Knowledge and practice of using airway pressure release ventilation mode in ARDS patients: A survey of physicians

Abstract

Background: Limited data is available on awareness and clinical management of the airway pressure release ventilation (APRV) mode of ventilation for acute respiratory distress syndrome (ARDS) patients among physicians who work at in adult critical areas. This study aimed to assess the knowledge and current practice of using APRV mode with ARDS patients and identify barriers to not using this mode of ventilation among physicians who work in adult critical areas in Saudi Arabia.

Methods: Between November 2022 and April 2023, a cross-sectional online survey was disseminated to physicians who work in adult critical areas in Saudi Arabia. The characteristics of the respondents were analyzed using descriptive statistics. Percentages and frequencies were used to report categorical variables.

Results: Overall, 498 physicians responded to the online survey. All responders (498, 100 %) reported that APRV is indicated in patients with ARDS, but 260 (52.2 %) did not know if there was an institutionally approved APRV protocol. Prone positioning was the highest recommended intervention by 164 (33.0 %) when a conventional MV failed to improve oxygenation in patients with ARDS. 136 (27.3 %) responders stated that the P-high should be set equal to the plateau pressure on a conventional ventilator while 198 (39.8 %) said that P-low should be 0 cmH₂O. Almost half of (229, 46.0 %) responders stated that the T-high should be set between 4 and 6 s, while 286 (57.4 %) said that the T-low should be set at 0.4-0.8 s. The maximum allowed tidal volume during the release phase should be 4-6 ml/kg. Moreover, just over half (257, 51.6 %) believed that the maximum allowed P-high setting should be 35 cmH₂O. One third of the responders (171, 34.3 %) stated that when weaning patients with ARDS while in APRV mode, the P-high should be reduced gradually to reach a target of 10 cmH₂O. However, 284 (36.9 %) thought that the T-high should be gradually increased to reach a target of 10 s. Most responders (331, 66.5 %) felt that the criteria to switch the patient to CPAP would be to have an FiO2 ≤ 0.4, P-high ≤10 cm H₂O, and T-high ≥10 s. Lack of training has been the most common barrier to not using APRV by 388 (77.9 %).

Conclusion: There is a lack of consensus on the use of APRV mode, probably due to several barriers. While there were some agreements on the management of ventilation and oxygenation, there were variations in the selection of the initial setting of APRV. Education, training, and the presence of standardized protocols may help to provide better management.

Keywords: APRV; ARDS; Mechanical ventilation; Physicians; Saudi Arabia.

Fig. 1

The order of interventions when levels of pH are unacceptably low and the PaCO₂ is elevated in patients with ARDS.Legend: The X-axis represents the percentage of intervention order. The first to third intervention are on the left side of the figure, whereas the fourth to sixth interventions are on the right side. The Y axis shows the interventions. Withing the figure box, the Y axis shows the percentages of being a first to third intervention (left) or being a fourth to sixth intervention (right). The complete percentages of the intervention orders are reported in Supplementary Table 2.

Fig. 2

The order of interventions when levels of oxygen are unacceptably low in patients with ARDS.Legend: The X-axis represents the percentage of intervention order. The first to third intervention are on the left side of the figure, whereas the fourth to sixth interventions are on the right side. The Y axis shows the interventions. Withing the figure box, the Y axis shows the percentages of being a first to third intervention (left) or being a fourth to sixth intervention (right). The complete percentages of the intervention orders are reported in Supplementary Table 3.

Fig. 3

The most common barriers to not using APRV mode.