2012 OPEN FORUM Abstracts
USE OF AIRWAY PRESSURE RELEASE VENTILATION (APRV) AS A RESCUE MODE FROM HIGH FREQUENCY OSCILLATORY VENTILATION (HFOV).
David Madden1, Penny Andrews2, Jeffery Brauer MD1, Nader Habashi MD2; 1Sinai Hospital, Baltimore, MD; 2University of Maryland Medical Center/Shock Trauma, Baltimore, MD
Introduction: High-frequency oscillatory ventilation (HFOV) and Airway Pressure Release Ventilation (APRV) are both strategies of mechanical ventilation based on the principle of the open-lung concept and aim to improve oxygenation by keeping the lung inflated for an extended period of time. This increased Pressure-Time Profile maintains alveolar stability and promotes homogeneity. Unfortunately, these modes of ventilation are typically applied as a last resort or as a rescue mode when treating acute respiratory distress syndrome (ARDS). In our facility, Sinai Medical Center in Baltimore, MD, patients are transitioned to HFOV if the ARDSnet protocol fails to resolve ARDS. We hypothesized that APRV could still be used as a rescue mode even after nitric oxide therapy, prone positioning and HFOV failed to improve oxygenation, preventing a patient from requiring Extracorporeal Membrane Oxygenation (ECMO). Case Summary: A 40 year old male was admitted to the ICU after being found down and unresponsive, having vomited and aspirated. The patient was intubated upon admission rapidly requiring increased ventilatory support with the initial P/F ratio of 45 and chest x-ray (CXR) demonstrating bilateral alveolar densities which is consistent with the American-European Consensus Conference diagnosis of ARDS. The ARDSnet protocol was implemented, however, the patient remained extremely hypoxic and was then paralyzed and transitioned to HFOV. In addition, nitric oxide therapy and prone positioning was initiated with little improvements in CXR or P/F ratio. Consequently, APRV was considered as a rescue therapy prior to transferring the patient to another facility for ECMO. Within 15 minutes of transitioning to APRV, the SpO2 increased from 83% to 100% and immediate improvements seen in CXR, a rapid reduction in FiO2, increased P/F ratio from 83 to 334. Discussion: The application of APRV was used as a rescue mode in this case when ARDSnet protocol, HFOV and adjuncts to therapy failed. Recent data has shown that earlier application may actually prevent the development of ARDS warranting further research. Sponsored Research - None