aprv
TRANSCRIPT
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AIRWAY PRESSURE RELEASE VENTILATION
APRVAhmed Al Gahtani, BSRC, RRT.
Associate Director Clinical Education & InstructorChairman, RTS Advisory Committee
Dept. of Respiratory Therapy ProgramInaya Medical College
SSRC Central & Northern Chapter Board Member for RC Education
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APRV• What • When • How
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What When How
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What is APRV ■ Airway pressure release ventilation (APRV) was described more than
20 years ago by Stock & Down in 1987 as a CPAP with an intermittent release phase.
■ APRV is a time-cycled alternant between two levels of positive airway pressure, with the main time on the high level and a brief expiratory release to facilitate ventilation allows spontaneous breathing throughout the ventilation cycle
■ APRV applies CPAP (P high) for a prolonged time (T high) to maintain adequate lung volume & alveolar recruitment, with a time cycled release phase to a lower set of pressure (P low) for a short period of time (T low) or (release time) where most of the ventilation & CO2 removal occurs
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■ The Dräger Evita was the first ventilator in the United States to provide APRV. Subsequently other intensive care unit (ICU) ventilators, such as the Hamilton G-5, the Puritan Bennett 840, the Dräger V500, the CareFusion AVEA, and the Maquet Servo-i, incorporated APRV.
■ Servo-i refers to APRV as Bi-vent ■ Puritan Bennett 840 uses the term Bi-level ■ Hamilton G5 refers to APRV as Duo-PAP. ■ The function of APRV may also be different with
each ventilator.■ ‘APRV’ is common to users in North America,
biphasic positive airway pressure (BIPAP) was introduced in Europe
What is APRV
Henzler Critical Care 2011, 15:115
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APRV Set Parameters
■P high. ■P low ■T high ■T low ■(10% to 30%)
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HOW
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When ■ APRV indicated for ARDS management and atelectasis after major
surgery.■ APRV presents many attractive benefits as an alternative mode of
mechanical ventilation in patients who do not respond to conventional modes.
■ APRV contraindicated with COPD & Asthma, Deep sedation, and NMD
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■ This study is the largest reported randomized trial of APRV to date. Trauma patients at risk for ARDS ventilated with
■ APRV had similar outcomes as those treated with LOVT ■ APRV seems to be a safe alternative ventilator modality that provides
increased mean airway pressure as a potential recruitment mechanism.■ Sedation requirements seem to be similar to SIMV.■ Additional trials in patients with documented ARDS will be necessary for
further clarification of its ultimate utility.
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■ The preemptive ventilation strategy presented in our study has the potential to change the current clinical practice paradigm from treating ARDS once it manifests to preventing it from ever developing.
■ Clinical application can begin without delay with an immediate impact on patient care.
■ If successful, our ventilation strategy would be the first prophylactic intervention of any kind to prevent ARDS.
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PROS AND CONSAdvantages■ alveolar recruitment and improved
oxygenation■ preservation of spontaneous
breathing■ reduction of left ventricular
transmural pressure and therefore reduction of left ventricular afterload
■ potential lung-protective effect■ better ventilation of dependent areas■ lower sedation requirements to allow
spontaneous breathing
Disadvantages■ risks of volutrauma from increased
transpulmonary pressure■ increased work of breathing due to
spontaneous breathing■ increased energy expenditure due to
spontaneous breathing■ worsening of air leaks (bronchopleural
fistula)■ Increased right ventricular afterload,
worsening of pulmonary hypertension■ Reduction of right ventricular venous return:
may worsen intracranial hypertension, may worsen cardiac output in hypovolemia
■ Risk of dynamic hyperinflation
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Four Hypotheses Are Possible1, APRV/BIPAP is better than A/C; 2, APRV/BIPAP is worse than A/C; 3,there is no difference between APRV/BIPAP and A/C; 4,it is undetermined whether there is a difference between APRV/BIPAP and A/C.
Henzler Critical Care 2011, 15:115
Finally