Rory Spiegel, an emergency physician and intensivist at MedStar Washington Hospital Center, dives deep into the world of Airway Pressure Release Ventilation (APRV). He discusses the practicalities of APRV through a case study of a patient with respiratory distress, highlighting its advantages over conventional methods. Listeners learn about crucial settings, spontaneous breathing's role, and how to tailor ventilation to individual needs. Spiegel also addresses the implications of lung injuries and hypotension, advocating for APRV's benefits in critical care scenarios.
APRV effectively helps restore functional residual capacity in patients with issues like obesity hypoventilation or lung injury through its unique ventilation strategy.
By minimizing the need for high sedation levels, APRV promotes patient comfort while facilitating natural ventilation patterns for better outcomes.
Individualizing APRV settings based on real-time patient assessments enhances lung mechanics and recruitment, adapting to patients' evolving conditions efficiently.
Deep dives
Overview of APRV and Its Application
APRV, or Airway Pressure Release Ventilation, is discussed as a mode of ventilation that provides continuous positive airway pressure with periodic releases. It is particularly useful for patients with significantly reduced lung volumes, aiming to restore functional residual capacity (FRC). This mode is suggested for patients who may experience issues such as obesity hypoventilation or lung injury, as it allows for less obstructive ventilation compared to conventional modes. The clinical case of a 60-year-old male with hypoxia and obesity demonstrates a scenario where APRV would be beneficial.
Benefits of Using APRV Over Conventional Modes
The advantages of APRV include avoiding the discomfort associated with high levels of sedation required for conventional modes, as it permits more natural ventilation patterns. One notable difference is that APRV can reach optimal PEEP levels without prior knowledge of the ideal settings, in contrast to standard ventilation methods that often rely on static compliance measurements. This capability allows clinicians to minimize iatrogenic complications related to sedation and prolonged mechanical ventilation. Consequently, APRV shifts the focus towards patient comfort and supports recruitment effectively.
Setting Initial Parameters for APRV
The initial settings for APRV are derived from the patient's previous ventilation parameters, usually starting with a P high around the plateau pressure and customizing T low based on individual needs. Clinicians typically set T high to accommodate the required minute ventilation while ensuring the longest time at high pressure for lung recruitment. As the patient's condition evolves, monitoring the release volumes and adjusting T high are necessary for maintaining an effective ventilation strategy. This approach emphasizes the importance of individualizing treatment based on real-time patient assessments rather than strict adherence to conventional protocols.
Monitoring and Adjustments in APRV
Monitoring patients on APRV involves assessing release volumes and driving pressures to gauge lung compliance and recruitment success. Driving pressure, calculated as the difference between P high and the end-expiratory pressure, is critical to safeguarding lung health and indicates the appropriateness of the tidal volumes given to the patient. Regular evaluation allows clinicians to adjust T highs independently from P highs, ensuring optimal lung mechanics while preventing derecruitment. By understanding these metrics, healthcare professionals can effectively manage patients throughout their recovery.
Patient Breathing Dynamics on APRV
A common misconception is that patients must spontaneously breathe while on APRV; however, this is only feasible for patients close to their FRC. Initially, patients may require deep sedation to prevent unsynchronized breathing due to high minute ventilation needs and lung stiffness. As a patient's condition improves with APRV, their ability to breathe naturally increases, which requires careful reassessment of sedation levels. Ultimately, the goal is to transition patients from mandatory ventilation to spontaneous breathing as their lung function allows without compromising safety.
We discuss the practicalities of using airway pressure release ventilation (APRV) with Dr. Rory Spiegel (@EMnerd_), emergency physician and intensivist at MedStar Washington Hospital Center (and EMNerd at Emcrit). Find us on Patreon here! Buy your merch here! Takeaway lessons
Remember Everything You Learn from Podcasts
Save insights instantly, chat with episodes, and build lasting knowledge - all powered by AI.
