The 30-year evolution of airway pressure release ventilation (APRV).
The 30-year evolution of airway pressure release ventilation (APRV).
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DOI：
10.1186/s40635-016-0085-2
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发表时间：
2016-12
影响因子：
3.5
通讯作者：
Habashi NM
中科院分区：
文献类型：
--
作者：
Jain SV;Kollisch-Singule M;Sadowitz B;Dombert L;Satalin J;Andrews P;Gatto LA;Nieman GF;Habashi NM
气道压力释放通气（APRV）于1987年首次描述，定义为持续气道正压通气（CPAP），短暂释放，同时允许患者在整个呼吸周期中自主呼吸。目前对最小化呼吸机相关肺损伤的最佳策略的理解是“打开肺并保持肺开放”。APRV应该是这种策略的理想选择，因为延长的CPAP持续时间可以复张肺，最小的释放持续时间可以防止肺萎陷。然而，APRV的定义并不一致，在实验研究和临床实践中使用的设置存在显著差异。本综述的目的是分析已发表的文献，并确定APRV作为肺保护策略的疗效。我们审查了作者声明使用APRV的所有原始文章。主要分析是将APRV设置与生理和临床结局相关联。结果显示，所有定义为APRV的设置存在巨大差异，特别是CPAP和释放阶段持续时间以及用于指导这些设置的参数。因此，不可能评估单一策略的有效性，因为几乎没有一个APRV设置是相同的。因此，我们将所有APRV研究分为两个基本类别：（1）固定设置APRV（F-APRV），其中设定释放阶段并保持恒定;和（2）个性化APRV（P-APRV），其中使用呼气流量曲线的斜率基于肺力学的变化设定释放阶段。结果显示，无论设置如何（F-ARPV或P-APRV），没有研究显示APRV的结局在统计学上显著更差。多项研究表明，P-APRV在临床相关动物模型和创伤患者中稳定肺泡并降低急性呼吸窘迫综合征（ARDS）的发生率。总之，自该模式成立以来的30多年里，在将机械呼吸定义为APRV方面没有严格的标准。P-APRV作为一种高度保护肺的通气策略已显示出巨大的前景。
Airway pressure release ventilation (APRV) was first described in 1987 and defined as continuous positive airway pressure (CPAP) with a brief release while allowing the patient to spontaneously breathe throughout the respiratory cycle. The current understanding of the optimal strategy to minimize ventilator-induced lung injury is to “open the lung and keep it open”. APRV should be ideal for this strategy with the prolonged CPAP duration recruiting the lung and the minimal release duration preventing lung collapse. However, APRV is inconsistently defined with significant variation in the settings used in experimental studies and in clinical practice. The goal of this review was to analyze the published literature and determine APRV efficacy as a lung-protective strategy. We reviewed all original articles in which the authors stated that APRV was used. The primary analysis was to correlate APRV settings with physiologic and clinical outcomes. Results showed that there was tremendous variation in settings that were all defined as APRV, particularly CPAP and release phase duration and the parameters used to guide these settings. Thus, it was impossible to assess efficacy of a single strategy since almost none of the APRV settings were identical. Therefore, we divided all APRV studies divided into two basic categories: (1) fixed-setting APRV (F-APRV) in which the release phase is set and left constant; and (2) personalized-APRV (P-APRV) in which the release phase is set based on changes in lung mechanics using the slope of the expiratory flow curve. Results showed that in no study was there a statistically significant worse outcome with APRV, regardless of the settings (F-ARPV or P-APRV). Multiple studies demonstrated that P-APRV stabilizes alveoli and reduces the incidence of acute respiratory distress syndrome (ARDS) in clinically relevant animal models and in trauma patients. In conclusion, over the 30 years since the mode’s inception there have been no strict criteria in defining a mechanical breath as being APRV. P-APRV has shown great promise as a highly lung-protective ventilation strategy.