Dr. Palen Mallory, a pediatric intensivist at Duke Children's Hospital, unpacks the essential nuances of Airway Pressure Release Ventilation (APRV) for ARDS. She discusses the importance of personalized ventilator settings and innovative strategies to boost oxygenation and ventilation. Advanced weaning techniques are explored, emphasizing the role of end-tidal CO2 monitoring. Mallory also highlights the need for standardized protocols in pediatric care and sheds light on future research directions, making for a compelling listen for healthcare professionals.
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volunteer_activism ADVICE
Setting Initial APRV Parameters
When initiating APRV, set P high near plateau pressure without exceeding 30-35 cm H2O.
Adjust T high for about 4-5 seconds releases to balance ventilation and oxygenation.
insights INSIGHT
Personalized APRV and Auto-PEEP
Personalized APRV uses auto-PEEP to maintain lung volume at exhalation.
This may improve lung recruitment compared to fixed P low settings but poses monitoring challenges.
volunteer_activism ADVICE
Improving Oxygenation in APRV
To improve oxygenation on APRV, increase mean airway pressure by raising P high or lengthening T high.
Always confirm lungs are not overexpanded on X-ray before increasing pressures.
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By the end of this series, listeners should be able to discuss:
The physiologic rationale supporting the use of airway pressure release ventilation (APRV) in ARDS.
The patient populations most likely to benefit from APRV.
Key published evidence that informs our use of APRV in critical care.
An expert approach to managing a patient with APRV.
Next steps in research that will direct our understanding of the use of APRV in pediatric critical care.
About our Guest:
Dr. Palen Mallory is an assistant professor of pediatrics at Duke University and a pediatric intensivist at Duke Children's Hospital. She completed medical school at Virginia Commonwealth University, a pediatric residency at Emory University, and a critical care fellowship at Vanderbilt University. She is interested in respiratory care research, including ECMO, respiratory failure, and ARDS.
Selected References:
Mallory, P., & Cheifetz, I. (2020). A comprehensive review of the use and understanding of airway pressure release ventilation. Expert Review of Respiratory Medicine, 14(3), 307–315. https://doi.org/10.1080/17476348.2020.1708719
Frawley, P. M., & Habashi, N. M. (2004). Airway pressure release ventilation and pediatrics: Theory and practice. Critical Care Nursing Clinics of North America, 16(3 SPEC. ISS.), 337–348. https://doi.org/10.1016/J.CCELL.2004.04.003
Fredericks, A. S., Bunker, M. P., Gliga, L. A., Ebeling, C. G., Ringqvist, J. R. B., Heravi, H., Manley, J., Valladares, J., & Romito, B. T. (2020). Airway Pressure Release Ventilation: A Review of the Evidence, Theoretical Benefits, and Alternative Titration Strategies. Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine, 14. https://doi.org/10.1177/1179548420903297
Andrews P, Shiber J, Madden M, Nieman GF, Camporota L, Habashi NM. Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal. Front Physiol. 2022 Jul 25;13:928562. doi: 10.3389/fphys.2022.928562. PMID: 35957
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