tranpulmonary pressure: why & how esophageal pressure€¦ · agostoni, mead, weibel, gattinoni...
TRANSCRIPT
![Page 1: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/1.jpg)
Tranpulmonary pressure:
Why & How Esophageal
pressure
Luciano Gattinoni, MD, FRCP
Università di Milano
Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico
Milan, Italy
2013, Toronto
![Page 2: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/2.jpg)
How the
pleural
pressure is
generated
![Page 3: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/3.jpg)
Volume (mL)
0 1000 2000 3000 4000 5000 6000
Ple
ura
l P
ress
ure
(cm
H2
O)
-30
-20
-10
0
10
20
Lung
Chest Wall
FRC
GaslessLung
Chest WallVolume
w/o Lung
Generation of pleural pressure
![Page 4: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/4.jpg)
Level
1
2
3
4
5
6
7
8
9
10
Ventral
Dorsal
Ppl G/T
![Page 5: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/5.jpg)
How to
measure the
pleural
pressure
![Page 6: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/6.jpg)
Bo WJ, Wolfman NT, Krueger WA, Meschan I. 1990.
Basic Atlas of Sectional Anatomy with Correlated Imaging. 2nd edition; WB Saunders Co. page 99
Anatomical section of a frozen cadaver between the thoracic vertebra 8 and 9
![Page 7: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/7.jpg)
Esophageal and gastric baloon
![Page 8: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/8.jpg)
PES (cmH2O)
Pp
l (c
mH
2O)
PES and Ppl
6 dogs,oleic acid
Pelosi et al. Am J Respir Crit Care Med pp 122-130, 2001
5 10 15 20-50
-5
5
10
15
20
Inspiratory
Expiratory
Ppl1 Non dependent
Ppl3dependent
middlePpl2
![Page 9: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/9.jpg)
Pleural
pressure and
mechanical
ventilation
![Page 10: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/10.jpg)
Chest wall elastance
EtotEtot
cmH2O
StiffStiff
2525
LEEL
“Soft”“Soft”
EwEw
55
StiffStiff
1515
EwEw
“Soft”“Soft”
1515
LEEL
EtottotE
![Page 11: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/11.jpg)
ΔPAW = ΔPL +ΔPpl
Driving
pressure
Drives
the lung
Drives
the chest
wall
Therefore…
![Page 12: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/12.jpg)
It follows that:
EW/ETOT = (ΔPpl/ΔV) * (ΔV/ΔPAW) = ΔPpl/ΔPAW
ΔPpl = ΔPAW * EW/ETOT
Mechanical ventilation
ΔPL = ΔPAW * EL/ETOT
![Page 13: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/13.jpg)
Airway plateau pressure (cmH2O)
0 10 20 30 40 50 60
0
10
20
30
40
50
60
Airway plateau pressure (cmH2O)
0 10 20 30 40 50 60T
ranspulm
ona
ry p
late
au p
ressue (
cm
H2O
)
0
10
20
30
40
50
60
A
Surgical control group
Medical control group ARDS patients
ALI patients
B
Chiumello et al, Am J Respir Crit Care Med. 2008
![Page 14: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/14.jpg)
Strain (dVgas/Vgas0)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Str
ess
(PL
, cm
H2
O)
0
5
10
15
20
25
30
35
40
45
50
55
Stress-strain curve of healthy pigs
Specific Lung
Elastance
5.8 cmH2O
Protti A. et al. Am J Respir Crit Care Med. 2011 Feb 4.
![Page 15: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/15.jpg)
Transpulmonary pressure (PL cmH2O)
0 4 8 12 16 20 24 28 32 36 40
40
50
60
70
80
90
100
%To
tal
Lu
ng
Ca
pacit
y
0.0
1.0
2.0
Resting Biotrauma Stress at rupture
Agostoni,
Mead, Weibel,
Gattinoni
Specific Lung Elastance
12 (cmH2O)
1.5
0.5
Strain
1 2 3
![Page 16: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/16.jpg)
Airway Pressure (cmH2O)
0 5 10 15 20 25 30 35 40 45 50
Ple
ura
l P
ress
ure
(cm
H2
O)
0
5
10
15
20
25
30
35
40
45
50
0.2
0.33
0.5
0.8
24
20.1
15
6
PL (cmH
2O) E
W/E
TOT
Mechanical ventilation
![Page 17: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/17.jpg)
Pleural
pressure and
spontaneous
breathing
![Page 18: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/18.jpg)
-ΔPmusc = ΔPW +ΔPpl
Driving
pressure
Drives
the chest
wall
Drives
the lung
Spontaneous breathing
![Page 19: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/19.jpg)
-ΔPmusc = ΔPW +ΔPpl
-ΔPmusc = -ΔPmusc*EW/ETOT +ΔPpl
ΔPpl = -ΔPmusc*(1-EW/ETOT )
ΔPpl = -ΔPmusc*EL/ETOT
Spontaneous breathing
![Page 20: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/20.jpg)
Airway Pressure (cmH2O)
0 5 10 15 20 25 30 35 40 45 50
Ple
ura
l P
ress
ure
(cm
H2
O)
-50
-45
-40
-35
-30
-25
-20
-15
-10
-5
0
0.8
0.67
0.5
0.2
24
20.1
15
6
PL (cmH
2O) EL/E
TOT
Spontaneous breathing
Muscular Pressure (cmH2O)
![Page 21: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/21.jpg)
Mechanical
Ventilation
Spontaneous
Breathing
Driving Pressure
Lung Motor
Chest Wall Motor
Paw Pmusc
PL Ppl
Ppl Pmusc – Ppl = PW
![Page 22: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/22.jpg)
Pleural pressure
during
spontaneous
breathing and
mechanical
ventilation
![Page 23: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/23.jpg)
Mixed ventilation
ΔPpl = ΔPAW * EW/ETOT -ΔPmusc*EL/ETOT
Ppl = PAW * EW/ETOT -Pmusc*EL/ETOT+K
![Page 24: Tranpulmonary pressure: Why & How Esophageal pressure€¦ · Agostoni, Mead, Weibel, Gattinoni Specific Lung Elastance 12 (cmH 2 O) 1.5 0.5 Strain 1 2 3. Airway Pressure (cmH 2 O)](https://reader034.vdocuments.us/reader034/viewer/2022042810/5f99c61a57c89b5ca021e4fc/html5/thumbnails/24.jpg)
Pleural pressure is of paramount
importance when:
1. Setting mechanical ventilation
2. Estimating risks of VILI
3. Monitoring Spontaneous breathing
4. Monitoring non-invasive ventilation
Extensive application has to be made to
completely define its role in ICU practice
Conclusions