APRV may offer potential clinical advantages for ventilator management of acute lung injury/acute respiratory distress syndrome and may be considered as an alternative "open lung approach" to mechanical ventilation. Whether APRV reduces mortality or increases ventilator-free days compared with a conventional volume-cycled "lung protective" strategy will require future randomized, controlled trials.

No abstract

BACKGROUND Improper mechanical ventilation can exacerbate acute lung damage causing a secondary ventilator induced lung injury (VILI). We hypothesize that VILI can be reduced by modifying specific components of the ventilation waveform (mechanical breath) and studied the impact of airway pressure release ventilation (APRV) and controlled mandatory ventilation (CMV) on the lung micro-anatomy (alveoli and conducting airways). The distribution of gas during inspiration and expiration and the strain generated during mechanical ventilation in the micro-anatomy (micro-strain) were calculated. STUDY DESIGN Rats were anesthetized, surgically prepared and randomized into one uninjured Control group (n=2) and four groups with lung injury: 1)APRV 75% (n=2)–time at expiration (TLow) set to terminate appropriately at 75% of Peak Expiratory Flow Rate (PEFR); 2)APRV 10% (n=2)-TLow set to terminate inappropriately at 10% of PEFR; 3)CMV with PEEP 5cmH2O (PEEP 5;n=2) or 4)PEEP 16cmH2O (PEEP 16;n=2). Lung injury was induced in the experimental groups by Tween lavage and ventilated with their respective settings. Lungs were fixed at peak inspiration and end expiration for standard histology. Conducting airway and alveolar air space areas were quantified and conducting airway micro-strain calculated. RESULTS All lung injury groups redistributed inspired gas away from alveoli into the conducting airways. APRV 75% minimized gas redistribution and micro-strain in the conducting airways and provided the alveolar air space occupancy most similar to Control at both inspiration and expiration. CONCLUSIONS In an injured lung, APRV 75% maintained micro-anatomical gas distribution similar to that of the normal lung. The lung protection demonstrated in previous studies using APRV 75% may be due to a more homogeneous distribution of gas at the micro-anatomical level as well as a reduction in conducting airway micro-strain.

Systematic review, level IV.