Setting PEEP using transpulmonary pressure monitoring


Author: Hamilton Medical

Date of first publication: 11.09.2017

Last change: 28.07.2023

Transpulmonary pressure measurement changed to monitoring

One of the greatest challenges when mechanically ventilating patients is finding the correct setting for positive end-expiratory pressure (PEEP). This task can be made easier by using transpulmonary pressure monitoring to distinguish between the pressure in the lungs and the chest wall components.

Setting PEEP using transpulmonary pressure monitoring

Partition between lung and chest wall components

The ability to partition between the lung and chest wall components helps you to set the optimal PEEP, define a safe range for driving and plateau pressures, and to titrate and optimize lung recruitment maneuvers. But how can you distinguish between them when the pressures measured at the airway opening cannot be used to accurately assess the stress and strain applied to the lungs? A simple way of partitioning them is by using esophageal pressure measurement. The airway pressure minus the esophageal pressure measured during an end-inspiratory or an end-expiratory occlusion gives you the transpulmonary pressure, which represents the true distending pressure of the lungs.

Transpulmonary pressure monitoring on Hamilton Medical ventilators

Transpulmonary pressure monitoring is available on the HAMILTON-G5/S1 (Not available in the US and some other marketsA​) and HAMILTON-C6 ventilators, which are equipped with an auxiliary port for the connection of an esophageal catheter. This is inserted through a nostril to the stomach and then withdrawn into the esophagus, with the balloon being positioned in the lower third of the esophagus. On the ventilator display, simply change to the four-waveform setting and the lower two waveforms will then show you the esophageal and transpulmonary pressure. You can freeze the screen to read the values.

Applications of transpulmonary pressure monitoring

In patients with acute respiratory distress syndrome (ARDS), you can set PEEP in order to achieve a transpulmonary pressure of 0 to 5 cmH2O at end expiration, with the aim of preventing atelectrauma caused by repeated opening and closing of the distal airways and alveoli. Transpulmonary pressure monitoring can also be used to set the tidal volume and inspiratory pressure for ARDS patients, and together with the P/V Tool® to assess lung recruitability and perform recruitment maneuvers. 

The video below shows you how to set PEEP using transpulmonary pressure monitoring on a HAMILTON-G5 ventilator.

Accurately setting PEEP with transpulmonary pressure

Watch this short demonstration to learn how to use transpulmonary pressure measurement to set PEEP in mechanically ventilated patients more accurately.
Doctor with intubated patient

Transpulmonary pressure. Better understand respiratory system mechanics

Transpulmonary pressure monitoring enables optimization of PEEP, tidal volume, and inspiratory pressure (Baedorf Kassis E, Loring SH, Talmor D. Should we titrate peep based on end-expiratory transpulmonary pressure?-yes. Ann Transl Med. 2018;6(19):390. doi:10.21037/atm.2018.06.351​) 

Should we titrate peep based on end-expiratory transpulmonary pressure?-yes.

Baedorf Kassis E, Loring SH, Talmor D. Should we titrate peep based on end-expiratory transpulmonary pressure?-yes. Ann Transl Med. 2018;6(19):390. doi:10.21037/atm.2018.06.35

Ventilator management of patients with acute respiratory distress syndrome (ARDS) has been characterized by implementation of basic physiology principles by minimizing harmful distending pressures and preventing lung derecruitment. Such strategies have led to significant improvements in outcomes. Positive end expiratory pressure (PEEP) is an important part of a lung protective strategy but there is no standardized method to set PEEP level. With widely varying types of lung injury, body habitus and pulmonary mechanics, the use of esophageal manometry has become important for personalization and optimization of mechanical ventilation in patients with ARDS. Esophageal manometry estimates pleural pressures, and can be used to differentiate the chest wall and lung (transpulmonary) contributions to the total respiratory system mechanics. Elevated pleural pressures may result in negative transpulmonary pressures at end expiration, leading to lung collapse. Measuring the esophageal pressures and adjusting PEEP to make transpulmonary pressures positive can decrease atelectasis, derecruitment of lung, and cyclical opening and closing of airways and alveoli, thus optimizing lung mechanics and oxygenation. Although there is some spatial and positional artifact, esophageal pressures in numerous animal and human studies in healthy, obese and critically ill patients appear to be a good estimate for the "effective" pleural pressure. Multiple studies have illustrated the benefit of using esophageal pressures to titrate PEEP in patients with obesity and with ARDS. Esophageal pressure monitoring provides a window into the unique physiology of a patient and helps improve clinical decision making at the bedside.

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