Validation of at-the-bedside formulae for estimating ventilator driving pressure during airway pressure release ventilation using computer simulation

Background Airway pressure release ventilation (APRV) is widely available on mechanical ventilators and has been proposed as an early intervention to prevent lung injury or as a rescue therapy in the management of refractory hypoxemia. Driving pressure ( Δ P ) has been identified in numerous studies as a key indicator of ventilator-induced-lung-injury that needs to be carefully controlled. Δ P delivered by the ventilator in APRV is not directly measurable in dynamic conditions, and there is no “gold standard” method for its estimation. Methods We used a computational simulator matched to data from 90 patients with acute respiratory distress syndrome (ARDS) to evaluate the accuracy of three “at-the-bedside” methods for estimating ventilator Δ P during APRV. Results Levels of Δ P delivered by the ventilator in APRV were generally within safe limits, but in some cases exceeded levels specified by protective ventilation strategies. A formula based on estimating the intrinsic positive end expiratory pressure present at the end of the APRV release provided the most accurate estimates of Δ P . A second formula based on assuming that expiratory flow, volume and pressure decay mono-exponentially, and a third method that requires temporarily switching to volume-controlled ventilation, also provided accurate estimates of true Δ P . Conclusions Levels of Δ P delivered by the ventilator during APRV can potentially exceed levels specified by standard protective ventilation strategies, highlighting the need for careful monitoring. Our results show that Δ P delivered by the ventilator during APRV can be accurately estimated at the bedside using simple formulae that are based on readily available measurements.