Brazilian Journal of Anesthesiology
Brazilian Journal of Anesthesiology
Clinical Research

The effect of preemptive airway pressure release ventilation on patients with high risk for acute respiratory distress syndrome: a randomized controlled trial

Mehtap Pehlivanlar Küçük, Çağatay Erman Öztürk, Nazan Köylü ̇Ilkaya, Ahmet Oğuzhan Küçük, Dursun Fırat Ergül, Fatma Ülger

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Background and objectives
The objective of this study was to investigate the use of early APRV mode as a lung protective strategy compared to conventional methods with regard to ARDS development.

The study was designed as a randomized, non-blinded, single-center, superiority trial with two parallel groups and a primary endpoint of ARDS development. Patients under invasive mechanical ventilation who were not diagnosed with ARDS and had Lung Injury Prediction Score greater than 7 were included in the study. The patients were assigned to APRV and P-SIMV + PS mode groups.

Patients were treated with P-SIMV+PS or APRV mode; 33 (50.8%) and 32 (49.2%), respectively. The P/F ratio values were higher in the APRV group on day 3 (p = 0.032). The fraction of inspired oxygen value was lower in the APRV group at day 7 (p = 0.011).While 5 of the 33 patients (15.2%) in the P-SIMV+PS group developed ARDS, one out of the 32 patients (3.1%) in the APRV group developed ARDS during follow-up (p = 0.197). The groups didn’t differ in terms of vasopressor/inotrope requirement, successful extubation rates, and/or mortality rates (p = 1.000, p = 0.911, p = 0.705, respectively). Duration of intensive care unit stay was 8 (2–11) days in the APRV group and 13 (8–81) days in the P-SIMV+PS group (p = 0.019).

The APRV mode can be used safely in selected groups of surgical and medical patients while preserving spontaneous respiration to a make benefit of its lung-protective effects. In comparison to the conventional mode, it is associated with improved oxygenation, higher mean airway pressures, and shorter intensive care unit stay. However, it does not reduce the sedation requirement, ARDS development, or mortality.


Acute respiratory distress syndrome,  APRV ventilation mode,  Bi-level continuous positive airway pressure, intensive care unit,  Ventilation modes


1 W. Garner, J.B. Downs, M.C. Stock, et al. Airway pressure release ventilation (APRV). A human trial Chest, 94 (1988), pp. 779-781

2 D.J. Dries, J.J. Marini Airway pressure release ventilation J Burn Care Res, PAP (2009), pp. 929-936

3 N. Habashi, P. Andrews Ventilator strategies for posttraumatic acute respiratory distress syndrome: airway pressure release ventilation and the role of spontaneous breathing in critically ill patients Curr Opin Crit Care, 10 (2004), pp. 549-557

4 P.L. Andrews, J.R. Shiber, E. Jaruga-Killeen, et al. Early application of airway pressure release ventilation may reduce mortality in high-risk trauma patients: a systematic review of observational trauma ARDS literature J Trauma Acute Care Surg., 75 (2013), pp. 635-641

5 Y. Zhou, X. Jin, Y. Lv, et al. Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndrome Intensive Care Med, 43 (2017), pp. 1648-1659

6 S. Roy, N. Habashi, B. Sadowitz, et al. Early airway pressure release ventilation prevents ARDS-a novel preventive approach to lung injury Shock, 39 (2013), pp. 28-38

7 B. Sadowitz Preemptive mechanical ventilation can block progressive acute lung injury World J Crit Care Med, 5 (2016), p. 74

8 B. Emr, L.A. Gatto, S. Roy, et al. Airway pressure release ventilation prevents ventilator-induced lung injury in normal lungs JAMA Surg, 148 (2013), pp. 1005-1012

9 V.M. Ranieri, G.D. Rubenfeld, B.T. Thompson, et al. Acute respiratory distress syndrome: The Berlin definition JAMA, 307 (2012), pp. 2526-2533

10 Z.M. Bauman, M.Y. Gassner, M.A. Coughlin, et al. Lung injury prediction score is useful in predicting acute respiratory distress syndrome and mortality in surgical critical care patients Crit Care Res Pract, 2015 (2015), Article 157408

11 F. Faul, E. Erdfelder, A.G. Lang, et al. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences Behav Res Methods, 39 (2007), pp. 175-191 Psychonomic Society Inc.

12 E.G. Daoud, H.L. Farag, R..L. Chatburn Airway pressure release ventilation: what do we know? Respir Care, 57 (2011), pp. 282-292

13 S.K. Roy, B. Emr, B. Sadowitz, et al. Preemptive application of airway pressure release ventilation prevents development of acute respiratory distress syndrome in a rat traumatic hemorrhagic shock model Shock, 40 (2013), pp. 210-216

14 J.-M. Boles, J. Bion, A. Connors, et al. Weaning from mechanical ventilation Eur Respir J, 29 (2007), pp. 1033-1056

15 J.W. Devlin, Y. Skrobik, C. Gélinas, et al. Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU Crit Care Med, 46 (2018) e825–73

16 O. Gajic, O. Dabbagh, P.K. Park, et al. Early identification of patients at risk of acute lung injury: evaluation of lung injury prediction score in a multicenter cohort study Am J Respir Crit Care Med, 183 (2011), pp. 462-470

17 J. Villar, D. Sulemanji, R.M. Kacmarek The acute respiratory distress syndrome Curr Opin Crit Care, 20 (2014), pp. 3-9

18 R.M. Durham, J.J. Moran, J.E. Mazuski, et al. Multiple organ failure in trauma patients J Trauma, 55 (2003), pp. 608-616

19 I.V.B.W. Dart, R.A. Maxwell, C.M. Richart, et al. Preliminary experience with airway pressure release ventilation in a trauma/surgical intensive care unit J Trauma, 59 (2005), pp. 71-76

20 T. Varpula, I. Jousela, R. Niemi, et al. Combined effects of prone positioning and airway pressure release ventilation on gas exchange in patients with acute lung injury Acta Anaesthesiol Scand, 47 (2003), pp. 516-524

21 E.L. Hirshberg, M.J. Lanspa, J. Peterson, et al. Randomized feasibility trial of a low tidal volume-airway pressure release ventilation protocol compared with traditional airway pressure release ventilation and volume control ventilation protocols Crit Care Med, 46 (2018), pp. 1943-1952

22 R.A. Maxwell, J.M. Green, J. Waldrop, et al. A randomized prospective trial of airway pressure release ventilation and low tidal volume ventilation in adult trauma patients with acute respiratory failure J Trauma, 69 (2010), pp. 501-510

23 A. Carsetti, E. Damiani, R. Domizi, et al. Airway pressure release ventilation during acute hypoxemic respiratory failure: a systematic review and meta-analysis of randomized controlled trials Ann Intensive Care., 9 (2019), p. 44

24 J.J. Marini, S.A. Ravenscraft Mean airway pressure Crit Care Med, 20 (1992), p. 1604

25 J. Rasanen, R.D. Cane, J.B. Downs, et al. Airway pressure release ventilation during acute lung injury: a prospective multicenter trial Crit Care Med, 19 (1991), pp. 1234-1241

26 J.Q. Li, N. Li, G.J. Han, et al. Clinical research about airway pressure release ventilation for moderate to severe acute respiratory distress syndrome Eur Rev Med Pharmacol Sci, 20 (2016), pp. 2634-2641

27 C. Putensen, S. Zech, H. Wrigge, et al. Long-Term Effects of spontaneous breathing during ventilatory support in patients with acute lung injury Am J Respir Crit Care Med, 164 (2001), pp. 43-49

28 L. Blanch, A. Villagra, B. Sales, et al. Asynchronies during mechanical ventilation are associated with mortality Intensive Care Med, 41 (2015), pp. 633-641

29 N..M. Habashi Other approaches to open-lung ventilation: airway pressure release ventilation Crit Care Med, 33 (2005), pp. S228-40

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