Ventilator management using esophageal balloon pressure measurements

Cristina Morataya MD, MPH, Sabiha Armin BS, Kenneth Nugent MD


Mechanical ventilation provides essential support for patients with acute respiratory failure and provides time for these patients to recover from the primary disorder. Ventilator strategies need to provide adequate oxygenation and avoid barotrauma. This trauma develops when some regions of the lungs are overinflated and develops when some regions are underinflated and have cyclical opening and closing during the respiratory cycle. The ARDS network trial demonstrated that a low tidal volume and low pressure strategy improved outcomes. Subsequent trials have tried to determine the optimal PEEP level in patients with moderate to severe ARDS. The use of esophageal balloons provides information about the transpulmonary pressure at the end of inspiration and the transpulmonary pressure at the end of expiration. However, available studies to date do not demonstrate a definite improvement in outcomes in patients with ventilator adjustments based on esophageal pressures. Beitler et al. randomized 200 patients with moderate to severe ARDS into one group in which PEEP titration was based on esophageal balloon pressure measurements, and a second group in which PEEP titration was based on a high FiO2/PEEP table studied in earlier trials. There were no differences in mortality between the two groups. Reanalysis of this information after the trial was completed suggested that transpulmonary pressures in the range of −2 to +2 cm H2O at the end of expiration were associated with improved outcomes compared to pressures outside that range. Two trials have studied lung recruitment maneuvers with PEEP adjustments based on optimal compliance levels or on the PEEP level at which desaturation occurred; neither approach improved outcomes. Mechanical ventilation strategies based on the underlying pathophysiology provide clinicians with a better understanding of lung disease and the hazards of mechanical ventilation. However, recent trials have not identified new strategies which reduce mortality.

Keywords: Mechanical ventilation, pleural pressure, esophageal balloon, PEEP, transpulmonary pressure

Article citation: Morataya C, Armin S, Nugent K. Ventilator management using esophageal balloon pressure measurements. The Southwest Respiratory and Critical Care Chronicles 2022;10(43):18–25
From: Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, Texas
Submitted: 4/1/2022
Accepted: 4/9/2022
Conflicts of interest: none
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