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Airway Pressure Release Ventilation (APRV) Management
Definition: Note:
Airway Pressure Release Ventilation: An elevated The earlier APRV is used, the more effective it is in
CPAP level with timed pressure releases. This recruiting the lung and the more likely it is to be
mode allows for spontaneous breathing. tolerated. If initiating APRV late in the course of
ARDS, patients sometimes will not look comfortable
Indications: despite optimal APRV settings, and they may need an
alternate mode.
1. Acute lung injury (ALI)/ARDS
2. Diffuse pneumonia Waveforms:
3. Atelectasis requiring >.50 FiO2
4. Tracheo-esophageal fistula It is important to observe the Flow -Time
waveform to optimize the settings. During the
Initial settings: (see Figure 1) pressure release phase, the patient will exhale
passively. Adjust the Tlow to cut off the expiratory
1. Phigh at the Pplateau flow during a release at about 50% (25-75%) of
(or desired Pmean + 3 cmH2O) peak expiratory flow rate (PEFR) (see Figure 2)
Try to keep Phigh below 35 cmH2O
2. Thigh at 4.5-6 seconds Thigh
3. Plow at 0 (to optimize expiratory flow) Inspiratory flow
4. Tlow at 0.5 to 0.8 second (see Waveforms)
5. Automatic tube compensation (ATC): on if
spontaneously breathing Expiratory flow 25%
50% of PEFR
T Pressure (30 lpm)
high PEFR 75%
ATC
(60 lpm)
Phigh
Tlow
Pmean Figure 2
Full exhalation
Plow

Spontaneous breaths
Tlow Never allow the termination of expiratory
Figure 1 flow to go <25% of the PEFR! This intentional
Flow intrinsic peep allows Plow to be set at 0 cmH2O
without causing de-recruitment.
Generally, the Tlow can be as short as 0.3
seconds (closer to 75% of the PEFR) in
restrictive diseases and as long as 1.5
seconds (closer to 25% of the PEFR) in
Like Pressure Control- Inverse Ratio Ventilation obstructive states.
(PC-IRV), APRV utilizes a long inspiratory time
(Thigh) to recruit alveoli and optimize gas Adjustments:
exchange. The open exhalation valve allows for
Figure 3
spontaneous breathing during Thigh.
Observation: Increased inspiratory effort trying to increase FRC

APRV should help rest the inspiratory muscles and
utilize the diaphragm. Once the initial settings are Flow
applied, look for the anterior chest muscles to be
used much less and the diaphragm to be doing the
majority of the work. This should occur within hours
after placement on APRV. The patient should be
breathing more comfortably as recruitment occurs.
Adjustments continued:
3. Increase Tlow to allow more time for alveolar
1. If the patient is consistently inhaling forcefully emptying, but only if the expiratory flow of a
with accessory muscles, he/she may need release doesnt drop below 25% of the PEFR.
alveolar recruitment (see Figure 3). Options are:
Increase Phigh; this will elevate the Pmean and 4. If further increases in Thigh fail to drop
encourage recruitment. PaCO2, you may need to do the opposite:
Decrease Tlow only if you can maintain the Decrease Thigh (to increase the rate of
flow during the release phase <75% of PEFR releases). This will decrease the Pmean and
and the PaCO2 and pH are acceptable. oxygenation. Therefore, also increase Phigh to
maintain the Pmean. Maximize Phigh and release
2. If the patient seems to be exhaling forcefully, rate up to 30 (more like PC-IRV)
over-inflation may be present (see Figure 4).
Options are: 5. If unable to manage the acidosis with APRV,
Decrease the Phigh in 1-2 cmH2O increments the mode may be changed to PCV attempting
and increase Thigh (to maintain the same to maintain the same rate and Pmean.
Pmean) and/or:
Increase the Tlow (allowing more time to Respiratory Alkalosis Options:
exhale) only if you can maintain the flow during
the release phase >25% of PEFR 1. Decrease Phigh (Sp02 may decrease)
CXR should be monitored for lung over-inflation 2. Increase Thigh to decrease the release rate
3. Turn ATC off if no spontaneous respirations
Forceful exhalation Weaning:
When FiO2 is titrated below .50, recruitment is

Flow maximized, and the patient is breathing
spontaneously, a continuous gradual wean can
begin by:
Decreasing the Phigh by 1-2 cmH2O and

Figure 4 Re-acceleration of expiratory flow increasing the Thigh by 0.5 seconds for every
1 cmH2O drop in Phigh. This is referred to as
drop and stretch.
Drop and stretch should be done every two
ABG Management hours or more if tolerated. As you drop and
stretch the Pmean is gradually lowered, so you
Oxygenation Options: will need to monitor SpO2. Changing to CPAP
or dropping Pmean too quickly will possibly
1. When possible: wean FiO2 to <.50 for a SpO2 de-recruit alveoli.
>90% or a PaO2 >60 torr. Throughout the weaning process, the patient
2. To improve oxygenation via higher Pmean: should be closely monitored for increasing work
Increase Phigh in increments of 2 cmH2O of breathing, tachypnea, or a drop in SpO2. If
Decrease Tlow to be closer to 75% PEFR this occurs, return to the previous settings.
When the Phigh reaches 10 cmH2O and the
Respiratory Acidosis Options: Thigh reaches 12-15 seconds, change the mode
to CPAP with PEEP at 10 and PS at 5-10 (ATC
1. Increase Phigh (up to 40 cmH20) or off). Slowly wean CPAP as tolerated.
2. Increase Thigh (if spontaneously breathing) in
increments of 0.5 seconds up to 8 seconds The patient should be spontaneously breathing
(see #5). throughout this process, therefore, it is not necessary
If PaCO2 increases with this change, it may to do spontaneous breathing trials.
reflect inadequate lung volume.
If this is the case, try increasing Phigh to
re-establish an adequate FRC.

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Airway Pressure Release Ventilation (APRV) Management

Observation: Increased inspiratory effort trying to increase FRC

When FiO2 is titrated below .50, recruitment is

Decreasing the Phigh by 1-2 cmH2O and

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