Should we titrate positive end-expiratory pressure based on an end-expiratory transpulmonary pressure?

Marini, John J.

doi:10.21037/atm.2018.08.22

Cited by 7 publications

(7 citation statements)

References 49 publications

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“…Although there is a general agreement on the reduction of tidal volume, plateau pressure, and driving pressure as key objectives of pulmonary care [ 2 ], the most adequate way to determine positive end-expiratory pressure is still debated, as it has been for decades [ 11 ].…”

Section: Discussionmentioning

confidence: 99%

An assessment of esophageal balloon use for the titration of airway pressure release ventilation and controlled mechanical ventilation in a patient with extrapulmonary acute respiratory distress syndrome: a case report

et al. 2021

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Background Esophageal pressure measurement is a minimally invasive monitoring process that assesses respiratory mechanics in patients with acute respiratory distress syndrome. Airway pressure release ventilation is a relatively new positive pressure ventilation modality, characterized by a series of advantages in patients with acute respiratory distress syndrome. Case presentation We report a case of a 55-year-old chilean female, with preexisting hypertension and recurrent renal colic who entered the cardiosurgical intensive care unit with signs and symptoms of urinary sepsis secondary to a right-sided obstructive urolithiasis. At the time of admission, the patient showed signs of urinary sepsis, a poor overall condition, hemodynamic instability, tachycardia, hypotension, and needed vasoactive drugs. Initially the patient was treated with volume control ventilation. Then, ventilation was with conventional ventilation parameters described by the Acute Respiratory Distress Syndrome Network. However, hemodynamic complications led to reduced airway pressure. Later she presented intraabdominal hypertension that compromised the oxygen supply and her ventilation management. Considering these records, an esophageal manometry was used to measure distending lung pressure, that is, transpulmonary pressure, to protect lungs. Initial use of the esophageal balloon was in a volume-controlled modality (deep sedation), which allowed the medical team to perform inspiratory and expiratory pause maneuvers to monitor transpulmonary plateau pressure as a substitute for pulmonary distension and expiratory pause and determine transpulmonary positive end-expiratory pressure. On the third day of mechanical respiration, the modality was switched to airway pressure release ventilation. The use of airway pressure release ventilation was associated with reduced hemodynamic complications and kept transpulmonary pressure between 0 and 20 cmH2O despite a sustained high positive end-expiratory pressure of 20 cmH2O. Conclusion The application of this technique is shown in airway pressure release ventilation with spontaneous ventilation, which is then compared with a controlled modality that requires a lesser number of sedative doses and vasoactive drugs, without altering the criteria for lung protection as guided by esophageal manometry.

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Section: Discussionmentioning

confidence: 99%

An assessment of esophageal balloon use for the titration of airway pressure release ventilation and controlled mechanical ventilation in a patient with extrapulmonary acute respiratory distress syndrome: a case report

et al. 2021

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“…7 The target recruitment pressure of 30 reached 0 cm H 2 O, assuming that dependent lung atelectasis starts to develop at negative values. [27][28][29] Baseline ventilation was then restarted with the optimized PEEP. Those patients without evidence of atelectasis (negative Air-Test and end-expiratory transpulmonary pressure 0 cm H 2 O or greater) continued to be ventilated using baseline settings.…”

Section: Protocol Design and Data Managementmentioning

confidence: 99%

Effect of an Individualized Lung Protective Ventilation on Lung Strain and Stress in Children Undergoing Laparoscopy: An Observational Cohort Study

Acosta,

Poliotto,

Abrego

et al. 2023

Anesthesiology

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Background Exaggerated lung strain and stress could damage lungs in anesthetized children. We hypothesized that the association of capnoperitoneum and lung collapse in anesthetized children increases lung strain-stress. Our primary aim was to describe the impact of capnoperitoneum on lung strain-stress and the effects of an individualized protective ventilation during laparoscopic surgery in children. Methods We performed an observational cohort study in healthy children aged 3-7 years scheduled for laparoscopic surgery in a community hospital. All received standard protective ventilation with 5 cmH2O of positive end-expiratory pressure (PEEP). Children were evaluated before capnoperitoneum (pre-CP), during capnoperitoneum (CP) prior and after lung recruitment and optimized PEEP [PEEP adjusted to get end-expiratory transpulmonary pressure of zero = CP-PEEPopt], and after capnoperitoneum with optimized PEEP (post-CP). The presence of lung collapse was evaluated by lung ultrasound, positive Air-Test (SpO2 ≤96% breathing 21% O2 for 5 minutes), and negative end-expiratory transpulmonary pressure. Lung strain was calculated as tidal volume/end-expiratory lung volume measured by capnodynamics, and lung stress as the end-inspiratory transpulmonary pressure. Results We studied twenty children. At pre-CP, mean lung strain was 0.20±0.07 (95%CI 0.17-0.23) and stress was 5.68±2.83 (95%CI 4.44-6.92) cmH2O. During CP, eighteen patients presented lung collapse and strain (0.29±0.13, 95%CI 0.23-0.35; p<0.001) and stress (5.92±3.18, 95%CI 4.53-7.31 cmH2O; p=0.374) increased compared to pre-CP. During CP-PEEPopt, children presenting lung collapse were recruited and optimized PEEP was 8.3±2.2 (95% CI 7.3-9.3) cmH2O. Strain returned to pre-CP values (0.20±0.07, 95%CI 0.17-0.22; p=0.318) but lung stress increased (7.29±2.67, 95% CI 6.12-8.46) cmH2O (p=0.020). At post-CP strain decreased (0.18±0.04, 95% CI 0.16-0.20; p=0.090) but stress remained higher (7.25±3.01, 95% CI 5.92-8.57 cmH2O; p=0.024) compared to pre-CP. Conclusion Capnoperitoneum increased lung strain in healthy children undergoing laparoscopy. Lung recruitment and optimized PEEP during capnoperitoneum decreased lung strain but slightly increased lung stress. This little rise in pulmonary stress was maintained within safe, lung protective and clinically acceptable limits.

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“…Stepwise staircase recruitment maneuver may allow better oxygenation and less haemodynamic instability than sustained inflation one. However, the optimal RM (with the best balance of benefit and harm) is still under discussion [5].…”

Section: Introductionmentioning

confidence: 99%

Efficacy of transalveolar pressure measurement as a monitoring parameter for lung recruitment in postcardiac surgery hypoxic patients

Ibrahim

Ahmed

Sabry

et al. 2021

Egyptian Journal of Anaesthesia

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Background: Lung atelectasis is a common complication post-cardiac surgery that can affect patient's outcomes significantly. The current study aimed to evaluate the efficacy of transalveolar pressure measurement (PTA) using esophageal manometer as a monitoring parameter during a modified stepwise staircase lung recruitment employing adaptive ventilation mode (AVM) in postcardiac surgery hypoxic patients. Settings and Design: This study was a prospective case series study. Methods: The study was carried out on 62 adult patients who were undergone on-pump cardiac surgeries. After haemodynamic stabilization of the patient in ICU, esophageal manometer catheter had been inserted then a modified stepwise staircase alveolar recruitment maneuver was done with the use of the transalveolar pressure as the main parameter for the monitoring of the effectiveness and safety of the recruitment maneuver. Agreement between parameters was done and weighted kappa, standard error and confidence intervals at 95% (95% CI) were calculated. Results: During the alveolar recruitment maneuver, the PTA Insp detected 96.7% of the patients with alveolar overdistention and the PTA Exp detected 98.3% of the patients with alveolar optimum PEEP. Statistical significant improvement in both hypoxic index and ultrasound lung aeration score from before to after alveolar recruitment. Conclusion: Transalveolar pressure inspiratory and expiratory were accurate monitoring parameters for alveolar overdistention and optimum PEEP detection selectively.

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Should we titrate positive end-expiratory pressure based on an end-expiratory transpulmonary pressure?

Cited by 7 publications

References 49 publications

An assessment of esophageal balloon use for the titration of airway pressure release ventilation and controlled mechanical ventilation in a patient with extrapulmonary acute respiratory distress syndrome: a case report

An assessment of esophageal balloon use for the titration of airway pressure release ventilation and controlled mechanical ventilation in a patient with extrapulmonary acute respiratory distress syndrome: a case report

Effect of an Individualized Lung Protective Ventilation on Lung Strain and Stress in Children Undergoing Laparoscopy: An Observational Cohort Study

Efficacy of transalveolar pressure measurement as a monitoring parameter for lung recruitment in postcardiac surgery hypoxic patients

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