Adaptive support ventilation (ASV) has entered wide use based on its attractive premise: it's patient-centered ventilation, adapting breath-by-breath to deliver precisely the right amount of pressure support to achieve a targeted minute ventilation. However, evidence for any superiority over conventional ventilator modes is limited to cardiac surgery patients who were extubated in ~6 hours regardless of the mode used (but faster with ASV). In heavy-duty, hard-to-wean patients, there's no known benefit to ASV. And in acute lung injury and ARDS, machines set on ASV's internal work-of-breathing equation routinely and blithely exceed 8 mL/kg tidal volumes, inducing shudders in pulmonary physicians. Kirakli et al randomized 97 patients with COPD and respiratory failure who were ready to wean to either go on ASV with stepwise reduction in minute ventilation support, or on pressure support ventilation in stepwise reductions. Patients went on a spontaneous breathing trial when they completed the step-down wean. This was at a single tertiary care center in Izmir, Turkey.