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Review
. 2020 Feb 5:14:1179548420903297.
doi: 10.1177/1179548420903297. eCollection 2020.

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

Andrew S Fredericks  1 , Matthew P Bunker  1 , Louise A Gliga  1 , Callie G Ebeling  1 , Jenny Rb Ringqvist  1 , Hooman Heravi  1 , James Manley  2   3 , Jason Valladares  1 , Bryan T Romito  1
Affiliations
Review

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

Andrew S Fredericks et al. Clin Med Insights Circ Respir Pulm Med. .

Abstract

Objective: To review the theoretical benefits of airway pressure release ventilation (APRV), summarize the evidence for its use in clinical practice, and discuss different titration strategies.

Data source: Published randomized controlled trials in humans, observational human studies, animal studies, review articles, ventilator textbooks, and editorials.

Data summary: Airway pressure release ventilation optimizes alveolar recruitment, reduces airway pressures, allows for spontaneous breathing, and offers many hemodynamic benefits. Despite these physiologic advantages, there are inconsistent data to support the use of APRV over other modes of ventilation. There is considerable heterogeneity in the application of APRV among providers and a shortage of information describing initiation and titration strategies. To date, no direct comparison studies of APRV strategies have been performed. This review describes 2 common management approaches that bedside providers can use to optimally tailor APRV to their patients.

Conclusion: Airway pressure release ventilation remains a form of mechanical ventilation primarily used for refractory hypoxemia. It offers unique physiological advantages over other ventilatory modes, and providers must be familiar with different titration methods. Given its inconsistent outcome data and heterogeneous use in practice, future trials should directly compare APRV strategies to determine the optimal management approach.

Keywords: Hypoxia; lung diffusion; respiratory disease; respiratory failure; ventilation.

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Conflict of interest statement

Declaration of conflicting interests:The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Pressure-volume curve showing the lower inflection point (LIP) and upper inflection point (UIP). Adapted with permission from Grinnan and Truwit.
Figure 2.
Figure 2.
An airway pressure release ventilation waveform showing the pressure and time relationship. Adapted with permission from Daoud.
Figure 3.
Figure 3.
Use of SERVO-i to identify end-expiratory flow rate to peak expiratory flow rate (EEFR: PEFR) ratio.
Figure 4.
Figure 4.
Using an inspiratory hold, the operator can determine the P plat, the static compliance, and the resistance.
Figure 5.
Figure 5.
Initial APRV settings as suggested by the Zhou protocol. APRV indicates airway pressure release ventilation.
See this image and copyright information in PMC

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