aprv
TRANSCRIPT
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APRV (BiLevel Mode)
Nikki Henry, Respiratory Therapy2011
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Is my patient in ARDS?
Divide the PaO2/FiO2
400-500 Normal<300 ALI (Acute Lung Injury) –
impending ARDS<200 ARDS
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IndicationsPEEP > 10 and FiO2 > 60% (Shunting)
PaO2/FiO2 < 300
Bilateral infiltrates
No evidence of left atrial hypertension
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TerminologyP High – the upper CPAP level. Analogous
to MAP (mean airway pressure) and thus affects oxygenation
P Low – is the lower pressure setting.
T High- is the inspiratory time phase for the high CPAP level (P High).
T PEEP or T low- is the release time allowing CO2 elimination
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Setting up APRVPress the vent set-up key on the
lower screen
Select Bilevel for mode – this will automatically set up the vent for PC (mandatory type)
Press continue
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Frequency
Set frequency at 6-8 (max 10)
This is the release rate when the vent will change from Phigh to Plow
Total rate for patient should be 18-38
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Initial Settings - PHighSet the Phigh to the plateau
pressure from previous VC/PC mode
P High – Set a plateau pressure typically about 20-25 cm H2O.
In patients with Pplateau at or above 30 cm H2O, set at 30 cm H2O
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PEEP LowSet PEEP at zero cm H2O.
This provides a rapid drop in pressure, and a maximum DP for unimpeded expiratory gas flow.
Avoid lung collapse during Tlow.
Rapid pressure drops allow for quick resumption of Phigh (recruitment)
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TLowOnce in the time bar screen you will see
three padlocks
Press on the padlock to the far right. This will hold Tlow constant.
Set Tlow at 0.4-1.0 sec
Make sure the Tlow value is displayed on the set parameters section (blue boxes above the time bar)
Patient should NOT take any spontaneous breaths on Tlow – if they do then the Tlow is too high!
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Goal of TLowThe goal of termination of Tlow is
between 50-75% of Peak Expiratory Flow Rate (PEFR)
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THigh Once Tlow is locked any change in frequency will
result in a change in Thigh
To adjust Thigh change frequency first
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Pressure Support on APRV
State with Tube Compensation. If the spontaneous Vt are low switch to PS
PS at Phigh = (Plow + PS) – Phigh
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Managing a patient on APRV
How to optimize PHigh at FiO2 > or = 60%
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How to manage CO2
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Weaning From APRV1. FiO2 SHOULD BE WEANED FIRST.
(Target < 50% with SpO2 appropriate.)
2. Reducing P High, by 2 cmH20 increments until the P High is below 20 cmH2O.
3. Increasing T High to change vent set rate by 5 releases/minute
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“Drop and Stretch” WeaningWhen ready to wean – Phigh
is dropped and the frequency is dropped in small increments. THigh will be stretched out sequentially. This is called the Drop and Stretch Method.
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“Drop and Stretch”
This is continued if the patient is spontaneously breathing and until the PHigh is 10-15 cmH2O and the THigh is 10-15 seconds.
At this point, the patient is effectively on CPAP.
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During WeaningAdd Pressure Support judiciously.
Add Pressure Support to P High in order to decrease WOB while avoiding over-distention,
P High + PS < 30 cmH2O.
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