Great job. In our facility I have been trying to push to use this mode more and more. I have found that many RT’s are scared to try it simply because they feel like it’s complicated. I have found that if you can make people realize that APRV is just CPAP with drops in pressure and that setup can be pretty simple it helps. I have also found that I like patients to be sedated initially. They often tolerate better when they wake up to it. Sometimes it’s hard to dial in your settings when your patient is spontaneously breathing. Thanks
Hey Mike! I agree, spontaneous breathing patients make it difficult to get your initial APRV settings just right. CPAP with a drop is a fantastic way to explain it to students, new grads, and even RRTs that are apprehensive to working with APRV. It's a good mode. Keep being an advocate for your patients that will benefit from it! Thanks for watching and for leaving the insightful comment!
That's awesome, Ann. I'm so proud of you! I'm speaking at the NJSRC Conference in Atlantic City in October! Maybe I'll see you there? If so, don't be a stranger!
thank you for the video lecture sir , great explanation , sir if you can please explain how do we select " p low and t low " when we switch to aprv from vc/ac or pc/ac ( do we select value according to the previous vent modes flow value.... , ). thank you sir
Can you explain a little bit how beneficial can this mode be for Ards patients? If it isn't, explain.Thanks again for everything that you are lecturing.
Thank you very much you are a good teacher pls help me with to know how to calculate on APRV VS BILEVEL the calculation is my problem secondly to show it on a computer once again thank you. Very much
Coach... ur doing an excellent job explaining these complex matters and making every thing make sense!! Thank u very much.. my question is, what determines tidal volume in bilevel? Is it peep High or pressure support? Thank u very much!
Hey, I passed my RRT last November 😊 I was treated so badly and I couldn’t say anything or do anything about it at the hospital I worked at because I was a CRT.
thank you so much for this great explanation🙏 my question is can we use APRV for COPD or is there some cases we shouldn’t use it for them 2nd can we use it for pediatrics thank you sir again and god bless you 🙏
Not ideal for COPDers, especially for the bullous emphysematic. Risk for pneumothorax increases exponentially in these patients. Having said that, haven't seen anything that identifies COPD as an absolute contraindication either. Would rely on my clinical judgement in that situation, honestly. As for pediatrics, yes you can. Just had a fellow RT reach out to me today asking for help with a neo patient in APRV. Again, haven't seen much research that supporrs the use in the neo/pedi world, but also none that recommends against APRV in that patient population. Please share with me if you come across something that states differently. Best wishes, Abdullah. Thanks for posting your question.
This 20 delta-P value is associated with excess mortality in patients with ARDS. How we should set P high in bilevel ventilation to avoid a driving pressure higher than 15?
This is a great question, and I'm probably not going to sufficiently answer it, but here goes. When we talk about driving pressure, we're referencing the difference between peep and plateau, not peep and pip. To correctly assess plateau you must be in a volume mode of ventilation. Otherwise, your plateau pressure is the same as your set insp pressure. Therefore, when in bi-level, a pressure controlled mode, driving pressure becomes a mute point. At least from the data that I've reviewed, the research surrounding driving pressure is related to volume control ventilation. Please let me know if you are aware of data showing otherwise. I would be interested in reviewing it. Hey Kelson, thanks for watching and leaving this great question.
I have been working my first RT job out of school, the facility I did my clinicals at used Drager ventilators but my job uses the 980 and 840. My question is do I need to calculate the trap rate on the 840 and 980 the same as on the Drager since I am setting the Peep low on the 840 and 980. We rarely use bi-level and the residents on the ICU are not familiar with it at all so when the attending is not there they are very confused. I want to make sure I’m running the vent correctly since I am only familiar with the Drager.
Hi Sally! I'm not familiar with the term "trap rate". I assume that refers to the time low? If so, then yes. Typically, and depending on what research you prefer, time low is set at 50-75% of peak exp flow. Does that make sense and answer your question? Kuddos to you for taking initiative to be the expert on this, instead of solely relying on residence. 👏👏👏
The Drager vent we use APRV has an AUTO RELEASE option that always us to use EXP.TERM% to determine how much we will expire from the Phigh level. This allows the vent to take the PEAK EXP. FLOW during the release and decent until the SET peak exp flow is reached. For example Exp.Term = 75% for setting. And the Peak flow upon expiration is 100 lpm then the release stops when it hits 75 lpm and returns to P-high setting. The Exp. Term % determines the P-low level. The vent also tells you what the T-low measurement is. Expiratory pause will measure the intrinsic peep which is your measured P-low. You can TRAP AIR by freezing the screen and measuring the Peak Exp. Flow. 100 lpm for simplicity for example. Take your calculator and multiply that by 0.75 . Scroll till you reach 75 lpm and calculate how many seconds it took to go from 100 lpm to 75 lpm. That Time difference is what you will set as your T-low. Usually the range will be (.30 to .90 sec). 75% offers the best alveolar recruitment and stability. (Equivalent to best peep in APRV). 75% of peak expiratory flow is the golden # however you can range between 50% and 75% if required. However you should always be climbing up to 75% when possible. TH-cam = Dr. Nader Habashi and APRV and you will recieve alot of lectures on it. I also have STEP by STEP APRV explained video on my channel.
So at our place peopel are not relly familiar with APRV. From time to time when we try it on an ARDS patient most of the time patients react by having high respiratory rates (up to 40-50/min) even when heavily sedated. Is it acceptable on the long term in this mode?
Since a possible problem with APRV with PEEP low set at 0 is derecruitment during time low, I have wondered if setting the PEEP low at something above 0 may be helpful. That way we are not replying on auto peep which may have some alveoli close and snap back open causing damage. If so I wonder how to determine the low PEEP.
Hello again. I'm not sure of the answer to this question. I haven't seen a peep low used with APRV. I do understand your concern though, and it makes sense, I just haven't seen it any other way than relying on the intrinsic peep. Great question.
@@RespiratoryCoach I wonder if the PEEP could be increased until the 75% flow can't be met and then drop it just a touch. That would keep from losing the expired volume yet ensure a more open lung. just a thought.
Wud like to know if APRV works in Covid ? Wud like to have bit more details on APRV .... about wat the settings wud be in Covid type lungs for example ? Thnx
Hi Tina! I think it can, but there is still much research that needs to be done to really understand the disease process before I can confidently speak on it. For now understanding how to manipulate oxygenation and ventilation using APRV is the best approach.
Respiratory Coach thnx ton Joe. Makes sense! Nevertheless wud appreciate if u cud talk about APRV in addition to wat is there in ur videos leisurely, wenever u got time. Ur videos been quite informative n of great help for me
Love your video. I do have a question. If a pt. is on this mode with EtCO2 monitor on, what has been the common readings? I would imagine EtCO2 readings would be lower than normal. Is that the case?
Not necessarily, it all depends on the patients minute ventilation requirements to maintain a normal co2. If you do see a decreasing etco2 in APRV, you should consider increasing your I time, which decreases the number of drops, which decreases your minute volume, which allows your co2 to rise back to the desired range. Hope this makes sense, and thanks for watching!!
Sure, Natalie. If your peak exp flow is 80lpm and you want to capture at 75%. Then you multiply 80 times .75 = 60. You would then set your time low to allow for peak exp flow to decay to 60lpm. If you want 50% capture time you multiply 80 by .5 = 40lpm. You would then extend your time low time to allow exp flow to decay to 40 lpm. Make sense? Please let me know if not. Thanks for watching and asking your question.
@@nataliebrown4875 I understand your concern, but obviously the child is sick. Consider the following. Accept adequate at this time instead of shooting for normal. SaO2 = 90%. What's your hemoglobin and PaCO2...one step further...what's your CaO2? Is the child getting enough oxygen to the tissues? Don't tear the lungs up trying to achieve normal. All of this being said very respectfully. I'm okay with PaO2 of 71 and a sat of 90% on a critically ill patient. This is the message we have to get out. Stop shooting for normal during not normal times. What's your thoughts?
@@RespiratoryCoachI like this approach. The doctors here are trying to shoot a higher spo2. Here at this hospital they focus mainly on p/f ratios and proning. This is a COVID patient at that.
I'm going to have to go back and watch this. I agree, the settings you commented with (both of them) are more like PCV settings. Typically in APRV, you'll see time high 6-10 times longer than time low. Anything else and like you said you are basically in a glorified PC mode, or bi-level. In your original comment, I would increase the time high to 5-6 seconds. Of course, that's without knowing pH and CO2. That would give you about 10 drops per minute to help with co2 removal and establish a more effective mean airway pressure. What do you think?
I tried APRV now on several patients that were all already far into their disease with severe ards I noticed that often i needed expiratory times of less than 0,2 seconds to get the termination of expiration at 75%, but our machine (we use pb 840) didnbt allow me to go below 0,2seconds. also i noticed a very sharp dip to peak expiratory flow. It goes straight down in a vertical line to around 90l/min, than almost straight back up vertically to maybe 60l/min and then takes an angle of around 45° or so . is that an artifact or typical for a very stiff lung or should i have thought of looking for kinks in the tube or try to suction
Strong work, Gab, and great observations combined with critical thinking. The key to what you are seeing is the PB840. The expiratory flow pattern that you are observing is, for whatever reason, essentially a flaw (or as you stated "artifact") in the depiction of expiratory flow. Your description of what you observe, is spot on (maybe not always 90 and 60lpm) for every patient on a PB840. You want to use the point where the expiratory flow transitions to the 45 degree angle as your PEF to determine your 75% capture time. This information would have been helpful for you up front, but obviously there's no way to include nuances of every ventilator. Let me know if you have better luck with this technique.
@@RespiratoryCoach Yea thats actually really helpful info thx a lot!! , it means i had many of my patients with a too short T -low and too high intrinsic peep. Still worked fine thouh. Any idea why the pb 840 has that flaw?
@@RespiratoryCoach ok thats good to know, at least then my t-Low wasnt too short, i just shouldnt have used that faulty PEF and probably t-low 0,3 would have been fine
Hi, Janea. In regards to APRV, absolutely, but APRV is designed to incorporate intentional auto-peep. So every patient will intentionally have auto-peep when using APRV, specifically with a low peep of 0. Having said that, I have not seen data supporting the use of APRV with the COPD population, specifically bullous emphysema. Do to the already present hyperinflation and blebs, this patient population would be at a higher risk for developing a pneumothorax in APRV. Hope this helps to clarify and thank you for watching!
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your videos are literally saving my life and giving me that constant push that I need to get through that 3rd semester.
Stay focused and Go Be Great!
Great job. In our facility I have been trying to push to use this mode more and more. I have found that many RT’s are scared to try it simply because they feel like it’s complicated. I have found that if you can make people realize that APRV is just CPAP with drops in pressure and that setup can be pretty simple it helps. I have also found that I like patients to be sedated initially. They often tolerate better when they wake up to it. Sometimes it’s hard to dial in your settings when your patient is spontaneously breathing. Thanks
Hey Mike! I agree, spontaneous breathing patients make it difficult to get your initial APRV settings just right. CPAP with a drop is a fantastic way to explain it to students, new grads, and even RRTs that are apprehensive to working with APRV. It's a good mode. Keep being an advocate for your patients that will benefit from it! Thanks for watching and for leaving the insightful comment!
This is the PERFECT explanation of APRV that I was looking for.
Awesome! Thank you for watching!
Brilliant Thankyou. Getting the percentage based off of peak expiratory flow makes a lot more sense now. Thanks again.
You're very welcome, Kyle. Glad it made sense. Let me know if you have further questions.
I passed my RRT in August!! Your videos were very helpful throughout my 2 year program! Thank you!
A our icu is using this more thanks to you, helping so many patients, god bless, merry Christmas
That's awesome, Lester. Any obstacles in getting docs and other RTs on board with it? Happy New Year!
Hi joe, I passed RRT, I just started working for atlanticare, in Atlantic City New Jersey, your videos helped me a lot🤗🤗🐞
That's awesome, Ann. I'm so proud of you! I'm speaking at the NJSRC Conference in Atlantic City in October! Maybe I'll see you there? If so, don't be a stranger!
@@RespiratoryCoach thanks coach, sure. I will. Thanks again for everything 😊
thank you for the video lecture sir , great explanation , sir if you can please explain how do we select " p low and t low " when we switch to aprv from vc/ac or pc/ac ( do we select value according to the previous vent modes flow value.... , ). thank you sir
Well well well explanation thank you so much
Thank you AR for watching and commenting!
Great job, i like your presentation .
Thank you! I like the fact that you watched and commented!!! Thank you!
Can you explain a little bit how beneficial can this mode be for Ards patients? If it isn't, explain.Thanks again for everything that you are lecturing.
thanks , I've had a difficult time understanding this
Thank you so much !
You are very welcome!!!! Thank you for watching.
Very good
Thank you very much you are a good teacher pls help me with to know how to calculate on APRV VS BILEVEL the calculation is my problem secondly to show it on a computer once again thank you. Very much
Coach... ur doing an excellent job explaining these complex matters and making every thing make sense!! Thank u very much.. my question is, what determines tidal volume in bilevel? Is it peep High or pressure support?
Thank u very much!
Wonderful
Glad you like it, Kamal. Thanks for watching!!!!
Hey, I passed my RRT last November 😊 I was treated so badly and I couldn’t say anything or do anything about it at the hospital I worked at because I was a CRT.
Congratulations on getting your RRT! I'm so proud of you. Go be Great!
thank you so much for this great explanation🙏 my question is can we use APRV for COPD or is there some cases we shouldn’t use it for them 2nd can we use it for pediatrics thank you sir again and god bless you 🙏
Not ideal for COPDers, especially for the bullous emphysematic. Risk for pneumothorax increases exponentially in these patients. Having said that, haven't seen anything that identifies COPD as an absolute contraindication either. Would rely on my clinical judgement in that situation, honestly. As for pediatrics, yes you can. Just had a fellow RT reach out to me today asking for help with a neo patient in APRV. Again, haven't seen much research that supporrs the use in the neo/pedi world, but also none that recommends against APRV in that patient population. Please share with me if you come across something that states differently. Best wishes, Abdullah. Thanks for posting your question.
This 20 delta-P value is associated with excess mortality in patients with ARDS. How we should set P high in bilevel ventilation to avoid a driving pressure higher than 15?
This is a great question, and I'm probably not going to sufficiently answer it, but here goes. When we talk about driving pressure, we're referencing the difference between peep and plateau, not peep and pip. To correctly assess plateau you must be in a volume mode of ventilation. Otherwise, your plateau pressure is the same as your set insp pressure. Therefore, when in bi-level, a pressure controlled mode, driving pressure becomes a mute point. At least from the data that I've reviewed, the research surrounding driving pressure is related to volume control ventilation. Please let me know if you are aware of data showing otherwise. I would be interested in reviewing it. Hey Kelson, thanks for watching and leaving this great question.
What was time high and what time low ??
In APRV mode, how to calculate tidal volume when there is spontaneous breathing, VT (TLOW)?
I have been working my first RT job out of school, the facility I did my clinicals at used Drager ventilators but my job uses the 980 and 840. My question is do I need to calculate the trap rate on the 840 and 980 the same as on the Drager since I am setting the Peep low on the 840 and 980. We rarely use bi-level and the residents on the ICU are not familiar with it at all so when the attending is not there they are very confused. I want to make sure I’m running the vent correctly since I am only familiar with the Drager.
Hi Sally! I'm not familiar with the term "trap rate". I assume that refers to the time low? If so, then yes. Typically, and depending on what research you prefer, time low is set at 50-75% of peak exp flow. Does that make sense and answer your question? Kuddos to you for taking initiative to be the expert on this, instead of solely relying on residence. 👏👏👏
The Drager vent we use APRV has an AUTO RELEASE option that always us to use EXP.TERM% to determine how much we will expire from the Phigh level. This allows the vent to take the PEAK EXP. FLOW during the release and decent until the SET peak exp flow is reached.
For example Exp.Term = 75% for setting. And the Peak flow upon expiration is 100 lpm then the release stops when it hits 75 lpm and returns to P-high setting. The Exp. Term % determines the P-low level. The vent also tells you what the T-low measurement is. Expiratory pause will measure the intrinsic peep which is your measured P-low.
You can TRAP AIR by freezing the screen and measuring the Peak Exp. Flow. 100 lpm for simplicity for example. Take your calculator and multiply that by 0.75 . Scroll till you reach 75 lpm and calculate how many seconds it took to go from 100 lpm to 75 lpm. That Time difference is what you will set as your T-low. Usually the range will be (.30 to .90 sec).
75% offers the best alveolar recruitment and stability. (Equivalent to best peep in APRV). 75% of peak expiratory flow is the golden # however you can range between 50% and 75% if required. However you should always be climbing up to 75% when possible.
TH-cam = Dr. Nader Habashi and APRV and you will recieve alot of lectures on it. I also have STEP by STEP APRV explained video on my channel.
So at our place peopel are not relly familiar with APRV. From time to time when we try it on an ARDS patient most of the time patients react by having high respiratory rates (up to 40-50/min) even when heavily sedated. Is it acceptable on the long term in this mode?
What happened to your CEU approved APRV youtube video? I was trying to site it for a presentation at work.
Send me an email to respiratorycoach@gmail.com
Since a possible problem with APRV with PEEP low set at 0 is derecruitment during time low, I have wondered if setting the PEEP low at something above 0 may be helpful.
That way we are not replying on auto peep which may have some alveoli close and snap back open causing damage.
If so I wonder how to determine the low PEEP.
Hello again. I'm not sure of the answer to this question. I haven't seen a peep low used with APRV. I do understand your concern though, and it makes sense, I just haven't seen it any other way than relying on the intrinsic peep. Great question.
@@RespiratoryCoach I wonder if the PEEP could be increased until the 75% flow can't be met and then drop it just a touch. That would keep from losing the expired volume yet ensure a more open lung.
just a thought.
Wud like to know if APRV works in Covid ? Wud like to have bit more details on APRV .... about wat the settings wud be in Covid type lungs for example ? Thnx
Hi Tina! I think it can, but there is still much research that needs to be done to really understand the disease process before I can confidently speak on it. For now understanding how to manipulate oxygenation and ventilation using APRV is the best approach.
Respiratory Coach thnx ton Joe. Makes sense! Nevertheless wud appreciate if u cud talk about APRV in addition to wat is there in ur videos leisurely, wenever u got time. Ur videos been quite informative n of great help for me
when inspiratory flow reaches zero and when not in flow scalars
Don't understand your question. Please clarify.
How do we find the PEF on the avea?
It's the bottom side of the flow waveform. You can freeze the screen and trace the flow waveform.
Love your video. I do have a question. If a pt. is on this mode with EtCO2 monitor on, what has been the common readings? I would imagine EtCO2 readings would be lower than normal. Is that the case?
Not necessarily, it all depends on the patients minute ventilation requirements to maintain a normal co2. If you do see a decreasing etco2 in APRV, you should consider increasing your I time, which decreases the number of drops, which decreases your minute volume, which allows your co2 to rise back to the desired range. Hope this makes sense, and thanks for watching!!
Can you explain the 25 to 75% PEFR a little better.
Sure, Natalie. If your peak exp flow is 80lpm and you want to capture at 75%. Then you multiply 80 times .75 = 60. You would then set your time low to allow for peak exp flow to decay to 60lpm. If you want 50% capture time you multiply 80 by .5 = 40lpm. You would then extend your time low time to allow exp flow to decay to 40 lpm. Make sense? Please let me know if not. Thanks for watching and asking your question.
Yes it does. I currently have a pt with so2 of 90%. The doctors changed her rate to 14 on an 840. Her p high 34 p low 0, ps of 39.
I am not sure how to correct. Her abg po2 was 71
@@nataliebrown4875 I understand your concern, but obviously the child is sick. Consider the following. Accept adequate at this time instead of shooting for normal. SaO2 = 90%. What's your hemoglobin and PaCO2...one step further...what's your CaO2? Is the child getting enough oxygen to the tissues? Don't tear the lungs up trying to achieve normal. All of this being said very respectfully. I'm okay with PaO2 of 71 and a sat of 90% on a critically ill patient. This is the message we have to get out. Stop shooting for normal during not normal times. What's your thoughts?
@@RespiratoryCoachI like this approach. The doctors here are trying to shoot a higher spo2. Here at this hospital they focus mainly on p/f ratios and proning. This is a COVID patient at that.
How would you take a APRV settings of: PH 40/PL 12 &
tH .6/tL 1.0. ? COViD pt. PO2 low ofcourse on abg.
I dont see your initial setting of 30/10 & tH 1.5/tL 1.5. That is PC mode. Why have does settings on APRV
I'm going to have to go back and watch this. I agree, the settings you commented with (both of them) are more like PCV settings. Typically in APRV, you'll see time high 6-10 times longer than time low. Anything else and like you said you are basically in a glorified PC mode, or bi-level. In your original comment, I would increase the time high to 5-6 seconds. Of course, that's without knowing pH and CO2. That would give you about 10 drops per minute to help with co2 removal and establish a more effective mean airway pressure. What do you think?
I tried APRV now on several patients that were all already far into their disease with severe ards
I noticed that often i needed expiratory times of less than 0,2 seconds to get the termination of expiration at 75%, but our machine (we use pb 840) didnbt allow me to go below 0,2seconds.
also i noticed a very sharp dip to peak expiratory flow. It goes straight down in a vertical line to around 90l/min, than almost straight back up vertically to maybe 60l/min and then takes an angle of around 45° or so . is that an artifact or typical for a very stiff lung or should i have thought of looking for kinks in the tube or try to suction
Strong work, Gab, and great observations combined with critical thinking. The key to what you are seeing is the PB840. The expiratory flow pattern that you are observing is, for whatever reason, essentially a flaw (or as you stated "artifact") in the depiction of expiratory flow. Your description of what you observe, is spot on (maybe not always 90 and 60lpm) for every patient on a PB840. You want to use the point where the expiratory flow transitions to the 45 degree angle as your PEF to determine your 75% capture time. This information would have been helpful for you up front, but obviously there's no way to include nuances of every ventilator. Let me know if you have better luck with this technique.
@@RespiratoryCoach
Yea thats actually really helpful info thx a lot!!
, it means i had many of my patients with a too short T -low and too high intrinsic peep. Still worked fine thouh.
Any idea why the pb 840 has that flaw?
@@gabmor7779 I do not. Went through the same trials you did. Finally asked the rep, and that's what I found out. No good explanation for it though.
@@RespiratoryCoach
ok thats good to know,
at least then my t-Low wasnt too short, i just shouldnt have used that faulty PEF and probably t-low 0,3 would have been fine
Wouldn’t this cause auto peeping in copd pt’s?
Hi, Janea. In regards to APRV, absolutely, but APRV is designed to incorporate intentional auto-peep. So every patient will intentionally have auto-peep when using APRV, specifically with a low peep of 0. Having said that, I have not seen data supporting the use of APRV with the COPD population, specifically bullous emphysema. Do to the already present hyperinflation and blebs, this patient population would be at a higher risk for developing a pneumothorax in APRV. Hope this helps to clarify and thank you for watching!