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TRANSCRIPT
Transpulmonary pressure…
mislead by esophageal pressure ?
Marcelo B. P. Amato
University of São Paulo, Brazil
Critical Care Canadian Forum
CCCF, Toronto, November 2013
I disclose the following financial relationships with commercial entities that produce healthcare-related products or services relevant to the content I am presenting:
Company Relationship Content Area
Covidien Consultant Mechanical Ventilation
Philips / Dixtal Research grants E.I.T.
Conflict of Interest Disclosure
Marcelo B.P. Amato
-20
-15
-10
-5
0
5
0 0.5 1
Pes
Ppl
-20
-15
-10
-5
0
5
0 0.5 1
Pes
Ppl
Non-dependent (left b) Dependent (left D6)
• low PSV • strong effort
Pressure sensor: 1.2cm disk
Diaphragm (inner surface: the view from inside the thorax)
The dependent lung
Original Article
Mechanical Ventilation Guided by Esophageal Pressure in Acute Lung Injury
Daniel Talmor, M.D., M.P.H., Todd Sarge, M.D., Atul Malhotra, M.D., Carl R. O'Donnell, Sc.D., M.P.H., Ray Ritz, R.R.T., Alan Lisbon, M.D., Victor Novack, M.D., Ph.D., and
Stephen H. Loring, M.D.
N Engl J MedVolume 359(20):2095-2104
November 13, 2008
Chiu
mello
et a
l.
S. Loring et al.
15 !
Getting more information
Introducing noise
X
sensor
sensor sensor
C balloon = ?
sensor sensor
C balloon = ?
sensor
C balloon = ?
C esophagus = ?
Pes catheter
Collapse:
55.6 %
Patient # 9
Pneumocystis
carinii pneumonia
FIO2 = 100 %; VT = 4 mL/kg; PEEP = 5 cmH2O
FIO2 = 100 %; VT = 4 mL/kg; PEEP = 25 cmH2O
( after recruitment maneuver )
Collapse:
0.9 %
Patient # 9
Pneumocystis
carinii pneumonia
PplPpl
NON-DEPENDENT
PplPpl
MIDDLE
Ppl
DEPENDENT
Ppl
LOCAL TRANSPULMONARY PRESSURE MEASUREMENT
CHEST-WALL P-V CURVES(super-syringe)
PLEURAL PRESSURES (cmH2O)
0 4 8 12 16 20
VO
LU
ME
(ple
thysm
ogra
ph
- m
L)
0
300
600
900
1200
1500
1800
Normal
CHEST-WALL P-V CURVES(super-syringe)
PLEURAL PRESSURES (cmH2O)
0 4 8 12 16 20
VO
LU
ME
(ple
thysm
ogra
ph
- m
L)
0
300
600
900
1200
1500
1800
Injury
CHEST-WALL P-V CURVES(super-syringe)
PLEURAL PRESSURES (cmH2O)
0 4 8 12 16 20
VO
LU
ME
(ple
thysm
ogra
ph
- m
L)
0
300
600
900
1200
1500
1800
Pes
CHEST-WALL P-V CURVES(super-syringe)
PLEURAL PRESSURES (cmH2O)
0 4 8 12 16 20
VO
LU
ME
(ple
thysm
ogra
ph
- m
L)
0
300
600
900
1200
1500
1800
Slope: 0.91
0
5
10
15
20
25
30
0 5 10 15 20 25 30
20
10
0
-10
20
10
0
-10
Airway pressure
(cmH2O)
Pleural pressure
(cmH2O)
Occlusion test Tube clamp
at the end of expiration
∆ Airway pressure
(cmH2O)
∆ Pleural pressure
(cmH2O)
BA
Pes as a surrogate for Ppl
Baydur A. Am Rev Respir Dis 1982;126:788
∆Ppl: -10cmH2O
-10-10-10
-10
-10
-10
-10
-10-10
-10
Diaphragmatic contraction
diaphragmatic contraction uniformly lowers Ppl
at all points on the lung surface
Apical:
3th ICS
Basal:
8-9th ICS
Collapse:
55.6 %
Patient # 9
Pneumocystis
carinii pneumonia
FIO2 = 100 %; VT = 4 mL/kg; PEEP = 5 cmH2O
sensor sensor
C balloon = ?
sensor
C balloon = ?
C esophagus = ?
Protti & Gattinoni - 2011 - AJRCCM - Lung stress and
strain during mechanical ventilation - any safe limit ?
Talmor et al.- 2008 - NEJM
S. Loring.- 2011 - JAP
Balloon volume (mL of room air )
Esophageal p
ressure
(end-e
xpiratio
n)
Signal
Noise
Balloon volume (mL of room air )
∆ E
sophageal p
ressure
60%
PEEP (cmH2O)
Com
pla
ince
Chest-
Wall
60%
Getting more information
Introducing noise
X
P or PTP ?
( PAW - Pesoph )
c
Lung
Str
ain
0.5
1.0
1.5
2.0
2.5
3.0S
trai
n
No-VILI VILI
Pla
teau
pre
ssure
10
20
30
40
50D
rivi
ngpr
ess
ure
No-VILI VILI
Injury!!∆
PA
W-∆
PE
soph
Injury!!∆
PA
W
Note that,
↑ Offset in Pleural press.
↓ Chest-wallCompliance≠
35 cmH O2
P = p l
15
Transpulmonary:
20 cmH O2
P = p l
-5
35 cmH O2
Transpulmonary:
40 cmH O2
P
PL
P
35 cmH O2
P = p l
15
Transpulmonary:
20 cmH O2
P = p l
-5
35 cmH O2
Transpulmonary:
40 cmH O2
??
…Chest-Wall compliance during anesthesia
was comparable to that measured in
non-obese, healthy subjects…
…This may be surprising, bearing in mind
the voluminous fat layers over chest
and abdomen…
…Thus, a weight placed on the rib-cage
does not affect chest-wall compliance,
but simply displaces the pressure-volume
relationship towards higher pressures…
EPVENT
+ 4.3 cmH2O above average ( P < 0.001)
Alveoli ARDSnet Express LOVS
Pla
teau
pre
ssu
re
EPVENT
Alveoli ARDSnet Express LOVS
Dri
vin
gp
ress
ure
DR
IVIN
G-P
RE
SS
UR
E
(cm
H2O
)
Body-Mass Index
High PEEP studies; N = 2259 pts.
R2 = 0.00
Thank you!
Collapse:
55.6 %
Patient # 9
Pneumocystis
carinii pneumonia
FIO2 = 100 %; VT = 4 mL/kg; PEEP = 5 cmH2O
FIO2 = 100 %; VT = 4 mL/kg; PEEP = 25 cmH2O
( after recruitment maneuver )
Collapse:
0.9 %
Patient # 9
Pneumocystis
carinii pneumonia
sensor sensor
C balloon = ?
sensor
C balloon = ?
C esophagus = ?