Ventilatory support by continuous positive airway pressure breathing improves gas exchange as compared with partial ventilatory support with airway pressure release ventilation

In acute lung injury, airway pressure release ventilation (APRV) with superimposed spontaneous breathing improves gas exchange compared with controlled mechanical ventilation. However, the release of airway pressure below the continuous positive airway pressure (CPAP) level may provoke lung collapse. Therefore, we compared gas exchange and hemodynamics using a crossover design in nine pigs with oleic acid-induced lung injury during CPAP breathing and APRV with a release pressure level of 0 and 5 cm H2O. At an identical minute ventilation ((V) over dot E 8 L/min) spontaneous breathing averaged 55%, 67%, and 100% of (V) over dot E during the two APRV modes and CPAP, respectively. Because of the concept of APRV, mean airway pressure was highest during CPAP and lowest during APRV with a release pressure of 0 cm H2O. Shunt was reduced to almost half during CPAP (6.6% of (Q) over dot t) compared with both APRV-modes (13.0% of (Q) over dot t). Cardiac output and oxygen consumption, in contrast, were similar during all three ventilatory settings. Thus, in our lung injury model, CPAP was superior to partial ventilatory support using APRV with and without positive end-expiratory pressure. This may be attributable to beneficial-effects of spontaneous breathing on gas exchange as well as to rapid lung collapse during the phases of airway pressure release below the CPAP level. These findings may suggest that the amount of mechanical ventilatory support using the APRV mode should be kept at the necessary minimum.