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PC-IRV is really APRV without the "free breathing" exhalation valve. One could setup a paitent in APRV, look at the tidal volumes generated, then go and setup the patient in exactly the same I:E ratio in CMV with Autoflow on and flow assist off. It would then just be "volume targeted APRV". The oxygenation might not be as good because as soon as lung was recruited then the "P High"/Autoflow PC/VC PiP target would immediately ramp down. Or one could setup the patient in the SIMV version of PC, no PS cept ATC, in exactly the same P High/P Low and I:E, other than the look of the screen and the adjustment interface, it would be the same as APRV. I am not really a detractor nor a rabid advocate of APRV. I just think it's funny that a mode can thought of as experimental when exactly the same thing can be accomplished via other modes and settings not thought to be experimental (i.e. PC-IRV). | |||
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<brandx> |
This is a horrible study. Again APRV was used to target volumes of 6mls/kg and the tlow and Plow settings were not appropriate. | ||
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Jeff, Yes APRV and PC-IRV are clesly related and could be set up simulair, but most of the time when people are setting up PC-IRV the are using I:E's of 2:1 to wher APRV is using I:E's of 6:1. And to go along with that the benifits of free breathing that you mentioned, and the ease of manipulating the Tlow independantly of each of other parameters. To achieve this in PC-IRV you would have to play with your RR and IT setting. PC-IRV also uses PEEP to maintain FRC instead of looking at Tlow and flow waveforms. Could some one set up a PC-IRV to look simulair to APRV yes, but why? APRV in principle is different in many areas than APRV, I can make something else look like, but it is still not APRV. My kid can dress up like sperman on halloween, but that does not mean he is. Light | |||
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Was that a typo? Or do you really let your kid dress up like Sperm Man for Halloween, complete with the tail and all? And if he did dress up like Sperm Man, would you call it experimental? I better stop there! The point I was trying to make is that I found it a bit silly that a place would embrace PC-IRV as OK and then view APRV as experimental. I agree with you in regards to the differences between APRV and PC-IRV, I just don't think that the difference is so great that someone could embrace PC-IRV yet view APRV as experimental. Also many of the Servo connected studies look at things like Open Lung Concept in which PC in high rates and purposeful auto-peep is done in a fashion of APRV, but clearly without augmenting spontaneous breathing. So it's almost like someone whom embraces MA-1 A/C mode but then looks at CMV/Autoflow or PRVC or VC+, better triggers, better response time, PC/VC hybrid, and would call it experimental. They are all just refinements of the basic strategy of A/C Volume targeted ventilation. When using such strategies with modes/vents such as PC-IRV, oscillator, Open Lung Concept, whether or not the patient is spontaneously breathing, I think APRV mode provides an easy interface to set it up. | |||
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We don't use PC-IRV or APRV. I want to use APRV but I would ask again. How does one convince an evidence based doc, that APRV has it's place? Chris Hanson RN, RRT-NPS, CPFT, AE-C ER Registered Nurse Grand Junction, Colorado | |||
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Jeff, Yes it was a typo, I have just had the opportunity to read what I wrote. Man I should really slow down I had MANY typo's in that last post and making my son a sperm was the worst (even though that would be funny to see peoples faces) Sorry to have miss read your last post, I did not get what you were going for. But yes we do agree the importance of APRV and sometime the comedy behind getting it started over other modes. the lack of understanding is interesting. I have had doc that would not let me increase the PEEP to 15, but would allow me to go to APRV with my own settings (Phigh of 30). GJ a evidence based doc should be the best to get to try APRV. There is a lot of evidence about its abilities. The hard ones are the ones stuck in their ways that do not want to look at the evidence. Light | |||
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The problem with evidence based docs and things like APRV is that there isn't solid evidence that it improves mortality or shortens ventilator days. Sure there is evidence that APRV works, but there is also evidence that it doesn't make a difference. This same problem occurs with things like high frequency oscillator in adults and recruitment maneuvers. People like Dr. Amato and Dr. Lachmann have been preaching for years about low tidal volumes and higher PEEP levels for ARDS patient (for them it made sense from a physiology point of view) but it wasn't till the huge ARDSnet study that people finally caught on. I would recommend using things like APRV or HFOV when you can no longer provide lung protective ventilation with conventional ventilation. (This what DR. Neil McIntyre at Duke does when it comes to HFOV in adults). Sorry, but until some large multicenter trials are done using APRV, you may be out of luck when it comes to convincing your doc about APRV. You could also try to make an argument from a physiology point but that's not always an easy task. -- Jeffd Also, I believe that modes don't really make a huge difference it how you use those modes that make a difference. | |||
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<brandx> |
JeffD, What is your definition of lung protective ventilation? I would also be curious to know from the forum how many patients being ventilated utilizing the the Low Tidal Volume approach do not require heavy sedation? I am a firm believer in the "Open Lung Strategy"; recruit the lung early and keep it open...for me there is no better mode than APRV to achieve these goals. | ||
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JeffD
1. Why? Though I unfortunately do not use APRV or HFOV, but am working towards APRV. Why use HFOV, different machine, circuit not as flexible. APRV appears that it would be better tolerated=less sedation. APRV uses ATC, not available with HFOV. Other than MRI you can transport(CT,OR,specials,etc.) on APRV, not so on HFOV. I've tried all the modes on our XL's via a mask and APRV did feel best to me=less sedation. How high can you get your MAP with ARDSnet vs. APRV? Why only use APRV in ARDS? 2. Just because Dr.Mcintyre does it doesn't mean it's the best or only choice. There needs to be a multicenter study comparing APRV to ARDSnet, since all newer ventilators offer APRV or their(840,AVEA,etc) version. GJThis message has been edited. Last edited by: GJ,RRT, Chris Hanson RN, RRT-NPS, CPFT, AE-C ER Registered Nurse Grand Junction, Colorado | |||
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