APRV/bivent

[Stitch]

Are you guys using this much for patients with ARDS? What are your thoughts? We've been using it more and more for our patients on VV ECMO secondary to ARDS (I'm picu), and quite like it. How are you weaning? My understanding is that you just wean the Phigh to eventually go to a CPAP trial, but here we seem to switch back to pressure control instead, then to CPAP. Just curious about others experiences.

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[jdh71]

Are you guys using this much for patients with ARDS? What are your thoughts? We've been using it more and more for our patients on VV ECMO secondary to ARDS (I'm picu), and quite like it. How are you weaning? My understanding is that you just wean the Phigh to eventually go to a CPAP trial, but here we seem to switch back to pressure control instead, then to CPAP. Just curious about others experiences.

I like it a lot. I follow the weaning suggestion found in Modrykamien's recent review (essentially APRV to CPAP)

Of course this is in adults, so I don't know if it's nuanced in the pediatric population. Some attendings I've worked with, like to "wean" to the A/C mode they are most comfortable with, and then to your per usual pressure support trials to extubate.

 

[Paseo Del Norte]

Are you guys using this much for patients with ARDS? What are your thoughts? We've been using it more and more for our patients on VV ECMO secondary to ARDS (I'm picu), and quite like it. How are you weaning? My understanding is that you just wean the Phigh to eventually go to a CPAP trial, but here we seem to switch back to pressure control instead, then to CPAP. Just curious about others experiences.

Not a physician, but my experiences have been similar. I typically see the patients weaned back into PCV, then a SBT when the patient shows improvement.

 

[souljah1]

Are your patients on VV ECMO paralyzed when you have them on APRV?

 

[Stitch]

Are your patients on VV ECMO paralyzed when you have them on APRV?

Can't really paralyze a patient using aprv since it really depends on the patient spontaneously breathing around a set high pressure. Unless I'm misunderstanding something?

If they are paralyzed on ECMO we just use 'resting' settings. PEEP 10, rate 10 (ish) and PC with PIP 20.

Many on ECMO (VA or VV) we'll allow to wake up somewhat and breath on their own. It depends on how stable they are though, and how much we let them wake up depends on the age and how cooperative. Just had a 15 year old mostly awake and communicating with me on VA ECMO for MRSA sepsis. This is becoming more common.

 

[souljah1]

Can't really paralyze a patient using aprv since it really depends on the patient spontaneously breathing around a set high pressure. Unless I'm misunderstanding something?

If they are paralyzed on ECMO we just use 'resting' settings. PEEP 10, rate 10 (ish) and PC with PIP 20.

Many on ECMO (VA or VV) we'll allow to wake up somewhat and breath on their own. It depends on how stable they are though, and how much we let them wake up depends on the age and how cooperative. Just had a 15 year old mostly awake and communicating with me on VA ECMO for MRSA sepsis. This is becoming more common.

I was asking bc my ecmo patients (adult micu) are always paralyzed. And, i have seen people use aprv in paralyzed patients - which drives me nuts for multiple reasons. I know quite well that you need to be not paralyzed to take full advantage of aprv.

 

[proman]

I did a lung transplant last year in a 20 something year old CF patient on VV ECMO, extubated, partcipating with PT. VA is obviously a different animal.

 

[Hernandez]

I was asking bc my ecmo patients (adult micu) are always paralyzed. And, i have seen people use aprv in paralyzed patients - which drives me nuts for multiple reasons. I know quite well that you need to be not paralyzed to take full advantage of aprv.

our trauma unit docs love bilevel.....on paralyzed pts.

 

[souljah1]

I have found numerous instances in which various surgical ICU teams have patients on modes of mechanical ventilation like BiLevel and APRV when their patients are paralyzed.

I find that I can almost always synchronize someone on AC/VC. If not, I go to PCV +/- inverse ratio mechanical ventilation. APRV and Bilevel are rarely used. AC/VC+ (terrible name) = PRVC is rarely used except in an LTACH-like patient who finds it more comfortable. That s*&t isn't low-stretch at all - and dumb housestaff think it is AC/VC + something special. A very misleading name, indeed.

For the patients with refractory hypoxemia who ultimately go on to require APRV - the lost their paddle in that creek a while ago.

 

[codeb1ue]

In my simplistic understanding of APRV, it more so ALLOWS the patient to spontaneously breathe rather than DEPENDING on it. The CO2 ventilation from the spontaneous breathing is minimal compared to that from the quick pressure release that occurs, therefore it doesn't matter whether theyre paralyzed or not. At least that was the explanation I received when I asked my attending yesterday about it. Correct me if I'm wrong.

 

[Hernandez]

the simplest explanation is that it is a Pressure control ventilation background that also allows the patient to spontaneously breath On-top of the PACV. in my mind, APRV also denotes, that unlike Bilevel, it is Inversed ratio PACV that it does not allow spontaneous breathing on the exhalation, granted, the exhalation on APRV tends to be much shorter than true inverses I:E PCV,

but it does not depend on spontaneous breathing, however, much of it's reported benefit is due to the spontaneous breaths. so paralyzing a pt on APRV/BiLevel makes little sense, you might as well just use PACV

 

[souljah1]

I agree with Hernandez. BiLevel and APRV incorporate spontaneous breathing. Using APRV in a paralyzed patient is the same thing as using PCV with extreme inverse ratio.

As I said previously, I can oxygenate and ventilate just about anyone using either AC/VC or AC/PC (occasionally needing some inverse ratio)..