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StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

Average Volume-Assured Pressure Support

Siva Naga S. Yarrarapu; Hollie Saunders; Devang K. Sanghavi.

Author Information and Affiliations

Last Update: August 8, 2023.

Continuing Education Activity

Respiratory failure is one of the most important and common causes of patient
admissions to the intensive care unit (ICU). In the last few years, non-invasive
ventilation has gained increased prominence in the management of a variety of
conditions causing acute as well as chronic respiratory failure. Different
modalities of non-invasive ventilation exist, with continuous positive airway
pressure (CPAP) and bilevel positive airway pressure (BiPAP) being the most
commonly used modes. Average volume-assured pressure support (AVAPS) is a
relatively newer modality of non-invasive ventilation that integrates the
characteristics of both volume and pressure-controlled non-invasive ventilation.
This activity reviews the utilization of average volume-assured pressure support
in the intensive care unit and highlights the role of the interprofessional team in
the management of patients with respiratory failure using this modality of non-
invasive ventilation.

Objectives:

Describe the functioning mechanism of average volume-assured pressure

support.

Summarize the clinical significance of average volume-assured pressure

support.

Outline the complications of average volume-assured pressure support.

Explain the importance of collaboration and communication amongst the

interprofessional team to enhance the delivery of care for patients on
average volume-assured pressure support.

Access free multiple choice questions on this topic.

Introduction
Respiratory failure is one of the most important and common causes of patient
admissions to the intensive care unit. It has a plethora of causes and, depending
on the duration of the condition; can be broadly categorized as either acute or
chronic respiratory failure. Treatment of the underlying cause and supportive
measures, involving the utilization of ventilatory support, form the fundamental
principles in the management of respiratory failure.[1][2][3]

In the last few years, non-invasive ventilation has gained increased prominence
in the management of a variety of conditions causing acute as well as chronic
respiratory failure. As studies demonstrating its benefits have materialized, its
usage has become more widespread and widely accepted. Contrary to invasive
ventilation, which uses an endotracheal or tracheostomy tube, non-invasive
ventilation makes use of nasal masks, oronasal masks, total face masks,
mouthpiece, or the helmet for respiratory assistance. Without causing any of the
complications of invasive ventilation, non-invasive ventilation, ultimately,
achieves adequate gaseous exchange correcting hypoxemia and/or
hypercapnia. Different modalities of non-invasive ventilation exist, with
continuous positive airway pressure (CPAP) and bilevel positive airway pressure
(BiPAP) being the most commonly used modes. Average volume-assured pressure
support (AVAPS) is a relatively newer modality of non-invasive ventilation that
integrates the characteristics of both volume and pressure-controlled non-
invasive ventilation.[4][5][6][7]

This review article focuses on AVAPS, its functioning, clinical significance,

complications, and interprofessional communication to enhance health care
outcomes.

Function
When the Respironics V60 ventilator debuted in 2009, it was equipped with an
intelligent newer modality of pressure-control ventilation called the average
volume-assured pressure support (AVAPS). This mode doesn’t contain an
inspiratory positive airway pressure (IPAP) setting. Instead, it has been replaced
with a target tidal volume (VT) setting.

Rather than having one fixed IPAP setting, the AVAPS mode has the capability to
set a range of values for the IPAP, a maximum and a minimum IPAP. The
pressure-support is no longer fixed as the IPAP changes by itself within the set
range. The ventilator does this based on the targeted tidal volume, a pre-set value.
It uses a feedback loop to either increase or decrease the inspiratory pressure
from breath to breath in order to ensure the pre-set tidal volume is delivered.
Patient-ventilator dyssynchronization is prevented as the inspiratory pressure
changes smoothly, thus improving patient comfort.

The tidal volume also varies with each breath but the machine ensures that the
average targeted tidal volume over the course of one minute is achieved.

Although there is a set range for the IPAP, the AVAPS has to select an initial
inspiratory pressure for the first breath. It uses either one of the following three
algorithms to calculate this value.

1. IPAP min

2. VT/60 ml/cmH2O + EPAP

3. 8 cm/H2O + EPAP cmH2O

The calculation which produces the highest value will be the initial IPAP setting.
AVAPS automatically calculates, selects, and then institutes the highest value as
the initial IPAP setting.
In AVAPS, the expiratory positive airway pressure (EPAP) is fixed; however, the
auto-titration mode of non-invasive ventilation, 'average volume-assured
pressure support-auto-titrating EPAP'(AVAPS-AE) regulates EPAP as well.

The ventilatory settings in AVAPS mode are typically predetermined, based on the
patient’s condition and his clinical assessment, and are then manually set on the
ventilator. The target tidal volume is set to 8 ml/kg of ideal weight and adjusted
based on the patient’s pathology. The maximal IPAP value is generally fixed at 20-
25 cm H20 and the minimal IPAP value equals to EPAP + 4 cm H20. The value of
the minimal inspiratory pressure is no less than 8 cmH2O and commonly higher.
The respiratory rate is set at 2-3 BPM below the resting respiratory rate.

It takes several minutes for the AVAPS to attain the targeted tidal volume. IPAP
automatically increases or decreases in synchronization with changes in the
patient’s respiratory effort, lung compliance, or extrinsic lung resistance.[8][9]
[10][11][4][12]

Clinical Significance
AVAPS in Chronic Respiratory Failure

Stable hypercapnic chronic obstructive pulmonary disease (COPD) - AVAPS has

been proven safe and reliable in the management of stable hypercapnic
COPD patients. Besides, it is a more favorable treatment strategy compared
to the non-invasive fixed inspiratory pressure support as the patients
perceive a better sleep efficiency and quality of life.[13][14]

Obesity hypoventilation syndrome - Not only is AVAPS as competent as the

BPV S/T modality of non-invasive ventilation, in improving oxygenation,
sleep quality, and health-related quality of life (HRQOL), but it also has the
added advantage of decreasing PtcCO2 more efficiently.[15]

Kyphoscoliosis - AVAPS has been associated with a significant improvement

in arterial blood gases and forced vital capacity of patients with
kyphoscoliosis-related chronic respiratory failure. It was well accepted by
the patients resulting in good patient-compliance to the treatment and is
thus an effective treatment option.[16]

Congenital central hypoventilation syndrome - Different case studies have

found the AVAPS to be beneficial in the management of pediatric patients
with congenital central hypoventilation syndrome. The evidence has
reported successful management of infants with this syndrome through
AVAPS. Furthermore, the successful transition from invasive ventilation to
non-invasive ventilation, via AVAPS, was demonstrated in children, and
teenagers as well, with this syndrome.[17][18][19]

AVAPS in Acute Respiratory Failure [20] [21] [9] [10]

AVAPS has been successful in the treatment of COPD-associated acute

hypercapnic respiratory failure. Significant improvement was seen in
arterial blood gases, pH, respiratory rate, and the Glasgow Coma Scale.
Nonetheless, it is important to note that the patients with a higher APACHE
 II score, calculated during ICU admission, had a higher risk of treatment
failure.

Although both AVAPS and BiPAP are reliable in the treatment of acute
hypercapnic respiratory failure, AVAPS is associated with a speedy
improvement of the patient clinically. The patients have also experienced
greater comfort and satisfaction comparatively, and therefore, improved
treatment-compliance.

In patients suffering from acute exacerbation of COPD compounded with

hypercapnic encephalopathy(GCS<10), treatment with BiPAP S/T + AVAPS
was more superior compared to the treatment with BiPAP S/T alone as
evidenced by a more rapid improvement in the arterial blood gases and
Glasgow Coma Score. Remember that both the therapies are effectual, and
there was no difference in the duration of hospital stay or the time-period
that the patient was on non-invasive ventilation.

AVAPS can be considered as the preferred treatment in patients with acute

exacerbation of COPD as well as obstructive sleep apnea in comparison to
the regular non-invasive ventilation.

AVAPS has been documented to facilitate successful extubation in Acute

respiratory distress syndrome (ARDS), thus demonstrating its potential in
saving ventilators and setting them aside for the sicker patients at times of
need.

Other Issues
Non-invasive positive pressure ventilation (NIPPV) is associated with substantial
financial benefits without compromising on the quality of patient healthcare. It is
associated with a decreased risk of pneumonia, sepsis, and mortality compared to
invasive positive pressure ventilation.[4] Data from several hospitals has shown
significant per annual savings for each patient following whether they received
non-invasive ventilation or not.[22]

Similar complications and contraindications exist for the varying modes of

noninvasive positive-pressure ventilation (NIPPV), including AVAPS, and
comprises the following:

Complications [23] [24]

Mucosal dryness/plugging

Nasal congestion

Sinus/ear pain

Claustrophobia

Air leaks

Fascial erythema/abrasions due to tight fascial mask

Gastric insufflation
 Treatment failure

Hypotension (seen in patients with cardiac dysfunction)

Pneumonia (infrequent)

Barotrauma (rare)

Contraindications [25]

Respiratory arrest

Cardiac arrest/hemodynamic compromise/unstable arrhythmia

Fascial trauma/surgery/burns

Blockage of upper-airway

Impaired cough reflex/swallowing (lack of airway protection)

Profuse gastrointestinal bleeding

Severe encephalopathy

Enhancing Healthcare Team Outcomes

AVAPS is a relatively newer modality of non-invasive ventilation and it
necessitates good collaboration amongst the interprofessional team of medical
professionals to ensure the appropriate selection of candidates for average
volume-assured pressure support.

Operating a ventilator is occasionally considered difficult, and requires good

experience and training to ensure successful therapy without causing any
negative harm. The nurses have little knowledge of operating the ventilators. To
avert the risks associated with it, effective communication, and teamwork
between the critical care specialist, pulmonologist, internist, critical care nurse,
and the healthcare workers in the ICU is essential to resuscitate the patient and
improve patient outcomes.[26]

Review Questions

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Comment on this article.

References
1. Mirabile VS, Shebl E, Sankari A, Burns B. StatPearls [Internet]. StatPearls
Publishing; Treasure Island (FL): Jun 11, 2023. Respiratory Failure in Adults.
[PubMed: 30252383]
2. Vincent JL, Akça S, De Mendonça A, Haji-Michael P, Sprung C, Moreno R,
Antonelli M, Suter PM., SOFA Working Group. Sequntial organ failure
assessment. The epidemiology of acute respiratory failure in critically ill
patients(*). Chest. 2002 May;121(5):1602-9. [PubMed: 12006450]
3.
Vincent JL, Sakr Y, Ranieri VM. Epidemiology and outcome of acute respiratory
failure in intensive care unit patients. Crit Care Med. 2003 Apr;31(4 Suppl):S296-9.
[PubMed: 12682455]
4. Seyfi S, Amri P, Mouodi S. New modalities for non-invasive positive pressure
ventilation: A review article. Caspian J Intern Med. 2019 Winter;10(1):1-6.
[PMC free article: PMC6386330] [PubMed: 30858934]
5. Pluym M, Kabir AW, Gohar A. The use of volume-assured pressure support
noninvasive ventilation in acute and chronic respiratory failure: a practical
guide and literature review. Hosp Pract (1995). 2015;43(5):299-307. [PubMed:
26559968]
6. Nava S, Hill N. Non-invasive ventilation in acute respiratory failure. Lancet.
2009 Jul 18;374(9685):250-9. [PMC free article: PMC7138083] [PubMed:
19616722]
7. Luo F, Annane D, Orlikowski D, He L, Yang M, Zhou M, Liu GJ. Invasive versus
non-invasive ventilation for acute respiratory failure in neuromuscular
disease and chest wall disorders. Cochrane Database Syst Rev. 2017 Dec
04;12(12):CD008380. [PMC free article: PMC6486162] [PubMed: 29199768]
8. Hess DR. Patient-ventilator interaction during noninvasive ventilation. Respir
Care. 2011 Feb;56(2):153-65; discussion 165-7. [PubMed: 21333176]
9. Okuda M, Kashio M, Tanaka N, Fujii T, Okuda Y. Positive outcome of average
volume-assured pressure support mode of a Respironics V60 Ventilator in
acute exacerbation of chronic obstructive pulmonary disease: a case report. J
Med Case Rep. 2012 Sep 10;6:284. [PMC free article: PMC3485098] [PubMed:
22963752]
10. Briones Claudett KH, Briones Claudett M, Chung Sang Wong M, Nuques
Martinez A, Soto Espinoza R, Montalvo M, Esquinas Rodriguez A, Gonzalez
Diaz G, Grunauer Andrade M. Noninvasive mechanical ventilation with
average volume assured pressure support (AVAPS) in patients with chronic
obstructive pulmonary disease and hypercapnic encephalopathy. BMC Pulm
Med. 2013 Mar 12;13:12. [PMC free article: PMC3637438] [PubMed: 23497021]
11. Mittal A, Forte M, Leonard R, Sangani R, Sharma S. Refractory Acute
Respiratory Distress Syndrome Secondary to COVID-19 Successfully
Extubated to Average Volume-assured Pressure Support Non-invasive
Ventilator. Cureus. 2020 Apr 27;12(4):e7849. [PMC free article: PMC7253078]
[PubMed: 32483500]
12. Pletsch-Assuncao R, Caleffi Pereira M, Ferreira JG, Cardenas LZ, de
Albuquerque ALP, de Carvalho CRR, Caruso P. Accuracy of Invasive and
Noninvasive Parameters for Diagnosing Ventilatory Overassistance During
Pressure Support Ventilation. Crit Care Med. 2018 Mar;46(3):411-417.
[PubMed: 29189344]
13. Crisafulli E, Manni G, Kidonias M, Trianni L, Clini EM. Subjective sleep
quality during average volume assured pressure support (AVAPS) ventilation
in patients with hypercapnic COPD: a physiological pilot study. Lung. 2009
Sep-Oct;187(5):299-305. [PubMed: 19672655]
14. Magdy DM, Metwally A. Effect of average volume-assured pressure support
treatment on health-related quality of life in COPD patients with chronic
hypercapnic respiratory failure: a randomized trial. Respir Res. 2020 Mar
06;21(1):64. [PMC free article: PMC7059298] [PubMed: 32143652]
15. Storre JH, Seuthe B, Fiechter R, Milioglou S, Dreher M, Sorichter S, Windisch
W. Average volume-assured pressure support in obesity hypoventilation: A
randomized crossover trial. Chest. 2006 Sep;130(3):815-21. [PubMed:
16963680]
16. Piesiak P, Brzecka A, Kosacka M, Jankowska R. Efficacy of noninvasive
volume targeted ventilation in patients with chronic respiratory failure due
to kyphoscoliosis. Adv Exp Med Biol. 2015;838:53-8. [PubMed: 25315620]
17. Vagiakis E, Koutsourelakis I, Perraki E, Roussos C, Mastora Z, Zakynthinos S,
Kotanidou A. Average volume-assured pressure support in a 16-year-old girl
with congenital central hypoventilation syndrome. J Clin Sleep Med. 2010 Dec
15;6(6):609-12. [PMC free article: PMC3014250] [PubMed: 21206552]
18. Saddi V, Teng A, Thambipillay G, Allen H, Pithers S, Sullivan C. Nasal mask
average volume-assured pressure support in an infant with congenital
central hypoventilation syndrome. Respirol Case Rep. 2019 Aug;7(6):e00448.
[PMC free article: PMC6589097] [PubMed: 31285823]
19. Gentin N, Williamson B, Thambipillay G, Teng A. Nocturnal respiratory
failure in a child with congenital myopathy - management using average
volume-assured pressure support (AVAPS). Respirol Case Rep. 2015
Sep;3(3):115-7. [PMC free article: PMC4571743] [PubMed: 26392861]
20. Ciftci F. Evaluation of the feasibility of average volume-assured pressure
support ventilation in the treatment of acute hypercapnic respiratory failure
associated with chronic obstructive pulmonary disease: A pilot study. J Crit
Care. 2017 Aug;40:282. [PubMed: 28599990]
21. Canpolat G, Ozgultekin A, Boran ÖF. Comparison of bilevel positive airway
pressure and average volume-assured pressure support mode in terms of
patient compliance and treatment success in hypercapnic patients. A cross-
sectional study. Ann Ital Chir. 2019;90:392-397. [PubMed: 31308266]
22. Trout D, Bhansali AH, Riley DD, Peyerl FW, Lee-Chiong TL. A quality
improvement initiative for COPD patients: A cost analysis. PLoS One.
2020;15(7):e0235040. [PMC free article: PMC7337310] [PubMed: 32628684]
23. Kelly CR, Higgins AR, Chandra S. Noninvasive Positive-Pressure Ventilation. N
Engl J Med. 2015 Sep 24;373(13):1279. [PubMed: 26398090]
24. Carron M, Freo U, BaHammam AS, Dellweg D, Guarracino F, Cosentini R,
Feltracco P, Vianello A, Ori C, Esquinas A. Complications of non-invasive
ventilation techniques: a comprehensive qualitative review of randomized
trials. Br J Anaesth. 2013 Jun;110(6):896-914. [PubMed: 23562934]
25. Nava S, Ceriana P. Causes of failure of noninvasive mechanical ventilation.
Respir Care. 2004 Mar;49(3):295-303. [PubMed: 14982651]
26. Williams LM, Sharma S. StatPearls [Internet]. StatPearls Publishing; Treasure
Island (FL): Aug 8, 2023. Ventilator Safety. [PubMed: 30252300]
Disclosure: Siva Naga Yarrarapu declares no relevant financial relationships with ineligible
companies.

Disclosure: Hollie Saunders declares no relevant financial relationships with ineligible

companies.

Disclosure: Devang Sanghavi declares no relevant financial relationships with ineligible

companies.
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