Esophageal pressure: research or clinical tool?

Kassis, Elias Baedorf; Loring, Stephen H.; Talmor, Daniel

doi:10.1007/s00063-017-0372-z

Cited by 7 publications

(8 citation statements)

References 45 publications

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“…The use of esophageal manometry has been used in respiratory physiology research, but its clinical use is not common. The evaluation of esophageal pressure (Pes) using esophageal manometry helps in the estimation of pleural pressures because its measurement can be influenced by the effects of the chest wall and lungs [ 42 ]. There is a gradual reduction in ventilatory support and increased patient effort during weaning from MV.…”

Section: Potential Methods For Predicting MV Weaning In Ardsmentioning

confidence: 99%

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Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management

Wawrzeniak

Vieira

Victorino

2018

BioMed Research International

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Acute respiratory distress syndrome (ARDS) is characterized by severe inflammatory response and hypoxemia. The use of mechanical ventilation (MV) for correction of gas exchange can cause worsening of this inflammatory response, called “ventilator-induced lung injury” (VILI). The process of withdrawing mechanical ventilation, referred to as weaning from MV, may cause worsening of lung injury by spontaneous ventilation. Currently, there are few specific studies in patients with ARDS. Herein, we reviewed the main aspects of spontaneous ventilation and also discussed potential methods to predict the failure of weaning in this patient category. We also reviewed new treatments (modes of mechanical ventilation, neuromuscular blocker use, and extracorporeal membrane oxygenation) that could be considered in weaning ARDS patients from MV.

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Section: Potential Methods For Predicting MV Weaning In Ardsmentioning

confidence: 99%

“…Yoshida et al suggest the use of the esophageal manometry to guide PEEP settings to reduce VILI [ 57 ]. Pes monitoring may be a useful tool and part of the intensivist's clinical armamentarium to show oscillations of pulmonary pressures during weaning from MV [ 42 , 43 ].…”

Section: Potential Methods For Predicting MV Weaning In Ardsmentioning

confidence: 99%

Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management

Wawrzeniak

Vieira

Victorino

2018

BioMed Research International

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“…Transpulmonary pressure is the pressure difference between the alveoli and the pleural cavity. Airway pressure—the pressure at the airway opening—is easier to measure but may not be as clinically informative as transpulmonary (or esophageal) pressure [ 58 ]. One measured airway pressure may not translate into consistent transpulmonary pressures between patients due to the heterogeneity of patient condition [ 59 ].…”

Section: Fundamentals Of Mechanical Ventilationmentioning

confidence: 99%

“…However, estimated measures of transpulmonary pressure require the use of a highly invasive balloon catheter to measure the pleural pressure [ 27 ] and are thus not often applied clinically. Please refer to a recent review discussing applications of transpulmonary (and esophageal) pressure [ 58 ].…”

Section: Fundamentals Of Mechanical Ventilationmentioning

confidence: 99%

Biomedical engineer’s guide to the clinical aspects of intensive care mechanical ventilation

et al. 2018

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BackgroundMechanical ventilation is an essential therapy to support critically ill respiratory failure patients. Current standards of care consist of generalised approaches, such as the use of positive end expiratory pressure to inspired oxygen fraction (PEEP–FiO2) tables, which fail to account for the inter- and intra-patient variability between and within patients. The benefits of higher or lower tidal volume, PEEP, and other settings are highly debated and no consensus has been reached. Moreover, clinicians implicitly account for patient-specific factors such as disease condition and progression as they manually titrate ventilator settings. Hence, care is highly variable and potentially often non-optimal. These conditions create a situation that could benefit greatly from an engineered approach. The overall goal is a review of ventilation that is accessible to both clinicians and engineers, to bridge the divide between the two fields and enable collaboration to improve patient care and outcomes. This review does not take the form of a typical systematic review. Instead, it defines the standard terminology and introduces key clinical and biomedical measurements before introducing the key clinical studies and their influence in clinical practice which in turn flows into the needs and requirements around how biomedical engineering research can play a role in improving care. Given the significant clinical research to date and its impact on this complex area of care, this review thus provides a tutorial introduction around the review of the state of the art relevant to a biomedical engineering perspective.DiscussionThis review presents the significant clinical aspects and variables of ventilation management, the potential risks associated with suboptimal ventilation management, and a review of the major recent attempts to improve ventilation in the context of these variables. The unique aspect of this review is a focus on these key elements relevant to engineering new approaches. In particular, the need for ventilation strategies which consider, and directly account for, the significant differences in patient condition, disease etiology, and progression within patients is demonstrated with the subsequent requirement for optimal ventilation strategies to titrate for patient- and time-specific conditions.ConclusionEngineered, protective lung strategies that can directly account for and manage inter- and intra-patient variability thus offer great potential to improve both individual care, as well as cohort clinical outcomes.

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“…Second, transpulmonary measurements may be used monitor for lung overdistension and to account for the stiffened chest wall during tidal breathing which may impact forces across the lungs. Additionally, other uses of P ES in the ICU include monitoring of dyssynchrony, estimation and adjustment for auto-PEEP and assisting with weaning, but have been covered in depth in other reviews (22)(23)(24)(25).…”

Section: A P P L I C a T I O N O F B A S I C P H Y S I O L O G I C P mentioning

confidence: 99%

Should we titrate peep based on end-expiratory transpulmonary pressure?—yes

Kassis¹,

Loring²,

Talmor³

2018

Ann. Transl. Med

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Ventilator management of patients with acute respiratory distress syndrome (ARDS) has been characterized by implementation of basic physiology principles by minimizing harmful distending pressures and preventing lung derecruitment. Such strategies have led to significant improvements in outcomes. Positive end expiratory pressure (PEEP) is an important part of a lung protective strategy but there is no standardized method to set PEEP level. With widely varying types of lung injury, body habitus and pulmonary mechanics, the use of esophageal manometry has become important for personalization and optimization of mechanical ventilation in patients with ARDS. Esophageal manometry estimates pleural pressures, and can be used to differentiate the chest wall and lung (transpulmonary) contributions to the total respiratory system mechanics. Elevated pleural pressures may result in negative transpulmonary pressures at end expiration, leading to lung collapse. Measuring the esophageal pressures and adjusting PEEP to make transpulmonary pressures positive can decrease atelectasis, derecruitment of lung, and cyclical opening and closing of airways and alveoli, thus optimizing lung mechanics and oxygenation. Although there is some spatial and positional artifact, esophageal pressures in numerous animal and human studies in healthy, obese and critically ill patients appear to be a good estimate for the "effective" pleural pressure. Multiple studies have illustrated the benefit of using esophageal pressures to titrate PEEP in patients with obesity and with ARDS. Esophageal pressure monitoring provides a window into the unique physiology of a patient and helps improve clinical decision making at the bedside.

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Esophageal pressure: research or clinical tool?

Cited by 7 publications

References 45 publications

Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management

Weaning from Mechanical Ventilation in ARDS: Aspects to Think about for Better Understanding, Evaluation, and Management

Biomedical engineer’s guide to the clinical aspects of intensive care mechanical ventilation

Should we titrate peep based on end-expiratory transpulmonary pressure?—yes

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