A Pilot Study of Patients With COVID–19-Related Respiratory Failure Utilizing Airway Pressure Release Ventilation (APRV)

Abstract

Background Pneumonia leading to acute respiratory distress syndrome (ARDS) is one of the devastating consequences of coronavirus disease 2019 (COVID-19). Airway pressure release ventilation (APRV) has been described as beneficial in acute lung injury and ARDS. We hypothesized that utilizing APRV would be advantageous in the COVID-19 ARDS population. Methods Prospective, observational, single-center study. Data were extracted on demographics, vasopressors, sedatives, analgesics, and oxygenation (PaO2/FiO2). A generalized linear mixed models analysis was performed to compare low tidal volume ventilation (LTV) with APRV for patients who required intubation due to ARDS from COVID-19 and who were managed with at least 48 consecutive hours of APRV in our surgical intensive care unit (SICU). Results Twelve patients met criteria; two were on APRV mode from admission to the SICU and were not included in the study. Ten patients were analyzed and were primarily male (70%), average age of 64.5 ± 12.9 years, and 70% were obese (average body mass index of 30.6 ± 8.0 kg/m2). There were no smokers in the sample, but two patients presented with underlying lung pathology. APRV was shown to significantly increase the PaO2/FiO2 ratio by 30% (5% to 61%) (p = 0.05) and was associated with up to a 12% (−26% to 5%) reduction in the level of FiO2 and reduction in the use of vasopressor support (−59% [−83% to −2%]), sedatives (−15% [−29% to 2%]), and analgesics (−16% [−38% to 12%]). Conclusions This pilot study showed that APRV was associated with decreases in FiO2, vasopressors, sedatives, and analgesic requirements with an increase in PaO2/FiO2 ratio. In the current pandemic, where providers are grappling with ways to manage COVID-19 ARDS, APRV may be the optimal ventilator mode. Prospective randomized studies are required to validate whether use of APRV in the COVID-19 population leads to improved oxygenation and a subsequent decrease of ventilator days and length of stay.

Airway Pressure Release Ventilation for Acute Respiratory Failure Due to Coronavirus Disease 2019: A Systematic Review and Meta-Analysis

“…Five studies 17,[20][21][22][23] were included in the analysis of PaO 2 / FiO 2 ratio and four studies 17,[21][22][23] were included in the analysis of PaCO 2 . Compared to CMV, APRV was associated with a 33% increase in PaO 2 /FiO 2 ratio (RoM, 1.33; 95%CI, 1.21-1.48; I², 29%) (Figure 5) and a 9% decrease in PaCO 2 (RoM, 0.91; 95% CI, 0.85-0.98; I², 0%) (Figure 6).…”

“…Of 181 articles screened, seven studies with a combined population of 354 patients satisfied the inclusion criteria (Figure 1), including one RCT, 17 two cohort studies, 18,19 and four beforeafter studies with no control group. [20][21][22][23] All studies were conducted in 2020, including one pre-print 21 and two conference abstracts. 18,23 The authors of the abstracts responded to our request for further details, with one provided us with the full text of the unpublished manuscript.…”

Functional pathophysiology of SARS-CoV-2-induced acute lung injury and clinical implications

“…In a recent pilot study on 10 patients with CARDS, it was shown that APRV, which was set and adjusted using the TCAV method, significantly improved / ratio and decreased usage of vasopressors, sedatives, and analgesics. The authors concluded that “APRV may be the optimal ventilator mode” for patients with CARDS and suggested conducting a randomized controlled trial based on their preliminary data ( 134 ). Others have suggested that APRV may be a good option for patients with COVID-19, since it recruits and stabilizes the lung, increasing functional residual capacity (FRC) ( 135 ).…”

Time controlled adaptive ventilation™ as conservative treatment of destroyed lung: an alternative to lung transplantation

“…The methodology used in this study closely resembled the TCAV ™ protocol, but showed some differences with our strategy because we initially used higher pressures and higher respiratory rates. Recently, the beneficial effects of APRV ventilation have been shown in patients with COVID-19, further emphasizing the relevance of this ventilation mode [26].…”