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APRV aka BiLevel

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  • 1. Then What Is APRV? • APRV - a form of BiLevel but utilizes a very short expiratory time for pressure release Airway Pressure Release • APRV always implies a severe inverse I:E ratio Ventilation • All spontaneous breathing is done at upper pressure level † Synchronized Transition FULL TIDAL VOLUME * Spontaneous Breaths * * * *† * * * VENTILATION † † PEEPHI P PEEPLO T Bottom Line Where do we ventilate patients? • Conventional strategies –• The patient does not need to be paralysed inflate along Vol or deeply sedated to be placed on inverse lower limb of V/P curve ratio ventilation, with severe hypoxia • Modern• Earlier weaning Strategies use• Preservation of respiratory muscle reserve the expiratory limb Pressure
  • 2. APRV Clinical Application Guidelines • Starting frequency commonly 6 - 10 breaths / min • Time at upper pressure not important • Time at lower pressure should be short enough so as not to allow complete exhalation - typically ~ 0.8 seconds Does APRVPCIRC 40 0.8 sec 30cmH2O 20 10 0 Make a difference? 10 -20 0 2 4 6 8 10 12sINSP 80 60 40 . 20 V 0 L 20 min 40 60EXP -80 Three-dimensional reconstructions of the chest Spontaneous breathing during APRV wall and atelectatic regions in the dependent part improves lung areation in OA induced ALI of the lungs in an anaesthetized patientHedenstierna G. Clinical Physiology and Functional Imaging 23 (3), 123-129. Wrigge et al. Anesthesiology 2003; 99:376-84
  • 3. APRV & Spontaneous Long-term effects of spontaneous Breathing breathing during MV in ARDS • 24 patients with severe ARDS • 30 patients with ARDS following major trauma • APRV with Spontaneous breathing vs PSV – Reduced shunt • 15 managed with PCV (+NMB) – Reduced dead space – weaned with APRV – Improved V/Q matching • 15 managed with APRV and spont. breath Purensen C, AJCCM 159:1999 Putensen AJRCCM 164: 2001 Long-term effects of spontaneous Long-term effects of spontaneous breathing during MV in ARDS breathing during MV in ARDS• Primary use of APRV was associated with:• Increases – In respiratory system compliance – In arterial oxygen tension (PaO2) – In cardiac index (CI) – In oxygen delivery (DO=)• Reductions in – Venous admixture (QVA/QT) – Oxygen extraction Putensen AJRCCM 164: 2001 Putensen AJRCCM 164: 2001