilation strategy, designed to adjust the level of support (gain) to target a predefined range of respiratory muscle pressure.	Other: PAV+ ventilation strategy; An algorithm for adjusting the level of support (gain) to maintain a predefined range of respiratory muscle pressure; patients not tolerating PAV+ (Puritan Bennett™ 840 or 980 ventilator) will be switched to Assist/Control mode according to predefined criteria

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Time from randomization to successful liberation from invasive mechanical ventilation.	"Successful liberation" is defined as removal of the endotracheal tube AND remaining alive with no need for reintubation/reinstitution of invasive mechanical ventilation for 7 days post extubation, or until successful ICU discharge, or until live hospital discharge, whichever comes first.	up to 90 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Ventilator-free days at 14, 21 and 28 days post randomization	"Ventilator-free days" (VFDs) are defined as the number of days alive and free of INVASIVE ventilation post SUCCESSFUL EXTUBATION or post successful termination of invasive mechanical ventilation (MV) from time of randomization to day 21 post randomization. "Successful extubation" is defined as removal of the endotracheal tube AND remaining alive with no need for reintubation/reinstitution of invasive mechanical ventilation for 7 days post extubation, or until successful ICU discharge, or until live hospital discharge, whichever comes first.	14, 21 and 28 days post randomization
Time from randomization to live ICU discharge (up to day 90)	Patients will remain in the study and will continue on the assigned ventilation strategy until: successful extubation, successful ICU discharge, live hospital discharge, death, or 90 days post randomization, whichever comes first.	up to 90 days
Time from randomization to live hospital discharge (up to day 90)	Patients will remain in the study and will continue on the assigned ventilation strategy until: successful extubation, successful ICU discharge, live hospital discharge, death, or 90 days post randomization, whichever comes first.	up to 90 days
Weaning Progress	Measured as time from randomization to: first SBT; first successful SBT; first extubation	up to 90 days
Weaning Difficulties	Measured as the number of patients failing first SBT or first extubation attempt and requiring up to 7 days to extubate (difficult weaning group/group 2); failing first SBT or first extubation attempt and requiring more than 7 days to extubate (prolonged weaning group/group 3)	90 days
Weaning Complications	Measured as the number of patients: requiring non-invasive ventilation post-extubation; ventilated more than 7 days post randomization, ventilated more than 21 days from time of intubation (prolonged MV group); receiving tracheostomy post-randomization, requiring re-intubation (up to 7d after planned extubation)	90 days
Tolerance of modes	Measured as number of patients ever requiring A/C mode post randomization; number of patient-days requiring A/C mode post randomization	90 days
Mortality	Measured as time to death, ICU mortality; hospital mortality; 21, 28, and 90 day mortality	up to 90 days
Serious Adverse Events	Incidence of reported serious adverse events	90 days

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Co-interventions	Co-interventions will be monitored and described including use of sedating medications	28 days
Subgroup analyses based on: (a) duration of MV prior to randomization as a continuous variable or as a binary variable of greater than 5 days	Identifies a subgroup of patients at time of randomization who are at risk for prolonged weaning	At randomization
Subgroup analyses based on (b) failing an SBT prior to randomization vs. failed CPAP 0 trial vs. failed weaning criteria prior to randomization	Identifies a subgroup of patients at time of randomization classified as difficult weaning vs. failed CPAP 0 trial vs. failed weaning criteria prior to randomization	At randomization
Subgroup analyses based on (c) failed extubation prior to randomization	Identifies a subgroup of patients at time of randomization classified as having "difficult weaning".	At randomization
Subgroup analyses based on (d) mild vs. moderate vs. severe frailty	Differentiates between severely frail and less frail	At ICU admission
Subgroup analyses based on COVID-19 positive test	Differentiates between COVID-19 positive and COVID-19 negative	At ICU admission
Subgroup analyses based on tracheostomy present at randomization	Identifies a subgroup of patients at risk of prolonged weaning	At randomization

Collaborators and Investigators

• Sponsor: London Health Sciences Centre Research Institute OR Lawson Research Institute of St. Joseph's
• Collaborators: Canadian Institutes of Health Research (CIHR); Medtronic; Canadian Critical Care Trials Group
• Investigators: Principal Investigator: Karen J Bosma, London Health Sciences Centre, London, Ontario, Canada; Principal Investigator: Laurent Brochard, St. Michael's Hospital, Toronto, Ontario, Canada

Publications and helpful links

Helpful Links

• Published Protocol
• The PROMIZING trial enrollment algorithm for early identification of patients ready for unassisted breathing
• PROMIZING Website

Study record dates

Study Major Dates

• Study Start (Actual): September 14, 2016
• Primary Completion (Actual): July 16, 2024
• Study Completion (Actual): July 16, 2024

Study Registration Dates

• First Submitted: May 8, 2015
• First Submitted That Met QC Criteria: May 14, 2015
• First Posted (Estimated): May 19, 2015

Study Record Updates

• Last Update Posted (Actual): May 22, 2025
• Last Update Submitted That Met QC Criteria: May 16, 2025
• Last Verified: August 1, 2024

More Information

Terms related to this study

• Keywords: Weaning; Pressure Support Ventilation; Proportional Assist Ventilation
• Additional Relevant MeSH Terms: Pathologic Processes; Disease Attributes; Respiratory Tract Diseases; Respiration Disorders; Respiratory Insufficiency; Critical Illness
• Other Study ID Numbers: IPR-327433, ISR-2014-10481

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: Data will be collected electronically and stored at the Clinical Coordinating Center at the Applied Health Research Centre (AHRC). A de-identified database of all data may be made available for use 3 years after the primary publication upon request and review of the statistical analysis plan by the PROMIZING steering committee.
• IPD Sharing Time Frame: 3 years after the primary publication
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No