The Application of Esophageal Pressure Measurement in Patients with Respiratory Failure
The Application of Esophageal Pressure Measurement in Patients with Respiratory Failure
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DOI：
10.1164/rccm.201312-2193ci
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发表时间：
2014-03-01
影响因子：
24.7
通讯作者：
Brochard, Laurent
中科院分区：
文献类型：
--
作者：
Akoumianaki, Evangelia;Maggiore, Salvatore M.;Brochard, Laurent
本报告总结了目前接受机械通气患者食管压力（Pes）测量的生理和技术知识。Pes的呼吸变化代表胸膜压的变化。气道压力（Paw）和Pes之间的差值是经肺动脉压的有效估计值。PES有助于确定应用Paw的哪一部分来克服肺和胸壁弹性。Pes通常是通过一个导管与充气薄壁乳胶气球插入鼻腔或口腔测量。为了验证Pes测量，动态阻塞测试测量在对闭合气道的吸气努力期间Pes的变化与Paw的变化的比率。接近1的比率表明系统提供了有效的测量。假设经尿道压力是肺扩张压力，并且胸壁弹性可能因个体而异，基于生理学的呼吸机策略应考虑经尿道压力。出于监测目的，临床医生主要依赖Paw和流量波形。然而，这些测量可能会掩盖严重的患者-呼吸机相关性，并且不允许进行呼吸肌努力评估。PES还允许在被动和主动呼吸期间测量透壁血管压力。Pes测量增强了我们对急性肺损伤、患者-呼吸机相互作用和撤机失败的病理生理学的理解。使用Pes进行呼气末正压滴定可能有助于改善氧合和顺应性。Pes的测量使得在机械通气和撤机过程中个体化肌肉努力水平成为可能。现在是时候应用从Pes获得的知识来改善危重病和呼吸机依赖患者的管理。
This report summarizes current physiological and technical knowledge on esophageal pressure (Pes) measurements in patients receiving mechanical ventilation. The respiratory changes in Pes are representative of changes in pleural pressure. The difference between airway pressure (Paw) and Pes is a valid estimate of transpulmonary pressure. Pes helps determine what fraction of Paw is applied to overcome lung and chest wall elastance. Pes is usually measured via a catheter with an airfilled thin-walled latex balloon inserted nasally or orally. To validate Pes measurement, a dynamic occlusion test measures the ratio of change in Pes to change in Paw during inspiratory efforts against a closed airway. A ratio close to unity indicates that the system provides a valid measurement. Provided transpulmonary pressure is the lung-distending pressure, and that chest wall elastance may vary among individuals, a physiologically based ventilator strategy should take the transpulmonary pressure into account. For monitoring purposes, clinicians rely mostly on Paw and flow waveforms. However, these measurements may mask profound patient-ventilator asynchrony and do not allow respiratory muscle effort assessment. Pes also permits the measurement of transmural vascular pressures during both passive and active breathing. Pes measurements have enhanced our understanding of the pathophysiology of acute lung injury, patient-ventilator interaction, and weaning failure. The use of Pes for positive end-expiratory pressure titration may help improve oxygenation and compliance. Pes measurements make it feasible to individualize the level of muscle effort during mechanical ventilation and weaning. The time is now right to apply the knowledge obtained with Pes to improve the management of critically ill and ventilator-dependent patients.