APRV (BiLevel Mode)

Nikki Henry, Respiratory

Therapy
2011
Is my patient in ARDS?

Divide the PaO2/FiO2

400-500 Normal
<300 ALI (Acute Lung Injury) –
impending ARDS
<200 ARDS

 Indications

 PEEP > 10 and FiO2 > 60% (Shunting)

 PaO2/FiO2 < 300

 Bilateral infiltrates

 No evidence of left atrial hypertension
Terminology
P High – the upper CPAP level.
Analogous to MAP (mean airway
pressure) and thus affects oxygenation

P Low – is the lower pressure setting.

T High- is the inspiratory time phase for
the high CPAP level (P High).

T PEEP or T low- is the release time
allowing CO2 elimination
Setting up APRV
Press the vent set-up key on the
lower screen

Select Bilevel for mode – this will
automatically set up the vent for
PC (mandatory type)

Press continue
Frequency

Set frequency at 6-8 (max 10)

This is the release rate when the
vent will change from Phigh to
Plow

Total rate for patient should be
18-38
Initial Settings - PHigh
Set the Phigh to the plateau
pressure from previous VC/PC
mode

P High – Set a plateau pressure
typically about 20-25 cm H2O.

In patients with Pplateau at or
above 30 cm H2O, set at 30 cm
H 2O
PEEP Low
Set PEEP at zero cm H2O.

This provides a rapid drop in
pressure, and a maximum ∆ P
for unimpeded expiratory gas
flow.


Avoid lung collapse during Tlow.


Rapid pressure drops allow for
quick resumption of Phigh
TLow
 Once in the time bar screen you will see
three padlocks

 Press on the padlock to the far right. This will
hold Tlow constant.

 Set Tlow at 0.4-1.0 sec

 Make sure the Tlow value is displayed on the
set parameters section (blue boxes above
the time bar)

 Patient should NOT take any spontaneous
Goal of TLow
The goal of termination of Tlow is
between 50-75% of Peak
Expiratory Flow Rate (PEFR)
 THigh

 Once Tlow is locked any change in frequency will
result in a change in Thigh

 To adjust Thigh change frequency first
Pressure Support on APRV

State with Tube Compensation. If
the spontaneous Vt are low
switch to PS

PS at Phigh = (Plow + PS) – Phigh

Managing a patient on
APRV


How to optimize PHigh at FiO2 >

or = 60%

How to manage CO2
Weaning From APRV
1.FiO2SHOULD BE WEANED FIRST.
(Target < 50% with SpO2
appropriate.)
2.
3.Reducing P High, by 2 cmH20
increments until the P High is
below 20 cmH2O.
4.
7.Increasing T High to change vent
set rate by 5 releases/minute
“Drop and Stretch”
Weaning
When ready to wean – Phigh is
dropped and the frequency is
dropped in small increments.
THigh will be stretched out
sequentially. This is called
the Drop and Stretch
Method.
“Drop and Stretch”

This is continued if the patient is
spontaneously breathing and
until the PHigh is 10-15 cmH2O
and the THigh is 10-15 seconds.
At this point, the patient is
effectively on CPAP.
During Weaning
 Add Pressure Support judiciously.


 Add Pressure Support to P High in

order to decrease WOB while
avoiding over-distention,


 P High + PS < 30 cmH2O.

