Esophageal pressure guided closed-loop ventilation: A theoretical framework toward precision mechanical ventilation

Ehab G Daoud

Abstract

Background

Esophageal balloon manometry is a surrogate for pleural pressure and has been in clinical use for decades. The main advantages for its use are to partition the total lung and chest wall mechanics, thus providing transpulmonary inspiratory, expiratory, and driving pressure monitoring as the true stress delivered to the lung, and the capability to measure the transpulmonary mechanical power as the true energy delivered to inflate the lungs. Thus, it can provide more insight into lung and diaphragmatic protective ventilation than total airway pressure alone. Its capability as the gold standard to measure patient effort, muscle pressure, and to diagnose patient-ventilator interactions and dyssynchronies adds further value to its usage.

Proposed Framework

As the paradigm shifts toward personalized lung and diaphragm-protective ventilation, alongside increased recognition of ventilator-induced and patient self-inflicted lung injury (VILI and P-SILI respectively), using esophageal balloon manometry seems to be the ultimate tool to achieve these goals. In this paper, we introduce an automated theoretical closed-loop ventilation mode that is based on adjusting the inspiratory and expiratory transpulmonary pressures to a safe zone to provide true individualized lung and diaphragmatic protective ventilation, while simultaneously adjusting the triggering, maintaining, and cycling of breaths according to the patient’s neural time and effort, potentially detecting and eliminating dyssynchronies.

Clinical Implications

This adaptive mode aims to optimize the balance between lung recruitment, overdistension, and respiratory muscle unloading, addressing VILI, P-SILI, ventilator induced diaphragm dysfunction (VIDD) and dyssynchronies.

Conclusion

The theoretical esophageal pressure guided closed-loop ventilation based on continuous input and feedback from the esophageal balloon represents a physiologically attractive framework toward individualized lung and diaphragm protective ventilation can conceptually lead to safer personalized ventilation, significantly lessen dyssynchronies, and potentially improve mortality outcomes in acute respiratory failure. However, this concept remains theoretical and unvalidated. Future studies are required before claims regarding feasibility, safety and outcome benefits can be made.

Keywords: Esophageal balloon manometry, Transpulmonary pressures, dyssynchronies, closed-loop ventilation.

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