aprv revision sistematica.pdf

8/10/2019 APRV REVISION SISTEMATICA.pdf

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Louise RoseMartyn Hawkins

Airway pressure release ventilation

and biphasic positive airway pressure:

a systematic review of definitional criteria

Received: 1 April 2008Accepted: 24 June 2008

Published online: 17 July 2008 Springer-Verlag 2008

This work was performed at the LawrenceS. Bloomberg Faculty of Nursing, Toronto,Canada and the Intensive Care Unit of theStirling Royal Infirmary, UK.

L. Rose ())Lawrence S. Bloomberg Faculty of Nursing,University of Toronto, 155 College Street,Room 276, Toronto, ON M5T 1P8, Canadae-mail: [email protected].: +1-416-9783492Fax: +1-416-9460665

M. Hawkins

Intensive Care Unit,Stirling Royal Infirmary,Stirling, Scotland, UK

Abstract Objective: The objec-tive of this study was to identify the

definitional criteria for the pressure-limited and time-cycled modes: air-way pressure release ventilation(APRV) and biphasic positive airwaypressure (BIPAP) available in thepublished literature. Design: Sys-tematic review. Methods: Medline,PubMed, Cochrane, and CINAHLdatabases (19822006) were searchedusing the following terms: APRV,BIPAP, Bilevel and lung protectivestrategy, individually and in combi-nation. Two independent reviewers

determined the paper eligibility andabstracted data from 50 studies and18 discussion articles. Measurementsand results: Of the 50 studies, 39(78%) described APRV, and 11(22%) described BIPAP. Variousstudy designs, populations, or out-come measures were investigated.Compared to BIPAP, APRV wasdescribed more frequently as extremeinverse inspiratory:expiratory ratio[18/39 (46%) vs. 0/11 (0%),P = 0.004] and used rarely as a

noninverse ratio [2/39 (5%) vs. 3/11(27%), P = 0.06]. One (9%) BIPAPand eight (21%) APRV studies used

mild inverse ratio ([1:1 to B2:1)(P = 0.7), plus there was increased

use of 1:1 ratio [7 (64%) vs. 12(31%), P = 0.08] with BIPAP. Inadult studies, the mean reported setinspiratory pressure (PHigh) was6 cm H2O greater with APRV whencompared to reports of BIPAP(P = 0.3). For both modes, the meanreported positive end expiratorypressure (PLow) was 5.5 cm H2O.Thematic review identified inconsis-tency of mode descriptions.Conclusions: Ambiguity exists inthe criteria that distinguish APRV and

BIPAP. Commercial ventilatorbranding may further add to confu-sion. Generic naming of modes andconsistent definitional parametersmay improve consistency of patientresponse for a given mode and assistwith clinical implementation.

Keywords Airway pressure releaseventilation Acute lung injury Mechanical ventilation Positive pressure respiration Assisted spontaneous breathing Biphasic positive airway pressure

Introduction

Airway pressure release ventilation (APRV) and bipha-sic positive airway pressure (BIPAP) are modes of

mechanical ventilation that allow unrestricted spontane-ous breathing independent of ventilator cycling, using anactive expiratory valve [14]. Both modes are pressure-limited and time-cycled. Ventilation occurs via the time-

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cycled switching between two set pressure levels. In theabsence of spontaneous breathing, these modes resembleconventional pressure-limited, time-cycled ventilation(Table1) [5].

A proposed advantage of APRV and BIPAP comparedto conventional pressure-controlled ventilation is the

improved distribution of gas to dependent lung regions asthe result of spontaneous breathing enabled during theinspiratory and expiratory time cycles. Radiologic studiesindicate that gas is directed to dependent well-perfusedregions of the lungs during spontaneous breathing due tothe movement of the posterior muscular sections of thediaphragm [2]. Improved gas distribution to dependentlung regions prevents atelectasis and promotes alveolarrecruitment resulting in an improved ventilationperfu-sion matching [6, 7].

Within the scientific literature, descriptions of APRVand BIPAP lack clarity. Various authors use the termAPRV to describe a range of ventilatory settings [811].Others use the term BIPAP to describe settings that areindistinguishable from certain descriptions of APRV [12].In North America, the acronym BiPAP is reserved fornoninvasive ventilation available on Respironics ventila-tors (Murrayville, PA, USA). With registration of thisacronym, ventilator companies have developed otherterms or acronyms to refer to modes with similarcharacteristics.

Reports of the international utilization of ventilatormodes indicate limited clinical uptake of pressure-con-trol modes, which include APRV and BIPAP [13, 14].Clarity of definitional criteria may assist in the clinicalunderstanding and application of these modes. The aimof this paper is to identify the criteria that define anddistinguish APRV and BIPAP within existing scientificliterature.

Methods

The following databases were electronically searched:Medline, PubMed, Cochrane Library, Cochrane Con-trolled Trials Registry, and CINAHL, from 1982 to 2006,using the terms APRV, BIPAP, Bilevel, and lung pro-

tective strategy, individually and in combination. Twoindependent reviewers determined the eligibility of papersbased on appraisal of the article title and abstract,retrieved potentially relevant studies, and decided onstudy eligibility. Reference lists of those papers meetinginclusion criteria were also examined. All study designswere included. Studies were considered for inclusion ifventilator mode characteristics were identified, specifi-cally inspiratory and expiratory times or I:E ratio. Studiesthat contained enough data to calculate these variables,e.g., respiratory rate and expiratory time, were alsoincluded.

No attempt was made to contact authors for unpub-

lished data, as the objective was to identify distinguishingcriteria for APRV and BIPAP existent in the availableliterature. Studies published only in abstract form werenot included. Data on the study design and population,mode settings, mode of comparison (if any), and outcomemeasures were then abstracted from included experi-mental studies onto predesigned forms by each reviewerfollowing comprehensive review. Both reviewers tran-scribed mode descriptions from discussion articles ontodata collection forms independently.

Analyses

Continuous variables describing mode characteristicsfrom experimental studies were summarized as mean and

Table 1 Ventilator mode characteristics

APRV BIPAP PCV (CMV) PCV (IMV) PCV (AC) PSV

Control variable Pressure Pressure Pressure Pressure Pressure PressurePhase variables

Trigger Time/pressure Time Time Time Time Flow/pressure (patient triggered)Limit Pressure Pressure Pressure Pressure Pressure PressureCycle Time Time Time Time Time Flow

Breath typesMandatory breathsa Yes Yes Yes Yes Yes No

Assisted breathsb No Noc No Nod Yes YesSpontaneous breathse Yes Yes No Yes Yes YesActive expiratory valve Yes Yes No No No No

APRVairway pressure release ventilation, BIPAPbiphasic positiveairway pressure, PCV pressure-controlled ventilation, CMV con-trolled mechanical ventilation, IMV intermittent mandatoryventilation, AC assist control, PSV pressure support ventilationa Mandatory breath: machine triggering and/or cycling of thebreathb Assisted breath: patient triggers and cycles the breath but theventilator also does some work

c Exception would be the addition of pressure support availablewith Bilevel ventilation (Puritan Bennett, Pleasanton, CA)d Breaths are assisted if pressure support is applied betweenmandatory breathse Spontaneous breath: breath in which the patient determines boththe timing and size

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SD and compared using Student t tests. Reported I:Eratios were categorized into four groups: noninverse, 1:1,mild inverse ([1:1 to B2.0), and extreme inverse (C2.1),and compared using Fisher exact tests due to smallexpected values. Other categorical data including studypopulation, study outcome, I:E ratio, and synchronization

of the switching between set inspiratory pressure (PHigh)and positive end expiratory pressure (PLow) levels tospontaneous effort were summarized as proportions andalso compared using chi square tests. Because of thesubstantial heterogeneity in study design, study popula-tion, comparative group, and primary outcome, noattempt was made to pool data for the purposes of meta-analysis. A two-tailed P value \0.05 was consideredstatistically significant. All analyses were performedusing Minitab 14 [15]. Discussion articles were examinedusing content analysis to identify themes [16]. Articlecontent was coded under theme headings such as enablesspontaneous breathing or APRV uses short release timeand long inspiratory times and then examined for repe-tition, characteristics and dimensions that identified andconfirmed categories.

Results

Database searching yielded 501 citations, of which 81were selected on review of the title and abstract. Onfurther review, data was abstracted from 50 studies and 18discussion articles. Both reviewers agreed in the selectionof included studies (j= 1). Excluded articles were thosethat contained editorial comment only (n = 8); the focus

of the article was either APRV or BIPAP, but nodescription of the mode was provided (n = 2); or themain focus was not the mode of ventilation (n = 2).

Of the 50 studies, 31 (62%) were human clinicalstudies [811, 1743] and 19 (38%) [12, 4460] wereexperimental (either animal or bench) studies. The 31

human clinical studies included 14 (45%) interventional[8, 9, 17, 18, 22, 30, 32, 3640, 42, 43] and 17 (55%)observational studies [10, 11, 1921, 2329, 31, 3335,41]. None of the human clinical studies were blinded;only two of the experimental studies were blinded. Inthese two studies reported by the same first author,investigators blinded to the mode of ventilation analyzedcomputed tomography images to determine aeration oflung tissue [59,60].

Airway pressure release ventilation was the namedmode in 39 (78%) studies [8,9,11,17,1921,2327,29,3133, 35, 36, 3843, 4653, 5561], and BIPAP in 11(22%) studies [10,12,18,22,28,30,34,37,44,45,54].All 50 studies described a ventilatory mode that enabledspontaneous breathing at two pressure levels. Themajority of reports involved either adult patients (21APRV and seven BIPAP studies) or animal studies (14APRV studies and 4 BIPAP studies). Only three studies[25,36,41] were conducted in the paediatric population,all describing the use of APRV. One study was conductedusing a lung model [61]. Eleven [8,9,11,21,24,26,28,29, 38, 42, 43] of the 31 (35%) human studies involvedpatients with acute lung injury (ALI) or acute respiratorydistress syndrome (ARDS), 5 (16%) reported the use ofthe ventilator mode in patients following coronary arterygraft surgery [18,27,30,34,40] and a further four (13%)studies were conducted in patients with acute respiratory

Table 2 Reported outcomes according to comparator mode

Outcome PCV(n = 13)

VCV(n = 10)

Spontaneous(n = 10)

More than onemode (n = 4)

APRVa

(n = 3)Other(n = 3)

Improved oxygenation/oxygen dynamicsb 9 (69) 2 (20) 4 (40) 0 (0) 0 (0) 0 (0)No difference in oxygenation/oxygen dynamics 0 (0) 5 (50) 4 (40) 2 (50) 2 (67) 2 (67)Improved ventilationc 3 (23) 1 (10) 2 (20) 1 (25) 1 (33) 2 (67)No difference in ventilatory parameters 3 (23) 3 (30) 3 (30) 1 (25) 1 (33) 1 (33)Improved hemodynamic parametersd 8 (61) 0 (0) 6 (60) 0 (0) 0 (0) 0 (0)No difference in hemodynamic parameters 3 (23) 6 (60) 1 (10) 3 (75) 0 (0) 0 (0)Reduction in peak airway pressure 2 (15) 10 (100) 0 (0) 3 (75) 0 (0) 0 (0)Reduced sedation 2 (15) 1 (10) 0 (0) 0 (0) 0 (0) 0 (0)

Othere

1 (8) 0 (0) 4 (40) 1 (25) 1 (33) 0 (0)

PCV pressure-controlled ventilation, VCV volume-controlled ven-tilation, APRV airway pressure release ventilationFigures reported are n (%). Percentages are[100% as most studiesreported more than one outcome of interesta APRV with various release timesb Indices of oxygenation included the following: PaO2, PaO2/FiO2ratio, mixed venous oxygen content, oxygen delivery, oxygenconsumption, shunt fraction, ventilation/perfusion ratioc Ventilatory parameters measured included the following: PaCO2,pH, minute ventilation

d Hemodynamic parameters measured included the following:heart rate, mean arterial pressure, cardiac output, cardiac index,stroke volume, pulmonary vascular resistance, global end diastolicvolume, right ventricular end diastolic volume, respiratory muscleblood flow, intestinal blood flowe Other includes the following: pressure time product; asyn-chrony of effort and ventilator cycling; increased aeration ofdependant lung regions close to diaphragm, power of breathing,indirect calorimetry

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failure distinct from ALI and ARDS [19,23,33,36]. Theremaining studies examined the use of APRV and BIPAPfor a variety of patient diagnoses.

Forty-three studies compared the identified mode toanother style of ventilation. Pressure-controlled ventila-tion was the most frequent mode of comparison (13/43,30% of comparative studies [9,10,28,29,32,42,44,45,52, 54, 59, 60]). Pressure-controlled ventilation wasapplied either through use of intermittent mandatoryventilation (IMV), assist control (A/C), or through neu-romuscular blockade-induced apnoea with APRV orBIPAP. Volume-controlled modes were evaluated in 10(23%) studies [11,17,19,27,30,33,34,36,38,58] andspontaneous modes, either continuous positive airwaypressure (CPAP) or pressure support ventilation wereevaluated in a further 10 (23%) studies [8,12,18,22,37,39, 47, 51, 55, 57]. Six (14%) studies looked at eitherdifferent release times for APRV [31,50,54], comparisonwith high frequency oscillatory ventilation [48], trachealgas insufflation [53] or automatic tube compensation [43].A further four (9%) studies [20,40,49,56] compared themode of interest with both mandatory (IMV or A/C) andspontaneous modes.

Table2 shows the reported outcomes of studies thatcompared APRV or BIPAP with another mode of venti-lation. The majority of studies (30/43, 70%) examined anumber of variables including determinants of gasexchange, lung mechanics hemodynamic variables, andsedation use. Studies that compared APRV or BIPAP tovolume-control ventilation all found a reduction in thepeak inspiratory pressure. Improvement in oxygenation

indices and hemodynamic parameters were the two mostfrequent findings when either APRV or BIPAP werecompared to a pressure-control mode (Table 2).

Ventilator settings

In adult studies, the mean reported set inspiratory pressure(PHigh) was 6 cm H2O higher with APRV when com-pared to reports of BIPAP (P = 0.3). The mean reported

positive end expiratory pressure (PLow) was the same forboth modes (Fig. 1). Various descriptors for set inspira-tory pressure (PHigh) and positive end expiratory

pressure (PLow) were identified (Table3). The meanreported inspiratory time was 3.4 1.7 s for APRVstudies conducted in adults compared to 2.4 0.9 s forstudies BIPAP (P = 0.08). Conversely, the mean reportedexpiratory time was nearly three times longer in BIPAPstudies compared to APRV (3.4 1.6 and 1.3 0.4 s,respectively,P = 0.01).

For analytical purposes, studies reporting I:E ratioswere categorised into the following: an extreme inverseratio ([2:1), mild inverse ratio ([1:1 to B2:0), 1:1 ratio,and a noninverse ratio. Extreme inverse I:E ratios wereused exclusively in APRV studies (P = 0.004), whereas1:1 and normal inverse ratios were used more frequently

in BIPAP studies (Table4).The majority (38/50, 76%) of identified experimental

studies did not discuss the method of patient-ventilatorsynchronization. Of the remaining 12 studies, eight statedthe identified mode synchronized with patients effort[10,18,20,22,31,37,39,61]. These comprised 36% ofthose identifying BIPAP as the mode of interest and 10%of APRV studies. Three (43%) APRV studies thatdescribed synchronization stated that it was not available[9,19, 38].

PHigh PLow

0

5

10

15

20

25

30

35APRV

BIPAP

Pressure Settings

c

mH2O

THigh TLow0

1

2

3

4

5APRV

BIPAP

Inspiratory/Expiratory Times

Se

conds

Fig. 1 Mode settings

Table 3 Descriptors of pressure settings

Descriptors

Set inspiratory pressure PHigh

PinspHigh CPAP levelPeak inspiratory pressurePinflationInflation pressure

Positive end expiratory pressure PLowLow CPAP levelPreleaseBaseline pressure

CPAP continuous positive airway pressure

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Discussion themes

The following themes describing the modes APRV andBIPAP were identified through content analysis of dis-cussion papers: enables spontaneous breathing during twophases of the respiratory cycle [14, 58, 6273]; appliestwo levels of CPAP [1, 3, 4, 58, 63, 64, 6669, 7174];the difference (between the two modes) is the I:E ratio;BIPAP implies conventional as well as inverse, APRValways implies inverse [64, 66, 68, 72]; modes are syn-onymous [71]; modes form a continuum [1,2,63]; APRVimplies short release times and long inspiratory times[14, 6368, 70];andaPLowof0 cmH2O is recommendedfor APRV [4,65,66]. Commonalities in the descriptionsof APRV and BIPAP were the ability for spontaneousbreathing throughout both the inspiratory and expiratoryphases of the respiratory cycle and the application of twolevels of CPAP [set inspiratory pressure (PHigh) andpositive end expiratory pressure (PLow)]. Inconsistencyexisted in the defining criteria to distinguish the two modes.Some authors acknowledged a distinction between APRVand BIPAP [64, 66, 68, 72]; others described the modes as acontinuum [1,2,63] while the two modes are referred tosynonymously elsewhere [71].

Discussion

The aim of this systematic review was to determine thedefining characteristics of the two ventilator modes,

APRV and BIPAP, existent in the published scientificliterature. A moderate number of scientific investigationsand educational or opinion articles were identified inwhich APRV was the named mode for the majority. Themajor distinction found in the description of the twomodes was the mean duration of set expiratory time;nearly three times longer in BIPAP studies compared toreports of APRV. Conversely, set inspiratory pressure(PHigh) and positive end expiratory pressure (PLow)settings were similar in reports of either mode.

Another key finding was the lack of consistentparameters to describe or distinguish these two modes. Insome studies, the ventilator settings used to apply APRVwere indistinguishable from those used for BIPAP[54, 55]. Moreover, summary descriptions reported foreducational purposes depicted APRV and BIPAP as either

distinct modes, belonging to a continuum of ventilatorstyles, or as synonymous. The application of APRV,however, was more frequently described as a prolongedinspiratory time and shortened expiratory time resulting inan extreme inverse ratio. In contrast, no BIPAP studiesdescribed this type of ventilatory settings.

The original work conducted on these two modes ofventilation was undertaken by separate groups in differ-ent countries and published within two years of eachother. Airway pressure release ventilation originated

from North America and was initially described by Stockand Downs as CPAP with an intermittent release phase[58]. Subsequently, BIPAP was described by the Euro-pean team, Baum and colleagues, as a mode thatcombined pressure-controlled ventilation and spontane-ous breathing [7,75].

In the original description of APRV, a mild inverseratio was applied (1.3:1 in normal lungs and 1.4:1 ininjured lungs) [58]. In subsequent studies, the appliedinspiratory time for APRV was extended to 4 s or greater[9, 29, 38, 57]. Conversely, in the initial description ofBIPAP, an inverse ratio of greater than 1:1 was distin-guished as inverse ratio (IR) BIPAP and described as avariation of the mode [62]. Only one identified study hasexamined the use of BIPAP with an I:E ratio greater than1:1 [28].

Commercial ventilator branding has imposed restric-tions on the naming of modes and possibly contributed tothe existing ambiguity in mode terminology. In NorthAmerica, the term BiPAP is reserved for noninvasive,pressure-controlled ventilation available on Respironicsventilators (Respironics Inc., Murraysville, PA, USA).This led ventilator companies to develop terms such asBiLevel (Puritan Bennett, Pleasanton, CA, USA; GEHealthcare, Madison, WI, USA), Bivent (Maquet, Solna,Sweden), DuoPaP (Hamilton Medical, Rhazuns,Switzerland), PCV+ (Drager Medical, Lubeck, Germany),or BiPhasic (Viasys, Conshocken, PA, USA).

Consistency in the parameters that define APRV andBIPAP is needed to enable clinicians to decide on an

appropriate style of ventilation based on a patientsclinical condition. Reports of the benefits of these modesdemonstrate improvements in gas exchange [25, 26],hemodynamic parameters [10, 29, 46, 51], and areduction in overall sedation requirements [29]. Some ofthese benefits may be attributable to the maintenance ofspontaneous breathing common to both ventilator modes[2, 6, 7]. Further improvements in gas exchange, how-ever, may be the result of an extended inspiratory timeand shortened expiratory time that promote recruitment

Table 4 Reported inspiratory:expiratory ratios

APRV n (%)N= 39

BIPAPn (%)N= 11

P valuea

Extreme inverseratio C2:1

18 (46) 0 (0) 0.004

Mild inverse

ratio[1.1 to B2:0

7 (21) 1 (9) 0.7

1:1 ratio 12 (31) 7 (64) 0.08Non-inverse ratio 2 (3) 3 (27) 0.06

APRV: airway pressure release ventilation, BIPAP Biphasic posi-tive airway pressurea P values calculated using Fishers exact tests

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of alveoli with longer time constants [4]. Theseimprovements may be dependent on the extreme inverseratio advocated by some APRV studies [25, 26, 29].There is the potential that expected improvements in gasexchange might not occur without use of an extremeinverse ratio, which may deter clinicians new to the

mode from using an unfamiliar style of ventilation.Anecdotally, some clinicians perceive APRV as anextreme form of ventilatory support that may pose riskto patients. This perception may prevent clinical uptakeof APRV, and by association BIPAP, used with a moreconventional I:E ratio.

Conclusions

Ambiguity exists in the criteria that distinguish APRVand BIPAP. When applied with the same I:E ratio, no

difference exists between the two modes. APRV asopposed to BIPAP, however, is more frequently described

with an extreme inverse ratio and advocated as a methodto improve oxygenation in refractory hypoxemia. Thisapplication of APRV warrants the consistent use of adistinguishing acronym similar to that used when differ-entiating the use of an inverse ratio in pressure-controlledventilation (PCV-IRV).

Uncertainty concerning the correct style of applicationfor APRV and BIPAP may obstruct the clinical adoptionof these modes. Generic naming of ventilator modes, aswith drug prescribing, combined with consistent defini-tions of the parameters that define and distinguish APRVand BIPAP, would help standardise research designed toinvestigate the effect of these modes of mechanical ven-tilatory support. This may improve the consistency ofpatient response and assist with future implementationinto clinical practice.

Conflict of interest statement The authors have no potentiallyconflicting financial interests or any other actual or potential con-flict of interest to be declared.

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