Targeting transpulmonary pressure to prevent ventilator-induced lung injury

ABSTRACT

Introduction: Transpulmonary pressure (PL) is the pressure distending the lung. This pressure equals the stress which develops into the parenchyma at each insufflation and it depends, for a given airway pressure, on the relationship between the lung and the chest wall elastance: a given stress is associated to a given strain, therefor PL is strictly related to ventilator-induced lung injury (VILI). Insufficient knowledge and increased workload account for its limited use in the clinical setting: indeed, the current recommendations for protective ventilation still rely only on the pressures applied to the respiratory system in total (Plateau pressure), without a direct measurement of the real lung stress.

Areas covered: We reviewed the significance, the assessment, the application and the limits of transpulmonary pressure in the clinical setting.

Expert opinion: Transpulmonary pressure represents a physiologically sound safety limit for mechanical ventilation that should be measured and targeted at least in the most severe ARDS patients. Targeting transpulmonary pressure means ‘personalizing’ the ventilatory settings.

KEYWORDS:

• ARDS
• esophageal pressure
• mechanical ventilation
• pleural pressure
• stress
• transpulmonary pressure
• VILI

Article highlights

• Transpulmonary pressure is the pressure distending the lung parenchyma (equal to the stress which develops into the parenchyma).

• The measurement of transpulmonary pressure is still under debate: absolute values of esophageal pressure or tidalic changes in esophageal pressure can both be used to calculate PL.

• Targeting transpulmonary pressure should be the most physiological approach to set mechanical ventilation and to prevent VILI when compared to the plateau pressure and driving pressure approach.

• Using a single value of transpulmonary pressure does not take into account lung inhomogeneity and ignores the role of respiratory rate and flow on the development of VILI.

Declaration of interest

The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewers Disclosure

Peer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.

Additional information

Funding

Institutional funding only.