Effect of Airway Pressure Release Ventilation on Dynamic Alveolar Heterogeneity

Kollisch-Singule, Michaela; Jain, Sumeet; Andrews, Penny; Smith, Bradford J.; Hamlington, Katharine L.; Roy, Somnath C.; DiStefano, David; Nuss, Emily; Satalin, Joshua; Meng, Qinghe; Marx, William; Bates, Jason H. T.; Gatto, Louis A.; Nieman, Gary F.; Habashi, Nader M.

doi:10.1001/jamasurg.2015.2683

Cited by 58 publications

(104 citation statements)

References 30 publications

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“…2b). Using these precisely controlled APRV settings, a number of studies have shown that P-APRV recruits and stabilizes the alveoli and alveolar ducts [54][55][56] and reduces the incidence of ARDS in multiple animal models [5,57,62]. A metaanalysis has shown a reduction in ARDS incidence in trauma patients [53].…”

Section: Discussionmentioning

confidence: 99%

“…The expiratory flow curve is analyzed, and the ratio of the end-expiratory flow (EEF) to the peak expiratory flow (PEF) is set so that the EEF/PEF ratio is 75 % [5,[49][50][51][52][53][54][55][56][57][58][59][60][61][62] (See figure on previous page.) Fig.…”

Section: How Expiratory Duration Was Personalizedmentioning

confidence: 99%

“…1d). However, recent animal experiments have shown the optimal EEF/PEF ratio necessary to open and stabilize the lung is 75 % [54][55][56].…”

Section: How Expiratory Duration Was Personalizedmentioning

confidence: 99%

“…Unlike the F-APRV studies that were mainly crossover studies, all of the P-APRV animal studies were randomized prospective cohort trials that compare nonprotective CPPV or low tidal volume (LTV) with APRV [5,49,52,54,55,57,61,62]. P-APRV was shown to reduce heterogeneity and both alveolar and alveolar duct microstrain (i.e., change in alveolar size with applied stress) [54][55][56] suggesting a mechanism for the improvement in the efficacy experiments (Table 3) [5,49,57,61,62].…”

Section: P-aprvmentioning

confidence: 99%

“…2a) and a brief release phase with the T Low personalized to the mechanics of the lung (Fig. 2b) producing a nearly static ventilated lung, which prevents alveolar collapse and reopening, thereby reducing dynamic tissue strain [54,56]. The question is, do these APRV settings that stabilize alveoli protect the lung?…”

Section: P-aprvmentioning

confidence: 99%

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Experiences Using Airway Pressure Release Ventilation for Pneumonia with Severe Hypercapnia or Postoperative Pulmonary Edema

Hong

Lee

2017

Korean J Crit Care Med

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Airway pressure release ventilation (APRV) was first described in 1987 and defined as continuous positive airway pressure (CPAP) with a brief release while allowing the patient to spontaneously breathe throughout the respiratory cycle. The current understanding of the optimal strategy to minimize ventilator-induced lung injury is to "open the lung and keep it open". APRV should be ideal for this strategy with the prolonged CPAP duration recruiting the lung and the minimal release duration preventing lung collapse. However, APRV is inconsistently defined with significant variation in the settings used in experimental studies and in clinical practice. The goal of this review was to analyze the published literature and determine APRV efficacy as a lung-protective strategy. We reviewed all original articles in which the authors stated that APRV was used. The primary analysis was to correlate APRV settings with physiologic and clinical outcomes. Results showed that there was tremendous variation in settings that were all defined as APRV, particularly CPAP and release phase duration and the parameters used to guide these settings. Thus, it was impossible to assess efficacy of a single strategy since almost none of the APRV settings were identical. Therefore, we divided all APRV studies divided into two basic categories: (1) fixed-setting APRV (F-APRV) in which the release phase is set and left constant; and (2) personalized-APRV (P-APRV) in which the release phase is set based on changes in lung mechanics using the slope of the expiratory flow curve. Results showed that in no study was there a statistically significant worse outcome with APRV, regardless of the settings (F-ARPV or P-APRV). Multiple studies demonstrated that P-APRV stabilizes alveoli and reduces the incidence of acute respiratory distress syndrome (ARDS) in clinically relevant animal models and in trauma patients. In conclusion, over the 30 years since the mode's inception there have been no strict criteria in defining a mechanical breath as being APRV. P-APRV has shown great promise as a highly lung-protective ventilation strategy.

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