title: Should mechanical ventilation be guided by esophageal pressure measurements?
abstract: OBJECTIVE
  Despite the well recognized role of mechanical ventilation in lung injury, appropriate surrogate markers to guide titration of ventilator settings remain elusive. One would like to strike a balance between protecting aerated units from overdistension while recruiting unstable units, thereby reducing tissue damage associated with their cyclic recruitment and derecruitment. To do so requires some estimate of the topographical distribution of parenchymal stress and strain.
  
  
  RESULTS
  Recent studies have highlighted the importance of chest wall recoil and its effect on pleural pressure (Ppl) in determining lung stress. Although esophageal pressure (Pes) has traditionally been used to measure the average Ppl in normal upright patients, in recumbent acute lung injury/acute respiratory distress syndrome patients Pes-based estimates of Ppl are subject to untestable assumptions. Nevertheless, Pes measurements in recumbent patients with injured lungs strongly suggest that Ppl over dependent parts of the lung can exceed airway pressure by substantial amounts. Moreover, results of a pilot study in which Pes was used to titrate positive end-expiratory pressure (PEEP) suggest clinical benefit.
  
  
  CONCLUSIONS
  Notwithstanding its theoretical limitations, esophageal manometry has shown promise in PEEP titration and deserves further evaluation in a larger trial on patients with injured lungs.
authors.affiliation: Thoracic Diseases Research Unit, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
authors.forename: Maria
authors.initials: M
authors.lastname: Plataki
authors.forename: Rolf D
authors.initials: RD
authors.lastname: Hubmayr
mesh_terms: D000399:Air Pressure; D015415:Biomarkers; D004947:Esophagus / Q000502:physiology*; D006801:Humans; D008991:Monitoring, Physiologic / Q000379:methods; D012121:Respiration, Artificial / Q000379:methods* / Q000592:standards; D055397:Ventilator-Induced Lung Injury / Q000517:prevention & control
chemical_list: D015415:Biomarkers