Critical Care: Original Research

Physiologic Comparison of Airway Pressure Release Ventilation and Low Tidal Volume Ventilation in ARDS: A Randomized Controlled Trial

Hongling Zhang, Yongran Wu, Ruiting Li, et al

Chest Available online 17 September 2024 https://doi.org/10.1016/j.chest.2024.08.050

Background

The physiologic effects of different ventilation strategies on patients with ARDS need to be better understood.

Research Question

In patients with ARDS receiving controlled mandatory ventilation, does airway pressure release ventilation (APRV) improve lung ventilation/perfusion () matching and ventilation homogeneity compared with low tidal volume (LTV) ventilation?

Study Design and Methods

This study was a single-center randomized controlled trial. Patients with moderate to severe ARDS were ventilated randomly with APRV or LTV ventilation. Electrical impedance tomography (EIT) was used to assess lung ventilation and perfusion. EIT-based data and clinical variables related to respiratory and hemodynamic conditions were collected shortly before randomization (0 hours) and at 12 and 24 hours after randomization.

Results

A total of 40 patients were included and randomized to the APRV or LTV ventilation group (20 per group). During the 24-hour trial period, patients receiving APRV exhibited significantly increased dorsal ventilation (difference value [24 hours minus 0 hours]: median, 10.82% [interquartile range (IQR), 2.62%-13.74%] vs 0.12% [IQR, –2.81% to 4.76%]; P = .017), decreased dorsal shunt (median, –4.67% [IQR, –6.83% to 0.59%] vs 1.73% [IQR, –0.95% to 5.53%]; P = .008), and increased dorsal  matching (median, 4.13% [IQR, –0.26% to 10.47%] vs –3.29% [IQR, –5.05% to 2.81%]; P = .026) than those receiving LTV ventilation. No difference in ventral dead space was observed between study groups (P = .903). Additionally, two indicators of ventilation distribution heterogeneity, global inhomogeneity index and center of ventilation, significantly decreased and significantly increased, respectively, in the APRV group compared with the LTV ventilation group. Patients receiving APRV showed significantly higher Pao₂ to Fio₂ ratio, higher respiratory system static compliance and lower Paco₂ than those receiving LTV ventilation at 24 hours. The cardiac output was comparable in both groups.

Interpretation

APRV, as compared with LTV ventilation, could recruit dorsal region, reduce dorsal shunt, increase dorsal  matching, and improve ventilation homogeneity of the lungs, leading to better gas exchange and respiratory system static compliance in patients with moderate to severe ARDS.

Clinical Trial Registry

ClinicalTrials.gov; No.: NCT05767125; URL: www.clinicaltrials.gov