Egyptian Journal of Chest Diseases and Tuberculosis xxx (2017) xxx–xxx

Contents lists available at ScienceDirect

Egyptian Journal of Chest Diseases and Tuberculosis

journal homepage: www.sciencedirect.com

Use of automatic tube compensation(ATC) for weaning from mechanical

ventilation in acute respiratory failure
Mahmoud ELBatanouny a,⇑, Akram M Abdelbary b
a
Chest Department Faculty of Medicine, Benisuief University, Egypt
b
Critical Care Department Faculty of Medicine, Cairo University, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: Aim of study: To evaluate the automatic tube compensation (ATC) as a method of weaning from mechan-
Received 20 April 2017 ical ventilation in acute respiratory failure in comparison to pressure support volume (PSV).
Accepted 2 July 2017 Patients and methods: 60 patients with, acute respiratory failure were enrolled in this study. Patients who
Available online xxxx
met the criteria of weaning had one hour of a spontaneous breathing trial (SBT) either with ATC (n = 35)
or with PSV (n = 25). Patients who passed the weaning trial were extubated and put on oxygen, while
Keywords: others who didn’t pass were put back on mechanical ventilation.
Acute respiratory failure
Results: The SBT in the 60 enrolled patients weaning was successful in 35 patients (58.3%). 20 of the 35
Automatic tube compensation (ATC)
Pressure support ventilation (PSV)
patients (57.1%) who underwent ATC had successful weaning, and 15 out of the 25 patients (60%) who
Weaning underwent PSV had also successful weaning. The difference had no statistical significance (p = 0.7).
Mechanical ventilation Sensitivity of 80.36% with a positive predictive value (PPV) of 90.14% and a specificity of 79.63% with a
negative predictive value (NPV) of 81.25% were shown in ATC, while PSV showed a sensitivity of
76.35% with a PPV of 88.63% and a specificity of 80.36% with a NPV of 71.4%. ATC was superior to PSV
regarding PaO2/FIO2 ratio, oxygen saturation, oxygen tension, dynamic compliance and airway resistance.
Conclusion: ATC is a useful mode of weaning in patients mechanically ventilated due to acute respiratory
failure.
Ó 2017 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and
Tuberculosis. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).

Introduction
Weaning from mechanical ventilation has always been a prob-
lem for critical care physicians especially in patients with ARF. ATC
is a mode of weaning that proved to be one of the superior modes
of weaning. Airway resistance and increased work of breathing due
to the endotracheal tube (ETT) was the main problem for T-tube
trials, thus ATC was developed to overcome this problem [1]. Nor-
mal volunteers stated that they felt more comfortable when sub-
jected to ATC versus PSV [2].
Some of the new ventilators in use today include ATC built-in
(e.g., Evita XL and Evita 4, Drager Medical, Lubeck, Nellcor Puritan
Bennett 840). ATC compensates for resistance associated with an
endotracheal tube via closed loop control of continuously calcu-
lated tracheal pressure.
ATC built-in in Puritan Bennett 840 allows the clinician to set
the percent support in a range from 10% to 100%. Should the clin-
ician desire, percent support is easily adjusted to support some-
thing less than total compensation. The built-in ATC also has the
ability to track patients with variable drive: A patient’s ventilatory
drive and resultant flow can change dramatically depending on
whether patients are sleep or awake, calm or agitated. ATC can
vary pressure considerably to compensate for any flow demand [3].
Aim of work
To evaluate the automatic tube compensation (ATC) as a
method of weaning from mechanical ventilation in acute respira-
tory failure in comparison to pressure support volume (PSV).

Patients and methods

Peer review under responsibility of The Egyptian Society of Chest Diseases and
Tuberculosis. The study was a prospective non randomized trial done on 60
⇑ Corresponding author. adult patients admitted to the Critical Care Medicine Department
E-mail address: madoelbatanony@hotmail.com (M. ELBatanouny). in Cairo University hospitals and Benisuief pulmonary critical care

http://dx.doi.org/10.1016/j.ejcdt.2017.07.002
0422-7638/Ó 2017 Production and hosting by Elsevier B.V. on behalf of The Egyptian Society of Chest Diseases and Tuberculosis.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Please cite this article in press as: M. ELBatanouny, A.M. Abdelbary, Use of automatic tube compensation(ATC) for weaning from mechanical ventilation in
acute respiratory failure, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2017.07.002
2 M. ELBatanouny, A.M Abdelbary / Egyptian Journal of Chest Diseases and Tuberculosis xxx (2017) xxx–xxx

unit presenting with ARF and mechanically ventilated for at least
24 h. Patients were above the age 18, resolution of the cause of fail-
ure, fully conscious and meeting the criteria of weaning.
There is no conflict of interest in this study.
Patients were divided into 2 groups; group I including 35
patients who were subjected to ATC as a trial of weaning and group
II including 25 patients who were subjected to PSV. The group of
ATC was breathing through the ventilator with flow trigger (1 L/
min), and PEEP of 5 cmH2O with ATC being set at 100%. ATC was
delivered through the ventilator (Puritan- Bennett 840). The group
of PSV was breathing through the ventilator with flow trigger (1 L/
min) and PEEP of 5 cmH2O adding 7 cmH2O of pressure support. In
the two modes, the FIO2 was at the same level needed before the
trial of breathing. Patients who passed the weaning trial were
extubated and put on oxygen, while others who didn’t pass were
put back on mechanical ventilation.
Statistical presentation and analysis of the present study was
conducted, using the mean, standard deviation and chi-square test
by SPSS V.l6.
Results
There were no significant differences between both groups as
regards PaCO2 and R/TV ratio (rapid shallow breathing index) (P
value >0.05) (Table 1).
Both groups were comparable to each other regarding their out-
come. (Table 4):
Discussion
A study [9] was done to assess the accuracy of ATC in mechan-
ical ventilators. It was found that ventilators with built-in ATC
don’t have expiratory tube compensation; which might be benefi-
cial for COPD patients, as ATC expiratory assistance will result in
closure of the small airways [9]. However, from another point of
view it might in fact eliminate dynamic hyperinflation. Further
clinical studies are needed to evaluate this issue.
The rate of reintubation in this study was 41.6%. Which is
higher than several studies varying from 13.5% [10]to 14% [7] to
18.6% [11] to 25% [12,13]. Most studies evaluated patients at low
risk for extubation failure, whose reintubation rates were about
10 to 15%, whereas several studies identified high-risk patients
with extubation failure rates exceeding 25 or 30%.
The high reintubation rate in our study may be explained by the
high percentage of patients with COPD with exacerbation (31.7%),
and bronchopneumonia (25%). These two are known to increase
the incidence of extubation failure. In cases of COPD with exacer-
bation, the patients are usually very severe COPD; these patients
have depleted muscles and severe emphysema which contributes
to more dependency on the ventilator and extubation failure.
These COPD patients may need more prolonged ventilation in addi-
tion to other methods of weaning as non-invasive mechanical ven-
tilation in case of repeated weaning failure. Patients with
bronchopneumonia may require more prolonged ventilation till
the bronchopneumonia resolves completely.
Randomized control study was not performed as the patients
were entitled in this study according to their admission to the
ICU and once inclusion criteria were met they were included in
the study as the ICU is a general one. So all causes of ARF can be
included in the study.

In our study, there was no significant difference in the number

of patients who tolerated the spontaneous breathing trial and then Table 2
showing precipitating cause of acute respiratory failure.
extubated between ATC and PSV groups (57.1% vs. 60% respec-
tively, p value = 0.663). Both modes had comparable sensitivity, Cause of respiratory failure Group Total
and positive predictive value. Sensitivity was 80.36%versus ATC PSV
79.63% and the positive predictive value was 90.14%, versus
Bronchopneumonia N 11 4 15
88.63% for ATC versus PSV respectively. The specificity was compa- % 31.4% 16.0% 25%
rable (79.63% versus 80.36% in ATC versus PSV respectively). ATC Cardiac arrest N 2 2 4
group had higher ve predictive value than PSV group (71.4% ver- % 5.7% 8.0% 6.7%
ARDS N 0 2 2
sus 81.25% respectively) (see Tables 2 and 3).
% 0% 8.0% 3.3%
This is compatible with the results obtained by a study that ran- COPD with acute exacerbation N 8 11 19
domized 180 ICU subjects on invasive mechanical ventilation into % 22.9% 44.0% 31.7%
2 groups (ATC, n = 87 and PSV, n = 93). They found that there was Suspected acute pulmonary embolism N 4 1 5
no statistically significant difference between both groups as % 11.4% 4.0% 8.3%
Acute pulmonary edema N 6 1 7
regards the extubation outcome (ATC, 65 of 87 (74.7%) vs. PSV.
% 17.1% 4.0% 11.7%
68 of 93 (73.1%); p = 0.81). They found that PSV had a higher PPV Traumatic brain injury N 1 1 2
predicting patients with successful extubation than ATC (PSV. % 2.9% 4.0% 3.3%
85% versus 80%); however, the difference was not significant Interstitial pulmonary fibrosis N 0 2 2
% 0% 8.0% 3.3%
(P = 0.87) [4].
Neuromuscular disease N 3 1 4
The possible cause for failure to find any superiority of ATC to % 8.7% 4.0% 6.7%
PSV could be attributed to the use of a ventilator having ATC Total N 35 25 60
built-in namely Puritan-Bennett 840, while in almost all other % 100% 100% 100%
studies [5,2,6,7] (Except that done by Cohen et al.,) [8] ATC was X2 1.336
P. value 0.225
done by using ventilators equipped with prototype ATC software
(see Table 5).

Table 1
showing demographic features (age and sex) in both groups.

ATC Group PSV Group t. test p. value

Age Range 24–83 23–82 0.635 0.418
Mean ± SD 57.7 ± 12.7 57.5 ± 14.1
Sex M 18(54.1%) 16(64%) 0.332 0.224
F 17(48.6%) 9(36%)

Please cite this article in press as: M. ELBatanouny, A.M. Abdelbary, Use of automatic tube compensation(ATC) for weaning from mechanical ventilation in
acute respiratory failure, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2017.07.002
 M. ELBatanouny, A.M Abdelbary / Egyptian Journal of Chest Diseases and Tuberculosis xxx (2017) xxx–xxx 3

Table 3
showing respiratory parameters at the end of the trial.

ATC Group PSV Group p. value

R/TV ratio Range 30–90 48–100 0.852
Mean ± SD 62.86 ± 13.42 65.2 ± 13.66
SPO2 Range 81–99 76–98 0.042
Mean ± SD 92.2 ± 2.70 91.4 ± 6.21
PaO2 Range 62.4–190 58–112 0.017
Mean ± SD 95.7 ± 21.5 83.1 ± 16.2
PaCO2 Range 30–48 21.5–55 0.880
Mean ± SD 40.1 ± 4.50 39.8 ± 8.02
PaO,/FIO2 Range 186–475 100–373 0.056
Mean ± SD 260.4 ± 67.3 226.4 ± 6514.7
Dynamic compliance Range 14.2–50 14.2–33.3 0.005
Mean ± SD 26.4 ± 6.52 20.73 ± 5.3
Airway resistance Range 1–7 3–11 0.009
Mean ± SD 3.62 ± 1.37 5.92 ± 2.08
Auto PEEP Range 0–7 0–9 0.001
Mean ± SD 0.57 ± 1.11 3.68 ± 2.80

Table 4
showing extubating Outcome:

ATC Group PSV Group X2 p. value

N % N %
Outcome Succeeded 20 57.1 15 60 0.049 0.663
Failed 15 42.8 10 40

Table 5
showing comparison between ATC and PSV as predictors of successful weaning:

Group Area under the curve Cutoff Sensitivity Specificity PPV NPV
ATC 0.635 0.752 80.36% 79.63% 90.14 81.25
PSV 0.769 0.528 76.35% 80.36% 88.63 71.4

Conclusion
ATC is a useful mode of weaning in patients mechanically ven-
tilated due to acute respiratory failure in comparison to PSV. ATC is
an additional mode for performing an SBT that shows promise for
enhancing weaning processes.
Higher baseline PaO2, higher PaO2/FIO2, and higher dynamic
compliance were predictors of successful weaning
Further studies with higher number of patients and better
design are needed to evaluate the exact role of ATC in relation to
other SBT techniques.
References
[1] I. Alia, A. Esteban, Weaning from mechanical ventilation, Crit. Care 4 (2000)
72–80.
[2] J. Guttmann, H. Bernhard, G. Mols, A. Benzing, P. Hofmann, C. Haberthur, D.
Zappe, B. Fabry, K. Geiger, Respiratory comfort of automatic tube
compensation and inspiratory pressure support in conscious humans,
Intensive Care Med. 23 (1997) 1119–1124.
[3] B. Fabry, C. Haberthur, D. Zappe, J. Guttmann, R. Kuhlen, R. Stocker, Bereathing
pattern and additional work of breathing in spontaneously breathing patients
with different ventilator demands during inspiratory pressure support and
automatic tube compensation, Intensive Care Med. 23 (5) (1997) 545–552.
[4] J. Cohen, M. Shapiro, E. Grozovski, B. Fox, S. Lev, P. Singer, Prediction of
extubation outcome: a randomized, controlled trial with automatic tube
compensation vs. pressure support ventilation, Crit. Care 13 (1) (2009), article
R21.
[5] C. Haberthur, S. Elsasser, L. Eberhard, R. Stocker, J. Guttmann, Total versus
tube-related additional work of breathing in ventilator-dependent patients,
Acta Anaesthesiol Scand. 44 (2000) 749–757.
[6] C. Haberthiir, B. Fabry, D. Zappe, J. Guttmann, Effects of mechanical unloading
and mechanical loading on respiratory loop gain and periodic breathing in
man, Respir. Physiol. 112 (1998) 23–36.
[7] C. Haberthur, G. Mols, S. Elsasser, R. Bingisser, R. Stocker, J. Guttmann,
Extubation after breathing trials with automatic tube compensation, T-tube, or
pressure support ventilation, Acta Anaesthesiol Scand. 46 (8) (2002) 973–979.
[8] J.D. Cohen, M. Shapiro, E. Grozovski, S. Lev, H. Fisher, P. Singer, Extubation
outcome following a spontaneous breathing trial with automatic tube
compensation versus continuous positive airway pressure, Crit. Care Med. 34
(3) (2006) 682–686.
[9] S. Elsasser, J. Guttmann, R. Stocker, G. Mols, H.J. Priebe, C. Haberthiir, Accuracy
of automatic tube compensation in new-generation mechanical ventilators,
Crit. Care Med. 31 (2003) 2619–2626.
[10] R. Kuhlen, R. Rossaint, Electronic extubation—is it worth trying?, Intensive
Care Med 23 (1997) 1105–1107.
[11] A. Esteban, I. Alia, F. Gordo, Extubation outcome after spontaneous breathing
trial with T-tube or pressure support ventilation (the Spanish Lung Failure
Collaborative Group), Am. J. Respir. Crit. Care Med. 156 (1997) 459–465.
[12] A. Uusaro, D.R. Chittock, J.A. Russell, K.R. Walley, Stress test and gastric-arterial
PCO2 measurement improve prediction of successful extubation, Crit. Care
Med. 28 (2000) 2313–2319.
[13] M. El-Khatib, G. Jamaleddined, R. Soubra, M. Muallem, Pattern of spontaneous
breathing: potential marker for weaning outcome, Int. Care Med. 27 (2001)
52–58.

Please cite this article in press as: M. ELBatanouny, A.M. Abdelbary, Use of automatic tube compensation(ATC) for weaning from mechanical ventilation in
acute respiratory failure, Egypt. J. Chest Dis. Tuberc. (2017), http://dx.doi.org/10.1016/j.ejcdt.2017.07.002