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DP Vs MF
DP Vs MF
, Editor
What Is Driving Pressure and How Is It Measured? available in current anesthesia machines for the presence of
a plateau at the end of the inspiratory pause allows for bet-
Driving pressure is defined as plateau pressure minus
ter decision on reliability of plateau pressure measurement.
PEEP (fig. 1).16 Plateau pressure is measured at the end of
Auto-PEEP is another potential source of error by leading
an inspiratory pause during volume-controlled constant
to driving pressure overestimation as the end-expiratory
flow ventilation and at the end of inspiration during pres-
pressure in alveolar units would be higher than the PEEP set
sure-controlled ventilation. Accordingly, in the absence of
in the ventilator and used to compute the driving pressure.
respiratory muscle effort by the patient, driving pressure is
It is important to recognize that driving pressure and
the pressure above PEEP applied to the entire respiratory
total airway pressure measured during mechanical ventila-
system to achieve tidal ventilation. A caveat on the compu-
tion have two components: one related to the expansion of
tation of plateau pressures is that they cannot be presumed
the lungs, the other to the expansion of the chest wall. Each
to represent end-inspiratory alveolar pressures when end-in-
of these two components can change substantially during
spiratory flows are not zero, indicating lack of equilibration
disease and surgical conditions and affect the interpretation
between airway and alveolar pressures. During volume-con-
of the driving pressure measurements.
trolled ventilation, an inspiratory pause greater than or equal
to 3 s provides best accuracy for plateau pressure measure-
ments in normal and diseased lungs.17,18 Short inspiratory What Is Transpulmonary Pressure and How Is It
pauses of 0.5 s overestimate plateau pressure by 11% in Measured?
ARDS patients and 17% in chronic obstrictive pulmonary Transpulmonary pressure is defined as the pressure differ-
disease patients.17 Examination of the airway pressure tracing ence between the airway opening and the pleural surface
(fig. 2).19,20 Accordingly, transpulmonary pressure comprises points, the airway pressures (plateau pressure at end-inspira-
the pressure to move air through the airways (airway open- tion and PEEP at end-expiration) are presumed to represent
ing – alveolar pressure) and the pressure to overcome the alveolar pressures, a reasonable assumption in the absence of
lung tissue elastic recoil (alveolar – pleural pressure), the lat- gas trapping.21 This approach to measure transpulmonary
ter most frequently associated with lung injury.19 Although pressure may have led to the misconception that it exclu-
continuous estimation of transpulmonary pressure is fea- sively expresses pressures at the alveolar level.19,22,23 The
sible, it is usually assessed at two critical points during the essential concept is that in static, i.e., zero flow, conditions
breathing cycle: the end of inspiration, relevant to prevent (end-inspiration and end-expiration), the transpulmonary
hyperinflation, and the end of expiration, relevant to avoid pressure approximates the lung tissue elastic recoil compo-
lung derecruitment. If respiratory flows are zero at these nent, which is the relevant pressure to quantify stress applied
Fig. 2. Airway opening, esophageal (Peso), and transpulmonary pressures (PL) measurements. PL is defined as the difference between airway
opening pressure (blue lines) and pleural pressure. Pleural pressure is frequently estimated from esophageal balloon pressure measurements
(Peso). Using a specific protocol, the esophageal balloon is placed in the lower third of the esophagus (A). Cardiac oscillations in Peso (B, green
lines) indicate accurate placement of the balloon, which can be confirmed by observation of similar airway pressure and Peso measurements
as gentle chest compressions are performed during expiratory pause or with occluded airway opening (A). PL can be estimated as the dif-
ference between airway and esophageal pressures (red and orange lines). Interventions such as pneumoperitoneum (B, mid panel) produce
a marked change in driving pressures (∆P = plateau pressure, PPlat, minus positive end-expiratory pressure, PEEP). In this example, ∆P
increased by 7 cm H2O. Yet ∆PL (end-inspiratory PL, PL EI, minus end-expiratory PL, PL EE) does not increase to the same degree as ∆P and
PPlat. The change in ∆PL in this example was 4 cm H2O. This demonstrates that part of the increases in ∆P and PPlat are due to the chest wall
component and not to pressures applied to the lung parenchyma. This contribution of the chest wall is evidenced by the increased EI to EE
oscillation in Peso after as compared to before pneumoperitoneum. In addition, the esophageal pressure at end-expiration (Peso EE, at ~4 s on
time scale) is positive before pneumoperitoneum while it is negative after pneumoperitoneum. This implies mechanical conditions consistent
with lung collapse after pneumoperitoneum. Indeed, while PL did not increase by the same magnitude as ∆P, it also increased, indicating loss
of lung compliance. Such conditions could prompt use of higher PEEP to prevent lung derecruitment. EE, end-expiratory; EI, end-inspiratory.
to lung tissue beyond airways,14 presumably responsible for strategy does not. A key assumption of the second approach
injury during mechanical ventilation.19 is that pleural pressures are zero at zero airway pressure.This
While assessment of airway pressures to calculate would be questionable in resting conditions, and, more
transpulmonary pressure is simple, estimates of pleural pres- markedly, in conditions consistent with increased pleural
sure are difficult to obtain. Esophageal manometry is cur- pressures such as in obese and ARDS patients,19 and pre-
rently the most widely accepted method to estimate pleural sumably during laparoscopic and abdominal procedures. In
pressures in the clinical setting.24–26 For this, a special bal- such cases, that assumption could lead to inadequate use
loon, either incorporated in a stand-alone catheter or as part of PEEP. The approaches based on absolute or differential
of a naso- or orogastric tube, is positioned with a specific esophageal pressure to estimate pleural pressure do not pro-
protocol24,27 in the lower third of the esophagus and con- vide equivalent measurements,33,36 and direct comparison to
nected to a pressure transducer (fig. 2A). Correct balloon an accepted standard are needed.
position is confirmed by the presence of cardiac oscillation Recently, an alternative method to assess transpulmonary
driving pressures above and less than that threshold found pressure, titration of mechanical ventilation to these values
that the higher driving pressure was associated with higher would avoid end-expiratory alveolar collapse.
lung stress.39 Application of such transpulmonary pressure based
While these are not prospective studies, the broad range approaches lead to improved oxygenation, respiratory sys-
of cases and patients included support the use of driving tem compliance, and a trend to reduction in mortality in
pressure as a marker of outcomes in mechanically ventilated patients with ARDS.25,43 Given the significant number of
patients. These studies also suggest that the traditional limits hypoxemic patients with unrecognized ARDS,46 use of
of airway pressure (e.g., less than or equal to 30 cm H2O2,4) esophageal pressure monitoring might be considered in
may not be enough to prevent lung injury. Instead, limiting any patient with worsening hypoxemia. In obese patients
or minimizing driving pressures could be a more relevant with respiratory failure, low to negative transpulmonary
target. Current estimates for safe driving pressures range pressure predicted lung collapse and intratidal recruitment/
from 14 to 18 cm H2O.5–7 Yet there are caveats to such a derecruitment, providing guidance for PEEP selection and
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