Journal Club: Change in plateau from peak pressure during inspiratory holds to identify effort and elastic workload

Article

Author: Maritza Henriques

Date of first publication: 07.06.2021

Last change: 20.02.2023

Changed categorization to exclude Application

Applying the optimal level of assistance is one of the major challenges in mechanical ventilation.

Journal Club: Change in plateau from peak pressure during inspiratory holds to identify effort and elastic workload

Too much support leads to low effort and may result in diaphragm atrophy, while too little support leads to high effort and greater stress and strain. It is essential to find a balance between lung protection and diaphragm protection, to reduce the risk of VILI, P-SILI and VIDD. A recent multicenter study (Kyogoku M, Shimatani T, Hotz JC, et al. Direction and Magnitude of Change in Plateau From Peak Pressure During Inspiratory Holds Can Identify the Degree of Spontaneous Effort and Elastic Workload in Ventilated Patients. Crit Care Med. 2021;49(3):517-526. doi:10.1097/CCM.00000000000047461) from Japan, the USA, and Italy, investigated whether the measurement of airway pressure during inspiratory holds could be used in spontaneous patients to estimate the degree of effort and elastic work, and thereby serve as a bedside tool to avoid injurious effort. In the video available for viewing below, we take a closer look at the results and limitations of this study, as well as the clinical relevance and application of the main findings.

Footnotes

References

1. Kyogoku M, Shimatani T, Hotz JC, et al. Direction and Magnitude of Change in Plateau From Peak Pressure During Inspiratory Holds Can Identify the Degree of Spontaneous Effort and Elastic Workload in Ventilated Patients. Crit Care Med. 2021;49(3):517-526. doi:10.1097/CCM.0000000000004746

Direction and Magnitude of Change in Plateau From Peak Pressure During Inspiratory Holds Can Identify the Degree of Spontaneous Effort and Elastic Workload in Ventilated Patients.

Kyogoku M, Shimatani T, Hotz JC, et al. Direction and Magnitude of Change in Plateau From Peak Pressure During Inspiratory Holds Can Identify the Degree of Spontaneous Effort and Elastic Workload in Ventilated Patients. Crit Care Med. 2021;49(3):517-526. doi:10.1097/CCM.0000000000004746

Link to article

OBJECTIVES

Inspiratory holds with measures of airway pressure to estimate driving pressure (elastic work) are often limited to patients without respiratory effort. We sought to evaluate if measures of airway pressure during inspiratory holds could be used for patients with spontaneous respiratory effort during mechanical ventilation to estimate the degree of spontaneous effort and elastic work.

DESIGN

We compared the direction and degree of change in airway pressure during inspiratory holds versus esophageal pressure through secondary analysis of physiologic data.

SETTING

ICUs at Children's Hospital Los Angeles.

PATIENTS

Children with pediatric acute respiratory distress syndrome with evidence of spontaneous respiration while on pressure control or pressure support ventilation.

INTERVENTIONS

Inspiratory hold maneuvers.

MEASUREMENTS AND MAIN RESULTS

From airway pressure, we defined "plateau - peak pressure" as Pmusc, index, which was divided into three categories for analysis (< -1 ["negative"], between -1 and 1 ["neutral"], and > 1 cm H2O ["positive"]). A total of 30 children (age 36.8 mo [16.1-70.3 mo]) from 65 study days, comprising 118 inspiratory holds were included. Pmusc, index was "negative" in 29 cases, was "neutral" in 17 cases, and was "positive" in 72 cases. As Pmusc, index went from negative to neutral to positive, there was larger negative deflection in esophageal pressure -5.0 (-8.2 to 1.9), -5.9 (-7.6 to 4.3), and -10.7 (-18.1 to 7.9) cm H2O (p < 0.0001), respectively. There was a correlation between max negative esophageal pressure and Pmusc, index (r = -0.52), and when Pmusc, index was greater than or equal to 7 cm H2O, the max negative esophageal pressure was greater than 10 cm H2O. There was a stronger correlation between Pmusc, index and markers of elastic work from esophageal pressure (r = 0.84).

CONCLUSIONS

The magnitude of plateau minus peak pressure during an inspiratory hold is correlated with the degree of inspiratory effort, particularly for those with high elastic work. It may be useful to identify patients with excessively high effort or high driving pressure.