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Critical Care Medicine:
doi: 10.1097/CCM.0b013e31828a3de5
Clinical Investigations

Pleural Pressure and Optimal Positive End-Expiratory Pressure Based on Esophageal Pressure Versus Chest Wall Elastance: Incompatible Results*

Gulati, Gaurav AB; Novero, Aileen BA; Loring, Stephen H. MD; Talmor, Daniel MD, MPH

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Abstract

Objectives:

1) To compare two published methods for estimating pleural pressure, one based on directly measured esophageal pressure and the other based on chest wall elastance. 2) To evaluate the agreement between two published positive end-expiratory pressure optimization strategies based on these methods, one targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H2O and the other targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H2O.

Design:

Retrospective study using clinical data.

Setting:

Medical and surgical ICUs.

Patients:

Sixty-four patients mechanically ventilated for acute respiratory failure with esophageal balloons placed for clinical management.

Methods:

Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure and setting positive end-expiratory pressure were retrospectively applied to each of the 64 patients. In patients who were ventilated at two positive end-expiratory pressure levels, chest wall and respiratory system elastances were calculated at each positive end-expiratory pressure level.

Measurements and Main Results:

The pleural pressure estimates using both methods were discordant and differed by as much as 10 cm H2O for a given patient. The two positive end-expiratory pressure optimization strategies recommended positive end-expiratory pressure changes in opposite directions in 33% of patients. The ideal positive end-expiratory pressure levels recommended by the two methods for each patient were discordant and uncorrelated (R2 = 0.05). Chest wall and respiratory system elastances grew with increases in positive end-expiratory pressure in patients with positive end-expiratory esophageal pressure-based transpulmonary pressures (p < 0.05).

Conclusions:

Esophageal pressure and chest wall elastance-based methods for estimating pleural pressure do not yield similar results. The strategies of targeting an end-expiratory esophageal pressure-based transpulmonary pressure of 0 cm H2O and targeting an end-inspiratory elastance-based transpulmonary pressure of 26 cm H2O cannot be considered interchangeable. Finally, chest wall and respiratory system elastances may vary unpredictably with changes in positive end-expiratory pressure.

Copyright © 2013 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins

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