APRV Guide for ARDS and Non-ARDS patients

If having problems / questions, pt not improving or P High

Change from conventional mechanical ventilation >35 mmHg or Resp Rate > 40 bpm call:

The rounding fellow or attending in the unit

Stop paralytics, decrease sedation to point of
spontaneous respiration (MAAS Score of 3)

Change mode to APRV Monitoring:

1. Do not use in patients with TBI or suspected

increased ICP.
2. For COPD patients, we might need Thigh 0.8-
1.2 seconds or sometimes higher, so this may
Initial settings:
not be the modality of choice.
1. P High: Set at 80% or equal to plateau pressure. Try to
3. No paralysis
maintain below 30 cmH2O. Typically we start at 20-
4. Maintain SpO2 >92%
25 cm H2O and adjust P High to achieve VT of 6-8
5. Minute ventilation may be 30-50 % less than
CC/PBW
the conventional ventilation
2. P Low: Prefer to set at 0. Or up to 5.
6. Monitor hemodynamics. Some patients will
3. T High: Start at 4-6 seconds.
have significant changes and will not tolerate
4. T Low: Start at 0.5- 0.8 seconds. This should be 25-
APRV, especially with RV dysfunction.
75% of the peak expiratory flow.
7. Mean airway pressure close to the P high
5. FiO2 to maintain SaO2 >90
8. Monitor EtCO2. Remember this mode
correlates with permissive hypercapnia.
9. ABG 2 hours after the initial settings.

Check ABG 30 min after changes

Watch EtCO2 with changes

PaO2 improved PaO2 improved PaO2 worse PaO2 worse PaO2 worse
(60-80mmHg) (60-80mmHg) (<60mmHg) (<60mmHg) (<60mmHg)
PaCaO2 acceptable PaCaO2 high PaCo2 acceptable PaCO2 high PaCO2 low
(<65mmHg) (>65mmHg) (<65mmHg) (>65mmHg) (<30mmHg)
-↓P High by 2 mmHg -Leave P High same - ↑P High by -↑P High by 2mmHg -↑P High 2mmHg
-↓T High (0.5 sec)
every 8 hours as long 2mmHg increments increments (up to 30 increments (up to 30
-↑T Low (0.1 sec)
as PaO2 60-80mmHg (up to 30 mmHg) mmHg) mmHg)
-Make sure pt is
-↑T High (0.5 sec) - ↑T High (0.5 sec) - Make sure pt is -↑T High (0.5 sec)
spontaneously spontaneously
with each drop in P breathing!! - ↓ T Low (0.1 sec) -↓T Low (0.1 sec)
breathing!!
High -If FiO2 >60% wean to -↓ T High (0.5 sec)
-If FiO2 >60% wean to SaO2 > 90%
SaO2 > 90% -↑T Low (0.1 sec)

Weaning from APRV

When ventilation/oxygenation goals are met RT will ‘Drop and Stretch’

Patient meets weaning criteria?

Hemodynamic stability

Adequate mental status

No upper airway obstruction

Is P High ≤ 16?

Is T High ≥10 seconds?

Is FiO2 ≤ 0.4?

If Yes

CPAP at 5-10 cmH2O

with PS 7 for 30 minute
Notify Fellow or
Collect weaning
attending if the patient is
parameters
ready or not ready for
extubation

FiO2 < 0.4