Airway Pressure Release Ventilation setting disagreements. A survey of clinicians

Sandeep Randhawa, Ryota Sato, Ehab G. Daoud

Abstract

Background
Airway pressure release ventilation has been available to clinicians for the last four decades. Unfortunately, its clinical value continues to be debatable. One of the many reasons responsible is the lack of consistency between its settings in clinical practice and research. We hypothesized that clinicians disagree on specific methods when establishing these parameters.

Materials and Methods
A questionnaire-based survey was developed and sent to clinicians (critical care attending physician, critical care fellows in training and respiratory therapists) in about one hundred different academic hospitals with critical care
training program. The survey consisted of ten questions including each of the four major APRV settings: T-High, T-Low, P-High, and P-Low. The survey was anonymous.

Main results
Amongst the 187 respondents, there were significant disagreements between different categories of clinicians regarding methodology for establishing initial settings of APRV. However, when the responses were analyzed after sub-grouping based on categories of clinicians (Critical care attending physician vs critical care fellows vs respiratory therapists), no significant differences could be found.

Conclusions
There is no agreement between different categories of clinicians when it comes to the methodology for establishing initial APRV settings. Our study highlights the need for larger clinical trials comparing different approaches to the
same which could then be used for establishing scientific guidelines based on best evidence.

Keywords

APRV, survey, T-High, T-Low, P-High, P-Low

References

1. Stock MC, Downs JB, Frolicher DA. Airway pressure release ventilation. Crit Care Med 1987; 15(5):462-466. https://doi.org/10.1097/00003246-198705000-00002 PMid:3552443

2. Daoud EG. Airway pressure release ventilation. Ann Thorac Med 2007; 2(4):176-179. https://doi.org/10.4103/1817-1737.36556 PMid:19727373 PMCid:PMC2732103

https://doi.org/10.4103/1817-1737.36556 https://doi.org/10.4103/1817-1737.36556 PMid:19727373 PMCid:PMC2732103

3. Daoud EG, Farag HL, Chatburn RL. Airwaypressure release ventilation: What do we know? Respir Care 2012; 57(2):282-292. https://doi.org/10.4187/respcare.01238 PMid:21762559

4. Putensen C, Zech S, Wrigge H, et al. Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury. Am J Respir Crit Care Med 2001; 164(1):43-49. https://doi.org/10.1164/ajrccm.164.1.2001078 PMid:11435237

5. Varpula T, Valta P, Niemi R, et al. Airway pressure release ventilation as a primary ventilatory mode in acute respiratory distress syndrome. Acta Anaesthesiol Scand 2004; 48(6):722-731. https://doi.org/10.1111/j.0001-5172.2004.00411.x PMid:15196105

6. González M, Arroliga AC, Frutos-Vivar F, et al. Airway pressure release ventilation versus assistcontrol ventilation: a comparative propensity score and international cohort study. Intensive Care Med 2010; 36(5):817-827. https://doi.org/10.1007/s00134-010-1837-1 PMid:20229042

7. Chatburn RL, Kallet RH, Sasidhar M. Airway pressure release ventilation may result in occult atelectrauma in severe ARDS. Respir Care 2016; 61:1278-1280. https://doi.org/10.4187/respcare.05099 PMid:27587873

8. Lalgudi Ganesan S, Jayashree M, Chandra Singhi S, et al. Airway Pressure Release Ventilation in Pediatric Acute Respiratory Distress Syndrome. A Randomized Controlled Trial. Am J Respir Crit Care Med 2018; 198(9):1199-1207. https://doi.org/10.1164/rccm.201705-0989OC PMid:29641221

9. Zhou Y, Jin X, Lv Y, et al. Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndrome. Intensive Care Med 201; 43(11):1648-1659. https://doi.org/10.1007/s00134-017-4912-z PMid:28936695 PMCid:PMC5633625

10. Carsetti A, Damiani E, Domizi R, et al. Airway pressure release ventilation during acute hypoxemic respiratory failure: a systematic review and metaanalysis of randomized controlled trials. Ann Intensive Care 2019; 4;9(1):44. https://doi.org/10.1186/s13613-019-0518-7 PMid:30949778 PMCid:PMC6449410

11. Lim J, Litton E. Airway pressure release ventilation in adult patients with acute hypoxemic respiratory failure: A systematic review and metaanalysis. Crit Care Med 2019; 47(12):1794-1799. https://doi.org/10.1097/CCM.0000000000003972 PMid:31517696

12. Rose L, Hawkins M. Airway pressure release ventilation and biphasic positive airway pressure: a systematic review of definitional criteria. Intensive Care Med 2008; 34:1766-1773. https://doi.org/10.1007/s00134-008-1216-3 PMid:18633595

13. Jain SV, Kollisch-Singule M, Sadowitz B, et al. The 30-year evolution of airway pressure release ventilation (APRV). Intensive Care Med Exp 2016; 4(1):11. https://doi.org/10.1186/s40635-016-0085-2 PMid:27207149 PMCid:PMC4875584

14. Habashi NM. Other approaches to open-lung ventilation: airway pressure release ventilation. Crit Care Med 2005; 33(3 Suppl):S228-240. https://doi.org/10.1097/01.CCM.0000155920.11893.37 PMid:15753733

15. Modrykamien A, Chatburn R, Ashton R. Airway pressure release ventilation: An alternative mode of mechanical ventilation in acute respiratory distress syndrome. Cleve Clin J Med 2011; 78:101-110. https://doi.org/10.3949/ccjm.78a.10032 PMid:21285342

16. De Magalhães RF, Cruz DG, Antunes MA, et al. Time-Controlled Adaptive Ventilation Versus Volume-Controlled Ventilation in Experimental Pneumonia. Crit Care Med 2020 Oct 15, ahead of print. https://doi.org/10.1097/CCM.0000000000004675 PMid:33060501

17. Daoud EG, Yamasaki KH, Nakamoto K, et al. Esophageal pressure balloon and transpulmonary pressure monitoring in airway pressure release ventilation: a different approach. Can J Respir Ther 2018; 54(3):62-65. https://doi.org/10.29390/cjrt-2018-010 PMid:30996644 PMCid:PMC6422107

18. Miller AG, Davies JD, Gentile.MA. APRV utilization and clinical management strategies: a survey of clinical practice. Accessed at www.ncsrc.org October 2020

19. Miller AG, Gentile MA, Davies JD, et al. Clinical Management Strategies for Airway Pressure Release Ventilation: A Survey of Clinical Practice. Respir Care 2017; 62(10):1264-1268. https://doi.org/10.4187/respcare.05494 PMid:28588118