What is the role of airway pressure release ventilation in the management of acute lung injury?

The lack of published evidence supporting the use of APRV in the pediatric critical care patient population may diminish its effective application in respiratory failure. The effect of APRV on the number of ventilator days, ICU stay, and mortality still remains to be studied. Further application of APRV in the role of rest settings for ECMO especially in the pediatric cardiac patient population needs to be investigated. Will the use of APRV decrease the time for adequate lung recruitment, decrease sheer trauma, and/or promote earlier decannulation upon the restoration of tolerable cardiac function? Can APRV be utilized as a re-recruitment maneuver? A comparison of APRV over sustained in a randomized-controlled fashion, will there be a significant difference in ventilator days, length of ICU stay, and/or mortality? Does re-recruitment at plateau pressures during suctioning, patient position changes, or in the face of increased airway resistance decrease the number of ventilator days, length of ICU stay, and/or mortality? Does the use of continuous monitoring of carbon dioxide production aid in optimizing P(high)? The list of questions, both speculative and scientific are too numerous to list. Speculation leads to inquiry which over time drives science. More focus is needed on randomized, controlled trials. Initially the comparison of APRV to HFOV needs to be the primary focus for a proactive approach for ALI. Once a comfort level is established with this modality, further scientific inquires will follow. In the meantime, its use is likely to remain controversial.