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跨肺压。 更好地了解呼吸系统力学指标

食道压 NutriVent 鼻饲管

内部见解。 食道压测量

食道压 (Pes) 测量是一种微创监测方法,我们可以通过它测定跨肺压。

最常用的 Pes 测量方法是使用与食道导管集成的气囊。

呼吸机显示屏显示食道压 (Pes) 及跨肺压 (Ptranspulm) 波形。 呼吸机显示屏显示食道压 (Pes) 及跨肺压 (Ptranspulm) 波形。

眼见为实! 显示屏上的 Pes 和跨肺压

将食道气囊导管连接至辅助端口并确认正确放置后,呼吸机显示屏显示食道压 (Pes) 及跨肺压 (Ptranspulm) 波形。

您可以采用吸气和呼气屏气操作测量静态 Ptranspulm。

医生和病人

通力合作! 评估肺的可复张性

为了评估肺复张性和执行肺复张操作,跨肺压还可与 P/V Tool® Pro 配合使用。

统计图:Talmor D. N Engl J Med.2008 Nov 13;359(20):2095-104

有哪些获益? 了解证据

  • 基于跨肺压的 PEEP 设置改善了 ARDS 病人的顺应性和氧合状态 (Talmor D, Sarge T, Malhotra A, et al.Mechanical ventilation guided by esophageal pressure in acute lung injury.N Engl J Med.2008;359(20):2095-2104. doi:10.1056/NEJMoa07086381​).
  • 目标正跨肺压可改善弹性和驱动压力,并可能与 28 天死亡率改善相关 (Baedorf Kassis E, Loring SH, Talmor D. Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS.Intensive Care Med.2016;42(8):1206-1213. doi:10.1007/s00134-016-4403-72​).
  • 跨肺压监测可避免对最严重病人使用 ECMO (Grasso S, Terragni P, Birocco A, et al.ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure.Intensive Care Med.2012;38(3):395-403. doi:10.1007/s00134-012-2490-73​).
  • 跨肺压导向的通气策略可增加严重 ARDS 病人成功撤离 ECMO 的几率 (Wang R, Sun B, Li X, et al.Mechanical Ventilation Strategy Guided by Transpulmonary Pressure in Severe Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation.Crit Care Med.2020;48(9):1280-1288. doi:10.1097/CCM.00000000000044454​)。
  • Pes 测量是评估呼吸努力和呼吸做功的金标准技术 (Bertoni M, Spadaro S, Goligher EC.Monitoring Patient Respiratory Effort During Mechanical Ventilation: Lung and Diaphragm-Protective Ventilation.Crit Care.2020;24(1):106.Published 2020 Mar 24. doi:10.1186/s13054-020-2777-y5​).
图:手持证书的学生

不可不知! 跨肺压培训资源

Watch this short demonstration to learn how to use transpulmonary pressure measurement to set PEEP in mechanically ventilated patients more accurately.

如何利用跨肺压 设置 PEEP

观看这段短片演示,了解如何利用跨肺压监测更准确地设置 PEEP。

电子书 13 条专家建议

免费电子书

13 条专家建议。 食道压测量

关于在 ARDS 病人中使用食道压力时应该做什么和应该避免什么的临床验证的建议。

耗材

我们提供 Cooper Surgical 食道气囊导管和 NutriVent 鼻饲管。

可用性

跨肺压监测是 HAMILTON-C6 和 HAMILTON-G5/S1 呼吸机上的一个标准功能。

Mechanical ventilation guided by esophageal pressure in acute lung injury.

Talmor D, Sarge T, Malhotra A, et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. N Engl J Med. 2008;359(20):2095-2104. doi:10.1056/NEJMoa0708638



BACKGROUND

Survival of patients with acute lung injury or the acute respiratory distress syndrome (ARDS) has been improved by ventilation with small tidal volumes and the use of positive end-expiratory pressure (PEEP); however, the optimal level of PEEP has been difficult to determine. In this pilot study, we estimated transpulmonary pressure with the use of esophageal balloon catheters. We reasoned that the use of pleural-pressure measurements, despite the technical limitations to the accuracy of such measurements, would enable us to find a PEEP value that could maintain oxygenation while preventing lung injury due to repeated alveolar collapse or overdistention.

METHODS

We randomly assigned patients with acute lung injury or ARDS to undergo mechanical ventilation with PEEP adjusted according to measurements of esophageal pressure (the esophageal-pressure-guided group) or according to the Acute Respiratory Distress Syndrome Network standard-of-care recommendations (the control group). The primary end point was improvement in oxygenation. The secondary end points included respiratory-system compliance and patient outcomes.

RESULTS

The study reached its stopping criterion and was terminated after 61 patients had been enrolled. The ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen at 72 hours was 88 mm Hg higher in the esophageal-pressure-guided group than in the control group (95% confidence interval, 78.1 to 98.3; P=0.002). This effect was persistent over the entire follow-up time (at 24, 48, and 72 hours; P=0.001 by repeated-measures analysis of variance). Respiratory-system compliance was also significantly better at 24, 48, and 72 hours in the esophageal-pressure-guided group (P=0.01 by repeated-measures analysis of variance).

CONCLUSIONS

As compared with the current standard of care, a ventilator strategy using esophageal pressures to estimate the transpulmonary pressure significantly improves oxygenation and compliance. Multicenter clinical trials are needed to determine whether this approach should be widely adopted. (ClinicalTrials.gov number, NCT00127491.)

Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS.

Baedorf Kassis E, Loring SH, Talmor D. Mortality and pulmonary mechanics in relation to respiratory system and transpulmonary driving pressures in ARDS. Intensive Care Med. 2016;42(8):1206-1213. doi:10.1007/s00134-016-4403-7



PURPOSE

The driving pressure of the respiratory system has been shown to strongly correlate with mortality in a recent large retrospective ARDSnet study. Respiratory system driving pressure [plateau pressure-positive end-expiratory pressure (PEEP)] does not account for variable chest wall compliance. Esophageal manometry can be utilized to determine transpulmonary driving pressure. We have examined the relationships between respiratory system and transpulmonary driving pressure, pulmonary mechanics and 28-day mortality.

METHODS

Fifty-six patients from a previous study were analyzed to compare PEEP titration to maintain positive transpulmonary end-expiratory pressure to a control protocol. Respiratory system and transpulmonary driving pressures and pulmonary mechanics were examined at baseline, 5 min and 24 h. Analysis of variance and linear regression were used to compare 28 day survivors versus non-survivors and the intervention group versus the control group, respectively.

RESULTS

At baseline and 5 min there was no difference in respiratory system or transpulmonary driving pressure. By 24 h, survivors had lower respiratory system and transpulmonary driving pressures. Similarly, by 24 h the intervention group had lower transpulmonary driving pressure. This decrease was explained by improved elastance and increased PEEP.

CONCLUSIONS

The results suggest that utilizing PEEP titration to target positive transpulmonary pressure via esophageal manometry causes both improved elastance and driving pressures. Treatment strategies leading to decreased respiratory system and transpulmonary driving pressure at 24 h may be associated with improved 28 day mortality. Studies to clarify the role of respiratory system and transpulmonary driving pressures as a prognosticator and bedside ventilator target are warranted.

ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure.

Grasso S, Terragni P, Birocco A, et al. ECMO criteria for influenza A (H1N1)-associated ARDS: role of transpulmonary pressure. Intensive Care Med. 2012;38(3):395-403. doi:10.1007/s00134-012-2490-7



PURPOSE

To assess whether partitioning the elastance of the respiratory system (E (RS)) between lung (E (L)) and chest wall (E (CW)) elastance in order to target values of end-inspiratory transpulmonary pressure (PPLAT(L)) close to its upper physiological limit (25 cmH(2)O) may optimize oxygenation allowing conventional treatment in patients with influenza A (H1N1)-associated ARDS referred for extracorporeal membrane oxygenation (ECMO).

METHODS

Prospective data collection of patients with influenza A (H1N1)-associated ARDS referred for ECMO (October 2009-January 2010). Esophageal pressure was used to (a) partition respiratory mechanics between lung and chest wall, (b) titrate positive end-expiratory pressure (PEEP) to target the upper physiological limit of PPLAT(L) (25 cmH(2)O).

RESULTS

Fourteen patients were referred for ECMO. In seven patients PPLAT(L) was 27.2 ± 1.2 cmH(2)O; all these patients underwent ECMO. In the other seven patients, PPLAT(L) was 16.6 ± 2.9 cmH(2)O. Raising PEEP (from 17.9 ± 1.2 to 22.3 ± 1.4 cmH(2)O, P = 0.0001) to approach the upper physiological limit of transpulmonary pressure (PPLAT(L) = 25.3 ± 1.7 cm H(2)O) improved oxygenation index (from 37.4 ± 3.7 to 16.5 ± 1.4, P = 0.0001) allowing patients to be treated with conventional ventilation.

CONCLUSIONS

Abnormalities of chest wall mechanics may be present in some patients with influenza A (H1N1)-associated ARDS. These abnormalities may not be inferred from measurements of end-inspiratory plateau pressure of the respiratory system (PPLAT(RS)). In these patients, titrating PEEP to PPLAT(RS) may overestimate the incidence of hypoxemia refractory to conventional ventilation leading to inappropriate use of ECMO.

Mechanical Ventilation Strategy Guided by Transpulmonary Pressure in Severe Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation.

Wang R, Sun B, Li X, et al. Mechanical Ventilation Strategy Guided by Transpulmonary Pressure in Severe Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation. Crit Care Med. 2020;48(9):1280-1288. doi:10.1097/CCM.0000000000004445



OBJECTIVES

Previous studies have suggested that adjusting ventilator settings based on transpulmonary pressure measurements may minimize ventilator-induced lung injury, but this has never been investigated in patients with severe acute respiratory distress syndrome supported with venovenous extracorporeal membrane oxygenation. We aimed to evaluate whether a transpulmonary pressure-guided ventilation strategy would increase the proportion of patients successfully weaned from venovenous extracorporeal membrane oxygenation support in patients with severe acute respiratory distress syndrome.

DESIGN

Single-center, prospective, randomized controlled trial.

SETTING

Sixteen-bed, respiratory ICU at a tertiary academic medical center.

PATIENTS

Severe acute respiratory distress syndrome patients receiving venovenous extracorporeal membrane oxygenation.

INTERVENTIONS

One-hundred four patients were randomized to transpulmonary pressure-guided ventilation group (n = 52) or lung rest strategy group (n = 52) groups. Two patients had cardiac arrest during establishment of venovenous extracorporeal membrane oxygenation in the lung rest group did not receive the assigned intervention. Thus, 102 patients were included in the analysis.

MEASUREMENTS AND MAIN RESULTS

The proportion of patients successfully weaned from venovenous extracorporeal membrane oxygenation in the transpulmonary pressure-guided group was significantly higher than that in the lung rest group (71.2% vs 48.0%; p = 0.017). Compared with the lung rest group, driving pressure, tidal volumes, and mechanical power were significantly lower, and positive end-expiratory pressure was significantly higher, in the transpulmonary pressure-guided group during venovenous extracorporeal membrane oxygenation support. In the transpulmonary pressure-guided group, levels of interleukin-1β, interleukin-6, and interleukin-8 were significantly lower, and interleukin-10 was significantly higher, than those of the lung rest group over time. Lung density was significantly lower in the transpulmonary pressure-guided group after venovenous extracorporeal membrane oxygenation support than in the lung rest group.

CONCLUSIONS

A transpulmonary pressure-guided ventilation strategy could increase the proportion of patients with severe acute respiratory distress syndrome successfully weaned from venovenous extracorporeal membrane oxygenation.

Monitoring Patient Respiratory Effort During Mechanical Ventilation: Lung and Diaphragm-Protective Ventilation.

Bertoni M, Spadaro S, Goligher EC. Monitoring Patient Respiratory Effort During Mechanical Ventilation: Lung and Diaphragm-Protective Ventilation. Crit Care. 2020;24(1):106. Published 2020 Mar 24. doi:10.1186/s13054-020-2777-y

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2020. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2020. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.