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volume delivered [6], it did facilitate faster weaning when compared with PSV [7] However, it could be argued that COPD patients are usually difficult to wean and should be carefully managed to prevent any iatrogenic harms such as air leaks which might occur as a result due to their highly compliant lung.And although the mode minimizes clinician's intervention which might minimize errors and prevent delay in weaning, their intervention might be needed when the ventilator provides more/less support needed when it is used as an initial mode of ventilation.Acute Respiratory Distress Syndrome (ARDS) and Acute Lung Injury (ALI) hence, one research indicated that ASV could provide more than 10ml/kg in such case [8] which does not follow lung protective strategies currently recommended for such lung abnormality [9].The patient is weaned from sedation, oriented with adequate level of consciousness Comparison with Other Weaning Modes A literature search on comparative studies between ASV and other weaning modes were conducted, for the aim of identifying the advantages of ASV over any of them if any.And although this time the ASV mode showed no superiority over SIMV followed by PS in the length of tracheal intubation, ICU stay, and amounts of postoperative sedation, the advantages of less clinician intervention needed might considered as an advantage for the ASV mode.However, the major concern within the weaning protocol was edited; by depending on the normalization of the PaCO2 value instead of taking extra 6 spontaneous breaths, which might be considered as a more reliable indicator for the patients allocated to the SIMV group to be eligible for the next phase of weaning.Interestingly, they stated that ASV delivered significantly higher tidal volumes, which might be beneficial for post open heart surgery patients who are prone to derecrutment, but it might be against the current recommendation about protective lung strategies using less volume.And although, their protocol for the PC group stated that once there was detected spontaneous breaths it was their indicator to switch the patients to PSV, the mandatory breaths on PC was set at 12-15 BPM which might be satisfactory for stable post- operative patients.In one study compared between ASV and Synchronised Intermittent Mandatory Ventilation (SIMV) followed by Pressure Support (PS) following a three phases protocol ASV group were extubated faster than SIMV followed by PS group [10].Furthermore, it would be interesting to investigate the differences between ASV mode and SIMV+PS mode, since most of the current ventilators provide SIMV

• PS as a single mode.When the targeted ABG values is reached which includes acceptable oxygenation PaO2>60 on FiO2<40 2.however, there was major concerns within their weaning protocol which could delay the weaning process for the SIMV group such as waiting for the patient to trigger 6 spontaneous breaths in addition to the set 12 mandatory breaths which might not considered as a proper approach.Hence, it could be argued that this mode would provide more support to the patient's spontaneous effort which might facilitate faster weaning.Thus, future studies comparing between various published protocols might be needed.The patient is clinically stable with adequate respiratory effort and equal bilateral air entry 5.ASV and Pressure Control (PC) modes were compared followed by PSV in weaning [5].Conclusion There is not enough evidence to proof ASV superiority over other weaning modes of ventilation.Additionally, every published study about ASV had used the mode with different protocol.Low inspiratory pressure (under 8cmH2o) to deliver acceptable volumes.Hence, most of the stable post-operative patients would not need to breathe more than 12 Breathes Per Minute (BPM).When Extubation is Recommended?However, there was no difference between both groups in time till extubation.Hemodynamically stable 3.Almost the same team conducted same study [11].2.1.4.

volume delivered [6], it did facilitate faster
weaning when compared with PSV [7] However,
it could be argued that COPD patients are usually
difficult to wean and should be carefully managed
to prevent any iatrogenic harms such as air leaks
which might occur as a result due to their highly
compliant lung.
2. Acute Respiratory Distress Syndrome (ARDS)
and Acute Lung Injury (ALI) hence, one research
indicated that ASV could provide more than
10ml/kg in such case [8] which does not follow
lung protective strategies currently recommended
for such lung abnormality [9].
When Extubation is Recommended?

1. When the targeted ABG values is reached which includes
   acceptable oxygenation PaO2>60 on FiO2