Does airway pressure release ventilation offer new hope for treating acute respiratory distress syndrome?

Jiangli Cheng, Aijia Ma, Meiling Dong, Yongfang Zhou, Bo Wang, Yang Xue, Peng Wang, Jing Yang, Yan Kang, Jiangli Cheng, Aijia Ma, Meiling Dong, Yongfang Zhou, Bo Wang, Yang Xue, Peng Wang, Jing Yang, Yan Kang

Abstract

Mechanical ventilation (MV) is an essential life support method for patients with acute respiratory distress syndrome (ARDS), which is one of the most common critical illnesses with high mortality in the intensive care unit (ICU). A lung-protective ventilation strategy based on low tidal volume (LTV) has been recommended since a few years; however, as this did not result in a significant decrease of ARDS-related mortality, a more optimal ventilation mode was required. Airway pressure release ventilation (APRV) is an old method defined as a continuous positive airway pressure (CPAP) with a brief intermittent release phase based on the open lung concept; it also perfectly fits the ARDS treatment principle. Despite this, APRV has not been widely used in the past, rather only as a rescue measure for ARDS patients who are difficult to oxygenate. Over recent years, with an increased understanding of the pathophysiology of ARDS, APRV has been reproposed to improve patient prognosis. Nevertheless, this mode is still not routinely used in ARDS patients given its vague definition and complexity. Consequently, in this paper, we summarize the studies that used APRV in ARDS, including adults, children, and animals, to illustrate the settings of parameters, effectiveness in the population, safety (especially in children), incidence, and mechanism of ventilator-induced lung injury (VILI) and effects on extrapulmonary organs. Finally, we found that APRV is likely associated with improvement in ARDS outcomes, and does not increase injury to the lungs and other organs, thereby indicating that personalized APRV settings may be the new hope for ARDS treatment.

Keywords: Acute respiratory distress syndrome; Airway pressure release ventilation; Organ protection; Outcome; Ventilator-induced lung injury.

© 2022 The Authors. Published by Elsevier B.V. on behalf of Chinese Medical Association.

Figures

Figure 1
Figure 1
Pressure (longitudinal axis) and time (horizontal axis) curve in APRV. Two mandatory breaths (without SB, switched by time) and two intermittent mandatory breaths (with SB, triggered by flow or pressure, switched by both time and SB) are shown. Black arrows represent high pressure (Phigh), low pressure (Plow), and mean airway pressure (Pmean). Red arrow represents SB. Blue fontin the horizontal axis represents high pressure time (Thigh) and low-pressure time (Tlow). APRV: Airway pressure release ventilation; SB: Spontaneous breathing.

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