Impact of physician education and availability of parameters regarding esophageal pressure and transpulmonary pressure on clinical decisions involving ventilator management

Norisue, Yasuhiro; Ashworth, Lonny; Naito, Takaki; Kataoka, Jun; Takeuchi, Muneyuki; Usami, Sunao; Takada, Junko; Fujitani, Shigeki

doi:10.1016/j.jcrc.2017.04.021

Cited by 4 publications

(2 citation statements)

References 19 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…P L might rather be included in a multimodal ventilatory strategy including other parameters reflecting respiratory mechanics, neuroventilatory control and/or haemodynamics. The use by trained physicians of standardised protocols allowing bedside assessment of respiratory and lung mechanics has shown to be associated with an improvement in protective ventilation and oxygenation 88 89. The growing interest in machine learning over the last decades led to the development of computer-based clinical decision support systems (CDS) for protective ventilation 90 91.…”

Section: Methodsmentioning

confidence: 99%

Pleural and transpulmonary pressures to tailor protective ventilation in children

Vedrenne-Cloquet¹,

Khirani

Khemani

et al. 2022

Thorax

View full text Add to dashboard Cite

This review aims to: (1) describe the rationale of pleural (PPL) and transpulmonary (PL) pressure measurements in children during mechanical ventilation (MV); (2) discuss its usefulness and limitations as a guide for protective MV; (3) propose future directions for paediatric research. We conducted a scoping review on PL in critically ill children using PubMed and Embase search engines. We included peer-reviewed studies using oesophageal (PES) and PL measurements in the paediatric intensive care unit (PICU) published until September 2021, and excluded studies in neonates and patients treated with non-invasive ventilation. PL corresponds to the difference between airway pressure and PPL. Oesophageal manometry allows measurement of PES, a good surrogate of PPL, to estimate PL directly at the bedside. Lung stress is the PL, while strain corresponds to the lung deformation induced by the changing volume during insufflation. Lung stress and strain are the main determinants of MV-related injuries with PL and PPL being key components. PL-targeted therapies allow tailoring of MV: (1) Positive end-expiratory pressure (PEEP) titration based on end-expiratory PL (direct measurement) may be used to avoid lung collapse in the lung surrounding the oesophagus. The clinical benefit of such strategy has not been demonstrated yet. This approach should consider the degree of recruitable lung, and may be limited to patients in which PEEP is set to achieve an end-expiratory PL value close to zero; (2) Protective ventilation based on end-inspiratory PL (derived from the ratio of lung and respiratory system elastances), might be used to limit overdistention and volutrauma by targeting lung stress values < 20–25 cmH2O; (3) PPL may be set to target a physiological respiratory effort in order to avoid both self-induced lung injury and ventilator-induced diaphragm dysfunction; (4) PPL or PL measurements may contribute to a better understanding of cardiopulmonary interactions. The growing cardiorespiratory system makes children theoretically more susceptible to atelectrauma, myotrauma and right ventricle failure. In children with acute respiratory distress, PPL and PL measurements may help to characterise how changes in PEEP affect PPL and potentially haemodynamics. In the PICU, PPL measurement to estimate respiratory effort is useful during weaning and ventilator liberation. Finally, the use of PPL tracings may improve the detection of patient ventilator asynchronies, which are frequent in children. Despite these numerous theoritcal benefits in children, PES measurement is rarely performed in routine paediatric practice. While the lack of robust clincal data partially explains this observation, important limitations of the existing methods to estimate PPL in children, such as their invasiveness and technical limitations, associated with the lack of reference values for lung and chest wall elastances may also play a role. PPL and PL monitoring have numerous potential clinical applications in the PICU to tailor protective MV, but its usefulness is counterbalanced by technical limitations. Paediatric evidence seems currently too weak to consider oesophageal manometry as a routine respiratory monitoring. The development and validation of a noninvasive estimation of PL and multimodal respiratory monitoring may be worth to be evaluated in the future.

show abstract

Section: Methodsmentioning

confidence: 99%

Pleural and transpulmonary pressures to tailor protective ventilation in children

Vedrenne-Cloquet¹,

Khirani

Khemani

et al. 2022

Thorax

View full text Add to dashboard Cite

show abstract

“…Additionally positive P ES values in some patients appear to not be "artifact" as some have claimed, but to actually be another valuable piece of clinical information that should not be ignored or discounted (20). Proper inflation (45), and balloon placement (46) are needed for correct interpretation, but these can be easily learned for proper implementation (47).…”

Section: Evidence Supporting Use Of the Actual Value Of P Esmentioning

confidence: 98%

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

Kassis¹,

Loring²,

Talmor³

2018

Ann. Transl. Med

View full text Add to dashboard Cite

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.

show abstract

Measuring Work of Breathing, Moving From Research to the Bedside?*

Pons-Òdena¹

2019

Pediatric Critical Care Medicine

View full text Add to dashboard Cite

Impact of physician education and availability of parameters regarding esophageal pressure and transpulmonary pressure on clinical decisions involving ventilator management

Cited by 4 publications

References 19 publications

Pleural and transpulmonary pressures to tailor protective ventilation in children

Pleural and transpulmonary pressures to tailor protective ventilation in children

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

Measuring Work of Breathing, Moving From Research to the Bedside?*

Contact Info

Product

Resources

About