Episode 142: Driving Pressure and Transpulmonary Pressure with Marcos Vidal Melo

In this 142nd episode I welcome Dr. Marcos Vidal Melo to the show to discuss Driving Pressure and Transpulmonary pressure. We discuss what they are, how they differ from plateau pressure, and how they may help guide safe mechanical ventilation.

References:

  1. Driving Pressure and Transpulmonary Pressure: How Do We Guide Safe Mechanical Ventilation? Williams EC, Motta-Ribeiro GC, Vidal Melo MF. Anesthesiology. 2019 Jul;131(1):155-163. 
  2. Loring SH, Topulos GP, Hubmayr RD: Transpulmonary pressure: The importance of precise definitions and limiting assumptions. Am J Respir Crit Care Med 2016; 194:1452–7
  3. Mauri T, Yoshida T, Bellani G, Goligher EC, Carteaux G, Rittayamai N, Mojoli F, Chiumello D, Piquilloud L, Grasso S, Jubran A, Laghi F, Magder S, Pesenti A, Loring S, Gattinoni L, Talmor D, Blanch L, Amato M, Chen L, Brochard L, Mancebo J; PLeUral pressure working Group (PLUG—Acute Respiratory Failure section of the European Society of Intensive Care Medicine): Esophageal and transpulmonary pressure in the clinical setting: meaning, usefulness and perspectives. Intensive Care Med 2016; 42:1360–73
  4. Akoumianaki E, Maggiore SM, Valenza F, Bellani G, Jubran A, Loring SH, Pelosi P, Talmor D, Grasso S, Chiumello D, Guérin C, Patroniti N, Ranieri VM, Gattinoni L, Nava S, Terragni PP, Pesenti A, Tobin M, Mancebo J, Brochard L; PLUG Working Group (Acute Respiratory Failure Section of the European Society of Intensive Care Medicine): The application of esophageal pressure measurement in patients with respiratory failure. Am J Respir Crit Care Med 2014; 189:520–31

3 Replies to “Episode 142: Driving Pressure and Transpulmonary Pressure with Marcos Vidal Melo”

  1. Great cast. A couple comments:

    1) If a patient is exerting respiratory effort while on a pressure controlled mode, it is entirely possible for their plateau pressure to be higher than the set inspiratory pressure. This is important for folks – especially early learners – to understand when thinking about your comments early in the podcast. Plateau pressure depends only on the volume inspired and the compliance. If the patient is vigorously inspiring (the vent will give them as much flow as they want in a pressure controlled breath), the risk of lung injury is very real. This is usually irrelevant with patients under anesthesia in the OR, but may be very relevant in the ICU.

    2) I think we need to be honest about the poor quality of evidence regarding driving pressure. The derivation cohort for Amato’s models was drawn from a few small, negative studies. The validation cohort was drawn from the ARMA trial, which suffers from significant therapeutic misalignment and is therefore unhelpful. Utilizing driving pressure makes physiologic sense, but the medical literature is full of things that make sense physiologically and then don’t pan out (or cause harm) when rigorously investigated. That said, I do think there is value in monitoring for changes in compliance, minimizing plateau pressure, and minimizing driving pressure to prevent lung injury.

    3) We do indeed have esophageal balloons at Hopkins. But you can only use them with the Carefusion Avea ventilators 🙂

  2. A bit late, but I just came across this case series, which includes a report of pneumothorax in a young trumpet player:

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3731861/

    It’s still surprising that this isn’t a more common occurrence, given the pressures involved, but Dr. Melo’s explanation at 19:20 makes it clear why. But then what could explain this one case?

    The article references a report of four patients who developed pneumothorax while *listening* to loud music, rather than playing it: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1747103/pdf/v059p00722.pdf Maybe this trumpeter developed his pneumothorax from the vibrations of the trumpet, rather than from the high pressures.

    With that in mind, I wonder if this case report actually shows a risk of HFOV, rather than a risk of high PEEP. I’m not too familiar with that topic, but maybe someone who is can chime in.

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