Setting positive end-expiratory pressure: The use of esophageal pressure measurements

Purpose of reviewTo summarize the key concepts, physiological rationale and clinical evidence for titrating positive end-expiratory pressure (PEEP) using transpulmonary pressure (P_L) derived from esophageal manometry, and describe considerations to facilitate bedside implementation.Recent findingsThe goal of an esophageal pressure-based PEEP setting is to have sufficient P_Lat end-expiration to keep (part of) the lung open at the end of expiration. Although randomized studies (EPVent-1 and EPVent-2) have not yet proven a clinical benefit of this approach, a recent posthoc analysis of EPVent-2 revealed a potential benefit in patients with lower APACHE II score and when PEEP setting resulted in end-expiratory P_Lvalues close to 0 ± 2 cmH₂O instead of higher or more negative values. Technological advances have made esophageal pressure monitoring easier to implement at the bedside, but challenges regarding obtaining reliable measurements should be acknowledged.SummaryEsophageal pressure monitoring has the potential to individualize the PEEP settings. Future studies are needed to evaluate the clinical benefit of such approach.