Transpulmonary pressure monitoring in critically ill patients: pros and cons—correction of description of the non-invasive PEEP-step method for separation of lung and chest wall mechanics
{"title":"Transpulmonary pressure monitoring in critically ill patients: pros and cons—correction of description of the non-invasive PEEP-step method for separation of lung and chest wall mechanics","authors":"Ola Stenqvist","doi":"10.1186/s13054-024-05125-5","DOIUrl":null,"url":null,"abstract":"<p>In a recent pro/con review on transpulmonary pressure by Ball, Talmor and Pelosi [1], the authors describe in detail positioning, inflation, and calibration of the esophageal balloon catheter and different interpretations of absolute esophageal and transpulmonary pressure measurements. They also briefly describe the only method that does not require esophageal pressure for separation of lung and chest wall mechanics, the PEEP-step method (PSM). However, they dismiss PSM invoking completely erroneous assumptions that the method “assumes implicitly that the end-expiratory transpulmonary pressure estimated with esophageal manometry is zero regardless of the applied PEEP level”. But PEEP causes an increase in EELV, and during inflation of the lung, transpulmonary pressure increases in relation to the volume inflated and the elastic properties of the lung, ΔV × EL. In five successful PSM validation studies, based strictly on tidal airway and esophageal pressure variations [2,3,4,5,6], we have shown that calculated end-expiratory transpulmonary pressure (PLEE) increases as much as PEEP (= PAWEE) is increased. Consequently, the change in end-expiratory esophageal pressure, calculated as ΔPAWEE - ΔPLEE , is zero, which proves that the chest wall does not impede PEEP inflation and therefore lung elastance can be determined as ΔPEEP/ΔEELV. Thus, it is not transpulmonary pressure, but tidally calculated esophageal pressure that remains zero and the dismissal statement is completely erroneous and misleading.</p><p>In data on absolute esophageal and transpulmonary pressure from the Brochard group, analysis of tidal variation in esophageal and transpulmonary pressure fully confirms the validity of PSM (for details, see, Figs. S2, S3, S4 in e-supplement).</p><p>Below, I give a correct description of the background physiology, validation, mathematical derivation and measurement procedure of the PEEP-step method.</p><h3>Background physiology</h3><p>The PEEP step method (PSM) is a non-invasive, esophageal pressure free method for separation of lung and chest wall mechanics, based on the physiological conditions at functional residual capacity (FRC), where the contra-directional forces of the elastic recoil of the lung, striving to lower lung volume, and the rib cage spring out force, striving to expand the chest wall, balance each other. Thus, the chest wall complex does not lean on, or squeeze the lung at end-expiration at FRC. In case of a pneumothorax, the chest wall expands to 70–80% of total lung capacity (TLC). If end-expiratory lung volume instead is increased by PEEP, the rib cage spring out force will move the chest wall complex outwards in parallel with the lung volume increase, i.e., the ΔPEEP (= ΔPAWEE) of the ventilator only has to overcome the recoil of the lung. Consequently, the end-expiratory transpulmonary pressure (PLEE) will increase as much as PEEP is increased and EELV will increase in relation to the size of ΔPEEP and the elastic properties of the lung only, ΔPEEP/EL. Thus, if ΔEELV is determined by the ventilator pneumotachograph as the cumulative difference in expiratory tidal volume between PEEP levels, lung elastance can be calculated as ΔPEEP/ΔEELV. (for details on determination of ΔEELV by cumulative expiratory tidal volume, see e-supplement).</p><h3>Validation</h3><p>The effect of the expansive chest wall off-loading the chest wall from the lung during PEEP inflation was confirmed by comparing ΔEELV measured by pneumotachograph of the ventilator with ΔEELV calculated as ΔPEEP/EL, where EL is determined by esophageal pressure as the difference between tidal airway and esophageal pressure variations divided by the tidal volume, (ΔPAW-ΔPES)/VT). Cumulative measured ΔEELV and cumulative calculated ΔEELV = ΔPEEP/EL in pooled raw data from [3, 5, 6] correlated along the line of identity, y = 1.03x, R<sup>2</sup> = 0.86, i.e., showing that the chest wall does not impede PEEP inflation.</p><p>To show that this correlation is not a result of faulty tidal esophageal pressure measurements by the PSM group, the correlation between cumulative measured ΔEELV versus cumulative ΔEELV calculated as ΔPEEP/EL, and the correlation between cumulative ΔPEEP and cumulative ΔPLEE calculated as ΔEELVxEL, on mean data from the PSM validation studies, were combined with data from studies with first name Katz [7, 8], Falke [9], Garnero [10], Pelosi [11], and Gattinoni [12]. The two plots showed correlation along the line of identity (Figs. 1 and 2).</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"311\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig1_HTML.png\" width=\"685\"/></picture><p><i>Left panel</i>: Correlation plot of cumulative ΔEELV measured PEEP step by PEEP step by the ventilator pneumotachograph versus cumulative ΔEELV calculated PEEP step by PEEP step as ΔPEEP/EL in Katz I [7], Katz II [8], Falke [9], Persson [5], Lundin [3], Stenqvist [6], Garnero [10], Pelosi [11], Gattinoni [12]. EL in these studies ranged from 9 to 43 cmH<sub>2</sub>O/L and the ratio of EL/ERS ranged from 0.28 to 0.95. As the change in EELV is ΔPEEP/EL, lung elastance can be determined as ΔPEEP/ΔEELV, without esophageal pressure, by increasing PEEP and determine ΔEELV. <i>Right panel</i>: Correlation plot between cumulative ΔPEEP and cumulative ΔPLEE calculated as ΔEELV x EL, PEEP step by PEEP step in [3, 5,6,7,8,9,10,11,12], showing that PLEE increases as much as PEEP is increased. The transpulmonary driving pressure (ΔPL) of a tidal volume equal to ΔEELV is equal to ΔPEEP</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 2</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig2_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 2\" aria-describedby=\"Fig2\" height=\"231\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig2_HTML.png\" width=\"685\"/></picture><p><i>Left panel</i>: 44 PEEP steps with average ΔPEEP of 5.1 cmH<sub>2</sub>O, in the same studies as listed in Fig. 1. The increase in end-expiratory transpulmonary pressure is calculated as ΔEELV × EL, where EL = (ΔPAW − ΔPES)/VT. The change in end-expiratory esophageal pressure (ΔPPLEE) is calculated as ΔPEEP − ΔPLEE. <i>Right panel</i>: ΔPEEP compared to transpulmonary driving pressure (ΔPLconv determined by esophageal pressure) for a tidal volume equal to the PEEP-induced change in end-expiratory lung volume (VT = ΔEELV). Values divided into three groups according to the size ΔEELV and corresponding tidal volume. From validation study in supposedly lung healthy in the OR, with permission from Elsevier [5]</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><table><tbody><tr><td><p><b>Tidal pressure variations equations for separation of lung and chest wall mechanics used for validation of PSM</b></p></td></tr><tr><td><p>Airway driving pressure = ΔPAW</p></td></tr><tr><td><p>Esophageal driving pressure = ΔPES</p></td></tr><tr><td><p>Transpulmonary driving pressure = ΔPAW − ΔPES = ΔPL</p></td></tr><tr><td><p>Respiratory system elastance: ERS = ΔPAW/VT</p></td></tr><tr><td><p>Chest wall elastance: ECW = ΔPES/VT</p></td></tr><tr><td><p>Lung elastance: EL = ΔPL/VT = ERS − ECW</p></td></tr><tr><td><p>End-expiratory airway pressure: PAWEE = PEEP</p></td></tr><tr><td><p>End-expiratory lung volume change: ΔEELV = ΔPEEP/EL</p></td></tr><tr><td><p>End-expiratory transpulmonary pressure change: ΔPLEE = ΔEELV × EL</p></td></tr><tr><td><p>End-expiratory esophageal pressure change: ΔPESEE = ΔPAWEE − ΔPLEE</p></td></tr></tbody></table><h3>The mathematical derivation</h3><p>PES based lung elastance is</p><span>$${\\text{EL}} = \\Delta {\\text{PL}}/{\\text{VT}}$$</span><p>and PEEP based lung elastance is</p><span>$${\\text{EL}} = \\Delta {\\text{PEEP}}/\\Delta {\\text{EELV}}$$</span><p>Thus</p><span>$$\\Delta {\\text{PL}}/{\\text{VT}} = \\Delta {\\text{PEEP}}/\\Delta {\\text{EELV}}$$</span><p>when <span>\\(\\Delta {\\text{EELV}} = {\\text{VT}}\\)</span></p><span>$$\\Delta {\\text{PL}} = \\Delta {\\text{PEEP}}$$</span><p>Thus, the transpulmonary driving pressure of a tidal volume equal ΔEELV is equal to ΔPEEP. As also the increase in end-expiratory transpulmonary pressure (ΔPLEE) is equal to ΔPEEP, the transpulmonary pressure at a certain lung volume is the same, irrespective of whether this volume has been reached by tidal or PEEP inflation.</p><p>The increase in EELV during the first expiration after increasing PEEP, is.</p><p>ΔPEEP/ERS [13].</p><p>Total ΔEELV is</p><span>$$\\Delta {\\text{PEEP}}/{\\text{EL}}$$</span><p>The difference between these two volumes constitutes the second phase multi-breath phase of PEEP inflation, which is</p><span>$$\\left( {\\Delta {\\text{PEEP }} \\times {\\text{ ECW}}} \\right)/\\left( {{\\text{ERS }} \\times {\\text{ EL}}} \\right).$$</span><p>The increase in end-expiratory esophageal pressure during the first expiration is the first expiration volume times chest wall elastance,</p><span>$${\\text{ECW}}\\; \\times \\, \\Delta {\\text{PEEP/ERS}}$$</span><p>The corresponding increase in end-expiratory transpulmonary pressure is</p><span>$${\\text{EL }} \\times \\, \\Delta {\\text{PEEP/ERS}}$$</span><p>The increase in end-expiratory transpulmonary pressure during the second phase PEEP inflation is</p><span>$${\\text{EL }} \\times \\, \\left( {\\Delta {\\text{PEEP }} \\times {\\text{ ECW}}} \\right)/\\left( {{\\text{ERS }} \\times {\\text{ EL}}} \\right) \\, = {\\text{ECW }} \\times \\, \\Delta {\\text{PEEP/ERS}}$$</span><p>Thus, the increase in transpulmonary pressure during the second phase multi-breath increase in ΔEELV, is equal to the increase in end-expiratory esophageal pressure during the first expiration after increasing PEEP. This proves that the chest wall is off-loaded from the lung at end-expiration during PEEP inflation due to the spring out force of the rib cage.</p><p>The mathematical derivation is summarized in Figs. 3 and S1 of e-supplement.</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 3</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig3_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 3\" aria-describedby=\"Fig3\" height=\"226\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig3_HTML.png\" width=\"685\"/></picture><p><i>Left panel</i>: A PEEP step in isolated lung. Airway pressure (red arrow) is equal to transpulmonary pressure (blue arrow). The tidal volume from low PEEP is 500 ml and the ∆PAW is 10 cmH<sub>2</sub>O. Increasing PEEP with 10 cmH<sub>2</sub>O, results in an increase in EELV with 500 ml. The end-inspiratory transpulmonary (= airway) P/V point from the low PEEP is equal to the end-expiratory transpulmonary (= airway) P/V point at the high PEEP (indicated by blue ring). Lung elastance is ∆PAW/VT and ∆PEEP/∆EELV in an isolated lung. <i>Right panel</i>: PEEP step in situ. The tidal volume from the low PEEP level is equal to the PEEP induced end-expiratory lung volume change. The end-inspiratory airway plateau pressure from ZEEP is right shifted (black arrow) from the position in isolated lung (blue ring). The difference between end-inspiratory plateau pressure of the tidal volume from the low PEEP level and the end-expiratory transpulmonary pressure at the high PEEP level is equal to tidal pleural pressure variation (green arrow, ΔPPL). The transpulmonary plateau pressure of the tidal volume from ZEEP is equal to the end-expiratory transpulmonary pressure at the high PEEP, 10 cmH<sub>2</sub>O</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><p>PEEP is increased by a default value of 70% of the airway driving pressure at baseline PEEP as the average ratio of EL/ERS (ΔPL/ΔAW) is ≈ 0.70, and ΔEELV will therefore on average be equal to the tidal volume. ΔEELV is determined as the cumulative difference in expiratory tidal volume between the PEEP levels and lung elastance is calculated as ΔPEEP/ΔEELV. Transpulmonary driving pressure is calculated as PSM derived EL times tidal volume. The whole procedure is 1.5–2 min (Fig. 3).</p><p>To account for the non-linearity of the lung pressure/volume curve, a two PEEP-step procedure is required to assess the curve from end-expiration at baseline PEEP to end-inspiratory plateau pressure at the highest PEEP level. A two-degree polynomial is fitted to three end-expiratory airway P/V points and the end-inspiratory transpulmonary P/V point at the highest PEEP level of the procedure is estimated based on tidal pleural pressure variation extrapolated from the two lower PEEP (Fig. 4).</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 4</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig4_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 4\" aria-describedby=\"Fig4\" height=\"202\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig4_HTML.png\" width=\"685\"/></picture><p><i>Left panel</i>: The lung P/V curve (blue) determined by a two PEEP-step procedure. Tidal airway P/V curves at three PEEP levels (red arrows). The pressure difference between the end-inspiratory airway plateau pressure and the transpulmonary pressure at the same volume level, i.e., the tidal variation in pleural pressure, is determined for each of the two lowest PEEP levels. The transpulmonary plateau pressure at the highest PEEP level is estimated by extrapolation the tidal pleural pressure variations at the two lower PEEP levels. The transpulmonary plateau pressure at the highest PEEP level is then calculated as the airway plateau pressure minus the extrapolated pleural pressure variation [14]. The difference between estimated transpulmonary plateau pressure and plateau pressure by esophageal pressure measurements were 0.2 ± 1.4 and 0.1 ± 0.8 cmH<sub>2</sub>O in ARF patients in the ICU and lung heathy in the OR, respectively [14, 15]. <i>Right panel</i>: Optimal PEEP, i.e. the PEEP level providing the lowest transpulmonary driving pressure, can be determined <i>by identifying the steepest point of the curve as the root of the second derivative of the polynomial and distributing the requested tidal volume symmetrically around this P/V point </i>[14]<i>.</i> The pressure corresponding to the end-expiratory volume can be calculated from the polynomial. This now calculated pressure is the optimal mechanical PEEP</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><p>As a tidal lung P/V curve, irrespective of volume and PEEP level, is superimposed on the total lung P/V curve, the transpulmonary driving pressure and plateau pressure of any combination of PEEP and tidal volume can be calculated from the equation for the lung P/V curve. This makes it possible to estimate the mechanical consequences of any combination of PEEP and tidal volume and identify risk of ventilator induced lung injury (VILI) and when more aggressive settings can be used to avoid ECMO treatment without risking VILI (Fig. 5).</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 5</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig5_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 5\" aria-describedby=\"Fig5\" height=\"240\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs13054-024-05125-5/MediaObjects/13054_2024_5125_Fig5_HTML.png\" width=\"685\"/></picture><p>Best fit lung P/V curve (light gray) of PEEP non-responder and responder with overall lung compliance (CLoa) of 54 and 112 ml/cmH<sub>2</sub>O, respectively [14]. Tidal lung P/V curves (blue arrows) for a VT of 6 ml/kg IBW (500 ml in a patient with 70 kg IBW) at PEEP 8 and 13 cmH<sub>2</sub>O superimposed on total lung P/V curve (light grey curve). In the non-responder, transpulmonary driving pressure increases to close to the upper safety limit when PEEP is increased by 5 cmH<sub>2</sub>O. In the responder, transpulmonary driving pressure falls from a moderate level to a low level as lung compliance increases with increasing PEEP</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><table><tbody><tr><td><p><b>PEEP-step method to determine transpulmonary pressure</b></p></td></tr><tr><td><p><i>Pro</i>: Validated and mathematically derived background physiology. Non-invasive, full PEEEP-trial, including ΔEELV, and optimal PEEP with lowest transpulmonary driving pressure determined in 3–4 min by a two PEEP-step procedure</p></td></tr><tr><td><p><i>Con</i>: Transpulmonary plateau pressure at highest PEEP level estimated by extrapolation of tidal pleural pressure variations from lower PEEP levels</p></td></tr></tbody></table><p>No datasets were generated or analysed during the current study.</p><ol data-track-component=\"outbound reference\" data-track-context=\"references section\"><li data-counter=\"1.\"><p>Ball L, Talmor D, Pelosi P. Transpulmonary pressure monitoring in critically ill patients: pros and cons. Crit Care. 2024;28(1):177.</p><p>Article PubMed PubMed Central Google Scholar </p></li><li data-counter=\"2.\"><p>Gudmundsson M, Persson P, Perchiazzi G, Lundin S, Rylander C. Transpulmonary driving pressure during mechanical ventilation-validation of a non-invasive measurement method. Acta Anaesthesiol Scand. 2020;64(2):211–5.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"3.\"><p>Lundin S, Grivans C, Stenqvist O. Transpulmonary pressure and lung elastance can be estimated by a PEEP-step manoeuvre. Acta Anaesthesiol Scand. 2015;59(2):185–96.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"4.\"><p>Persson P, Lundin S, Stenqvist O. Transpulmonary and pleural pressure in a respiratory system model with an elastic recoiling lung and an expanding chest wall. Intensive Care Med Exp. 2016;4(1):26.</p><p>Article PubMed PubMed Central Google Scholar </p></li><li data-counter=\"5.\"><p>Persson P, Stenqvist O, Lundin S. Evaluation of lung and chest wall mechanics during anaesthesia using the PEEP-step method. Br J Anaesth. 2018;120(4):860–7.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"6.\"><p>Stenqvist O, Grivans C, Andersson B, Lundin S. Lung elastance and transpulmonary pressure can be determined without using oesophageal pressure measurements. Acta Anaesthesiol Scand. 2012;56(6):738–47.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"7.\"><p>Katz JA, Ozanne GM, Zinn SE, Fairley HB. Time course and mechanisms of lung-volume increase with PEEP in acute pulmonary failure. Anesthesiology. 1981;54(1):9–16.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"8.\"><p>Katz JA, Zinn SE, Ozanne GM, Fairley HB. Pulmonary, chest wall, and lung-thorax elastances in acute respiratory failure. Chest. 1981;80(3):304–11.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"9.\"><p>Falke KJ, Pontoppidan H, Kumar A, Leith DE, Geffin B, Laver MB. Ventilation with end-expiratory pressure in acute lung disease. J Clin Investig. 1972;51(9):2315–23.</p><p>Article PubMed PubMed Central Google Scholar </p></li><li data-counter=\"10.\"><p>Garnero A, Tuxen D, Ducros L, Demory D, Donati SY, Durand-Gasselin J, Cooper J, Hodgson C, Arnal JM. Non-invasive assessment of lung elastance in patients with acute respiratory distress syndrome. Minerva Anestesiol. 2015;81(10):1096–104.</p><p>PubMed Google Scholar </p></li><li data-counter=\"11.\"><p>Pelosi P, Cereda M, Foti G, Giacomini M, Pesenti A. Alterations of lung and chest wall mechanics in patients with acute lung injury: effects of positive end-expiratory pressure. Am J Respir Crit Care Med. 1995;152(2):531–7.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"12.\"><p>Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Amer J Respir Crit Care Med. 1998;158(1):3–11.</p><p>Article Google Scholar </p></li><li data-counter=\"13.\"><p>Dellamonica J, Lerolle N, Sargentini C, Beduneau G, Di Marco F, Mercat A, Richard JC, Diehl JL, Mancebo J, Rouby JJ, et al. PEEP-induced changes in lung volume in acute respiratory distress syndrome. Two methods to estimate alveolar recruitment. Intensive Care Med. 2011;37(10):1595–604.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"14.\"><p>Grivans C, Stenqvist O. Gas distribution by EIT during PEEP inflation: PEEP response and optimal PEEP with lowest trans-pulmonary driving pressure can be determined without esophageal pressure during a rapid PEEP trial in patients with acute respiratory failure. Physiol Meas. 2022;43(11):114001.</p><p>Article Google Scholar </p></li><li data-counter=\"15.\"><p>Persson P, Stenqvist O. Protective positive end-expiratory pressure and tidal volume adapted to lung compliance determined by a rapid positive end-expiratory pressure-step procedure in the operating theatre: a post hoc analysis. Br J Anaesth. 2022;128(4):e284–6.</p><p>Article PubMed Google Scholar </p></li></ol><p>Download references<svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></p><p>None</p><p>No funding.</p><h3>Authors and Affiliations</h3><ol><li><p>Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden</p><p>Ola Stenqvist</p></li></ol><span>Authors</span><ol><li><span>Ola Stenqvist</span>View author publications<p>You can also search for this author in <span>PubMed<span> </span>Google Scholar</span></p></li></ol><h3>Contributions</h3><p>OS wrote the manuscript and prepared the figures.</p><h3>Corresponding author</h3><p>Correspondence to Ola Stenqvist.</p><h3>Ethics approval and consent to participate</h3>\n<p>Not applicable.</p>\n<h3>Consent for publication</h3>\n<p>Not applicable.</p>\n<h3>Competing interests</h3>\n<p>OS holds shares in the Lung Barometry AB (LBAB), which owns the commercial rights to the PSM technology. LBAB has recently entered into an agreement to commercialize the PEEP-step method with a Med Tech company.</p><h3>Publisher's Note</h3><p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p><h3>Supplementary Material 1.</h3><p><b>Open Access</b> This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. 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Transpulmonary pressure monitoring in critically ill patients: pros and cons—correction of description of the non-invasive PEEP-step method for separation of lung and chest wall mechanics. <i>Crit Care</i> <b>28</b>, 355 (2024). https://doi.org/10.1186/s13054-024-05125-5</p><p>Download citation<svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></p><ul data-test=\"publication-history\"><li><p>Received<span>: </span><span><time datetime=\"2024-09-30\">30 September 2024</time></span></p></li><li><p>Accepted<span>: </span><span><time datetime=\"2024-10-06\">06 October 2024</time></span></p></li><li><p>Published<span>: </span><span><time datetime=\"2024-11-04\">04 November 2024</time></span></p></li><li><p>DOI</abbr><span>: </span><span>https://doi.org/10.1186/s13054-024-05125-5</span></p></li></ul><h3>Share this article</h3><p>Anyone you share the following link with will be able to read this content:</p><button data-track=\"click\" data-track-action=\"get shareable link\" data-track-external=\"\" data-track-label=\"button\" type=\"button\">Get shareable link</button><p>Sorry, a shareable link is not currently available for this article.</p><p data-track=\"click\" data-track-action=\"select share url\" data-track-label=\"button\"></p><button data-track=\"click\" data-track-action=\"copy share url\" data-track-external=\"\" data-track-label=\"button\" type=\"button\">Copy to clipboard</button><p> Provided by the Springer Nature SharedIt content-sharing initiative </p>","PeriodicalId":10811,"journal":{"name":"Critical Care","volume":null,"pages":null},"PeriodicalIF":8.8000,"publicationDate":"2024-11-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Critical Care","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1186/s13054-024-05125-5","RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q1","JCRName":"CRITICAL CARE MEDICINE","Score":null,"Total":0}
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Abstract
In a recent pro/con review on transpulmonary pressure by Ball, Talmor and Pelosi [1], the authors describe in detail positioning, inflation, and calibration of the esophageal balloon catheter and different interpretations of absolute esophageal and transpulmonary pressure measurements. They also briefly describe the only method that does not require esophageal pressure for separation of lung and chest wall mechanics, the PEEP-step method (PSM). However, they dismiss PSM invoking completely erroneous assumptions that the method “assumes implicitly that the end-expiratory transpulmonary pressure estimated with esophageal manometry is zero regardless of the applied PEEP level”. But PEEP causes an increase in EELV, and during inflation of the lung, transpulmonary pressure increases in relation to the volume inflated and the elastic properties of the lung, ΔV × EL. In five successful PSM validation studies, based strictly on tidal airway and esophageal pressure variations [2,3,4,5,6], we have shown that calculated end-expiratory transpulmonary pressure (PLEE) increases as much as PEEP (= PAWEE) is increased. Consequently, the change in end-expiratory esophageal pressure, calculated as ΔPAWEE - ΔPLEE , is zero, which proves that the chest wall does not impede PEEP inflation and therefore lung elastance can be determined as ΔPEEP/ΔEELV. Thus, it is not transpulmonary pressure, but tidally calculated esophageal pressure that remains zero and the dismissal statement is completely erroneous and misleading.
In data on absolute esophageal and transpulmonary pressure from the Brochard group, analysis of tidal variation in esophageal and transpulmonary pressure fully confirms the validity of PSM (for details, see, Figs. S2, S3, S4 in e-supplement).
Below, I give a correct description of the background physiology, validation, mathematical derivation and measurement procedure of the PEEP-step method.
Background physiology
The PEEP step method (PSM) is a non-invasive, esophageal pressure free method for separation of lung and chest wall mechanics, based on the physiological conditions at functional residual capacity (FRC), where the contra-directional forces of the elastic recoil of the lung, striving to lower lung volume, and the rib cage spring out force, striving to expand the chest wall, balance each other. Thus, the chest wall complex does not lean on, or squeeze the lung at end-expiration at FRC. In case of a pneumothorax, the chest wall expands to 70–80% of total lung capacity (TLC). If end-expiratory lung volume instead is increased by PEEP, the rib cage spring out force will move the chest wall complex outwards in parallel with the lung volume increase, i.e., the ΔPEEP (= ΔPAWEE) of the ventilator only has to overcome the recoil of the lung. Consequently, the end-expiratory transpulmonary pressure (PLEE) will increase as much as PEEP is increased and EELV will increase in relation to the size of ΔPEEP and the elastic properties of the lung only, ΔPEEP/EL. Thus, if ΔEELV is determined by the ventilator pneumotachograph as the cumulative difference in expiratory tidal volume between PEEP levels, lung elastance can be calculated as ΔPEEP/ΔEELV. (for details on determination of ΔEELV by cumulative expiratory tidal volume, see e-supplement).
Validation
The effect of the expansive chest wall off-loading the chest wall from the lung during PEEP inflation was confirmed by comparing ΔEELV measured by pneumotachograph of the ventilator with ΔEELV calculated as ΔPEEP/EL, where EL is determined by esophageal pressure as the difference between tidal airway and esophageal pressure variations divided by the tidal volume, (ΔPAW-ΔPES)/VT). Cumulative measured ΔEELV and cumulative calculated ΔEELV = ΔPEEP/EL in pooled raw data from [3, 5, 6] correlated along the line of identity, y = 1.03x, R2 = 0.86, i.e., showing that the chest wall does not impede PEEP inflation.
To show that this correlation is not a result of faulty tidal esophageal pressure measurements by the PSM group, the correlation between cumulative measured ΔEELV versus cumulative ΔEELV calculated as ΔPEEP/EL, and the correlation between cumulative ΔPEEP and cumulative ΔPLEE calculated as ΔEELVxEL, on mean data from the PSM validation studies, were combined with data from studies with first name Katz [7, 8], Falke [9], Garnero [10], Pelosi [11], and Gattinoni [12]. The two plots showed correlation along the line of identity (Figs. 1 and 2).
Tidal pressure variations equations for separation of lung and chest wall mechanics used for validation of PSM
Thus, the transpulmonary driving pressure of a tidal volume equal ΔEELV is equal to ΔPEEP. As also the increase in end-expiratory transpulmonary pressure (ΔPLEE) is equal to ΔPEEP, the transpulmonary pressure at a certain lung volume is the same, irrespective of whether this volume has been reached by tidal or PEEP inflation.
The increase in EELV during the first expiration after increasing PEEP, is.
ΔPEEP/ERS [13].
Total ΔEELV is
$$\Delta {\text{PEEP}}/{\text{EL}}$$
The difference between these two volumes constitutes the second phase multi-breath phase of PEEP inflation, which is
Thus, the increase in transpulmonary pressure during the second phase multi-breath increase in ΔEELV, is equal to the increase in end-expiratory esophageal pressure during the first expiration after increasing PEEP. This proves that the chest wall is off-loaded from the lung at end-expiration during PEEP inflation due to the spring out force of the rib cage.
The mathematical derivation is summarized in Figs. 3 and S1 of e-supplement.
PEEP is increased by a default value of 70% of the airway driving pressure at baseline PEEP as the average ratio of EL/ERS (ΔPL/ΔAW) is ≈ 0.70, and ΔEELV will therefore on average be equal to the tidal volume. ΔEELV is determined as the cumulative difference in expiratory tidal volume between the PEEP levels and lung elastance is calculated as ΔPEEP/ΔEELV. Transpulmonary driving pressure is calculated as PSM derived EL times tidal volume. The whole procedure is 1.5–2 min (Fig. 3).
To account for the non-linearity of the lung pressure/volume curve, a two PEEP-step procedure is required to assess the curve from end-expiration at baseline PEEP to end-inspiratory plateau pressure at the highest PEEP level. A two-degree polynomial is fitted to three end-expiratory airway P/V points and the end-inspiratory transpulmonary P/V point at the highest PEEP level of the procedure is estimated based on tidal pleural pressure variation extrapolated from the two lower PEEP (Fig. 4).
As a tidal lung P/V curve, irrespective of volume and PEEP level, is superimposed on the total lung P/V curve, the transpulmonary driving pressure and plateau pressure of any combination of PEEP and tidal volume can be calculated from the equation for the lung P/V curve. This makes it possible to estimate the mechanical consequences of any combination of PEEP and tidal volume and identify risk of ventilator induced lung injury (VILI) and when more aggressive settings can be used to avoid ECMO treatment without risking VILI (Fig. 5).
PEEP-step method to determine transpulmonary pressure
Pro: Validated and mathematically derived background physiology. Non-invasive, full PEEEP-trial, including ΔEELV, and optimal PEEP with lowest transpulmonary driving pressure determined in 3–4 min by a two PEEP-step procedure
Con: Transpulmonary plateau pressure at highest PEEP level estimated by extrapolation of tidal pleural pressure variations from lower PEEP levels
No datasets were generated or analysed during the current study.
Ball L, Talmor D, Pelosi P. Transpulmonary pressure monitoring in critically ill patients: pros and cons. Crit Care. 2024;28(1):177.
Article PubMed PubMed Central Google Scholar
Gudmundsson M, Persson P, Perchiazzi G, Lundin S, Rylander C. Transpulmonary driving pressure during mechanical ventilation-validation of a non-invasive measurement method. Acta Anaesthesiol Scand. 2020;64(2):211–5.
Article PubMed Google Scholar
Lundin S, Grivans C, Stenqvist O. Transpulmonary pressure and lung elastance can be estimated by a PEEP-step manoeuvre. Acta Anaesthesiol Scand. 2015;59(2):185–96.
Article PubMed Google Scholar
Persson P, Lundin S, Stenqvist O. Transpulmonary and pleural pressure in a respiratory system model with an elastic recoiling lung and an expanding chest wall. Intensive Care Med Exp. 2016;4(1):26.
Article PubMed PubMed Central Google Scholar
Persson P, Stenqvist O, Lundin S. Evaluation of lung and chest wall mechanics during anaesthesia using the PEEP-step method. Br J Anaesth. 2018;120(4):860–7.
Article PubMed Google Scholar
Stenqvist O, Grivans C, Andersson B, Lundin S. Lung elastance and transpulmonary pressure can be determined without using oesophageal pressure measurements. Acta Anaesthesiol Scand. 2012;56(6):738–47.
Article PubMed Google Scholar
Katz JA, Ozanne GM, Zinn SE, Fairley HB. Time course and mechanisms of lung-volume increase with PEEP in acute pulmonary failure. Anesthesiology. 1981;54(1):9–16.
Article PubMed Google Scholar
Katz JA, Zinn SE, Ozanne GM, Fairley HB. Pulmonary, chest wall, and lung-thorax elastances in acute respiratory failure. Chest. 1981;80(3):304–11.
Article PubMed Google Scholar
Falke KJ, Pontoppidan H, Kumar A, Leith DE, Geffin B, Laver MB. Ventilation with end-expiratory pressure in acute lung disease. J Clin Investig. 1972;51(9):2315–23.
Article PubMed PubMed Central Google Scholar
Garnero A, Tuxen D, Ducros L, Demory D, Donati SY, Durand-Gasselin J, Cooper J, Hodgson C, Arnal JM. Non-invasive assessment of lung elastance in patients with acute respiratory distress syndrome. Minerva Anestesiol. 2015;81(10):1096–104.
PubMed Google Scholar
Pelosi P, Cereda M, Foti G, Giacomini M, Pesenti A. Alterations of lung and chest wall mechanics in patients with acute lung injury: effects of positive end-expiratory pressure. Am J Respir Crit Care Med. 1995;152(2):531–7.
Article PubMed Google Scholar
Gattinoni L, Pelosi P, Suter PM, Pedoto A, Vercesi P, Lissoni A. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes? Amer J Respir Crit Care Med. 1998;158(1):3–11.
Article Google Scholar
Dellamonica J, Lerolle N, Sargentini C, Beduneau G, Di Marco F, Mercat A, Richard JC, Diehl JL, Mancebo J, Rouby JJ, et al. PEEP-induced changes in lung volume in acute respiratory distress syndrome. Two methods to estimate alveolar recruitment. Intensive Care Med. 2011;37(10):1595–604.
Article PubMed Google Scholar
Grivans C, Stenqvist O. Gas distribution by EIT during PEEP inflation: PEEP response and optimal PEEP with lowest trans-pulmonary driving pressure can be determined without esophageal pressure during a rapid PEEP trial in patients with acute respiratory failure. Physiol Meas. 2022;43(11):114001.
Article Google Scholar
Persson P, Stenqvist O. Protective positive end-expiratory pressure and tidal volume adapted to lung compliance determined by a rapid positive end-expiratory pressure-step procedure in the operating theatre: a post hoc analysis. Br J Anaesth. 2022;128(4):e284–6.
Article PubMed Google Scholar
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Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
Ola Stenqvist
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OS wrote the manuscript and prepared the figures.
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OS holds shares in the Lung Barometry AB (LBAB), which owns the commercial rights to the PSM technology. LBAB has recently entered into an agreement to commercialize the PEEP-step method with a Med Tech company.
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Stenqvist, O. Transpulmonary pressure monitoring in critically ill patients: pros and cons—correction of description of the non-invasive PEEP-step method for separation of lung and chest wall mechanics. Crit Care28, 355 (2024). https://doi.org/10.1186/s13054-024-05125-5
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DOI: https://doi.org/10.1186/s13054-024-05125-5
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由于 EELV 的变化为 ΔPEEP/EL,因此在不考虑食管压力的情况下,可通过增加 PEEP 并确定 ΔEELV 来确定肺弹性为 ΔPEEP/ΔEELV。右图:累积 ΔPEEP 和累积 ΔPLEE 之间的相关图,计算公式为 ΔEELV x EL,[3,5,6,7,8,9,10,11,12]中逐级 PEEP,显示 PLEE 随 PEEP 的增加而增加。潮气量等于 ΔEELV 时的跨肺驱动压(ΔPL)等于 ΔPEEPFull size image图 2左侧面板:44 个 PEEP 步骤,平均 ΔPEEP 为 5.1 cmH2O,与图 1 中列出的研究相同。呼气末跨肺压的增加按 ΔEELV × EL 计算,其中 EL = (ΔPAW - ΔPES)/VT。呼气末食管压力变化(ΔPPLEE)的计算公式为 ΔPEEP - ΔPLEE。右图:在潮气量等于 PEEP 引起的呼气末肺容量变化(VT = ΔEELV)时,ΔPEEP 与跨肺驱动压力(由食管压力确定的 ΔPLconv)的比较。根据 ΔEELV 和相应潮气量的大小将数值分为三组。全尺寸图片潮气压力变化方程用于分离肺和胸壁力学,用于验证 PSMA 气道驱动压力 = ΔPAWE 食管驱动压力 = ΔPEST 肺驱动压力 = ΔPAW - ΔPES = ΔPL呼吸系统弹性:ERS = ΔPAW/VTC 胸壁弹性:ECW = ΔPES/VTLung elastance:EL = ΔPL/VT = ERS - ECWE呼气末气道压力:PAWEE = PEEP末期呼气肺容积变化:ΔEELV = ΔPEEP/ELE 末期呼气跨肺压力变化:ΔPLEE = ΔEELV × ELE末期呼气食管压力变化:ΔPESEE = ΔPAWEE - ΔPLEET数学推导基于PES的肺弹性为$${text{EL}} = \Delta {\text{PL}}/{\text{VT}}$ 而基于PEEP的肺弹性为$${\text{EL}} = \Delta {\text{PL}}/{text{VT}}$因此${text{PL}}/{text{VT}} = \Delta {text{PEEP}}/\Delta {text{EELV}}$Thus$\Delta {text{PL}}/{text{VT}} = \Delta {text{PEEP}}/\Delta {text{EELV}}$(\△{text{EELV}}={\text{VT}}\)$$△{text{PL}}=\△{text{PEEP}}$$因此、潮气量等于 ΔEELV 时的跨肺驱动压等于 ΔPEEP。由于呼气末跨肺压力(ΔPLEE)的增加也等于ΔPEEP,因此在一定肺容量下的跨肺压力是相同的,无论该肺容量是通过潮气量还是 PEEP 充气达到的。ΔEELV的总和为$$Δ{text/{PEEP}}/{text{EL}}$这两个体积之差构成了PEEP膨胀的第二阶段多呼阶段,即$$left( {\Δ{text{PEEP }} \times {\{text{ ECW}}} \right)/left( {{text{ERS }} \times {\{text{ EL}}} \right)。\times \, \Delta {text/{PEEP/ERS}}$第二阶段 PEEP 充气期间呼气末转肺压的增加值为$${text{EL }}\times \, \left( {\Delta {text{PEEP }} \times {\text{ ECW}}} \right)/\left( {{\text{ERS }} \times {\text{ EL}}} \right) \, = {\text{ECW }}\因此,在 ΔEELV 增加的第二阶段多呼期间,跨肺压的增加等于增加 PEEP 后第一次呼气期间呼气末食管压的增加。这证明了在 PEEP 充气过程中,由于肋骨的弹出力,胸壁在呼气末从肺部卸载。图 3 左侧面板:离体肺中的 PEEP 步骤。气道压力(红色箭头)等于跨肺压力(蓝色箭头)。低 PEEP 时的潮气量为 500 毫升,ΔPAW 为 10 cmH2O。增加 PEEP 10 cmH2O 会导致 EELV 增加 500 毫升。低 PEEP 时的吸气末转肺(= 气道)P/V 点等于高 PEEP 时的呼气末转肺(= 气道)P/V 点(蓝色环表示)。在孤立肺中,肺弹性为 ∆PAW/VT 和 ∆PEEP/ ∆EELV。右图:原位 PEEP 阶跃。低 PEEP 水平的潮气量等于 PEEP 引起的呼气末肺容积变化。来自 ZEEP 的吸气末气道平台压力与离体肺的位置(蓝色环)相比右移(黑色箭头)。低 PEEP 水平的潮气量吸气末高原压与高 PEEP 水平的呼气末跨肺压之差等于潮气胸膜压变化(绿色箭头,ΔPPL)。 由于 EL/ERS 的平均比率(ΔPL/ΔAW)≈ 0.70,因此ΔEELV 平均等于潮气量。ΔEELV 是根据 PEEP 水平之间呼气潮气量的累积差值确定的,肺弹性的计算公式为 ΔPEEP/ΔEELV。跨肺驱动压力的计算公式为 PSM 导出 EL 乘以潮气量。为了考虑肺压/容积曲线的非线性,需要采用两级 PEEP 程序来评估从基线 PEEP 时的呼气末到最高 PEEP 水平时的吸气末高原压力曲线。根据两个较低 PEEP 推断出的潮气胸膜压力变化,对三个呼气末气道 P/V 点进行两度多项式拟合,并估算出程序中最高 PEEP 水平时的吸气末跨肺 P/V 点(图 4):通过两级 PEEP 程序确定的肺 P/V 曲线(蓝色)。三个 PEEP 水平下的潮气道 P/V 曲线(红色箭头)。在两个最低 PEEP 水平下,分别确定吸气末气道高原压与同一容积水平下的肺转压之间的压力差,即胸膜压力的潮气变化。最高 PEEP 水平下的跨肺高原压是根据两个较低 PEEP 水平下的潮气胸膜压力变化推算出来的。最高 PEEP 水平下的跨肺高原压计算方法为气道高原压减去外推胸膜压力变化[14]。在重症监护室的 ARF 患者和手术室的肺热患者中,估计的跨肺高原压与食管压力测量的高原压之间的差异分别为 0.2 ± 1.4 和 0.1 ± 0.8 cmH2O [14,15]。右图:最佳 PEEP,即提供最低跨肺驱动压力的 PEEP 水平,可通过将曲线最陡峭的点确定为多项式二次导数的根,并将所需潮气量对称分布在该 P/V 点周围来确定[14]。根据多项式可以计算出呼气末容积对应的压力。由于潮气量肺 P/V 曲线(与容量和 PEEP 水平无关)叠加在总肺 P/V 曲线上,因此可以根据肺 P/V 曲线方程计算出任何 PEEP 和潮气量组合的跨肺驱动压力和高原压力。这样就可以估计 PEEP 和潮气量任何组合的机械后果,并确定呼吸机诱发肺损伤(VILI)的风险,以及何时可以使用更积极的设置来避免 ECMO 治疗,而不会有 VILI 的风险(图 5)。图 5 PEEP 无反应者和反应者的最佳拟合肺 P/V 曲线(浅灰色),肺总顺应性(CLoa)分别为 54 和 112 ml/cmH2O[14]。在 PEEP 为 8 和 13 cmH2O 时,VT 为 6 毫升/千克 IBW(70 千克 IBW 患者为 500 毫升)时的潮气肺 P/V 曲线(蓝色箭头)与总肺 P/V 曲线(浅灰色曲线)叠加。在无反应的情况下,当 PEEP 增加 5 cmH2O 时,跨肺驱动压力增加到接近安全上限。在有反应者中,随着肺顺应性随 PEEP 的增加而增加,转肺驱动压力从中等水平降至较低水平:经过验证和数学推导的背景生理学。Con: 通过对较低 PEEP 水平的潮气胸膜压力变化进行外推估计出最高 PEEP 水平的跨肺高原压力在当前研究中未生成或分析数据集。Crit Care.2024; 28(1):177.Article PubMed PubMed Central Google Scholar Gudmundsson M, Persson P, Perchiazzi G, Lundin S, Rylander C. Transpulmonary driving pressure during mechanical ventilation-validation of a non-invasive measurement method.Acta Anaesthesiol Scand.2020; 64(2):211-5.Article PubMed Google Scholar Lundin S, Grivans C, Stenqvist O. Transpulmonary pressure and lung elastance can be estimated by a PEEP-step manoeuvre.Acta Anaesthesiol Scand.2015;59(2):185-96.Article PubMed Google Scholar Persson P, Lundin S, Stenqvist O. Transpulmonary and pleural pressure in a respiratory system model with an elastic recoiling lung and an expanding chest wall. 1186/s13054-024-05125-5Download citationReceived:30 September 2024Accepted:06 October 2024Published: 04 November 2024DOI: https://doi.org/10.1186/s13054-024-05125-5Share this articleAnyone you share with the following link will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard Provided by the Springer Nature SharedIt content-sharing initiative
期刊介绍:
Critical Care is an esteemed international medical journal that undergoes a rigorous peer-review process to maintain its high quality standards. Its primary objective is to enhance the healthcare services offered to critically ill patients. To achieve this, the journal focuses on gathering, exchanging, disseminating, and endorsing evidence-based information that is highly relevant to intensivists. By doing so, Critical Care seeks to provide a thorough and inclusive examination of the intensive care field.