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In retrospect, the "discovery" of auto-PEEP and the devising of a practical means for its detection took place over a span of less than 30 minutes.
APRV raises mean airway pressure higher than standard ventilation; foregoes tight control over true maximal trans-alveolar pressure; and deliberately generates unmeasured and variable levels of auto-PEEP. Assuming its upper- and lower-pressure baselines are held constant, mean airway pressure falls as the number of release (ventilating) cycles increases, Moreover, while APRV encourages spontaneous breathing efforts, it is not certain that the theoretical V/Q benefits of spontaneous ventilation are preserved when mean airway pressure is so high.
Danger also lurks for those with severe airflow obstruction who vary their levels of breathing effort and auto-PEEP. A high level of pressure needed to overcome resistance during active breathing may over distend of the compliant lung when breathing demands lessen and/or as the expiratory muscle activity that braked flow to trigger timely expiration abates with sedation.
Were I to advise RCPs in practice or in training, it would be to prepare well in physiology, to question what you do not understand from a base of confidence gained from that physiological knowledge, and to look very carefully--there are more phenomena like auto-PEEP waiting to be described by the brightest and most committed among you.
They include: lung compliance and airway resistance, the set pressure level, the amount of auto-PEEP and the patient's effort.
The resulting tidal volume is dependent on airway resistance, chest wall and lung compliance and the amount of auto-PEEP.
This assists in oxygenation and may be increased to assist patient triggering of the ventilator by overcoming their auto-PEEP.