Top

Published in:

01-11-2014 | Original

The assessment of transpulmonary pressure in mechanically ventilated ARDS patients

Authors: Davide Chiumello, Massimo Cressoni, Andrea Colombo, Giovanni Babini, Matteo Brioni, Francesco Crimella, Stefan Lundin, Ola Stenqvist, Luciano Gattinoni

Published in: Intensive Care Medicine | Issue 11/2014

Abstract

Purpose

The optimal method for estimating transpulmonary pressure (i.e. the fraction of the airway pressure transmitted to the lung) has not yet been established.

Methods

In this study on 44 patients with acute respiratory distress syndrome (ARDS), we computed the end-inspiratory transpulmonary pressure as the change in airway and esophageal pressure from end-inspiration to atmospheric pressure (i.e. release derived) and as the product of the end-inspiratory airway pressure and the ratio of lung to respiratory system elastance (i.e. elastance derived). The end-expiratory transpulmonary pressure was estimated as the product of positive end-expiratory pressure (PEEP) minus the direct measurement of esophageal pressure and by the release method.

Results

The mean elastance- and release-derived transpulmonary pressure were 14.4 ± 3.7 and 14.4 ± 3.8 cmH₂O at 5 cmH₂O of PEEP and 21.8 ± 5.1 and 21.8 ± 4.9 cmH₂O at 15 cmH₂O of PEEP, respectively (P = 0.32, P = 0.98, respectively), indicating that these parameters were significantly related (r ² = 0.98, P < 0.001 at 5 cmH₂O of PEEP; r ² = 0.93, P < 0.001 at 15 cmH₂O of PEEP). The percentage error was 5.6 and 12.0 %, respectively. The mean directly measured and release-derived transpulmonary pressure were −8.0 ± 3.8 and 3.9 ± 0.9 cmH₂O at 5 cmH₂O of PEEP and −1.2 ± 3.2 and 10.6 ± 2.2 cmH₂O at 15 cmH₂O of PEEP, respectively, indicating that these parameters were not related (r ² = 0.07, P = 0.08 at 5 cmH₂O of PEEP; r ² = 0.10, P = 0.53 at 15 cmH₂O of PEEP).

Conclusions

Based on our observations, elastance-derived transpulmonary pressure can be considered to be an adequate surrogate of the release-derived transpulmonary pressure, while the release-derived and directly measured end-expiratory transpulmonary pressure are not related.

Available only for authorised users

Gattinoni L, Chiumello D, Carlesso E et al (2004) Bench-to-bedside review: chest wall elastance in acute lung injury/acute respiratory distress syndrome patients. Crit Care 8:350–355PubMedCrossRefPubMedCentral

Grasso S, Mascia L, Del Turco M et al (2002) Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthesiology 96:795–802PubMedCrossRef

Ranieri VM, Brienza N, Santostasi S et al (1997) Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension. Am J Respir Crit Care Med 156:1082–1091PubMedCrossRef

Chiumello D, Carlesso E, Cadringher P et al (2008) Lung stress and strain during mechanical ventilation for acute respiratory distress syndrome. Am J Respir Crit Care Med 178:346–355PubMedCrossRef

De Prost N, Dreyfuss D (2012) How to prevent ventilator-induced lung injury? Minerva Anestesiol 78:1054–1066PubMed

Cherniak RM, Farhi LE, Armstrong BW et al (1955) A comparison of esophageal and intrapleural pressure in man. J Appl Physiol 8:203–211

Milic-Emili J, Mead J, Turner JM et al (1964) Improved technique for estimating pleural pressure from esophageal balloons. J Appl Physiol 19:207–211PubMed

Petit JM, Milic-Emili G (1958) Measurement of endoesophageal pressure. J Appl Physiol 13:481–485PubMed

Grasso S, Terragni P, Birocco A et al (2012) ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med 38:395–403PubMedCrossRef

10.

Staffieri F, Stripoli T, De M, V et al (2012) Physiological effects of an open lung ventilatory strategy titrated on elastance-derived end-inspiratory transpulmonary pressure: study in a pig model. Crit Care Med 40:2124–2131PubMedCrossRef

11.

Grasso S, Fanelli V, Cafarelli A et al (2005) Effects of high versus low positive end-expiratory pressures in acute respiratory distress syndrome. Am J Respir Crit Care Med 171:1002–1008PubMedCrossRef

12.

Krebs J, Pelosi P, Tsagogiorgas C et al (2009) Effects of positive end-expiratory pressure on respiratory function and hemodynamics in patients with acute respiratory failure with and without intra-abdominal hypertension: a pilot study. Crit Care 13:R160PubMedCrossRefPubMedCentral

13.

Kubiak BD, Gatto LA, Jimenez EJ et al (2010) Plateau and transpulmonary pressure with elevated intra-abdominal pressure or atelectasis. J Surg Res 159:e17–e24PubMedCrossRef

14.

Briel M, Meade M, Mercat A et al (2010) Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis. JAMA 303:865–873PubMedCrossRef

15.

Guerin C (2011) The preventive role of higher PEEP in treating severely hypoxemic ARDS. Minerva Anestesiol 77:835–845PubMed

16.

Talmor D, Sarge T, Malhotra A et al (2008) Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med 359:2095–2104PubMedCrossRefPubMedCentral

17.

Knowles John H, Hong Suk Ki, Rahn Hermann (1959) Possible errors using esophageal balloon in determination of pressure-volume characteristics of the lung and thoracic cage. J Appl Physiol 14:525–530

18.

Hedenstierna G (2012) Esophageal pressure: benefit and limitations. Minerva Anestesiol 78:959–966PubMed

19.

Talmor D, Sarge T, O’Donnell CR et al (2006) Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med 34:1389–1394PubMedCrossRefPubMedCentral

20.

Loring SH, O’Donnell CR, Behazin N et al (1985) (2010) Esophageal pressures in acute lung injury: do they represent artifact or useful information about transpulmonary pressure, chest wall mechanics, and lung stress? J Appl Physiol 108:515–522CrossRef

21.

Washko GR, O’Donnell CR (1985) Loring SH (2006) Volume-related and volume-independent effects of posture on esophageal and transpulmonary pressures in healthy subjects. J Appl Physiol 100:753–758CrossRef

22.

Ferguson ND, Fan E, Camporota L et al (2012) The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 38:1573–1582PubMedCrossRef

23.

Chiumello D, Cressoni M, Carlesso E et al (2014) Bedside selection of positive end-expiratory pressure in mild, moderate, and severe acute respiratory distress syndrome. Crit Care Med 42:252–264PubMedCrossRef

24.

Gattinoni L, Caironi P, Cressoni M et al (2006) Lung recruitment in patients with the acute respiratory distress syndrome. N Engl J Med 354:1775–1786PubMedCrossRef

25.

Pelosi P, Cereda M, Foti G et al (1995) Alterations of lung and chest wall mechanics in patients with acute lung injury: effects of positive end-expiratory pressure. Am J Respir Crit Care Med 152:531–537PubMedCrossRef

26.

Gattinoni L, Pesenti A, Bombino M et al (1988) Relationships between lung computed tomographic density, gas exchange, and PEEP in acute respiratory failure. Anesthesiology 69:824–832PubMedCrossRef

27.

Bland JM, Altman DG (1986) Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1:307–310PubMedCrossRef

28.

Critchley LA, Critchley JA (1999) A meta-analysis of studies using bias and precision statistics to compare cardiac output measurement techniques. J Clin Monit Comput 15:85–91PubMedCrossRef

29.

Terragni PP, Rosboch G, Tealdi A et al (2007) Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med 175:160–166PubMedCrossRef

30.

Higgs BD (1983) Measurement of pleural pressure with esophageal balloon in anesthetized humans. Anesthesiology 59:340–343PubMedCrossRef

31.

Buytendijk HJ (1949) Oesophagusdruk en longelasticiteit. PhD thesis, University of Groningen, Groningen

32.

Akoumianaki E, Maggiore SM, Valenza F et al (2014) The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med 189:520–531PubMedCrossRef

33.

Cortes I, Penuelas O, Esteban A (2012) Acute respiratory distress syndrome: evaluation and management. Minerva Anestesiol 78:343–357PubMed

34.

Dantzker DR, Brook CJ, Dehart P et al (1979) Ventilation-perfusion distributions in the adult respiratory distress syndrome. Am Rev Respir Dis 120:1039–1052PubMed

35.

de Chazal I, Hubmayr RD (2003) Novel aspects of pulmonary mechanics in intensive care. Br J Anaesth 91:81–91PubMedCrossRef

36.

Marini JJ, O’Quin R, Culver BH et al (1982) Estimation of transmural cardiac pressures during ventilation with PEEP. J Appl Physiol Respir Environ Exerc Physiol 53:384–391PubMed

37.

Pelosi P, Goldner M, McKibben A et al (2001) Recruitment and derecruitment during acute respiratory failure: an experimental study. Am J Respir Crit Care Med 164:122–130PubMedCrossRef

38.

Gillespie DJ (1973) Comparison of esophageal and pleural pressures in the anesthetized dog. J Appl Physiol 35:709–713PubMed

39.

Gulati G, Novero A, Loring SH et al (2013) Pleural pressure and optimal positive end-expiratory pressure based on esophageal pressure versus chest wall elastance: incompatible results. Crit Care Med 41:1951–1957PubMedCrossRef

40.

Guerin C, Richard JC (2012) Comparison of 2 correction methods for absolute values of esophageal pressure in subjects with acute hypoxemic respiratory failure, mechanically ventilated in the ICU. Respir Care 57:2045–2051PubMed

Title: The assessment of transpulmonary pressure in mechanically ventilated ARDS patients
Authors: Davide Chiumello
Massimo Cressoni
Andrea Colombo
Giovanni Babini
Matteo Brioni
Francesco Crimella
Stefan Lundin
Ola Stenqvist
Luciano Gattinoni
Publication date: 01-11-2014
Publisher: Springer Berlin Heidelberg
Published in: Intensive Care Medicine / Issue 11/2014
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-014-3415-4

Keynote webinar | Spotlight on medication adherence

Springer Medicine

The assessment of transpulmonary pressure in mechanically ventilated ARDS patients

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

Please log in to get access to this content

Other articles of this Issue 11/2014

Predictors of difficult intubation in ICU: are children and adults alike?

Prevalence, risk factors and consequences of severe burnout syndrome in ICU

The echographic “butterfly wing” aspect of the sphenoid bone is a critical landmark to insonate the middle cerebral artery

Mechanisms of the effects of prone positioning in acute respiratory distress syndrome

My paper 20 years later: effects of dobutamine on the VO2/DO2 relationship

Feasibility of bedside open lung biopsy in patients treated with extracorporeal membrane oxygenation