REVIEW

CURRENT
OPINION Monitoring respiratory mechanics during
assisted ventilation
Giacomo Grasselli a,b, Matteo Brioni a, and Alberto Zanella a,b

Purpose of review
Accurate monitoring of the mechanical properties of the respiratory system is crucial to understand the
pathophysiological mechanisms of respiratory failure in mechanically ventilated patients, to optimize
mechanical ventilation settings and to reduce ventilator-induced lung injury. However, although the
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assessment of respiratory mechanics is simple in patients undergoing fully controlled ventilation, it becomes
quite challenging in the presence of spontaneous breathing activity. Aim of the present review is to describe
how the different components of respiratory mechanics [resistance, static compliance, and intrinsic positive
end-expiratory pressure (PEEP)] can be measured at the bedside during assisted modes of ventilation.
Recent findings
Available techniques for bedside measurement of resistance during assisted ventilation are complex and
not commonly implemented. On the contrary, an increasing number of reports indicate that measurement of
static compliance and intrinsic PEEP can be easily obtained, both with advanced monitoring systems
(esophageal and gastric manometry, diaphragm electromyography, electrical impedance tomography)
and, with some limitations, with simple airways occlusion maneuvers.
Summary
Assessment of respiratory mechanics in spontaneously breathing patients, with some limitations, is feasible
and should be included in everyday clinical practice; however, more data are needed to understand the
clinical relevance of the measures obtained during assisted ventilation.
Keywords
airway resistance, assisted mechanical ventilation, driving pressure, intrinsic positive end-expiratory pressure,
static respiratory system compliance

INTRODUCTION: BASIC PRINCIPLES AND
THE EQUATION OF MOTION
Respiratory failure arises whenever the ‘respiratory
pump’ is unable to sustain the work of breathing
needed to overcome the elastic, resistive, and iner-
tive load of the lungs and chest wall.
The equation of motion describes the pressure
applied at the airway opening (Pao) to increase the
volume of the respiratory system (lung and chest
wall) from its resting point at end-expiration to its
value at end-inspiration [1].
Specifically, Pao is the sum of
(1) the pressure needed to generate the airflow
overcoming airways resistance (resistive pres-
sure, Pres) and inertance (Pinert)
(2) the pressure needed to inflate a volume of gas in
the alveoli overcoming the elastance of the
system (elastic pressure, Pel)
(3) the elastic recoil pressure at end-expiration,
which is the sum of the PEEP applied by the
ventilator and any eventual intrinsic PEEP
(PEEPi)
According to the mode of ventilation, the
mechanical ventilator and the patient’s inspira-
tory muscles contribute differently to the genera-
tion of Pao.
(1) During controlled ventilation in passive
patients (no inspiratory muscle activity), the
ventilator generates all the pressure (Pvent):
a
Department of Anesthesiology, Intensive Care and Emergency, Fonda-
zione IRCCS Ca’ Granda Ospedale Maggiore Policlinico and bDepartment
of Pathophysiology and Transplantation, University of Milan, Milan, Italy
Correspondance to Giacomo Grasselli, Department of Pathophysiology
and Transplantation, University of Milan, Via Francesco Sforza 35, 20122
Milan, Italy. Tel: +39 0255033258; fax: +39 0255033648;
e-mail: giacomo.grasselli@unimi.it
Curr Opin Crit Care 2020, 26:11–17
DOI:10.1097/MCC.0000000000000681

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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Respiratory system
KEY POINTS
 Available techniques for bedside measurement of
resistance during assisted ventilation are complex and
not commonly implemented.
 Static compliance and intrinsic positive end-expiratory
pressure (PEEP) measurement are more easily
obtainable at the bedside, also without advanced
monitoring systems.
 The occlusion maneuver can be applied also during
assisted ventilation modes, but several pitfalls must be
taken into account.
 More data are needed to understand the clinical
relevance of respiratory mechanics measures obtained
during assisted modes of ventilation.
Pao ¼ Pvent ¼ Pres þ Pinert þ Pel þ PEEP þ PEEPi:
In physics, resistance is a pressure gradient
divided by a flow. Applying this relationship to
the respiratory system, inspiratory resistance (Rrs)
is the pressure difference between the airway open-
ing and the alveoli divided by inspiratory flow (V̇i),
thus Pres equals Rrs  V̇i. Elastance, in turn, is a
pressure change divided by a change in volume.
During breathing, respiratory system static elastance
(Ers) is computed as the ratio between alveolar pres-
sure change from inspiration to end-expiration in
static (no-flow) conditions (driving pressure, DP)
and tidal volume (Vt). Hence, Pel is Ers  Vt. Being
static compliance (Crs) the inverse of static ela-
stance, Pel equals Vt/Crs. As inertive forces are negli-
gible during most forms of mechanical ventilation,
Pinert is usually omitted [2].
Consequently, the equation of motion becomes
Pao ¼ Prs  V̇i þ Vt=Crs þ PEEP þ PEEPi:
Notably, this model represents an oversimplifi-
cation, based on the assumption that the respiratory
system behaves like an elementary monodimen-
sional single-compartment model, depicted by a
balloon attached to a spring and acted on by a
unidirectional force [3].
(1) During spontaneous unassisted breathing, the
respiratory muscles (Pmus) generate all the pres-
sure, thus we can write
Pmus ¼ Rrs  V̇i þ Vt=Crs þ PEEP þ PEEPi:
Pmus is negative as the contraction of inspiratory
muscles determines a fall in intrathoracic pres-
sure below the atmospheric pressure.
12 www.co-criticalcare.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
(2) During assisted modes of mechanical ventila-
tion, such as pressure support ventilation (PSV),
the patient and the ventilator share the work of
breathing: part of the pressure applied to the
system is generated by the ventilator and part by
the respiratory muscles.
Pao ¼ Pvent þ Pmus :
From these premises, it should be clear that
accurate monitoring of the mechanical properties
of the respiratory system is crucial to understand the
causes and pathophysiological mechanisms of respi-
ratory failure in mechanically ventilated patients,
which in turn is essential to improve the setting of
mechanical ventilation. However, although the
assessment of respiratory mechanics is simple in
patients undergoing fully controlled ventilation, it
becomes quite challenging in the presence of spon-
taneous breathing activity. Theoretically, during
assisted ventilation, measurement of respiratory
mechanics requires an efficient esophageal pressure
(Pes) line and complex offline analysis of pressure
tracings [1,4]. However, alternative techniques that
do not require Pes monitoring are available. Aim of
the present review is to describe how the different
components of respiratory mechanics (resistance,
static compliance, and intrinsic PEEP) can be mea-
sured at the bedside in patients undergoing assisted
modes of ventilation.
INSPIRATORY RESISTANCE
Rrs is composed of airways resistance, both natural
and artificial (the endotracheal tube), and tissue
resistance. Rrs may abruptly change during ventila-
tion, leading to increase in airway pressure, reduc-
tion in minute ventilation, increase in patient effort,
impairment of gas exchange, and hemodynamic
instability. Recognizing an increase in Rrs as the
cause of a deteriorating respiratory function is
extremely important for the adjustment of ventila-
tion settings and the early institution of
appropriate treatment.
During volume-controlled ventilation (Fig. 1),
characterized by a constant inspiratory flow rate, a
simple end-inspiratory occlusion maneuver allows to
compute inspiratory Rrs as (peak inspiratory pressur-
e  plateau inspiratory pressure)/V̇i (cmH2O/l/s).
During the occlusion maneuver, in the absence of
flow, plateau pressure (Pplat) is a good estimate of
alveolar pressure. Total Rrs in a healthy human during
controlled mechanical ventilation is 10–15 cmH2O/
l/s [5]. When the pressure drop from peak inspiratory
pressure (Ppeak) to Pplat is biphasic (P1 and P2), it
is possible to separate the airway component
Volume 26  Number 1  February 2020
 Respiratory mechanics during assisted ventilation Grasselli et al.

FIGURE 1. Inspiratory and expiratory pause during controlled mechanical ventilation. The figure shows airway pressure (Paw),
flow, volume, and esophageal pressure (Pes) tracings in controlled mechanical ventilation during tidal ventilation, inspiratory,
and expiratory pause. No breathing effort is made by the patient, as shown by positive shift of Pes during inspiration. During
inspiratory pause (no flow, constant volume) Paw drops from peak inspiratory pressure (Ppeak) to plateau pressure (Pplat) in a
biphasic manner: Ppeak to P1 drop is related to airway resistance, whereas P1 to P2 (Pplat) drop is related to tissue resistance
and pendelluft. During expiratory pause (no flow, constant volume), PEEPtot can be measured. Driving pressure (DP) is the
difference between Pplat and PEEPtot and represents lung elastic recoil pressure because of tidal volume inflation.

(Ppeak  P1)/V̇i, from the tissue resistance (P1  P2)/V̇i.
Unfortunately, this technique cannot be applied
during assisted ventilation, as reliable measurements
can be obtained only in the absence of patient effort,
thus deep sedation or neuromuscular blockade
are needed.
Similarly, whole-body plethysmography, the
reference method for measurement of Rrs, can
hardly be applied during assisted ventilation [6].
The following techniques have been proposed
to measure Rrs during assisted ventilation:
(1) The fast interrupter technique [4] allows measure-
ment of Rrs during assisted ventilation, assum-
ing that alveolar pressure and Pao are equal after
the flow interruption. However, the reliability
of this technique is highly influenced by the
properties of the shutter device and decreases in
conditions of diseased airways and low compli-
ance. Rocha et al. [7] recently reported a low
accuracy of Rrs measurement through an inter-
rupter technique in patients with cystic fibrosis.
(2) The least-squares fitting technique (LSF) [8], based
on multiple regression analysis, derives Rrs and
Crs from the equation of motion. It can be
applied during both controlled and assisted
ventilation, but in the presence of spontaneous
breathing activity, it gives reliable results only if
a near-relaxation condition (no detectable
inspiratory efforts) is achieved [8]. Hence,
applying the LSF method during assisted venti-
lation requires the application of very high
levels of pressure support to render the patient’s
muscular effort negligible, which can be
clinically contraindicated.
(3) The forced oscillation technique (FOT) applies
high-frequency oscillating airflows to the air-
ways during breathing, allowing for continuous
measurement of Rrs in paralyzed and nonpara-
lyzed patients [9]. The American Thoracic Soci-
ety and The European Respiratory Society
indicate FOT as an alternative technique for
measuring respiratory system mechanics
[10,11].
(4) A new optimized proportional assist ventilation
mode (PAVþ) automatically and semicontinu-
ously estimates the patient’s elastance and resis-
tance through transient reduction of Paw and
flow in the early inflation phase [12].
Unfortunately, all these techniques have signif-
icant limitations that restrict their clinical applica-
tion, and bedside measurement of Rrs in actively
breathing patients remains extremely challenging.

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Respiratory system

RESPIRATORY SYSTEM STATIC inversely related to Crs, is considered by several

COMPLIANCE
Crs, which is usually around 50–80 ml/cmH2O in
normal patients during anesthesia [5,13], is often
reduced during hypoxemic respiratory failure, as it is
proportional to the size of the residual normally
aerated lung tissue [which corresponds to end-expi-
ratory lung volume (EELV) and is significantly
reduced in acute respiratory distress syndrome
(ARDS) patients, the ‘baby lung’ [14,15]] and can
also be influenced by specific chest wall and lung
diseases (e.g., pulmonary fibrosis). As explained
above, Crs is computed as the ratio between tidal
volume (Vt) and driving pressure (DP). In patients
with ARDS, Vt should be scaled to the size of the
‘baby lung’ to limit the risk of ventilator-induced
lung injury (VILI) caused by excessive stress and
strain on the lung parenchyma. Unfortunately, scal-
ing Vt to ideal body weight, as recommended by
current guidelines [16,17], does not accurately
reflect the amount of aerated lung tissue. Targeting
DP, which is directly proportional to Vt and
experts a better way to normalize Vt for the lung’s
capacity to accept it [18].
Indeed, a high DP (above 14 cmH2O) during
controlled mechanical ventilation is associated with
significantly increased morbidity and mortality in
ARDS patients [19]. For these reasons, measurement
of Crs and DP is essential to tailor mechanical venti-
lation settings according to the severity of each
patient’s respiratory impairment.
DP is computed as the difference between airway
end-inspiratory pressure (Pplat) and total airway
end-expiratory pressure (PEEPtot) (Fig. 2). Unfortu-
nately, obtaining accurate measurements of Pplat
and PEEPtot (and consequently of Crs and DP) in
actively breathing patients is challenging and
requires monitoring of either esophageal and gas-
tric pressure swings or of diaphragm and abdominal
muscle electromyography to detect inspiratory and
expiratory efforts. However, with some limitations,
Crs and DP can be measured during assisted ventila-
tion also without these complex monitoring

FIGURE 2. Inspiratory and expiratory pause during assisted mechanical ventilation (pressure support). The figure shows
airway pressure (Paw), flow, volume, and esophageal pressure (Pes) tracings in pressure support ventilation during tidal
ventilation, inspiratory, and expiratory pause. Patient’s spontaneous breathing efforts (black arrowheads) are evident
observing inspiratory negative shifts of Pes. During inspiratory pause (no flow, constant volume), a brief relaxation phase is
evident: Paw reaches a plateau value (Pplat) higher than Pvent (PEEP þ pressure support). The difference between Pplat and Pvent is
called Pmus index and is an accurate estimate of patient inspiratory effort [20]. At the end of inspiratory pause a spontaneous
breathing effort against the occluded airway is evident as a negative deflection on Paw tracing, mirroring that on Pes tracing.
Similar negative deflections with the same significance are visible during expiratory pause (no flow, constant volume): in this
case is difficult to obtain a reliable measure of PEEPtot, because of incomplete respiratory muscle relaxation.

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 Respiratory mechanics during assisted ventilation Grasselli et al.
techniques. As reported in the previous section, the
rapid interrupter technique [4] and the LSF method
[8] provide an estimate of Crs also in actively breath-
ing patients, but they are not commonly utilized in
the clinical practice. At variance, the end-inspiratory
occlusion maneuver can be easily applied at the bed-
side and allows reliable measurement of Pplat during
assisted ventilation. It has been demonstrated that
during PSV a brief inspiratory pause is feasible and
usually well tolerated by the patient [20]. Once the
inspiratory flow ceases, airway pressure rapidly
reaches a plateau level that, if the patient makes
no effort, is usually equal to or slightly lower than
the sum of PEEP and pressure support (i.e., the
pressure delivered by the ventilator, Pvent). Instead,
if a spontaneous inspiratory effort is present (also if
not visible on ventilator pressure waveforms), dur-
ing the end-inspiratory occlusion the airway pres-
sure increases and [21], if the patient relaxes the
inspiratory muscles, plateaus to a level higher than
Pvent. This Pplat value has exactly the same physio-
logical meaning as Pplat measured during controlled
ventilation, reflecting the static recoil pressure of
the respiratory system generated by Vt added to
EELV [4]. As mentioned, during PSV, Pplat measured
at end-inspiration may be higher than Pvent, and the
difference between the two is called Pmus index
(PMI) [20]. It has been demonstrated that Pplat val-
ues obtained with the end-occlusion maneuver dur-
&
ing PSV allow reliable estimates of Crs [22,23,24 ]. In
addition, Foti et al. [20] showed, in nine patients on
PSV, that PMI is an accurate estimation of patient
inspiratory effort and can be used clinically to
titrate the level of ventilator support.
&
Recently, Grasselli et al. [25 ] demonstrated
that the same technique can be applied also dur-
ing neurally adjusted ventilatory assist (NAVA), a
proportional mode of assisted ventilation. In 12
patients during the early postoperative phase
after bilateral lung transplantation, Pplat and Crs
measurements were performed during PSV and
NAVA at three different levels of support and at
two PEEP levels. During NAVA, an end-inspiratory
occlusion of 2 s was well tolerated and provided
measurements of Pplat and Crs that were signifi-
cantly correlated with those obtained during PSV
&
[25 ].
However, the end-inspiratory occlusion maneu-
ver can be hindered by several pitfalls, and Pplat
measures should be considered reliable only if a stable
plateau is seen on airway pressure tracings, indicating
complete relaxation of the respiratory muscles during
the occlusion. Especially if the patient’s respiratory
drive is very high and/or the patient’s neural inspira-
tory time is longer than the ventilator’s, obtaining a
stable Pplat can be challenging because of residual
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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
inspiratory muscle activity during occlusion. For this
reason, pressure support cycling-off criteria must be
set carefully, avoiding patient–ventilator asyn-
chrony. Moreover, the rise in airway pressure at the
end of inspiratory occlusion could be determined not
only by the elastic recoil of the respiratory system but
also by active expiratory muscles contraction
& &
[21,24 ,26 ]. Clinical examination can help in detect-
ing abdominal muscles contraction, but in difficult
cases, esophageal and gastric manometry is necessary
to confirm the absence of respiratory muscle activity
&
[26 ].
Finally, electrical impedance tomography (EIT)
has been recently proposed as an alternative method
to measure Crs during assisted ventilation. In a pilot
study, Becher et al. [27] used lung inflation changes
measured with EIT during a stepwise PEEP increase
to compute Crs during PSV. The method showed a
good correlation and an acceptable agreement with
reference values of Crs measured during sedation
and paralysis [27].
Although several experts have confirmed that
the measurement of Pplat and Crs in spontaneously
breathing patients is feasible and reliable, it is still
rarely applied in the clinical practice. In addition,
not all the available ICU ventilators allow occlusion
maneuvers during assisted ventilation modes.
Indeed, clinical research on respiratory failure and
VILI prevention has been mainly focused on the
acute phase of the disease and controlled mechani-
&&
cal ventilation settings [28 ], and consequently
data regarding the clinical relevance of Crs and DP
measures during assisted modes of ventilation are
&&
limited. Indeed, Bellani et al. [29 ] recently pub-
lished a retrospective study on 154 ARDS patients on
PSV and analyzed respiratory mechanics data during
the first three days of assisted ventilation. They
found that nonsurvivors had significantly higher
DP and lower Crs compared with survivors despite
similar peak airway pressure and that low Crs and
high DP were each independently associated with
&&
ICU mortality [29 ].
INTRINSIC POSITIVE END-EXPIRATORY
PRESSURE
Total pressure due to lung elastic recoil at end-
expiration (PEEPtot) is the sum of PEEP applied by
the ventilator and ‘intrinsic-PEEP’ (PEEPi) due to
alveolar gas trapping. During controlled ventilation,
PEEPtot is easily measured by means of an end-expi-
ratory occlusion maneuver. The same technique can
also be applied during assisted modes of mechanical
ventilation, but obtaining reliable measures is more
complex as the expiratory hold is not well tolerated
and it is difficult to achieve complete respiratory
www.co-criticalcare.com 15
Respiratory system
muscle relaxation. Indeed, activation of expiratory
muscles is frequent and may lead to overestimation
of PEEPi: in this case, accurate measurement of PEEPi
can be obtained only with gastric manometry, by
subtracting the end-expiratory gastric (abdominal)
pressure rise [30,31].
Under dynamic conditions, the presence of
PEEPi leads to higher inspiratory muscle workload,
as the patient must overcome this pressure to trigger
the ventilator [32]. The reference technique to mea-
sure this ‘additional pressure’ generated by inspira-
tory muscles to counterbalance PEEPi is represented
by esophageal manometry: PEEPi is the drop in Pes
preceding the start of inspiratory flow [33]. How-
ever, the initial drop in Pes can also be due to
expiratory muscle relaxation, and in patients with
active expiration an accurate measurement of
dynamic PEEPi needs a correction for end-expiratory
Pga rise, as described above.
Finally, in a physiological study on 10 patients,
Bellani et al. [34] showed that dynamic PEEPi could
be accurately estimated also from the value of
diaphragm electrical activity (EAdi) preceding the
inspiratory flow. Differently from Pes, EAdi is not
influenced by expiratory muscle activity [34].
CONCLUSION
Assessment of the mechanical properties of the
respiratory system is essential to understand the
pathophysiological mechanisms underlying a
patient’s respiratory failure and to tailor the
mechanical ventilation settings. However, although
measurement of Rrs, Crs, and PEEPi is simple during
controlled mechanical ventilation, it is more chal-
lenging during assisted modes of ventilation, when
active inspiratory efforts occur. Available techni-
ques for bedside measurement of Rrs are complex
and not commonly implemented. On the contrary,
an increasing number of reports indicate that mea-
surement of Pplat and PEEPi (and consequently of Crs
and DP) can be easily obtained by means of simple
end-inspiratory and end-expiratory occlusions also
during assisted modes of ventilation (in particular
PSV and NAVA), provided that respiratory muscle
relaxation is achieved during the maneuvers. How-
ever, assessment of respiratory mechanics in spon-
taneously breathing patients is still far from being
routinely applied in everyday clinical practice and
more data are needed to understand the clinical
relevance of the measures obtained during assisted
modes of ventilation.
Acknowledgements
None.
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Financial support and sponsorship
None.
Conflicts of interest
M.B. and A.Z. have no conflict of interest.
G.G. has received payment for lectures from Thermo-
fisher, Getinge, Pfizer Pharmaceuticals, Fisher & Paykel
and Draeger Medical, and travel/accommodation/con-
gress registration support from Getinge and Biotest; none
of these COIs is related to this work.
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