The time-controlled adaptive ventilation protocol: mechanistic approach to reducing ventilator-induced lung injury

Kollisch-Singule, Michaela; Andrews, Penny; Satalin, Joshua; Gatto, Louis A.; Nieman, Gary F.; Habashi, Nader M.

doi:10.1183/16000617.0126-2018

Cited by 24 publications

(17 citation statements)

References 108 publications

(161 reference statements)

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“…Our TCAV method using the APRV mode has been discussed in detail elsewhere (Habashi, 2005;Jain et al, 2016;Nieman et al, 2018Nieman et al, , 2019Kollisch-Singule et al, 2019). Briefly, TCAV consists of an extended (4-5 s) open valve continuous positive airway pressure (CPAP) phase with a very short (≤0.5 s) release phase.…”

Section: The Tcav Methods To Open and Stabilize The Acutely Injured Lungmentioning

confidence: 99%

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

et al. 2020

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Acute respiratory distress syndrome (ARDS) causes a heterogeneous lung injury and remains a serious medical problem, with one of the only treatments being supportive care in the form of mechanical ventilation. It is very difficult, however, to mechanically ventilate the heterogeneously damaged lung without causing secondary ventilatorinduced lung injury (VILI). The acutely injured lung becomes time and pressure dependent, meaning that it takes more time and pressure to open the lung, and it recollapses more quickly and at higher pressure. Current protective ventilation strategies, ARDSnet low tidal volume (LVt) and the open lung approach (OLA), have been unsuccessful at further reducing ARDS mortality. We postulate that this is because the LVt strategy is constrained to ventilating a lung with a heterogeneous mix of normal and focalized injured tissue, and the OLA, although designed to fully open and stabilize the lung, is often unsuccessful at doing so. In this review we analyzed the pathophysiology of ARDS that renders the lung susceptible to VILI. We also analyzed the alterations in alveolar and alveolar duct mechanics that occur in the acutely injured lung and discussed how these alterations are a key mechanism driving VILI. Our analysis suggests that the time component of each mechanical breath, at both inspiration and expiration, is critical to normalize alveolar mechanics and protect the lung from VILI. Animal studies and a meta-analysis have suggested that the time-controlled adaptive ventilation (TCAV) method, using the airway pressure release ventilation mode, eliminates the constraints of ventilating a lung with heterogeneous injury, since it is highly effective at opening and stabilizing the time-and pressure-dependent lung. In animal studies it has been shown that by "casting open" the acutely injured lung with TCAV we can (1) reestablish normal expiratory lung volume as assessed by direct observation of subpleural alveoli; (2) return normal parenchymal microanatomical structural support, known as alveolar interdependence and parenchymal tethering, as assessed by morphometric analysis of lung histology; (3) facilitate regeneration of normal surfactant function measured as increases in surfactant proteins A and B; and (4) significantly increase lung compliance, which reduces the pathologic impact of driving pressure and mechanical power at any given tidal volume.

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Section: The Tcav Methods To Open and Stabilize The Acutely Injured Lungmentioning

confidence: 99%

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

et al. 2020

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“…“Trapping” of air based on a time is the key element of this ventilatory strategy and results in an auto-peep that stabilizes the lung by minimizing the alveolar size variation during expiration. Initial in vivo animal experiments showed that with a cutoff of 75%, most of the exhaled air was from the conducting airways with a minimal change in the alveolar size ( Nieman et al, 2018 ; Kollisch-Singule et al, 2019 ) thereby “splinting” the alveoli open. This air splint, in theory, minimizes atelectrauma and maximizes the maintenance of recruitment.…”

Section: The Airway Pressure Release Ventilation With Time-controlled...mentioning

confidence: 99%

Airway Pressure Release Ventilation With Time-Controlled Adaptive Ventilation (TCAV™) in COVID-19: A Community Hospital’s Experience

Rola¹,

Daxon

2022

Front. Physiol.

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Santa Cabrini Ospedale, a community hospital in Montreal, Canada, used the airway pressure release ventilation following a time-controlled adaptive ventilation (APRV-TCAV™) approach for several patients in the first wave of the coronavirus disease 2019 (COVID-19) outbreak in the spring of 2021. Based on favorable patient responses, it became the primary mode of invasive mechanical ventilation—from initiation through extubation—during the second and third waves of COVID-19. In this article, we describe our success with APRV-TCAV™ over more conventional modes and protocols and look at three cases that aptly demonstrate our experience. We then outline several risks with our approach and the lessons learned from our experience. While we generally saw improvement in patients’ clinical course with APRV-TCAV™, there are inherent risks with this approach that others must prepare for if they attempt to implement it in their practice.

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“…Interestingly, in a porcine model of severe smoke inhalation injury, Batchinsky and colleagues found that APRV-treated animals developed ARDS faster than those treated with conventional volume-controlled ventilation [7]. Proponents argue that APRV improves alveolar recruitment and stability, improves ventilation-perfusion matching, increases mean airway pressure, minimizes peak and plateau pressures, preserves spontaneous breathing, and reduces sedation requirements [34][35][36]. Reduced sedation preserves airway reflexes and cough, and has the theoretical benefits in burn patients of reducing ventilator-associated pneumonia and increasing rehabilitation performance.…”

Section: Airway-pressure-release Ventilationmentioning

confidence: 99%

Mechanical Ventilation Strategies in the Critically Ill Burn Patient: A Practical Review for Clinicians

Folwell

Basel

Britton

et al. 2021

EBJ

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Burn patients are a unique population when considering strategies for ventilatory support. Frequent surgical operations, inhalation injury, pneumonia, and long durations of mechanical ventilation add to the challenging physiology of severe burn injury. We aim to provide a practical and evidence-based review of mechanical ventilation strategies for the critically ill burn patient that is tailored to the bedside clinician.

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The time-controlled adaptive ventilation protocol: mechanistic approach to reducing ventilator-induced lung injury

Cited by 24 publications

References 108 publications

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

A Physiologically Informed Strategy to Effectively Open, Stabilize, and Protect the Acutely Injured Lung

Airway Pressure Release Ventilation With Time-Controlled Adaptive Ventilation (TCAV™) in COVID-19: A Community Hospital’s Experience

Mechanical Ventilation Strategies in the Critically Ill Burn Patient: A Practical Review for Clinicians

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