EC Pulmonology and Respiratory Medicine

Airway pressure release ventilation (APRV) was first introduced in 1987 by Downs and Stock. It was developed as a lung-protective mode allowing for constant recruitment of alveoli, while minimizing ventilator-induced lung injury [1,2]. This method of ventilation provides increased airway pressure for an extended period of time with a momentary release, allowing for recoil of the lung producing a tidal volume relative to its elastic properties [3]. In essence, it is a continuous positive airway pressure therapy (CPAP) with a release phase allowing spontaneous breathing which provides potential benefits of decreased sedation, shorter duration of mechanical ventilation, and improvement in cardiac performance [4]. With no spontaneous breaths, APRV simply becomes an inverse inspiratory expiratory ratio (I: E) pressure controlled time cycled ventilatory mode. Its performance however is dependent on the operator selected [5]. Although it has not shown benefit in mortality, its effect on improving oxygenation with lung protective strategy is gaining popularity [6,7].

1. Downs JB and Stock MC. “Airway pressure release ventilation: a new concept in ventilatory support”. Critical Care Medicine5 (1987): 459-461.
2. Modrykamien A., et al. “Airway pressure release ventilation: An alternative mode of mechanical ventilation in acute respiratory distress syndrome”. Cleveland Clinic Journal of Medicine2 (2011): 101-110.
3. Roy S., et al. “Early airway pressure release ventilation prevents ARDS-a novel preventive approach to lung injury”. Shock1 (2013): 28.
4. Facchin F and Fan E. “Airway pressure release ventilation and high-frequency oscillatory ventilation: potential strategies to treat severe hypoxemia and prevent ventilator-induced lung injury”. Respiratory Care10 (2015): 1509-1521.
5. Mireles-Cabodevila E and Kacmarek RM. “Should Airway Pressure Release Ventilation Be the Primary Mode in ARDS?” Respiratory Care6 (2016): 761-773.
6. Daoud EG., et al. “Airway pressure release ventilation: what do we know?” Respiratory Care2 (2012): 282-292.
7. González M., et al. “Airway pressure release ventilation versus assist-control ventilation: a comparative propensity score and international cohort study”. Intensive Care Medicine 36.5 (2010): 817-827.
8. Dreyfuss D and Saumon G. “Ventilator-induced lung injury: lessons from experimental studies”. American Journal of Respiratory and Critical Care Medicine1 (1998): 294-323.
9. Hotchkiss JR., et al. “Effects of decreased respiratory frequency on ventilator-induced lung injury”. American Journal of Respiratory and Critical Care Medicine2 (2000): 463-468.
10. Putensen C., et al. “Spontaneous breathing during ventilatory support improves ventilation-perfusion distributions in patients with acute respiratory distress syndrome”. American Journal of Respiratory and Critical Care Medicine 4-1 (1999): 1241-1248.
11. Putensen C., et al. “Long-term effects of spontaneous breathing during ventilatory support in patients with acute lung injury”. American Journal of Respiratory and Critical Care Medicine1 (2001): 43-49.
12. Hedenstierna G and Lichtwarck-Aschoff M. “Interfacing spontaneous breathing and mechanical ventilation. New insights”. Minerva Anestesiologica 4 (2006): 183-198.
13. Daoud EG. “Airway pressure release ventilation”. Annals of Thoracic Medicine4 (2007): 176-179.
14. Froese AB and Bryan AC. “Effects of anesthesia and paralysis on diaphragmatic mechanics in man”. Anesthesiology3 (1974): 242-255.
15. Yoshida T., et al. “The impact of spontaneous ventilation on distribution of lung aeration in patients with acute respiratory distress syndrome: airway pressure release ventilation versus pressure support ventilation”. Anesthesia and Analgesia6 (2009): 1892-900.
16. Maung AA., et al. “Lessons learned from airway pressure release ventilation”. The Journal of Trauma and Acute Care Surgery 3 (2012): 624-628.
17. Hirani A., et al. “Airway pressure release ventilation (APRV) for the treatment of severe life-threatening ARDS in a morbidly obese patient”. Critical Care and Shock 4 (2008): 132-136.
18. Walsh MA., et al. “Airway pressure release ventilation improves pulmonary blood flow in infants after cardiac surgery”. Critical Care Medicine 12 (2011): 2599-604.
19. Hering R., et al. “Spontaneous breathing during airway pressure release ventilation in experimental lung injury: Effects on hepatic blood flow”. Intensive Care Medicine 34 (2008): 523-527.
20. Stock MC., et al. “Airway pressure release ventilation”. Critical Care Medicine 5 (1987): 462-466.
21. Davis K., et al. “Airway pressure release ventilation”. Archives of Surgery12 (1993): 1348-1352.
22. Arshad Z., et al. “Ventilating Patient with Refractory Hypercarbia: Use of APRV Mode”. Journal of Clinical and Diagnostic Research1 (2016): UD01-UD02.
23. Pinsky MR. “Determinants of pulmonary arterial flow variation during respiration”. Journal of Applied Physiology: Respiratory, Environmental and Exercise Physiology 5 (1984): 1237-1245.
24. Hering R., et al. “Effects of spontaneous breathing during airway pressure release ventilation on respiratory work and muscle blood flow in experimental lung injury”. Chest 128 (2005): 2991-2998.
25. Hering R., et al. “Effects of spontaneous breathing during airway pressure release ventilation on intestinal blood flow in experimental lung injury”. Anesthesiology 99 (2003): 1137-1144.
26. Kaplan LJ., et al. “Airway pressure release ventilation increases cardiac performance in patients with acute lung injury/adult respiratory distress syndrome”. Critical Care 5 (2001): 221-226.
27. Hering R., et al. “Effects of spontaneous breathing during airway pressure release ventilation on renal perfusion and function in patients with acute lung injury”. Intensive Care Medicine 28 (2002):1426-1433.
28. Kress JP., et al. “Sedation and analgesia in the intensive care unit”. American Journal of Respiratory and Critical Care Medicine8 (2002): 1024-1028.
29. Arroliga A., et al. “Use of sedatives and neuromuscular blockers in a cohort of patients receiving mechanical ventilation”. Chest2 (2005): 496-506.
30. Morehead RS and Pinto SJ. “Ventilator-associated pneumonia”. Archives of Internal Medicine13 (2000): 1926-1936.
31. Sydow M., et al. “Long term effects of two different ventilatory modes on oxygenation in acute lung injury. Comparison of airway pressure release ventilation and volume-controlled inverse ratio ventilation”. American Journal of Respiratory and Critical Care Medicine 149 (1994): 1550-1556.
32. Fan E., et al. “Sedation and Analgesia with Airway Pressure Release and Assist-Control Ventilation for Acute Lung Injury”. Journal of Intensive Care Medicine6 (2008): 376-383.
33. Jain SV., et al. “The 30-year evolution of airway pressure release ventilation (APRV)”. Intensive Care Medicine Experimental1 (2016): 1.
34. Kollisch-Singule M., et al. “Mechanical breath profile of airway pressure release ventilation: the effect on alveolar recruitment and microstrain in acute lung injury”. JAMA Surgery11 (2014): 1138-1145.
35. Li JQ., et al. “Clinical research about airway pressure release ventilation for moderate to severe acute respiratory distress syndrome”. European Review for Medical and Pharmacological Sciences12 (2016): 2634-2641.
36. Walkey AJ., et al. “Use of airway pressure release ventilation is associated with a reduced incidence of ventilator-associated pneumonia in patients with pulmonary contusion”. Journal of Trauma (2010).
37. Ware LB and Matthay MA. “The acute respiratory distress syndrome”. The New England Journal of Medicine18 (2000): 1334-1349.
38. Parsons PE., et al. “NHLBI Acute Respiratory Distress Syndrome Clinical Trials Network. Lower tidal volume ventilation and plasma cytokine markers of inflammation in patients with acute lung injury”. Critical Care Medicine1 (2005): 1-6.
39. Albert S., et al. “Comparison of “open lung” modes with low tidal volumes in a porcine lung injury model”. Journal of Surgical Research1 (2011): e71-e81.
40. Lachmann B. “Open up the lung and keep the lung open”. Intensive Care Medicine6 (1992): 319-321.
41. Sydow M., et al. “Longterm effects of two different ventilatory modes on oxygenation in acute lung injury. Comparison of airway pressure release ventilation and volume-controlled inverse ratio ventilation”. American Journal of Respiratory and Critical Care Medicine6 (1994): 1550-1556.
42. Pelosi P., et al. “Vertical gradient of regional lung inflation in adult respiratory distress syndrome”. American Journal of Respiratory and Critical Care Medicine 149 (1994): 8-13.
43. Shipley J., et al. “Ventilator mode and clinical factors influence adherence to low tidal volume ventilation in ARDS/ALI”. Chest (2011): 140.
44. Neumann P., et al. “Influence of different release times on spontaneous breathing pattern during airway pressure release ventilation”. Intensive Care Medicine12 (2002): 1742-1749.
45. Papazian L., et al. “Neuromuscular blockers in early acute respiratory distress syndrome”. The New England Journal of Medicine12 (2010): 1107-1116.
46. Hirani A., et al. “Airway pressure-release ventilation in pregnant patients with acute respiratory distress syndrome: a novel strategy”. Respiratory Care10 (2009): 1405-1408.
47. Vasquez DN., et al. “Clinical characteristics and outcomes of obstetric patients requiring ICU admission”. Chest3 (2007): 718-724.
48. Morimoto Y., et al. “Successful management using airway pressure release ventilation for severe postoperative pulmonary edema”. International Journal of Surgery Case Reports 27 (2016): 93-95.
49. Varpula T., et al. “Combined effects of prone positioning and airway pressure release ventilation on gas exchange in patients with acute lung injury”. Acta Anaesthesiologica Scandinavica5 (2003): 516-524.
50. Davis Brandy L., et al. “Use of Airway Pressure Release Ventilation with Traumatic Brain Injured Patient Respiratory Care”. Respiratory Care (2011).
51. Fletcher JJ., et al. “Changes in Therapeutic Intensity Level Following Airway Pressure Release Ventilation in Severe Traumatic Brain Injury”. Journal of Intensive Care Medicine3 (2016): 196-202.
52. Marik PE., et al. “The effect of APRV ventilation on ICP and cerebral hemodynamics”. Neurocritical Care2 (2012): 219-223.
53. Stawicki SP., et al. “Analytic reviews: high-frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV): a practical guide”. Journal of Intensive Care Medicine4 (2009): 215-229.
54. Fan E., et al. “Novel approaches to minimize ventilator-induced lung injury”. BMC Medicine1 (2013): 85.
55. Frawley PM and Habashi NM. “Airway pressure release ventilation: theory and practice”. AACN Advanced Critical Care2 (2001): 234-246.
56. Maung AA., et al. “Compared to conventional ventilation, airway pressure release ventilation may increase ventilator days in trauma patients”. The Journal of Trauma and Acute Care Surgery2 (2012): 507-510.
57. Marini JJ. “Dynamic Hyperinflation and Auto–Positive End-Expiratory Pressure: Lessons Learned over 30 Years”. American Journal of Respiratory and Critical Care Medicine7 (2011): 756-762.
58. Ely EW., et al. “Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit”. Journal of the American Medical Association14 (2004): 1753-1762.