Respiratory Therapy APRV vs BiLevel

[@JB-cg1rn]

I can’t thank you enough for all your videos. This makes total sense finally

[@RespiratoryCoach]

You just did, JB!! Glad it finally makes sense!

[@Hello252]

Hi respiratory coach! I’m a current RRT of 2+ years and still find your videos to be super useful in further enhancing my skills to benefit my patients to the best of my ability! Thankyou!! Was wondering if you could talk about the advanced settings during the use of APRV, specifically on the Avea- (T sync High and T sync low % settings) the hospital I work at likes to have these set at 10%. Could you explain what it does and how changing it affects the patient?

[@jiaelee6333]

Thank you so much! It was so difficult for me to understand what the Bi-livel is and how it's working. This lecture video is really amazing and awesome! Very easy to understand. Really appreciate it! 👍👍👍👍👍

[@RespiratoryCoach]

So glad it helped clarify things for you, Jiae. I appreciate you watching and commenting.

[@johnnybravo1204]

I think APRV is good with Pressure control modes with helping expand body surface area of AC (Alveolar Capillary) membrane and then use Bilevel for Volume control AC mode.

[@RespiratoryCoach]

Hey Johnny. Thank you for this addition. Do you mind expanding a bit on your comment of bilevel with volume control AC? I'm not familiar with bilevel being an addition to a volume mode,. Does this idea pertain to a specific ventilator? I'm intrigued and interested to learn more about this. Thank you again.

[@johnnybravo1204]

@@RespiratoryCoach Well I probably shouldn't say "use" bilevel for volume control ac mode. It looks to me that VC-AC mode functions similarly to Bilevel. I could be wrong.

[@johnnybravo1204]

@@RespiratoryCoach On another thought I was relating my comment to how you take off the set respiratory rate on a vent using SIMV mode to have it function like a CPAP. But when I thought about that, another question came to mind. Would it make better sense to assume that Bilevel is more similar to SIMV with Pressure Support added?

[@RespiratoryCoach]

@@johnnybravo1204 Hey Johnny, thank you for the clarification. I think the comparison to PC-SIMV is more appropriate. Although, bilevel allows for spontaneous breathing to occur during all aspects of the breath. This is different from SIMV, where the patient can only breathe spontaneously in between mandatory breaths. Bilevel is a pressure controlled mode of mechanical ventilation, where pressure is set and volumes vary. It's actually just inversed I:E ratio pressure control ventilation where the patient can breathe spontaneously at any point of the breath phase. Thanks again for the comments and the discourse.

[@johnnybravo1204]

@@RespiratoryCoach Okay, now I fully understand. Thank you for your detailed answer. Keep up the good work!

[@ajaytomy844]

Thank you very much sir ,all your video's are outstanding.

[@RespiratoryCoach]

Thank you for watching!

[@futurerustic]

Hi Coach, thanks for everything you do. I am at a school with a truly horrible MV instructor, so after every class I rush to your channel to actually learn the material. My question on APRV is, if the pressure only drops for that brief moment, how does the patient actually exhale properly? Isn't the high pressure maintaining their alveoli in an open position? Or is it that they're actually taking breaths during the hi pressure phase (in which case they have a spontaneous RR?) Thanks in advance!

[@deanhealy6414]

Very good explanation of APRV and Bi-Level modes.

[@RespiratoryCoach]

Thank you for watching and kindly commenting! I appreciate you!

[@km221ssd]

Thank you so much for quick response and explaining ❤️👍🏼

[@RespiratoryCoach]

You bet man! Any time! Thanks for watching and for commenting. Did I answer your question?

[@km221ssd]

Respiratory Coach yes you did Thank you

[@paytenbaughey4821]

I'm in my second year of RT school and my teacher is making my clinical partner and I do our research project on "Bilevel". She also said "you should be researching bilevel and APRV". I have no freaking clue..lol

[@AlreadyAJD]

What i found the most wonderful about your method, is that you thoroughly clear everyone's doubt in the comment section! wonderful supplementation to this nice video! great work sir. learning so much from u.

[@adrianevans1507]

Wow, awesome video, explanation and easy to follow 👍

[@huyproluvthanh]

Thanks for a very informative video. I have a few questions: 1. To fix the low PaO2, do you change I:E ratio (T-high) or do you change P-High or P-low? I have been seeing some RTs And Docs raise peep low (or P-Low) to 14-16 to fix PaO2. 2. Are we allowing permissive hypercabnic for patient on APRV? if we want to correct PCo2, what is the first parameter you world change between RR or P-high to change the minute volume? 3. What is an appropriate weaning guide for patient on APRV? Should we switch them straight to conventional mode before TSB patient? Thanks again!

[@RespiratoryCoach]

Hello! Here you go... 1. In Bi-level, increasing both will affect PaO2. Mainly because increasing either will increase mean airway pressure. It really depends on how long you are holding at P-high. In APRV, P-high is your main oxygenation tool because you aren't spending enough time at P-low for it to matter. 2. Yes, permissive hypercapnia is acceptable in APRV. It would depend on your current settings and return volumes. Let's say you're at a rate of 4 with a P-high of 35, then I would increase my rate. Knowing that both RR and P-high affect minute volume (as you stated) is the key. From there, utilize your clinical judgement and critical thinking skills to know when and which parameter to change, depending on the data you currently have. 3. There's nothing that states you can't go from APRV to SBT. If you're able to wean down to a minimal P-high with an acceptable P/F ratio, and minimal rate with a good spontaneous RSBI and the patient looks good, then I would go straight to SBT and assess for readiness for extubation. Of course, every situation is different. Some patients will go to a conventional mode before SBT, but it's not "absolutely" necessary. Hope this clarifies things for you. Thanks for watching and commenting with your questions.

[@rajasekharthottadi5151]

@@RespiratoryCoach Will you please give me some knowledge regarding P/F ratio.. Thank you

[@haziatura9322]

thank you so much for your time

[@RespiratoryCoach]

Thank you for watching and commenting!!!!

[@yanciclaros4921]

Thank you sooo much I needed this video! Your videos have helped me so much through school. I'm currently on my third semester got two more to go.

[@RespiratoryCoach]

Fantastic and thank you for the kind comment! Best wishes during your last two semesters!

[@chebej2254]

One of the best talks about the mode comparisons I've heard. Thank you!!

[@elisefine1]

Hello! We are learning about APRV and the advanced modes now in class. Can you explain the difference between an active or an open exhalation valve?

[@Redfeather80]

Working with the Maquet Servo U’s right now.

[@emmanuelonochie5584]

Normally, the Plow is set at 0 because you don't want to de-recruit the alveoli mostly in ARDS patients.

[@a.i.dimmer4616]

i thought DRAGER owns the patent for APRV,thanks for clarrifying that...both are open lung strategies.Seen in one neo vent(SLE 5000), a high breed cmv+ hfov that can be configured this way like APRV or Bilevel,only the hfov is supperimposed on every cmv breath.

[@RespiratoryCoach]

Thanks, AI, for that contribution. Neo/pedi is way outside my scope.

[@thatthiskitchen8193]

Respiratory Coach, as usual I love your explanation. I wish I had watched this before the last night. I had one of my COVID-19 patients on APRV last night and it was my fist APRV patient. He was in a bad shape, nothing was working for him and they decided to try APRV. I was received him on APRV, P high 30, P low 0, T high 6.5 and T low 0.4. and I know what you think, yes it was 0.4. He was on 60%, somewhat sedated on Dragger 500. He was breathing 22/23. I noticed that his SpO2 was decreasing and ETCO2 was increasing. Because of the concern did an ABG. PO2 was 74 PO2 was 56. Only 2 increase of CO2 and almost the same PO2. Even though, I wanted changes, covering .... did not want to make any change. Later, I had to increase FiO2 even to 80% to maintain his >92%. At one point his ETCO2 was outrageous and increased to high 80s, and I even to low 90s. Did an ABG again and pH 7.16, PCO2 was 87, and PO2 was 54. At that point, I increased P high to 32 to and to 35, decreased T high to 5 secs and increased T low to 0.5 secs. I was able to bring down ETCO2. Did an ABG PO2 was 80. That was the time to turn over my assignment, luckily he was a more experienced therapist; I was glad and by the time I was leaving I saw ETCO2 was reading in high 60s to low 70s. I wish I got the risk of changing numbers earlier but I was not confident on making those changes. But I am proud that I am a better therapist than yesterday. (By the way, my changes were approved later.) My questions are, 1. What was the best thing for me to do to reverse the situation. 2. If it was not the end of the shift, what could have I done further. 3. Will you be able to do a video explaining on maintaining this kind of patients on APRV please.

[@thatthiskitchen8193]

I meant "Only 2 increase of CO2 and almost the same PO2" by comparing the ABG done during the day, few hours ago

[@RespiratoryCoach]

Hi, Nandasiri. I think you made the appropriate move by decreasing Time high. In doing so, you added three additional drops (essentially increased the rate from 8 to 11). This allowed for more CO2 removal, which is why you observed the drop on your ETCO2. I'm just glad you were actually utilizing ETCO2. I wouldn't have done anything else from that point. CO2 was decreasing and O2 was increasing. We get caught up in trying to achieve normal, when adequate should be our focus in treating these critically ill patients. Does that make sense?

[@thatthiskitchen8193]

@@RespiratoryCoach Yes, it does. And thank you! I just started watching all your videos, even the topics that I am very good at, it's just because I am just loving your explanation plus it gives me an opportunity to learn something new or an easy way of thinking to reach a goal. Please keep doing what you do.

[@7269641]

Hi, quick question, what percentage was your PEFR?

[@RespiratoryCoach]

@@7269641In APRV, depending on your facility protocol, you're typically looking to capture 50-75% of PEFR. Some early literature supported 25%, but I think that has extended out to 50-75% in recent literature and approaches to APRV.

[@buczma91]

Hey Respiratory Coach! I think im little bit confused? Can you explain me this: if during APRV or BiLevel we are generating positive pressue (Phigh and Plow) in airways then this gradient of pressures is generating tidal volume,right? Same as in pressure controlled ventilation? So how come the patient on the top of Phigh still can breath spontanously? thanks so much!

[@buczma91]

I mean, if during PCV pressure gradient of 15cmH2O can generate Vt of 450-500ml, how come during APRV/BiLevel patient who is recieving that pressure gradient or even more can still make additional breath on the top of Phigh?

[@RespiratoryCoach]

Hey, Rafal. It's the ventilator technology. Traditional pressure control operates with a closed expiratory valve, which prohibits the patient from being able to breath during a mechanical breath. With APRV the expiratory valve stays open throughout all phases of the breath. This is how spontaneous breathing is allowed to occur during peep high of APRV and Bilevel. Also, note that in APRV, they don't refer to the inspiratory phase of the breath as an inspiratory pressure, they distinctly call it PEEP high. This distinction gives way to udnerstanding that the patient is allowed to breathe on top of, essentially, a raised baseline pressure, or cpap, and not a controlled mechanical breath. Does that make sense? And yes, despite the naming difference, the pressure gradient between peep high and peep low does indeed generate a exhaled tidal volume, which does aid in bulk CO2 removal. Hope this helps. Let me know if not. And thanks for watching!

[@buczma91]

@@RespiratoryCoach thank you very much! now it makes more sense to me, still have to read more about those two. They seem to be good options in weaning patient from MV as they provide some sort of ventilatory support (they don't seem to be that invasive), right? Greetings from Poland! Thanks so much!

[@ajt8862]

How do you decide if u have to switch a pt from a VC/pC mode to APRV to optimize pt status? What could be some scenarios ?

[@maxpla168]

Joe, our hospital is using the Bellavista's now, what's your thought on it and did you use this ventilator yet?

[@RespiratoryCoach]

Hey Max. I actually have not worked with the Bellavista in the clinical setting, but have put myself in front of it to learn how it works and how to maneuver from screen to screen, mode to mode, etc. I think it is very versatile in the number of modes it offers, but not naturally user friendly. One key element is knowing if you have "target" ventilation on or off. What's your thoughts on it?

[@hollieburger8695]

still struggling to understand everything about APRV/BILEVEL. Can you do pt scenarios on the ventilator for us?

[@hollieburger8695]

i have my quiz and exam over this mode next week ah!

[@emmawhite3354]

Good video but I think you left some things out. In APRV you will choose either tube comp or pressure support. Also, you want to lock in your time low and manipulate the time high by adjusting the respiratory rate. In regards to bilevel, I have never seen such a long time low. You still want a higher time high in order to recruit alveoli. Please let me know your thought.

[@RespiratoryCoach]

This is true, but the time high is controlled directly in some vents (Avea), not by RR. Yes, tube comp or PS, while many think that tube comp is superior within these modes. And yes, the time low in bilevel, for sure should be shorter than time high, but in my region we see bilevel being used like a glorified pressure control. Not that I agree with that strategy, but was attempting to simply illustrate the differences. Thank you for the additions and for watching!

[@gabmor7779]

how high would you set the pressure support in APRV? Lets say u have your P-high at 25, if you set Pressure support at lets say 10, that would take the pressure up to 35. Thats a bit high for some patients. Still lung protective? Or better set the pressure support at around 5 jsut to compensate for the tube

[@RespiratoryCoach]

Hey, man. Great question. Depends on what vent you are using. Some vents add PS on top of PEEP high, while others only add PS if it exceeds peep high. For example, on the PB 840, peep high of 25, a PS of 30 will only add 5 cwp of PS while at peep high. Does that make sense?

[@gabmor7779]

@@RespiratoryCoach We use bennetts at our shop. I will try aprv there and report back. A ps of 30 seems crazy to me. In bilevel i will usually set the support on somewhere between 5 and 10 because i always assumed its on top of the peep low. Aprv on the bennett is just bilvl with a tweak and im afraid pressure support of 30 will pop the lung :p

[@johnnybravo1204]

@@gabmor7779 I think you can get away with 15 pressure support. But probably no more than that. Popping a pneumo would suck though

[@AMS9928]

Thanks for this video, is Bipap and Bilevel are same or different?

[@janvanlandeghem9749]

Aprv seems bilivel with inversed ratio? (so longer Thigh and shorter Tlow)? What about Co2 build up in that mode? Seems a lot inhaling and very short exhaling (if patiënt is fully sedated)

[@RespiratoryCoach]

You're exactly right with your bilevel analogy. And yes, CO2 removal must be monitored. Remember the patient can breathe spontaneously during the time high period, so that helps with co2 removal. If more co2 removal is needed then consider adding more drops by decreasing the time high. Also, keep in mind for these patients, permissive hypercapnia strategies may be considered. Great comment! Thanks for watching!

[@colintaylor6599]

Should patients be heavily sedated on APRV mode? And do users need to worry much about risk of breath stacking?

[@RespiratoryCoach]

Not necessarily. Spontaneous breathing is encouraged as it aids hemodynamic performance. Also no, the whole mode of APRV functions on the concept of intentional auto-peep. Of course, this depends on which method or approach to APRV you are taking. Great question!

[@colintaylor6599]

@@RespiratoryCoach thank you

[@deniza859]

hello, great video. thanks. btw a little note: its not Hamilton 840 its Puritan Bennett 840 :)

[@趙祥元]

Hi Couch, sorry I have some stupid questions. It sounds like BIPAP and AVRP are all good modes when patient has spontaneous breathing. Then, why do we still need pressure support mode? Can we augment tidal volume by setting a higher high PEEP? Thank you so much. The other question is that how to decide to use BiPAP instead of APRV or use APRV instead of BIPAP? Thank you so much

[@aborrm375]

Thank you for this amazing video just I have one question Can we give muscle relaxant during APRV and if given what about ventilation

[@RespiratoryCoach]

Yes, with paralyzing agents during APRV you must know this and understand that all of co2 removal is happening during your pressure drops. Therefore, you commonly must have more drops to accommodate this. Hope that makes sense. Thank you for watching and commenting with this great question.

[@almhandalmhand5614]

Thats mean we can't use APRV with heavy sedation or muscle relaxant right ? But we can use Bilevel because we have RR

[@dizzyplayz4507]

Well done explaining. Thank you.

[@BossBtv321]

Excellent breakdown bro

[@twistedtea7046]

wish the rt at hospital am at understood this stuff. half of them still think that ppv BLOWS water out of the lungs in stuff like pulm edema. and they argue vent settings w us without a rudimentary physiologic understanding of the resp system.

[@RespiratoryCoach]

That's not good! Are you a physician, med student, resident, etc??? Thanks for watching and commenting!!

[@twistedtea7046]

@@RespiratoryCoach resident. They just havent seen your videos yet thats the problem ;) on the flip side im sure there are residents and some fellows that dont know a whole lot about basic vent settings either. but its not their one job

[@Dopp3lganger420]

As a Resident you might want to reconsider your wording of “one job”. RRTs have many jobs one of which is making sure Residents don’t kill their patients. So these RTs that think PPV “blows” water out of the lungs... I bet they can fix your patient just the same. Some of the more seasoned RRTs haven’t been in school in decades and their knowledge is from years of bedside care. Just because they might not know the “book learning” you have finished within most likely the last 5yrs or less doesn’t mean you can’t learn from them just as well. So why don’t you share your knowledge instead of honing your God complex? Everyone wins ESPECIALLY the patient.

[@twistedtea7046]

@@Dopp3lganger420 the RT was actually the one who was rude about it. also, the whole notion of nurses and other support staff saving patients from mindless residents is one of the most overblown fallacies known to man. If you only have to know one body system at least know the basics. Butthurt much?

[@Dopp3lganger420]

No I’m not “butthurt”. You watched an educational video presented by a Respiratory Care Instructor only to turn around and insult him by saying his depth of knowledge was relegated to one body system. If the therapists were rude at your facility that’s them not the whole profession. Do you believe the respiratory system is independent unto itself and that as a respiratory therapist our education and knowledge starts at the pulmonary artery and stops at the pulmonary veins? Again, you insult an entire profession and feel your profession in residency is infallible? Hopefully you’ll be gracious enough when the day comes and a Respiratory Therapist not only saves your patient but your ass to thank them.

[@olawaleajiboye9090]

What informs decisions to use either of these settings for a patient or does it depend on what type of ventilators at the disposal of the personnel?

[@inspiredx3866]

Its been some time since i worked with PB 840 vents... but also in bilevel cant you set pressure support for those spont breaths?

[@RespiratoryCoach]

Hey Adam. You can, but ATC is recommended rather PS due to the way PS is applied to PEEP high. None the less, yes, PS can be added to aid those spontaneous breaths.

[@nenjoramluvdub9637]

Hi coach, I have a doubt If pt can do spontaneous breath during P high phase of Bilevel why can do IP phase of BiPaP

[@greensahuaro2834]

Many thanks!

[@tinajacob9632]

Hello Joe. Need your help with ventilatory strategies for Proned Covid patients with very high CO2 and very low pO2; P/F ratio less than 80-100 and no option for ECMO. We using Macquet Servo I. Please advise

[@PCMcKinnon]

You are awesome!!

[@olivianicastro5107]

I know I focus on semantics, but I want to understand if there is a difference between BiVent and APRV? Some use this verbiage interchangeably with APRV? I thought there was a difference?

[@RespiratoryCoach]

Hello, Olivia. There is a difference between BiLevel/BiVent and APRV. However, you can manipulate either to function like the other. They both are essentially two pressures (High peep/ low peep) and the patient can breathe freely on top of either pressure. The difference with APRV is the very short time low, typically less than 1 second. BiVent may spend 3 seconds at peep high and 3 seconds at peep low, where APRV might spend 5.5 seconds at peep high and .5 seconds. Does this help?

[@latestlatest4760]

Hi, a really great video...one question: i am so confused about how company always made so many names for the same thing! 😅..just wanna ask a thing: what is the difference between these modes and BiPAP in NIV? Please help..thank you🙏

[@RespiratoryCoach]

Great question. Bipap doesn't have a drop in pressure from peep high to peep low. Bipap also augments spontaneous inspirations with a set IPAP. APRV does not augment spontaneous volumes. The change from peep high to peep low are independent from spontaneous respirations.

[@latestlatest4760]

@@RespiratoryCoach thx u!!🙏..so, basically, that means they (Biphasic modes vs Respironic's BiPAP) work differently, and only share the same pronounciation, am I right?

[@RespiratoryCoach]

@@latestlatest4760 That's correct, if I'm understanding the question correctly. Invasive biphasic modes (APRV and Bilevel) do not function the same as NIV Bipap.

[@latestlatest4760]

@@RespiratoryCoach thx for the quick reply..that is actually what I asked..thanks again🙏😊

[@latasharma4016]

Thx good comparison

[@queeniefung7514]

Great video ❤

[@morganliaw2968]

Hi the ventilator I'm using only can set pressure suppot and peep, there isn't a setting for peep high or peep low or time high/low. how can i apply this in my situation.

[@RespiratoryCoach]

Hi, Morgan. You can't achieve this method of mechanical ventilation with pressure support and peep. What vent are you using?

[@morganliaw2968]

@@RespiratoryCoachZoll EMV PLUS

[@jolisaw1244]

is there any way possible you can do just a aprv video? we’re going over it in class but due to it being online plus it’s such a limited time i don’t want to take the whole class period with all my questions. my main confusion is on the p high, t high, p low t low.

[@RespiratoryCoach]

Hello Jaay! I can, but I'm so backed up with request that it may take a while. It will be quicker to send me an email with your specific questions. [e-mail] Also, I want to say this for other students that might read this. Also, this is coming from a place of encouragement and compassion towards you and all students. Do not ever not ask questions based on the idea of taking up class time, instructor's time, or classmates' time. You are paying for your education. You'll get exactly what you pay for, and if don't ask the 1, 3 or 20 questions you have, you'll not obtain the knowledge and education for which you are paying for. It's too damn much money to leave questions on the table. So ask away, and away and away!!! You deserve the answers and clarity you seek. Go be great!!!

[@oliviamfragoso]

@@RespiratoryCoach Thank you for your videos

[@Bibekshrestha3024]

Hey coach is there a back up rate ?what if the patient goes apneic?

[@507Eldoctor]

On those mode de pt can’t not be fully sedate ????

[@MrTatersalad22]

Have you ever heard of aprv being used in neonates?

[@ndog37]

Sir I have learned a lot from your videos thank you so much. Some said Bilevel and PC SIMV+(draeger) is the same. May I ask your opinion about this? and on these modes, does ventilator count spontaneous breathing on P-High to start the next controlled or assisted breath? thanks again in advance.

[@RespiratoryCoach]

Hey, Ndog! Here's a video I did on PC-SIMV+. kzbin.info/www/bejne/fZfQh6CrebuagpY It does seem to be a very close relative of Bilevel, and no the spont breathing during inspiration doesn't alter the time triggered breath schedule. Thanks for watching and commenting with this great question.

[@nataliebrown4875]

How do you know what rate to set in APRV?

[@RespiratoryCoach]

That's a great question. Your time high will probably start 6-8 seconds, with a time low of .5 seconds. Total cycle time will be 6.5 - 8.5, this gives you a rate of approximately 9 - 7 drops per minute. So, 7-10 breaths per minute would be a safe initial rate and then assess and adjust from there. Hope this helps. Thanks for watching and asking your question.

[@nuwansampathedirisinghe]

In APRV ps also present

[@rajeevegopuran]

Does aprv mode washout co2 level while giving mask in a copd patient

[@1102397787]

can bilevel be used non invasively ?

[@RespiratoryCoach]

I'm going to have to ask around for this one. I've never seen it done so, but that doesn't mean it can or can't be. Thanks Sonal!

[@doctorahmedsalem7711]

Is aprv the same avaps ?? Can someone help me

[@karenpatriciahuaman6555]

isnt not 4.5? the t low in the seconds

[@RespiratoryCoach]

Yes, it is. I recognize my error and comment on it at the 9:58 mark. Thanks for watching!

[@karenpatriciahuaman6555]

yeah sorry i was quick in commenting lol. icu nurse. byeee

[@RespiratoryCoach]

@@karenpatriciahuaman6555 lol, it's all good!

[@greensahuaro2834]

Many thanks!