Airway pressure release ventilation for lung protection in acute respiratory distress syndrome: an alternative way to recruit the lungs

Author:

Camporota Luigi12,Rose Louise13,Andrews Penny L.4,Nieman Gary F.5,Habashi Nader M.4

Affiliation:

1. Department of Critical Care, Guy's & St Thomas’ NHS Foundation Trust

2. Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences

3. Florence Nightingale Faculty of Nursing, Midwifery, and Palliative Care, King's College London, London, UK

4. Department of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland

5. Department of Surgery, Upstate Medical University, Syracuse, New York, USA

Abstract

Purpose of review Airway pressure release ventilation (APRV) is a modality of ventilation in which high inspiratory continuous positive airway pressure (CPAP) alternates with brief releases. In this review, we will discuss the rationale for APRV as a lung protective strategy and then provide a practical introduction to initiating APRV using the time-controlled adaptive ventilation (TCAV) method. Recent findings APRV using the TCAV method uses an extended inspiratory time and brief expiratory release to first stabilize and then gradually recruit collapsed lung (over hours/days), by progressively ‘ratcheting’ open a small volume of collapsed tissue with each breath. The brief expiratory release acts as a ‘brake’ preventing newly recruited units from re-collapsing, reversing the main drivers of ventilator-induced lung injury (VILI). The precise timing of each release is based on analysis of expiratory flow and is set to achieve termination of expiratory flow at 75% of the peak expiratory flow. Optimization of the release time reflects the changes in elastance and, therefore, is personalized (i.e. conforms to individual patient pathophysiology), and adaptive (i.e. responds to changes in elastance over time). Summary APRV using the TCAV method is a paradigm shift in protective lung ventilation, which primarily aims to stabilize the lung and gradually reopen collapsed tissue to achieve lung homogeneity eliminating the main mechanistic drivers of VILI.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Critical Care and Intensive Care Medicine

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