A Clinical Guideline for Airway Pressure Release Ventilation in Difficult-to-Oxygenate Patients

Adult intensive care unit patients often suffer from derangements of oxygen demand and delivery that, if untreated, result in organ dysfunction and possibly death. One clinical condition that contributes to profound hypoxemia is acute respiratory distress syndrome (ARDS). Patients who develop ARDS experience high mortality rates despite improvements in diagnosis and treatment over the past 30 years. Multiple ventilator strategies have been employed to restore blood oxygen content to adequate levels and prevent complications of ARDS. However, even when treating patients by following evidence-based guidelines with traditional ventilator strategies, it is often difficult to achieve adequate blood oxygen content in the most severe cases. Airway pressure release ventilation (APRV) represents an innovative treatment strategy for patients suffering from ARDS. Despite the possible benefits of this modality, few studies have demonstrated a mortality benefit when compared with traditional strategies. Despite the lack of evidence to support widespread application of APRV, some studies have demonstrated important benefits. Such benefits may translate to improved mortality if patients are carefully and strategically selected for APRV treatment based upon available evidence. The scarcity and obscurity of literature results in a lack of familiarity and knowledge about when and how APRV can benefit patients. To date, there is no clinical standard to guide the selection of patients for APRV and the initiation, titration, and discontinuation of this modality. As such, the author completed a scholarly project utilizing the ACE Star Model of Knowledge Transformation to evaluate the literature and develop a clinical guideline for the utilization of APRV. An algorithm was also created for clinician reference in the application of APRV. Information, guidelines, and algorithm were compiled into an article prepared for submission for publication in a professional journal to disseminate the information. Recommendations for future endeavors include the systematic testing of these guidelines in original research studies with revisions as indicated. Furthermore, once the guidelines and the clinical algorithm have been tested and revised, they can be applied to randomized controlled trials which could evaluate the utility of APRV in treating patients with mild, moderate, and severe ARDS. This may allow for the detection of a statistically significant improvement in morbidity and mortality in one or more of the ARDS subsets.