Airway Pressure Release
Ventilation (APRV)
Dr. Bichitrovanu Sarkar
MBBS(Cal) DCH(Cal) MRCPCH(UK) FRCPCH(UK)
ICTPICM(UK) Fellowship in Paediatric Intensive Care
Senior Consultant Paediatric Intensivist
Institute of Neurosciences, Kolkata
Accredited Teacher
IAP-ICC College of Pediatric Intensive Care
Introduction
• First described in 1987
• Became available commercially in mid-1990s
• Novel concept as compared to conventional
ventilation
• Conventional – Ventilatory cycle begins at a lower
baseline pressure and increases pressure to achieve
tidal volume
• APRV – commences at elevated plateau pressure
with periodic deflation to achieve tidal ventilation
• Allows spontaneous breathing throughout the
cycle
Oxygenation
• Oxygen is Diffusion-limited under pathological
conditions
• Fick’s Law of Diffusion:
• Rate of Diffusion = (A x D x DP) / T
• PiO2 depends on
• FiO2
• Mean Airway Pressure (MAP)
Five different ways to increase
MAP
MAP = (RR x TI)/60 x (PIP – PEEP) + PEEP
1. Increase Gas Flow Rate
2. Increase PIP
3. Increase Ti
4. Increase PEEP
5. Increase Ventilator Rate
without changing Ti
Inverse Ratio
Ventilation
• TI > T E
• Increases MAP
• Improves Oxygenation
• Unphysiological and Uncomfortable
Convention
al Modes
stretched
too far
Inverse
Ratio
Ventilatio
n
Ti > Te
Airway
Pressure
Release
Ventilatio
Essentially n
Unphysiological
Airway Pressure Release Ventilation
• Extreme form of Inverse Ratio Ventilation
• Continuous positive pressure with intermittent time
cycled releases – APRV
• Cycling between a CPAP Phase and a Release Phase
Airway Pressure Release
Ventilation
• Pressure Controlled Intermittent Mandatory Ventilation
– using Inverse Inspiratory-Expiratory (I:E) Ratios
• Advantages
• Lower airway pressures
• Minimal adverse cardiopulmonary interaction
• Spontaneous breaths throughout the cycle
• Decreased sedation and muscle relaxant use
• Preserves diaphragmatic activity
• Contra-indication
• Obstructive airway disease
• Relative contra-indication
• Needs higher TLow
When can I not use APRV mode?
Unique terminologies of
APRV
CPAP Phase and Release
Phase
TLow (Release Time)
• Most well researched parameter of APRV
• Crucial to balance between adequate ventilation
and prevention of alveolar collapse
• Excessively long TLow causes alveolar collapse
• Inadequate TLow results in inadequate exhalation
• Generally remains unchanged once set
• Depends on Expiratory Time Constant (Compliance x
Resistance)
• Low compliance states eg ARDS Low TLow
• High resistance states eg Asthma High TLow
TLow (Release Time)
• Set to achieve expiratory flow rate termination at 75% of peak
expiratory flow
• Usually set between 0.2 – 0.8 s
• Important to have a balance between TLow and PLow
• Low PLow with a long TLow causes lung collapse
EELV at different EFT/EFP Ratios
Setting up APRV
• Newly intubated children:
• PHigh: at desired plateau level (20 - 25 cm H2O)
• Restrict to < 35 cm H2O
• PLow: Set at 0 – allows unimpeded exhalation
• THigh: 2 – 5 s
• Tlow: 0.2 – 0.8 s
• Set to achieve expiratory flow rate termination at 75% of peak expiratory flow
• Transition from Volume / Pressure Ventilation:
• PHigh: At Pplat of VC / 2 – 3 cm H2O above MAP of PC
• PLow: 0
• THigh: 2 – 5 s
• Tlow: 0.2 – 0.8 s
• Set to achieve expiratory flow rate termination at 75% of peak expiratory flow
• Transition from HFOV:
• PHigh: 2 – 4 cm H2O above MAP
• PLow: 0
• THigh: 2 – 5 s
• Tlow: 0.2 – 0.8 s
• Set to achieve expiratory flow rate termination at 75% of peak expiratory flow
Titrating APRV
Weaning from APRV
• “Drop and Stretch”
• Once FiO2 is reduced to 40% Drop PHigh by 2 – 3
cm H2O
• Once PHigh drops to 20 Stretch THigh by 0.5 – 2.0
s each time PHigh is dropped further
• Achieve CPAP at 12 cm H2O
• Wean CPAP further to 6 – 12 cm H2O Extubate
To Summarize …
• Primarily used for refractory hypoxaemia
• Extreme form of Inverse Ratio Ventilation
• Allows spontaneous breaths
• Preferred for post-operative care of Right
sided cardiac conditions
• Less sedation requirement
• Not preferred in obstructive lung condition
More at Hands-on …
