Airway pressure release ventilation (APRV) mode of mechanical ventilation is an elevated CPAP level with timed pressure releases. This mode allows for spontaneous breathing. These breaths can be unsupported, pressure supported, or supported by automatic tube compensation. They key is a dynamic expiratory valve in the circuit which allows spontaneous breathing at high lung volumes. While any patient can be adequately supported using APRV, it is generally used for patients the require recruitment of alveoli to maintain oxygenation, such as in ARDS (along with other treatments such as inhaled prostacyclin, neuromuscular blockade, PEEP, and prone position).

Indications for APRV ventilation

  • Acute lung injury (ALI/ARDS)
  • Diffuse pneumonia
  • Atelectasis requiring greater than 50% FiO2
  • Tracheo-esophageal fistual

Initial APRV Settings

  • PHigh at the PPlateau (or desired PMean + 3 cmH2O). If your are switching to APRV from a different mode, then PHigh can be set at the previous mean airway pressure.  A good starting level would be 28 cmH2O. Higher transalveolar pressures recruit additional alveoli, but, try to keep PHigh below 35 cmH2O.
  • THigh at 4.5-6.0 seconds. This is the inspiratory time. The respiratory rate should be 8 to 12 breaths per minute — never more.
  • PLow at 0 cmH2O to optimize expiratory flow. The large pressure ramp allows for tidal ventilation in very short expiratory times.
  • TLow at 0.5-0.8 seconds. The expiratory time should be short enough to prevent derecruitment and long enough to obtain a suitable tidal volume. A tidal volume target is between 4 and 6ml/kg. If the tidal volume is inadequate, the expiratory time is lengthened; if it