Abstract: We pooled summary estimates from 10 trials evaluating SmartCare™ involving 654 participants. Overall, eight trials were judged to be at low or unclear risk of bias, and two trials were judged to be at high risk of bias. Compared with non-automated strategies, SmartCare™ decreased weaning time (mean difference (MD) -2.68 days, 95% confidence interval (CI) -3.99 to -1.37; P value < 0.0001, seven trials, 495 participants, moderate-quality evidence), time to successful extubation (MD -0.99 days, 95% CI -1.89 to -0.09; P value 0.03, seven trials, 516 participants, low-quality evidence), length of ICU stay (MD -5.70 days, 95% CI -10.54 to -0.85; P value 0.02, six trials, 499 participants, moderate-quality evidence) and proportions of participants receiving ventilation for longer than seven and 21 days (risk ratio (RR) 0.44, 95% CI 0.23 to 0.85; P value 0.01 and RR 0.39, 95% CI 0.18 to 0.86; P value 0.02). SmartCare™ reduced the total duration of ventilation (MD -1.68 days, 95% CI -3.33 to -0.03; P value 0.05, seven trials, 521 participants, low-quality evidence) and the number of participants receiving ventilation for longer than 14 days (RR 0.61, 95% CI 0.37 to 1.00; P value 0.05); however the estimated effects were imprecise. SmartCare™ had no effect on time to first successful SBT, mortality or adverse events, specifically reintubation. Subgroup analysis suggested that trials with protocolized (versus non-protocolized) control weaning strategies reported significantly shorter ICU stays. Sensitivity analysis excluded two trials with high risk of bias and supported a trend toward significant reductions in weaning time favouring SmartCare™. Compared with non-automated weaning strategies, weaning with SmartCare™ significantly decreased weaning time, time to successful extubation, ICU stay and proportions of patients receiving ventilation for longer than seven days and 21 days. It also showed a favourable trend toward fewer patients receiving ventilation for longer than 14 days; however the estimated effect was imprecise. Summary estimates from our review suggest that these benefits may be achieved without increasing the risk of adverse events, especially reintubation; however, the quality of the evidence ranged from low to moderate, and evidence was derived from 10 small randomized controlled trials.

Plain-language summary: We identified 10 trials of moderate quality involving 654 participants and comparing SmartCare™ versus non-automated weaning strategies. Compared with non-automated strategies, SmartCare™ significantly decreased weaning time, time to successful removal from breathing machines and time spent in the ICU, with fewer patients receiving breathing machine support for longer than seven days and 21 days, and no increase in adverse events. SmartCare™ also showed a favourable trend toward fewer patients receiving ventilation for longer than 14 days, with no increase in adverse events. Subgroup analyses suggested more beneficial effects on weaning time in trials comparing SmartCare™ to a protocolized weaning strategy versus a non-protocolized control strategy. Sensitivity analyses, which excluded two trials with high risk of bias, supported significant reductions in weaning time with SmartCare™.