Keywords
Airway Pressure Release Ventilation
ARDS
How to Cite
Abstract
Introduction: Positive pressure ventilation is key in the treatment of patients with acute respiratory distress syndrome. Bilevel Positive Airway Pressure and Airway Pressure Release Ventilation modalities aim to improve oxygenation and reduce lung injury, but their hemodynamic effects vary.
Objective: To compare the clinical and hemodynamic effects of Bilevel Positive Airway Pressure and Airway Pressure Release Ventilation in acute respiratory distress syndrome patients.
Materials and Methods: Clinical studies published through November 2025 in the PubMed, Scopus, and Web of Science databases were analyzed. Articles on acute respiratory distress syndrome patients treated with Bilevel Positive Airway Pressure or Airway Pressure Release Ventilation that reported hemodynamic parameters were included. Studies without hemodynamic data, those outside acute respiratory distress syndrome, and non-clinical studies were excluded.
Results: Bilevel Positive Airway Pressure improves alveolar ventilation and oxygenation while modestly reducing left ventricular afterload; cardiac output remains stable in normovolemic patients. Airway Pressure Release Ventilation significantly increases oxygenation and ejection fraction, reduces alveolar shunt, and opens atelectatic alveoli, but is associated with more pronounced decreases in mean arterial pressure and preload. Clinical studies report that Airway Pressure Release Ventilation increases cardiac index and reduces central venous pressure, improving oxygenation while reducing the need for hemodynamic support.
Conclusions: Bilevel Positive Airway Pressure is suitable for moderate acute respiratory distress syndrome and hypercapnic respiratory failure, offering favorable hemodynamics and noninvasive support. Airway Pressure Release Ventilation is preferred in severe acute respiratory distress syndrome with refractory hypoxemia, as it provides superior oxygenation and alveolar recruitment but requires careful hemodynamic monitoring. The choice of modality should balance respiratory benefits with cardiovascular risks.
References
Matthay MA, Arabi Y, Arroliga AC, et al. A New Global Definition of Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2024; 209(1): pp. 37–47. doi: 10.1164/rccm.202303-0558ws
Daphale A, Acharya S, Shukla S, Alegaonkar S. Bleomycin Induced Acute Respiratory Distress Syndrome. Journal of Case Reports. 2017: pp. 55–57. doi: 10.17659/01.2017.0015.
Baftiu Nehat, Anesteziologjia dhe reanimacioni, botimi dyte, ISBN: 978-9951-460-48-4,
Sheard S, et al. Imaging of Acute Respiratory Distress Syndrome. Respir Care. 2012; 57(4): p.607-612. doi: 10.4187/respcare.01731
Zompatori M, et al. Overview of current lung imaging in acute respiratory distress syndrome. European Respiratory Review. 2014; 23(134): p.519-530. doi: 10.1183/09059180.00001314
Papazian L, et al. Diagnostic workup for ARDS patients. Intensive Care Med. 2016; 42(5): p.674-685. doi:
Papazian L, et al. Diagnostic workup for ARDS patients. Intensive Care Med. 2016; 42(5): p.674-685. doi: 10.1007/s00134-016-4324-5
Fan E, Del Sorbo L, Goligher EC, et al. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017; 195(9): p.1253-1263. doi: 10.1164/rccm.201703-0548stOpen in Read by QxMD
Qadir N, Sahetya S, Munshi L, et al. An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2024; 209(1): p.24-36. doi: 10.1164/rccm.202311-2011stOpen in Read by QxMD
Rawal G, et al. Acute respiratory distress syndrome: An update and review. Journal of Translational Internal Medicine. 2018; 6(2): p.74-77. doi: 10.1515/jtim-2016-0012Open in Read by QxMD
Walkey AJ, Del Sorbo L, Hodgson CL, et al. Higher PEEP versus Lower PEEP Strategies for Patients with Acute Respiratory Distress Syndrome. A Systematic Review and Meta-Analysis. Annals of the American Thoracic Society. 2017; 14(Supplement_4): p.S297-S303. doi: 10.1513/annalsats.201704-338otOpen in Read by QxMD
Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023; 49(7): p.727-759. doi: 10.1007/s00134-023-07050-7Open in Read by QxMD
Tonna JE, Abrams D, Brodie D, et al. Management of Adult Patients Supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO): Guideline from the Extracorporeal Life Support Organization (ELSO). ASAIO J. 2021; 67(6): p.601-610. doi: 10.1097/mat.0000000000001432Open in Read by QxMD
Zhao X, Li Y, Zhang Z, et al. Noninvasive positive-pressure ventilation may be an effective option for the initial treatment of ARDS patients in AP, but the use of NPPV should be applied cautiously. Crit Care. 2016;20(1):1–2. doi:10.1186/s13613-016-0702-0.
Grieco DL, Menga LS, Cesarano M, et al. Non-invasive ventilatory support and high-flow nasal oxygen in acute hypoxemic respiratory failure: a physiological review. Breathe (Sheff). 2021;17(1):e1–e10. doi:10.1183/20734735.0019-2020.
Stoll SE, Henningsen J, Möller P, et al. Comparison of airway pressure release ventilation and bilevel positive airway pressure in COVID-19-associated ARDS: a prospective observational study. BMC Anesthesiol. 2025;25(1):1–9. doi:10.1186/s12871-025-02904-7.
Corp A, Thomas C, Adlam M. The cardiovascular effects of positive pressure ventilation. BJA Education. 2021; 21(6): p.202-209. doi: 10.1016/j.bjae.2021.01.002Open in Read by QxMD
Davidson AC, Banham S, Elliott M, et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016; 71(Suppl 2): p.ii1-ii35. doi: 10.1136/thoraxjnl-2015-208209Open in Read by QxMD
Davidson AC, Banham S, Elliott M, et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016; 71(Suppl 2): p.ii1-ii35. doi: 10.1136/thoraxjnl-2015-208209Open in Read by QxMD
Davidson AC, Banham S, Elliott M, et al. BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults. Thorax. 2016; 71(Suppl 2): p.ii1-ii35. doi: 10.1136/thoraxjnl-2015-208209Open in Read by QxMD
Stoll SE, Henningsen J, Möller P, et al. Comparison of airway pressure release ventilation and bilevel positive airway pressure in COVID-19-associated ARDS: a prospective observational study. BMC Anesthesiol. 2025;25(1):1–9. doi:10.1186/s12871-025-02904-7.
Zhou L, Zhang Z, Li Y, et al. Biphasic positive airway pressure spontaneous breathing improves gas exchange in early severe ARDS: an experimental study. BMC Anesthesiol. 2022;22(1):1–9. doi:10.1186/s12871-022-01763-w.
Li R, Zhang Y, Wang Y, et al. Effects of airway pressure release ventilation on lung ventilation and perfusion in patients with early moderate-to-severe ARDS: a prospective observational study. Crit Care. 2023;27(1):1–9. doi:10.1186/s13613-023-02104-0.
Zou X, Zhang Y, Li J, et al. Physiologic comparison of airway pressure release ventilation and low tidal volume ventilation in patients with moderate to severe ARDS. Chest. 2025;S0012-3692(24):05154-7. doi:10.1016/j.chest.2025.02.013.
Stoll SE, Leupold T, Drinhaus H, et al. Comparison of airway pressure release ventilation (APRV) versus biphasic positive airway pressure (BIPAP) ventilation in COVID-19 associated ARDS using transpulmonary pressure monitoring. BMC Anesthesiol. 2025;25(1):52. doi:10.1186/s12871-025-02904-7.
Daoud EG, Farag HL, Chatburn RL. Airway pressure release ventilation: what do we know? Respir Care. 2012;57(2):282–92. doi:10.4187/respcare.01238.
Taha A, Shafie A, Mostafa M, Hon H, Marktanner R. Airway pressure release ventilation restores hemodynamic stability in patients with cardiogenic shock: initial experience in cardiac intensive care. Crit Care. 2014;18(Suppl 1):P282. doi:10.1186/cc13472.
Kaplan J, Bailey H, Forman S, McCambridge A, Morlock C, Janosky J. Airway pressure release ventilation increases cardiac performance in patients with acute lung injury/adult respiratory distress syndrome. Crit Care Med. 2001;29(7):1334–1340. doi:10.1097/00003246-200107000-00004.