The Cochrane database of systematic reviewsJul 18, 2025

Automatic versus manual breathing support to shorten ventilator time in critically ill adults and children

Circadian Biology Weekly Brief ↗PubMed ↗DOI ↗

Updated Mar 29, 2026

Abstract

Automated closed-loop systems probably reduce the duration of mechanical ventilation by 24% compared to non-automated weaning methods.

Automated closed-loop systems likely decrease ICU length of stay by 14%.
They may lower hospital length of stay by 10%.
These systems probably reduce the need for reintubation by 27%.
Automated systems likely decrease the use of non-invasive ventilation following extubation by 26%.
They may also reduce prolonged ventilation and the need for tracheostomy.

Simplified

RATIONALE: Automated closed-loop systems may improve the adaptation of mechanical ventilatory support to an individual's ventilatory needs. They may also facilitate systematic and early recognition of the patient's ability to breathe spontaneously and come off the ventilator. This is an update of a Cochrane review originally published in 2013 and last updated in 2014.

OBJECTIVES: To evaluate the benefits and harms of automated weaning systems compared with non-automated weaning methods in critically ill, mechanically ventilated adults and children.

SEARCH METHODS: We searched MEDLINE ALL, Embase Classic+Embase, the Cochrane Library (Wiley), CINAHL (EBSCO), the Web of Science Core Collection, and trial registries on 2 February 2024. We checked the reference lists of included studies and relevant systematic reviews for other potentially eligible studies.

ELIGIBILITY CRITERIA: We included randomized controlled trials (RCTs) evaluating automated closed-loop ventilator applications versus non-automated weaning methods (including non-protocolized usual care and protocolized weaning) in people aged over four weeks who were receiving invasive mechanical ventilation in an intensive care unit (ICU).

OUTCOMES: Our critical outcomes were duration of mechanical ventilation (from randomization to successful unassisted breathing or death), mortality, ICU length of stay, and hospital length of stay. Our important outcomes included other ventilation durations, adverse events related to mechanical ventilation, and health-related quality of life.

RISK OF BIAS: Two review authors independently assessed risk of bias using the Cochrane risk of bias tool RoB 1.

SYNTHESIS METHODS: Two review authors independently extracted study data. We synthesized results for each outcome using meta-analysis (random-effects modeling). Subgroup and sensitivity analyses were conducted according to pre-established criteria. We used GRADE to assess the certainty of evidence for each outcome.

INCLUDED STUDIES: This update included 62 trials (59 in adults, 3 in children) with 5052 participants (4834 adults, 218 children). The trials evaluated 10 commercially available automated closed-loop systems and one non-commercial system. Forty trials were conducted in mixed or medical ICU populations, the remainder in surgical ICU populations.

SYNTHESIS OF RESULTS: Automated closed-loop systems probably reduce the duration of mechanical ventilation compared with non-automated weaning methods (mean difference [MD] -0.28 log hours, 95% confidence interval [CI] -0.36 to -0.20; I= 87%; 51 RCTs, 3929 participants; moderate-certainty evidence). These data translate to a relative reduction of 24% (95% CI 18% to 30%). Automated closed-loop systems probably result in little to no difference in mortality compared with non-automated weaning methods (risk ratio [RR] 0.94, 95% CI 0.82 to 1.07; I= 0%; 38 RCTs, 3620 participants, 618 events; moderate-certainty evidence). Automated closed-loop systems probably reduce ICU length of stay compared with non-automated weaning methods (MD -0.15 log days, 95% CI -0.20 to -0.09; I= 71%; 40 RCTs, 3571 participants; moderate-certainty evidence). These data translate to a relative reduction of 14% (95% CI 9% to 18%). Automated closed-loop systems probably reduce hospital length of stay compared with non-automated weaning methods (MD -0.11 log days, 95% CI -0.16 to -0.05; I= 43%; 26 RCTs, 2094 participants; moderate-certainty evidence). These data translate to a relative reduction of 10% (95% CI 5% to 15%). In relation to adverse events related to mechanical ventilation, automated closed-loop systems compared with non-automated weaning methods probably reduce the need for reintubation (RR 0.73, 95% CI 0.59 to 0.89; I= 0%; 28 RCTs, 2670 participants; moderate-certainty evidence), non-invasive ventilation following extubation (RR 0.74, 95% CI 0.62 to 0.88, I= 0%; 23 RCTs, 2451 participants; moderate-certainty evidence), prolonged ventilation (RR 0.54, 95% CI 0.34 to 0.87; I= 0%; 11 RCTs, 1191 participants; moderate-certainty evidence), and tracheostomy (RR 0.75, 95% CI 0.62 to 0.91; I= 0%; 17 RCTs, 1857 participants; moderate-certainty evidence). No studies reported health-related quality of life. Evidence certainty was downgraded for heterogeneity or imprecision. 2 2 2 2 2 2 2 2

AUTHORS' CONCLUSIONS: Based on moderate-certainty evidence from 62 trials including over 5000 critically ill people (mainly adults), we found that automated closed-loop systems probably reduce the duration of mechanical ventilation and the length of ICU and hospital stay compared with non-automated weaning methods. Automated systems probably have little to no effect on mortality but probably reduce the need for reintubation, non-invasive ventilation, prolonged ventilation, and tracheostomy. Given the moderate-certainty evidence of benefit and no evidence of harm, the adoption of automated closed-loop ventilation systems into adult critical care clinical practice warrants consideration. There is a need for further adequately powered multi-center trials in adults and children. Future trials should include health-related quality of life among their outcomes.

FUNDING: This review received no funding.

REGISTRATION: The original review was registered with the Cochrane Database of Systematic Reviews, registration number CD009235. The original protocol, published in 2011, is available at DOI: 10.1002/14651858.CD009235. Previous versions of the review are available at DOI: 10.1002/14651858.CD009235.pub2 (2013) and DOI: 10.1002/14651858.CD009235.pub3 (2014).

Funding

Competing interests

LR completed a randomized controlled trial (RCT) comparing automated weaning using SmartCare/PS with usual care that was included in this systematic review (Rose 2008). She received no funding from Draeger Medical for this study. SmartCare/PS software, and associated technical upgrades for two ventilators, were provided free of charge to the Intensive Care Unit of The Royal Melbourne Hospital by Draeger Medical, Australia. LR also co‐authored an RCT on neurally adjusted ventilatory assist (NAVA; Hadfield 2020). She received no funding for this study. For both studies, LR did not contribute to study selection, data extraction, risk of bias assessment, or GRADE assessment. She has received speaking fees from Draeger Medical and served on a Data and Safety Monitoring Board for Hamilton Medical. MJS is a co‐author of an RCT comparing adaptive support ventilation (ASV) with usual care (Dongelmans 2009) and an RCT comparing INTELLiVENT with usual care (De Bie 2020), both of which were included in this systematic review. For both studies, MJS did not contribute to study selection, data extraction, risk of bias assessment, or GRADE assessment. His research group has received research funding from Hamilton Medical (Switzerland) to conduct studies of ASV and INTELLiVENT. This money was used to buy equipment, a computer, statistician time, and to cover costs involved with the presentation of the results at a scientific meeting and publication of the manuscript. MJS worked part‐time as a team leader at Hamilton Medical AG (Bonaduz, Switzerland) from January 2022 to January 2023. CRC has declared he has no conflict of interest. FP is a co‐author of a study comparing ASV with usual care (Dongelmans 2009) that was included in this review. For that study, she did not contribute to study selection, data extraction, risk of bias assessment, or GRADE assessment. KC has declared he has no conflict of interest. PJ completed an RCT comparing automated weaning using SmartCare/PS with usual care that was included in this systematic review (Jouvet 2013). He received no funding from Draeger for this study, although Draeger Medical provided one ventilator for the purpose of the study. PJ did not contribute to study selection, data extraction, risk of bias assessment, or GRADE assessment for the study he was involved in. He received speaker fees from Philips Medical. BB is a Cochrane Editor for the Emergency and Critical Care Group but was not involved in the editorial process for this review.

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Automatic versus manual breathing support to shorten ventilator time in critically ill adults and children

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Competing interests

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