Shimatani Tatsutoshi, Kyogoku Miyako, Ito Yukie, Takeuchi Muneyuki, Khemani Robinder G
Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima-shi, Hiroshima, Japan.
Department of Critical Care Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
J Intensive Care. 2023 May 22;11(1):22. doi: 10.1186/s40560-023-00671-6.
Transpulmonary pressure is an essential physiologic concept as it reflects the true pressure across the alveoli, and is a more precise marker for lung stress. To calculate transpulmonary pressure, one needs an estimate of both alveolar pressure and pleural pressure. Airway pressure during conditions of no flow is the most widely accepted surrogate for alveolar pressure, while esophageal pressure remains the most widely measured surrogate marker for pleural pressure. This review will cover important concepts and clinical applications for esophageal manometry, with a particular focus on how to use the information from esophageal manometry to adjust or titrate ventilator support. The most widely used method for measuring esophageal pressure uses an esophageal balloon catheter, although these measurements can be affected by the volume of air in the balloon. Therefore, when using balloon catheters, it is important to calibrate the balloon to ensure the most appropriate volume of air, and we discuss several methods which have been proposed for balloon calibration. In addition, esophageal balloon catheters only estimate the pleural pressure over a certain area within the thoracic cavity, which has resulted in a debate regarding how to interpret these measurements. We discuss both direct and elastance-based methods to estimate transpulmonary pressure, and how they may be applied for clinical practice. Finally, we discuss a number of applications for esophageal manometry and review many of the clinical studies published to date which have used esophageal pressure. These include the use of esophageal pressure to assess lung and chest wall compliance individually which can provide individualized information for patients with acute respiratory failure in terms of setting PEEP, or limiting inspiratory pressure. In addition, esophageal pressure has been used to estimate effort of breathing which has application for ventilator weaning, detection of upper airway obstruction after extubation, and detection of patient and mechanical ventilator asynchrony.
跨肺压是一个重要的生理概念，因为它反映了肺泡两侧的真实压力，并且是肺应激的更精确指标。要计算跨肺压，需要估计肺泡压和胸膜压。无气流状态下的气道压是最广泛接受的肺泡压替代指标，而食管压仍然是最广泛测量的胸膜压替代指标。本综述将涵盖食管测压的重要概念和临床应用，特别关注如何利用食管测压信息来调整或滴定呼吸机支持。测量食管压最常用的方法是使用食管球囊导管，尽管这些测量可能会受到球囊内空气量的影响。因此，使用球囊导管时，校准球囊以确保最合适的空气量很重要，我们将讨论几种已提出的球囊校准方法。此外，食管球囊导管仅估计胸腔内特定区域的胸膜压，这引发了关于如何解释这些测量结果的争论。我们将讨论直接法和基于弹性的方法来估计跨肺压，以及它们如何应用于临床实践。最后，我们将讨论食管测压的一些应用，并回顾许多迄今为止发表的使用食管压的临床研究。这些应用包括使用食管压分别评估肺和胸壁顺应性，这可以为急性呼吸衰竭患者在设置呼气末正压或限制吸气压力方面提供个体化信息。此外，食管压已被用于估计呼吸功，这在呼吸机撤机、拔管后上气道梗阻的检测以及患者与机械通气不同步的检测中都有应用。
