Airway Pressure Release Ventilation: A Review of the Evidence, Theoretical Benefits, and Alternative Titration Strategies

Fredericks, Andrew; Bunker, Matthew P.; Gliga, Louise A.; Ebeling, Callie; Ringqvist, Jenny; Heravi, Hooman; Manley, James S.; Valladares, Jason; Romito, Bryan T.

doi:10.1177/1179548420903297

Cited by 23 publications

(22 citation statements)

References 66 publications

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“…However, with simplicity inevitably comes a reduction in flexibility. Proportional valves allow precise regulation of flow rate or pressure, for advanced ventilation modes, such as APRV (airway pressure release ventilation), although it remains unclear whether these modes really offer clinical benefit ( 22 , 23 ). We also cannot provide an automated control of flow rate for NIV, which is found in many ICU ventilators, but manual control could easily be incorporated if required.…”

Section: Discussionmentioning

confidence: 99%

A Novel Ventilator Design for COVID-19 and Resource-Limited Settings

Madekurozwa

Bonneuil

Frattolin

et al. 2021

Front. Med. Technol.

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There has existed a severe ventilator deficit in much of the world for many years, due in part to the high cost and complexity of traditional ICU ventilators. This was highlighted and exacerbated by the emergence of the COVID-19 pandemic, during which the increase in ventilator production rapidly overran the global supply chains for components. In response, we propose a new approach to ventilator design that meets the performance requirements for COVID-19 patients, while using components that minimise interference with the existing ventilator supply chains. The majority of current ventilator designs use proportional valves and flow sensors, which remain in short supply over a year into the pandemic. In the proposed design, the core components are on-off valves. Unlike proportional valves, on-off valves are widely available, but accurate control of ventilation using on-off valves is not straightforward. Our proposed solution combines four on-off valves, a two-litre reservoir, an oxygen sensor and two pressure sensors. Benchtop testing of a prototype was performed with a commercially available flow analyser and test lungs. We investigated the accuracy and precision of the prototype using both compressed gas supplies and a portable oxygen concentrator, and demonstrated the long-term durability over 15 days. The precision and accuracy of ventilation parameters were within the ranges specified in international guidelines in all tests. A numerical model of the system was developed and validated against experimental data. The model was used to determine usable ranges of valve flow coefficients to increase supply chain flexibility. This new design provides the performance necessary for the majority of patients that require ventilation. Applications include COVID-19 as well as pneumonia, influenza, and tuberculosis, which remain major causes of mortality in low and middle income countries. The robustness, energy efficiency, ease of maintenance, price and availability of on-off valves are all advantageous over proportional valves. As a result, the proposed ventilator design will cost significantly less to manufacture and maintain than current market designs and has the potential to increase global ventilator availability.

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Section: Discussionmentioning

confidence: 99%

A Novel Ventilator Design for COVID-19 and Resource-Limited Settings

Madekurozwa

Bonneuil

Frattolin

et al. 2021

Front. Med. Technol.

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“…Although some studies evaluating APRV in patients with ARDS consider this mode a suitable alterative to standard lung-protective ventilation, the data are quite variable and few studies compare APRV directly to low tidal volume ventilation. 13 APRV also requires its own knowledge and skill set. For this reason, clinicians who are less familiar with APRV may be less inclined to use this setting.…”

Section: Managementmentioning

confidence: 99%

“…Airway pressure-release ventilation (APRV) is a continuous bilevel pressure mode in which high pressures are held for a longer length of time, with quick releases to low pressure with the intention to maximize alveolar recruitment (Figure 2). Although some studies evaluating APRV in patients with ARDS consider this mode a suitable alterative to standard lung-protective ventilation, the data are quite variable and few studies compare APRV directly to low tidal volume ventilation 13. APRV also requires its own knowledge and skill set.…”

Section: Managementmentioning

confidence: 99%

Acute respiratory distress syndrome

Powers

2022

Jaapa

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Acute respiratory distress syndrome (ARDS) is a severe, often fatal, lung condition frequently seen in patients in the ICU. ARDS is triggered by an inciting event such as pneumonia or sepsis, which is followed by an inappropriate host inflammatory response that results in pulmonary edema and impaired gas exchange, and may progress to fibrosis. With the increased spotlight and discussion focused on ARDS during the COVID-19 pandemic, healthcare providers must be able to identify and manage symptoms based on evidence-based research.

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“…The auto-PEEP so generated allows slow non-traumatic recruitment to occur, despite differing alveolar re-expansion time constants. [71][72][73][74][75][76] Spontaneous ventilation also frequently allows sedation or neuromuscular blockade (NMB) to be reduced or avoided.…”

Section: Airway Pressure Release Ventilation (Aprv)mentioning

confidence: 99%

The optimal management of the patient with COVID‐19 pneumonia: HFNC, NIV/CPAP or mechanical ventilation?

Broadhurst

Botha²,

Calligaro³

et al. 2022

Afr J Thoracic Crit Care Med

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The recent pandemic has seen unprecedented demand for respiratory support of patients with COVID‐19 pneumonia, stretching services and clinicians. Yet despite the global numbers of patients treated, guidance is not clear on the correct choice of modality or the timing of escalation of therapy for an individual patient.This narrative review assesses the available literature on the best use of different modalities of respiratory support for an individual patient, and discusses benefits and risks of each, coupled with practical advice to improve outcomes. On current data, in an ideal context, it appears that as disease severity worsens, conventional oxygen therapy is not sufficient alone. In more severe disease, i.e. PaO2/FiO2 ratios below approximately 200, helmet‐CPAP (continuous positive airway pressure) (although not widely available) may be superior to high‐flow nasal cannula (HFNC) therapy or facemask non‐invasive ventilation (NIV)/CPAP, and that facemask NIV/CPAP may be superior to HFNC, but with noted important complications, including risk of pneumothoraces. In an ideal context, invasive mechanical ventilation should not be delayed where indicated and available. Vitally, the choice of respiratory support should not be prescriptive but contextualised to each setting, as supply and demand of resources vary markedly between institutions. Over time, institutions should develop clear policies to guide clinicians before demand exceeds supply, and should frequently review best practice as evidence matures.

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Airway Pressure Release Ventilation: A Review of the Evidence, Theoretical Benefits, and Alternative Titration Strategies

Cited by 23 publications

References 66 publications

A Novel Ventilator Design for COVID-19 and Resource-Limited Settings

A Novel Ventilator Design for COVID-19 and Resource-Limited Settings

Acute respiratory distress syndrome

The optimal management of the patient with COVID‐19 pneumonia: HFNC, NIV/CPAP or mechanical ventilation?

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