RT Clinic: APRV start-up, management, and weaning

APRV - Airway Pressure Release Ventilation is a great mode to use when protecting the lungs from barotrauma during ARDS. APRV has been adopted by many facilities as a part of a lung protection protocol for mechanical ventilation. Early implementation is very important to the protection of lung tissue.
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Common Terms :
T high - the amount of time set for the application of P high.
T low - the amount of time set for the application of P low.
P high - the pressure set for opening of the lungs (commonly starts at the P plateau in conventional modes)
P low- the target pressure set for exhalation
Releases - the number of transitions per minute from P high to P low
Open Lung Ventilation - The expiratory valve remains open allowing the patient to take a spontaneous breath at any time of the respiratory cycle.
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Intro Music: NeedtoBreathe-Keep Your Eyes Open

[lauradavis]

Amazing video! Thank you so much for posting educational videos. It helps soon to be RT’s such as myself. Which then leads to properly helping patients. Thank you so much!

[colleen_tal]

This was great ! I needed a refresher on APRV . Feeling more confident . Thank You !

[kennethweiss]

Watched for second time;so much great info. Ty!!

[bishnya]

Thank you!!! I tried it on my covid patient that kept breath stacking on every mode & her pao2 pretty much doubled from 54 to 122

[martiniasmith]

Makes more sense. You get right to the point.

[Petertheconcertpianist]

Thank You for the assistance. You truly make GREAT VIDEOS!! You need to do more! A LOT MORE Respiratory videos!!!!

[DGTALSYNAPS]

09:38 “I’m a respiratory therapist...it’s alright.” Man I’m dead. This is verbatim what I say.

[maxineagina]

Amazing! Thank you! I’ve finally understood this mode!

[Petertheconcertpianist]

Hi. I know my question isn’t related to APRV but could you please respond!!? Your videos are GREAT!!!

[Petertheconcertpianist]

Jimmy? I'm one of you frequent viewers, as I watch your videos ALL THE TIME!! I told you my story years ago, but I don't see a video on standard ventilator weaning, so I think I'll ask my question here. OK! So as You know, ventilators like THAT ONE, the Drager V500, have the capability to perform Respiratory Mechanics, such as a NIF, or a PO.1 maneuver. Now Lots of the modern ventilators like the Drager Series, the Puritan Bennetts, such as the PB980, or the older PB840, and even the old PB7200, have the capability to do this NIF maneuver. Now on the 7200, I think it's called a MIP maneuver. But my question is, which do you think is more accurate? The use of the Ventilator to conduct a NIF maneuver, or using those stand alone NIFometers as they're called? Now I happen to have in a drawer behind me, a Mercury Medical NIFometer. It is a disposable device, and there's a patient occlusion button that occludes the airway. people still use those things now days. Even at a regional hospital I go to they have a PB840, and they're still taking the patients off to perform a NIF! What do you think is more Accurate?NIF from the Ventilator, or NIF from a NIFometer?

[gabmor]

i tried aprv on some covid patients and in one patient in particular the fio2 went from 70 to 40 within couple hours!!
i just wonder about lung protection with those higher mean airway pressures, but listening to dr.habashi is it rather more lung protective compared to standard ards ventilation. oh well who knows. sure is interesting

[Petertheconcertpianist]

Your videos are GREAT! I have a question. Ok. When a patient is on a Ventilator obviously, they have the Circuit secured on the support arm. Let’s say you have s Trach patient who is awake and alert and able to move some. You want the patient to have comfort without too much pull on the Trach. How tight to you tighten the support arm screw device? Should the arm be able to swing easily, or kept tight??

[solodeking]

Thanks Jimmy for a brilliant elucidation.
So, a patient has to be started on VC-AC so as to determine the Pplat before switching on to APRV?
And we are doing all this fir a spontaneously breathing patient, who is not paralyzed, but adequately sedated. Right?

[aundreahenry]

What is the best way to keep them comfortable using this mode? What type of sedation are you using?

[ashleyharmon]

Can you do a video showing the modes for VC and PC? I'm learning that in school right now and I seem to be struggling.

[mujobella]

Can you explain why the flowcurve looks like that?

[steves]

Relying on Auto PEEP seems dangerous since all lung units are not the same.

Since the compliance is subject to change, and thus the AutoPEEP would change as well at a given Time Low, why not set a PEEP that still allows your flow to decrease by 75%?

This could be done by increasing PEEP until the flow doesn't get to the 75% point and then back it down slightly. Id think that this would help prevent some units from closing and being snapped back open. Just a little bit of safety possibly?

[ronaldshiffman]

I have 34 years of bedside respiratory therapy experience and have worked with hundreds of patients on APRV. This mode HAS NEVER been shown to be as good or better than other more conventional ventilatory modalities. I would never use it on a patient if I were an MD. Think about it physiologically. It violates every known principle of breathing. APRV makes no sense in the real world and should never be used.