Transpulmonary pressure monitoring during mechanical ventilation: a bench-to-bedside review

Different ventilation strategies have been suggested in the past in patients with acute respiratory distress syndrome(ARDS). Airway pressure monitoring alone is inadequate to assure optimal ventilatory support in ARDS patients. Theassessment of transpulmonary pressure (PTP) can help clinicians to tailor mechanical ventilation to the individualpatient needs. Transpulmonary pressure monitoring, defined as airway pressure (Paw) minus intrathoracic pressure(ITP), provides essential information about chest wall mechanics and its effects on the respiratory system and lungmechanics. The positioning of an esophageal catheter is required to measure the esophageal pressure (Peso), which isclinically used as a surrogate for ITP or pleural pressure (Ppl), and calculates the transpulmonary pressure. The benefitsof such a ventilation approach are avoiding excessive lung stress and individualizing the positive end-expiratory pressure (PEEP) setting. The aim is to prevent over-distention of alveoli and the cyclic recruitment/derecruitment or shear stress of lung parenchyma, mechanisms associated with ventilator-induced lung injury (VILI). Knowledge of the real lung distending pressure, i.e. the transpulmonary pressure, has shown to be useful in both controlled and assistedmechanical ventilation. In the latter ventilator modes, Peso measurement allows one to assess a patient’s respiratoryeffort, patient-ventilator asynchrony, intrinsic PEEP and the calculation of work of breathing. Conditions that havean impact on Peso, such as abdominal hypertension, will also be discussed briefly.Different ventilation strategies have been suggested in the past in patients with acute respiratory distress syndrome(ARDS). Airway pressure monitoring alone is inadequate to assure optimal ventilatory support in ARDS patients. Theassessment of transpulmonary pressure (PTP) can help clinicians to tailor mechanical ventilation to the individualpatient needs. Transpulmonary pressure monitoring, defined as airway pressure (Paw) minus intrathoracic pressure(ITP), provides essential information about chest wall mechanics and its effects on the respiratory system and lungmechanics. The positioning of an esophageal catheter is required to measure the esophageal pressure (Peso), which isclinically used as a surrogate for ITP or pleural pressure (Ppl), and calculates the transpulmonary pressure. The benefitsof such a ventilation approach are avoiding excessive lung stress and individualizing the positive end-expiratory pressure (PEEP) setting. The aim is to prevent over-distention of alveoli and the cyclic recruitment/derecruitment or shear stress of lung parenchyma, mechanisms associated with ventilator-induced lung injury (VILI). Knowledge of the real lung distending pressure, i.e. the transpulmonary pressure, has shown to be useful in both controlled and assistedmechanical ventilation. In the latter ventilator modes, Peso measurement allows one to assess a patient’s respiratoryeffort, patient-ventilator asynchrony, intrinsic PEEP and the calculation of work of breathing. Conditions that havean impact on Peso, such as abdominal hypertension, will also be discussed briefly