Airway Pressure Release Ventilation as a Rescue Therapy in Pediatric Acute Respiratory Distress Syndrome (pARDS): Goodwill or Devil?

Excerpt

Pediatric Acute Respiratory Distress Syndrome is a significant cause of morbidity and mortality among children admitted to the pediatric intensive care unit. Various ventilation strategies have been used to improve oxygenation and ventilation in pARDS with further avoidance of secondary lung injury. Lung protective strategy using low tidal volume through conventional mechanical ventilation is the standard of care in pARDS. However, evidence on non-conventional ventilation modes such as High frequency oscillatory ventilation (HFOV) and Airway pressure release ventilation (APRV) has been scarce. A recent randomised control trial comparing HFOV and APRV for refractory hypoxemia in pARDS by Lalgudi et al. showed significant increase in mortality in the APRV group which led to premature termination of the trial [1]. APRV, as the name indicates, is a continuous positive pressure with a brief intermittent release phase which allows partial release of the lung volume for carbon dioxide exhalation. The strategies in APRV include Personalized APRV (P-APRV) which uses a T_low based on lung mechanics with a zero P_low with a T_High > 90% of the total breath time and a Fixed APRV (F-APRV) which works with a constant T_low and a non-zero P_low with a T_High < 90% of the total cycle time [2]. The main advantage of APRV is its ability to maximize the recruitment of alveoli and hence improving oxygenation along with added benefit of spontaneous breathing minimizing the risk of barotrauma [3]. It also has added advantages such as increased comfort for the patient and decreased sedative use [1, 4]. The contraindication to its use is children who require deep sedation for the underlying disease states like status epilepticus, raised intracranial pressure, severe obstructive airway disease, air leak syndromes [3]. …