Proportional modes for weaning from invasive mechanical ventilation in adult patients: a systematic review and network meta-analysis of randomized controlled trials

Background.Liberation from invasive mechanical ventilation (IMV) is a key objective in critically ill patients. Pressure support ventilation (PSV)is the most commonly used and may be associated with patient–ventilator asynchrony and suboptimal assistance. Advanced ventilatory modes, including neurally adjusted ventilatory assist (NAVA), proportional assist ventilation (PAV), adaptive support ventilation (ASV), and SmartCare/pressure support (SmartCare/PS), may improve patient–ventilator interaction and facilitate weaning. We performed a systematic review and network meta-analysis (NMA) comparing these modes with PSV in adult ICU patients undergoing IMV weaning. Methods.MEDLINE, Scopus, and ClinicalTrials.gov were searched from inception to March 27, 2026 (PROSPERO CRD420251268880) for randomized controlled trials enrolling adult ICU patients undergoing IMV weaning and comparing NAVA, PAV, ASV, SmartCare/PS, and PSV. The primary outcome was weaning success. Secondary outcomes included weaning duration, IMV duration, patient–ventilator asynchrony index (AI), severe AI, 28-day ventilator-free days, reintubation, and ICU, hospital, and 28-day mortality. A frequentist random-effects NMA was performed, with treatment ranking based on P-scores. Certainty of evidence was assessed using CINeMA. Results.Twenty-one RCTs involving 3,611 patients were included. Compared with PSV, NAVA significantly increased weaning success (RR 1.31, 95% CI 1.01–1.69), reduced weaning duration (MD −0.58 days, 95% CI −0.99 to −0.18), decreased AI (MD −7.77%) and severe asynchrony (MD −0.38), shortened IMV duration, increased ventilator-free days, and reduced hospital mortality (RR 0.59, 95% CI 0.40–0.86). PAV (RR 1.16, 95% CI 0.96–1.41), ASV (RR 1.05, 95% CI 0.87–1.26), and SmartCare/PS (RR 1.04, 95% CI 0.91–1.19) showed non-significant trends toward higher weaning success. ASV significantly shortened weaning duration (MD −0.65 days, 95% CI −1.06 to −0.24) and reduced severe asynchrony. No significant differences were observed in reintubation, ICU mortality or 28-day mortality. Conclusions.NAVA improved weaning success, reduced asynchrony and hospital mortality, shortened IMV duration, increased ventilator-free days, compared with PSV. ASV reduced weaning duration and severe asynchrony. These findings support NAVA, and to a lesser extent ASV, as preferred weaning modes, particularly in patients at high risk of asynchrony or prolonged ventilation.