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David Pitts II, RRT Clinical Applications Specialist, Maquet Birmingham, Alabama Sponsored by Maquet, Inc Servo Ventilators
Objectives
Provide the definition and names for APRV Explain the four set parameters. Identify recruitment in APRV using exhaled CO2. Recommend appropriate initial settings for APRV Make adjustments based on arterial blood gas results Discontinue ventilation with APRV
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) Keep plateau pressures < 30 cm H2O Use low tidal volume ventilation (4-6 mL/kg IBW) Use PEEP to restore the functional residual capacity (FRC)
Alternative Techniques
Increase the ventilator rate Permissive Hypercapnia Airway Pressure Release Ventilation High Frequency Ventilation Extracorporeal Life Support
Indications
Primarily used as an alternative ventilation technique in patients with ARDS. Used to help protect against ventilator induced lung injury.
Goal
To provide the lung protective ventilation supported by the ARDSnet research. Use an Open lung approach. Minimize alveolar overdistension. Avoid repeated alveolar collapse and reexpansion. Restore FRC through recruitment and, Maintain FRC by creating intrinsic PEEP.
APRV Description
A mode of ventilation along with spontaneous ventilation to promote lung recruitment of collapsed and poorly ventilated alveoli. The CPAP is released periodically for a brief period. The short release along with spontaneous breathing promote CO2 elimination. Release time is short to prevent the peak expiratory flow from returning to a zero baseline.
The short release along with spontaneous breathing promote CO2 elimination. Release time is short to prevent the peak expiratory flow from returning to a zero baseline.
APRV
AKA
BiVent Servo APRV Drager BiLevel Puritan Bennett APRV Hamilton Etc.
Bilateral Infiltrates PaO2/FIO2 ratio < 300 and falling Plateau pressures greater than 30 cm H2O No evidence of left heart failure (e.g. PAOP of 18 mm Hg or greater) In other words, persistent ARDS
Possible Contraindications
Unmanaged increases in intracraneal pressure. Large bronchopleural fistulas. Possibly obstructive lung disease. Technically, it may be possible to ventilate nearly any disorder.
Terminology
Terminology
T High plus T PEEP (T low) is the total time of one cycle. I:E ratio becomes irrelevant because APRV is really best thought of as CPAP With occasional releases
Advantages of APRV
Uses lower PIP to maintain oxygenation and ventilation without compromising the patients hemodynamics (Syndow AJRCCM 1994, Kaplan,
CC, 2001)
Required a lower VE suggesting reduced VD/VT (Varpula, Acta Anaesthesiol Scand 2001)
APRV increases oxygen delivery and Reduces the need for sedation and paralysis APRV also improves renal perfusion and urine output when spontaneous breathing is maintained. (Kaplan, Crit Care, 2001;
Hering, Crit Care Med 2002)
New Water Coolers are Being Installed in the ICU Waiting Rooms
The benefits of APRV may be related to the preservation of spontaneous breathing. Maintaining the normal cyclic decrease in pleural pressure, augmenting venous return and improving cardiac output. (Putensen, AJRCCM,
1999)
The dashed line in each figure represents the normal position of the diaphragm. The shaded area represents the movement of the diaphragm. (Froese, 1974)
Spontaneous breathing provides ventilation to dependent lung regions which get the best blood flow, as opposed to PPV with paralyzed patients.
((Frawley, AACN Clinical 2001. Froese, Anesth, 1974).
During PPV (paralyzed patient), the anterior diaphragm is displaced towards the abdomen with the nondependent regions of the lung receiving the most ventilation where perfusion is the least.
Reduces atrophy of the muscles of ventilation associated with the use of PPV and paralytic agents. (Neuman, ICM,2002)
Another Advantage
During PPV atelectasis formation can occur near the diaphragm, when activity of this muscle is absent. (paralysis) However, if spontaneous breathing is preserved, the formation of atelectasis is offset by the activity of the diaphragm. (Hedenstierna, Anesth, 1994)
P High Set a plateau pressure (adult) or mean airway pressure (pediatric) Typically about 20-25 cm H2O. In patients with Pplateau at or above 30 cm H2O, set at 30 cm H2O
Setting Phigh
Over-distention of the lung must be avoided. Maximum Phigh of 35 cm H2O. (controversial) Exceptions for higher settings morbid obesity, decreased thoracic or abdominal compliance (ascites).
Setting Thigh
The inspiratory time (Thigh) is set at a minimum of about 4.0 seconds In children, others use lower settings (Childrens Med Ctr. Uses 2 sec.) Thigh is progressively increased (10 to 15 seconds (Habashi, et al) Target is oxygenation.
Setting Thigh
Progress slowly. For example, 5 sec Thigh to 0.5 sec Tlow, a 10:1 ratio. Increasing to 5.5 sec to 0.5 sec is an 11:1 ratio; not a big change. Old patients may be fragile.
APRV
Currently, with ARDS thinking is not to let exhalation go to complete emptying, i.e. do not let expiratory flow returning to zero. (McCunn, Crit Care
2002)
Set PEEP at zero cm H2O. This provides a rapid drop in pressure, and a maximum DP for unimpeded expiratory gas flow. (Frawley, AACN Clin Issues 2001) Avoid lung collapse during Tlow.
Set T PEEP (T low) so that expiratory flow from patient ends at about 50 to 75% of peak expiratory flow. This can be determine saving a screen and calculating peak expiratory flow. Or, it can be estimated
Expiratory Flow
Adults 0.5 to 0.8 seconds Pediatric/neonatal settings 0.2 to 0.6 seconds. Or one time constant. (TC = C x R)
Too long a release time would interfere with oxygenation and allow lung units to collapse.
Initial Settings
P high 20-30 cm H2O, according to the following chart. P/F <250 <200 <150 MAP 15-20 20-25 25-28 T High/T low- 12-16 releases T High (s) T low (s) Freq. 3.0 4.0 5.0 0.5 0.5 0.5 17 13 11
6.0
0.5
Bi-Vent Settings
Set Releases and I:E
Bi-Vent Ventilation
P High
T PEEP
T High
Spontaneous Breathing
DP (Phigh Plow) determines flow out of the lungs and volume exchange (VT and PaCO2). Some clinicians suggest a target minute ventilation of 2 to 3 L/min. (Frawley, 2001). Optimize spontaneous ventilation.
Decrease T High.
Shorter T High means more release/min. No shorter than 3 seconds Example: T High 5 sec. = 12 releases/min T High 4 sec = 15 releases/min
To Increase PaCO2
Increase T high. (fewer releases/min) Slowly! In increments of 0.5 to 2.0 sec. Decrease P High to lower DP.
Monitor oxygenation and Avoid derecruitment.
It may be better to accept hypercapnia than to reduce P high so much that oxygenation decreases.
Management of PaO2
To Increase PaO2 1. Increase FIO2 2. Increase MAP by increasing P High in 2 cm H2O increments. 3. Increase T high slowly (0.5 sec/change) 4. Recruitment Maneuvers 5. Maybe shorten T PEEP (T low) to increase PEEPi in 0.1 sec. increments (This may reduce VT and affect PaCO2)
2.
3.
FiO2 SHOULD BE WEANED FIRST. (Target < 50% with SpO2 appropriate.) Reducing P High, by 2 cmH20 increments until the P High is below 20 cmH2O. Increasing T High to change vent set rate by 5 releases/minute
4.
The patient essentially transitions to CPAP with very few releases. Patients should be increasing their spontaneous rate to compensate.
During Weaning
Add Pressure Support judiciously. Add Pressure Support to P High in order to decrease WOB while avoiding overdistention, P High + PS < 30 cmH2O.
Weaning Bi-Vent
Lower Rate
Longer T High
Lower P High Add PS
Weaning Bi-Vent
Lower Rate
Disadvantages of APRV
If spontaneous efforts are not matched during the transition from Phigh to Plow and Plow to Phigh, may lead to increased work load and discomfort for the patient. Limited staff experience with this mode may make implementation of its use difficult.