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APRV, DuoPAP, BiPAP: Pro & Con…M Wysocki – March 2009

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Plan

• Definitions…

• Spontaneous ventilation is important…

• No evidences…

• Increasing complexity…

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Definitions

L Rose, Intensive Care Med 2008

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Definitions

L Rose, Intensive Care Med 2008

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APRV: How it looks…

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APRV… with versus without SB in pigs

Wrigge H, Anesthesiology 2003

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APRV w/o SB reduced Pigs Intestinal Blood Flow?

Hering R, Anesthesiology 2003

0

10

20

30

40

50

60

70

80

90

100

Stom

ach

Duoden

um

Jeju

num

Ileon

Colon

Inte

stin

al B

lood

Flo

w (

mL/

gr/m

in) APRV w SB

APRV w/o SB and high VT

APRV w/o SB and low VT

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APRV with SB better than PCV in polytrauma…

Putensen C, Am J Respir Crit Care Med 2001

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ASV with SB vs VC preserves diaphragmatic Funct°

Dia

ph

rag

mat

ic f

un

ctio

n

ASVVC

Duration of Mechanical Ventilation

Jung B, SRLF 2009

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APRV: Where are the clinical evidences?

• Valentine – Am Respir Resp Dis 1991: Cross Over study

• Räsänen – Crit Care Med 1991: Cross Over study

• Davis – Arch Surg 1993: Short term physiologic study

• Sydow – Am J Respir Crit Care Med 1994: Short term physiologic study

• Putensen - Am J Respir Crit Care Med 1999: Cross Over study

• Putensen - Am J Respir Crit Care Med 2001: n = 30 APRV vs PCV (cf slide before)

• Hering – Intensive Care Med 2002: Cross Over study

• Varpula – Acta Anesthesiol Scand 2003: Short term w/wo prone

• Varpula - Acta Anesthesiol Scand 2004: n = 58; SIMV vs APRV – equivalent

• Uyar – Anaesth Intensive Care 2005: n = 20: PSV vs APRV - equivalent

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APRV: how to make your life complex…

9 settings!!!

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…while it can be easier!!!

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…while it can be easier!!!

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…while it can be easier!!!

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…while it can be easier!!!

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APRV: CONCLUSIONS

• Spontaneous breathing is important…

• APRV – DuoPAP – BIPAP are:

1. Complex

2. Dangerous

3. No evidence showing the opposite…

« What’s difficult is to make things easier »