Alveolar Recruitment

with APRV Ventilation

Anthony Tsai, M.D.
Shawn Terry, M.D. FACS
Department of Surgery
York Hospital
 Introduction
„ Mechanical Ventilation
‹ Art or Science?
‹ Challenges

‹ Is ARDS avoidable?

„ APRV (Airway Pressure Release Ventilation)

‹ what is it?
‹ Do we need another mode of ventilation?

‹ Advantages
 Mechanical Ventilation
„ HISTORY: developed to help patients with non-
parenchymal respiratory failure (e.g. polio)
„ CURRENT: use extended to parenchymal respiratory
failure (e.g. acute lung injury)
„ Mode selection: based on availability or simplicity of
the ventilator, user experience, tradition
„ 1993 ACCP consensus conference – failed “to agree
on an optimum mode of ventilation”
 Common Modes of
Mechanical Ventilation
Mode Trigger Limit Cycle Off Spont Flow of
breathing Gas
AC (vol) Time/Pt Volume Time No Constant

AC (Ps) Time/Pt Pressure Time No Decel

SIMV Time/Pt Volume Time Yes Constant

PSV Pt Pressure Gas flow No Decel

PRVC Time/Pt* Volume Time No Decel

APRV Time Pressure Time Yes Decel

 ARDS
„ 30-50% mortality rate
„ Ventilator-associated lung injury
„ Lung protective strategies
‹ Avoid high-volume lung injury

‹ Avoid low-volume lung injury

‹ Avoid inflammatory lung injury

 Lung Protective Strategies
„ Reduced tidal volumes (ARDSNet trial)
‹ 6 ml/kg vs. 12ml/kg
„ Elevated PEEP (Amato et al.)
‹ Decreased cyclic airway reopening
„ Avoid extension of lung injury
„ Mean airway pressure (Paw) – oxygen toxicity
‹ Minimize peak Paw
‹ Alveoli recruitment by raising mean Paw
„ Prevent atelectasis
„ Use of sedation and paralysis
Conventional Volume
Ventilation
APRV
Advantages of APRV
1. High-volume Lung Injury Reduction
‹ Lower peak Paw
‹ ↓ minute ventilation Æ reduced dead space
ventilation
‹ Optimizing end-inspiratory lung volume

 Limitsalveolar over-distension
 Decrease airway pressure
Advantages of APRV
2. Low-Volume Lung Injury Reduction
‹ Alveolar recruitment
‹ Increased mean Paw

‹ Spontaneous breathing

 Improved ventilation-perfusion matching

 Reduced atelectasis

 Increased alveolar opening

Advantages of APRV
3. Reduction of Inflammatory lung Injury
„ No compromise of circulatory function and
tissue oxygenation
„ Decreased need for sedation use or
neuromuscular blockade
Disadvantages
„ Dyssynchrony with spontaneous respiration
„ New technology
‹ Staff stress
‹ Increased risk to patient

„ Limited access to technology capable of

delivering APRV
„ Limited research and clinical experience
Study Design
„ Retrospective review of all patients placed on
APRV at York Hospital
„ N = 13
„ Time Intervals: 0-3hrs, 3-6hrs, 6-9hrs, 9-12hrs
„ Exclusion criteria:
‹ Initial Tidal Volume not recorded
‹ Peak or trough airway pressure adjusted
Measurements of Alveolar
Recruitment
„ Tidal Volume increase
„ PaO2/FIO2 increase
„ A-a gradient decrease
Results
„ Data series = 14
„ 9 Male, 4 Female
„ Mean age = 59.9
„ Tidal volume
‹ Initial: 500-1100
‹ Range: 405-1100
Tidal Volume vs Time Interval

Increase in Tidal Volume

Interval Mean SD CI

0-3hrs 9.2% 15.4 0.5-17.9

3-6hrs 7.8% 12.4 1.0-14.6

6-9hrs 4.9% 11.5 -2.6-12.4

9-12hrs 12.4% 16.0 2.0-23.0

Tidal Volume vs Time Interval
25
Tidal Volume (% increase)

20

15

10

0
0-3 hrs 3-6 hrs 6-9 hrs 9-12 hrs
-5

Time Interval (hrs post initiation)

Other Measurements
„ PaO2/FIO2: increased with no statistical
significance
„ A-a gradient: decreased with no statistical
significance
Conclusion
„ APRV improves alveolar recruitment
„ Elements of lung protection in APRV
‹ Decreased cyclic airway reopening

‹ Increased mean Paw

‹ Decreased peak Paw

‹ Alveolar recruitment

„ Utility of APRV in preventing ARDS

Randomized Double-Blind Study
„ APRV vs. conventional mode ventilation
„ Measurements of alveolar recruitment
‹ At defined intervals
 ABG
 A-a gradient
 Tidal Volume Index
 Paw – mean and Peak

„ Computer-assisted measurements
„ Maintain vent settings for 24 hours