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Airway Pressure Release Ventilation. APRV review and indications in paediatrics. APRV. Terminology How it works Indications Advantages/disadvantages Review of paediatric studies Set-up (paed specific) Weaning Discussion. APRV.

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airway pressure release ventilation

Airway Pressure Release Ventilation

APRV review and indications in paediatrics

slide3
APRV
  • Terminology
  • How it works
  • Indications
  • Advantages/disadvantages
  • Review of paediatric studies
  • Set-up (paed specific)
  • Weaning
  • Discussion
slide4
APRV
  • Continuous positive airway pressure with regular, brief releases in airway pressure to facilitate alveolar ventilation and CO2 removal
  • Time triggered, pressure limited, time cycled mode
  • Allowing unrestricted spon. Breathing throughout the ventilatory cycle
terminology
Terminology
  • P high = the baseline airway pressure level,
  • P low = airway pressure resulting from airway release (PEEP)
  • Time high = the length of time that P high is maintained
  • Time PEEP = time spent in airway release at P low
how does it work
How does it work?
  • The constant airway pressure at P high facilitates alveolar recruitment and therefore enhances gas diffusion
  • The long time at P high allows alveolar units with slow time constants to open
  • The timed releases in pressure T PEEP allows alveolar gas to be expelled via natural lung recoil not with repetitious opening of alveoli
indications
Indications
  • Recruitable low compliance lung disorders
  • Lung dysfunction secondary to thoracic restriction i.e.. obesity, acites
  • Inadequate oxygenation with FiO2 > .60
  • PIP> 35 cmH2O and /or PEEP>10 cmH2O
  • Lung protective strategies (high PEEP, low Vt) are failing
  • Can be used with other interventions i.e.. INO therapy, prone positioning
advantages
Advantages
  • Significantly lower peak Paw and improved oxygenation when compared to conventional ventilation
  • Requires lower min. vol. suggesting decreased dead space ventilation
  • Avoids low volume lung injury by avoiding repetitious opening of alveoli
advantages10
Advantages
  • Allows for spontaneous breathing at all points in the respiratory cycle
  • Spon. breathing tends to improve V/Q matching
  • Decreased need for sedation and near eliminating need for neuromuscular blockade
disadvantages
Disadvantages
  • Volumes affected by changes in compliance and resistance and therefore close monitoring required
  • Integrating new technology
  • Limited research and clinical experience
paediatric studies
Paediatric Studies
  • Studies in the paediatric population are few and small
  • Several are ongoing
  • 3 published
  • Most evidence is extrapolated from the adult studies
slide13
Airway pressure release ventilation in paediatricsSchultz T, et al. Pediatric Crit Care Med. 2001 jul;2(3):24 3-6

Airway pressure release ventilation in paediatricsSchultz T, et al. Pediatric Crit Care Med. 2001 jul;2(3):24 3-6

  • a prospective, randomized, cross-over trial of 15 PICU pt. >8kg
  • Randomized to either VCV (9) or APRV (6)
  • APRV had lower PIP and Pplat than VCV in all patients
  • No sig. differences in physiologic variables e.g.. EtCO2
slide14

Airway Pressure Release in a Paediatric PopulationJones R, Roberts T, Christensen D. St.Luke’s Reginal Medical Center, Boise, ID AARC open Forum 2004

  • A case series of 7 paediatric patients aged 3 to 13 with ALI
  • All failing conventional PPV with severe hypoxemia
  • 2 failed HFOV with severe hypoxemia
  • 6/7 lower PIP, all had higher MAP, all had improved oxygenation, all had lower FiO2 requirements
slide15

Airway Pressure Release Ventilation: A Pediatric Case SeriesKrishnan,J. ,Morrison, M.: University of Maryland, Pediatric Pulmonology 42:83-88. 2007

  • retrospective review of 7 pediatric cases
  • Approved by the University of Maryland institutional review board
  • All pt.s failed on conventional ventilation
  • Implemented similar starting parameters as to be described later
case 1
Case 1
  • 9 y.o. leukemia with septic shock, ARDS and MSOF
  • SIMV PC , FiO2 = 1.0, PIP/PEEP= 38/14 cmH2O, PaO2= 91 mmHg
  • Failed HFOV secondary to hypotension
  • APRV – Phigh 37 cmH20, Plow 0cmH2O with Pmean of 32 cmH2O
  • PaO2 improved over 84 hrs and required no NMB
  • Weaned and d/ced home
case 2
Case 2
  • 5 y.o. 60% body area burns with development of sepsis and ARDS
  • Failed convention ventilation (39/19) and was placed on HFOV with intractable hypercarbia (PaCO2= 121mmHg)
  • APRV of 40/0 PaCO2 improved to 78mmHg
  • MSOF worsened and pt. made limited resuscitation
case 3
Case 3
  • 8 y.o. CF with development of ARDS
  • Pt. required heavy sedation with CV with 30/13 and FiO2 = .50
  • APRV settings 28/0 and sedation was decreased and pt. was extubated to NIV
  • No NMB was required
case 4
Case 4
  • 4 y.o. with fever, jaundice, hepatomegaly, pancytopenia and hypofibrinogenemia
  • Requiring CRRT for MSOF and ARDS
  • CV with 40/10 cmH20 and FiO2 = 1.0
  • APRV 34/0 and O2 weaned to .6 and NMB was lifted
  • Weaned to CPAP and septic shock resolved but pt suffered an intracranial haemorrhage which led to his death
  • Autopsy revealed hemophagocytic lymphohistiocytosis
case 5
Case 5
  • 1 y.o. leukemia post bone marrow transplant with sepsis and neutropenia and graft vs host disease and tracheotomy
  • Difficult to ventilate with PaCO2 of 64mmHg and tachypnea and distress
  • APRV 30/0 cmH20 and was rapidly weaned with noted increase in comfort
  • Weaned to FiO2 to .45 and PaCO2 = 39mmHg
  • Later exacerbation of leukemia resulted in renal failure
hints for set up
Hints for set-up
  • P high = same as plateau or 125% of mean Paw
  • PEEP = 0 cmH2O
  • T PEEP = long enough to get returned Vt but not long enough to derecruit – titrate to end at 25 -50% of the PEF
  • T high = manipulated to achieve RR
  • PS = set to avoid flow hunger with spon. resps.
set up
Set-up

Set-up

  • Be patient
  • The change to APRV may not provide instant improvement in oxygenation
  • The effects may take hours to be realized
  • Has been shown that the maximum benefit occurred at approx. 8 hours after implementation
weaning
Weaning
  • Decrease FiO2 first and then P high is small increments
  • As compliance improves the TCs lengthen and T PEEP may need adjustment to allow for adequate Vt
  • When P high is weaned to a low level consider extubation
  • Lengthen T high and therefore decreasing the # of pressure releases per minute
lets talk
Lets talk!

Any questions?