Joshua O Benditt MD
Introduction
Historical Development
Techniques
Physiologic Background
Technique of Catheter Placement
Measurements and Clinical Applications
Compliance Measurements
Work of Breathing Measurement
Tension-Time Index and Pressure-Time Product
Respiratory Muscle Function
Left-Atrial Distending Pressure
Measurement of Intra-Abdominal Pressure With a Bladder Catheter
Summary
The measurement of esophageal and gastric pressures with balloon-tipped catheters has been used
with great success over the past half century to delineate the physiology of the mechanical respi-
ratory system. Pleural pressure and abdominal pressure values estimated from esophageal and
gastric pressure measurements allow analysis of lung and chest wall compliance, as well as work of
breathing, respiratory muscle function, and the presence of diaphragm paralysis. Although much
of the use of these measurement techniques has been in the clinical laboratory, to improve the
understanding of basic physiologic mechanisms, the techniques have also been used in clinical
situations to diagnose diaphragm paralysis, assess the work of breathing during mechanical ven-
tilation, and estimate pulmonary compliance. In this article I review the historical background,
physiology, placement techniques, and potential clinical applications of esophageal and gastric
pressure measurements. In addition, I will briefly review the measurement of bladder pressure,
which is a related topic. Key words: esophageal pressure, gastric pressure, pleural pressure, work of
breathing, diaphragm paralysis, lung compliance, chest wall compliance, pressure time index. [Respir
Care 2005;50(1):68 –75. © 2005 Daedalus Enterprises]
Joshua O Benditt MD is affiliated with the Division of Pulmonary and Correspondence: Joshua O Benditt MD, Division of Pulmonary and Crit-
Critical Care Medicine, University of Washington, Seattle, Washington. ical Care Medicine, University of Washington School of Medicine, Box
356522, 1959 NE Pacific Street, Seattle WA 98195-8673. E-mail:
Joshua O Benditt MD presented a version of this article at the 34th
benditt@u.washington.edu.
RESPIRATORY CARE Journal Conference, Applied Respiratory Physiology:
Use of Ventilator Waveforms and Mechanics in the Management of
Critically Ill Patients, held April 16–19, 2004, in Cancún, Mexico.
Historical Development
Fig. 2. Computed tomogram of the chest, showing the proximity of the esophagus to the pleural space.
measure Patm, and by convention, Patm is said to equal a work of breathing (WOB), (3) respiratory muscle perfor-
pressure of zero. Ppl is measurable directly only by placing mance, and (4) transmural cardiac distending pressures.
a catheter in the pleural space, which is not usually pos-
sible in clinical practice. Fortunately, the pressure in the Technique of Catheter Placement
lower one third of the esophagus (Pes) closely approxi-
mates the pressure in the adjacent pleura6 – 8 when the sub- Figure 3 shows a diagram of the devices required for
ject is in the upright posture. Figure 2 shows the reason for placing and recording measurements from an esophageal
this; it is a cross-sectional computed tomogram view of the catheter. The components include the balloon catheter, pres-
thorax, which shows the close proximity of the esophagus sure transducer, and a recording device (either a computer
to the pleural space. Because the body of the esophagus is or strip-chart recorder).7
essentially a passive structure (except during a swallow), The catheters are commercially available but can be
able to transmit pressure from the adjacent pleural space easily manufactured in the laboratory. The device consists
(Ppl) to the measurement catheter in the esophagus, Pes is of a thin polyethylene catheter with multiple small holes in
a reasonably close surrogate for Ppl in a human being in the distal 5–7 cm of its length (Figure 4). The distal end of
the upright posture.6,8 This does not necessarily hold true the catheter is then placed in a 10-cm latex balloon that
in the supine posture, in which the mediastinum may com- prevents the holes in the catheter from being occluded by
press the esophagus, and compression of the posterior and esophageal tissue and maintains a column of air within and
inferior portions of the lung can create large regional dif- around the catheter, in order to measure pressure in the
ferences in pleural pressure.9,10 surrounding structure. The proximal end of the catheter is
In addition to the measurement of Pes, it is also possible attached to the pressure transducers and recording equipment.
to measure the gastric pressure (Pga) by placing another The balloon catheter (or catheters) is passed through the
catheter more distally, in the stomach. Pga closely approx- nares into the posterior pharynx. At this point the subject
imates the pressure in the abdominal cavity. With accurate is instructed to swallow (if spontaneously breathing) and
measurements of Ppl and abdominal cavity pressure, a wide the catheter is passed into the esophagus and then into the
variety of useful measurements of the mechanical respira- stomach. The catheter is attached to the transducer/recorder
tory system can be determined. I will discuss below some system, and 2.0 mL of air is injected into the balloon. Then
of the more clinically important of these measurements, 1.5 mL of air is withdrawn, to leave 0.5 mL of air in the
which include: (1) lung and chest wall compliances, (2) system to partially inflate the balloon and the catheter. The
Compliance Measurements
or
C ⫽ ⌬V/⌬P (2)
tem (CRS) into its components of lung compliance (CL) Table 1. Weaning Outcome Predicted by Work of Breathing
and chest wall compliance (CCW) The calculations are: Measurements
Ventilator-Dependent Ventilator-Independent
CL ⫽ VT/(PAO ⫺ Pes) end-inhalation – Study Work/L Work/min Work/L Work/min
(PAO ⫺ Pes) end-exhalation (4) (J/L) (J/min) (J/L) (J/min)
NM ⫽ not measured
This can be extremely important clinically, as we are
most often interested in lung pathology changes over time,
and therefore we are interested in changes in CL rather
than changes in CCW, which often occur but are usually work is expressed as L ⫻ cm H2O. In practice, work is
not clinically important. For example, if we rely on CRS often expressed in the form of joules. One joule equals the
measured at the bedside to follow changes in the severity work when 10 cm H2O is applied to 1 L of gas. Campbell
of a patient’s acute respiratory distress syndrome, we may refined earlier analyses and developed the Campbell dia-
see changes in the value that do not reflect changes in CL gram, which revolutionized the analysis of WOB and al-
but may reflect changes in CCW incurred by changes in lowed partitioning of WOB into its elastic, resistive, in-
edema in the chest wall soft tissue structures, abdominal spiratory, expiratory, lung, and chest wall components.15
distention, paralytic agents, or even simple changes in pa- By using an esophageal balloon, it is possible to partition
tient position. In an upright human the normal value for the WOB into components and to identify how much work
compliance of the chest wall and the lung is approximately the patient is actually performing. Work is most often
200 mL/cm H2O. The compliance of the respiratory sys- described in joules, and work units are often presented in
tem is approximately 100 mL/cm H2O. 2 ways: J/min and J/L of gas.
Several commercial devices (eg, CP-100, Bicore Mon-
Work of Breathing Measurement itoring Systems, Irvine, California, and Ventrak, Novame-
trix Medical Systems, Wallingford, Connecticut) marketed
The WOB is often substantially elevated in individuals in the 1990s were designed to measure WOB in real time
with illness that requires ICU admission. Techniques for mea- in mechanically ventilated patients.13,14 One of the intended
suring the WOB have been available for nearly a century.3 uses for these devices was the assessment of a minimum
With the advent of novel modes of mechanical ventilation, “cutoff” level for WOB as a predictor for ventilator de-
much interest has developed in the WOB imposed by various pendence. The hypothesis is that spontaneous ventilation
ventilation modes and devices. Several commercial devices without mechanical assistance is not possible for prolonged
for measuring WOB have been used in the clinical setting, periods. Table 1 shows the results of 4 such studies, in
although their popularity has declined recently.13,14 which the WOB was studied in groups of ventilated pa-
From classic physics, work in a 2-dimensional system is tients, some of whom were weaned from ventilation and
equal to the force applied to an object multiplied by the others of whom were not.16 –19 The WOB was used a pre-
distance the object travels. That is, work ⫽ force ⫻ dis- dictor for identifying which individuals could be weaned
tance, or W ⫽ F ⫻ D. from mechanical ventilation. Unfortunately, all the “cut-
However, in the 3 dimensions that apply in the respira- off” points in these studies were determined post-hoc and
tory system, work now becomes the pressure applied to there was a great deal of overlap among the patient groups
yield a change in the volume of the system, or that were and were not weanable from mechanical venti-
lation. No study has prospectively looked at WOB as a
W ⫽ P ⫻ V ⫽ 兰0VP ⫻ dv (6) determinate of weaning failure and ventilator dependence.
Use of these devices in the ICU has decreased substan-
in which 兰0VP is the integral of the pressure across the tially in the past decade.
respiratory system, as a function of volume, and dv is the Clearly, measurement of WOB in an investigational set-
change in the volume of the respiratory system. Work ting can be quite accurate and has greatly aided our under-
performed on the lung and chest wall can be depicted standing of disease processes and mechanical ventilation. For
graphically as areas under the active inflation and defla- example Marini et al elegantly demonstrated, using the mea-
tion pressure-volume curves as they relate to passive pres- surement principals described above, that substantial respira-
sure-volume curves of those structures. In this situation tory muscle work often occurred during conventional me-
REFERENCES 21. Rochester DF, Bettini G. Diaphragmatic blood flow and energy ex-
penditure in the dog: effects of inspiratory airflow resistance and
1. Carson J. On the elasticity of the lungs. Philos Trans R Soc Lond
hypercapnia. J Clin Invest 1976;57(3):661–672.
1820;110:29–44.
22. Field S, Sanci S, Grassino A. Respiratory muscle oxygen consump-
2. Donders F. Beitrage zum Mechanismus der Respiration und Circulation
tion estimated by the diaphragm pressure-time index. J Appl Physiol;
im gesunden und kranken Zustande. Z Rat Med 1853;3:287–319.
1984;57(1):44–51.
3. Wirz K. Das Verhalten des Druckes im Peuraraum bei der Atmung
23. Jubran A, Tobin MJ. Pathophysiologic basis of acute respiratory
und die Ursachen seiner Veranderlichkeit. Pfluegers Arch Gesamte
disstress in patients who fail a trial of weaning from mechanical
Physio Menschen Tiere 1923;199:1–56.
ventilation. Am J Respir Crit Care Med 1997;155(3):906–915.
4. Aron E. Ueber einen Versuch, den intrapeuralen Druck am lebenden
24. Bellemare F, Wight D, Lavigne CM, Grassino A. Effect of tension
Menschen zu messen. Virchows Arch Pathol Anat Physiol 1891;126:
and timing of contraction on the blood flow of the diaphragm. J Appl
517–533.
Physiol 1983;54(6):1597–1606.
5. Comroe J. Lags. In: Comroe J. Retropectoscope: insights into med-
25. Davis J, Goldman M, Loh L, Casson M. Diaphragm function and
ical discovery. Menlo Park, CA: Von Gehr Press 1977:106–109.
alveolar hypoventilation. Q J Med 1976;45(177):87–100.
6. Milic-Emili J, Mead J, Turner JM. Topography of esophageal pressure
26. Rochester D. Tests of respiratory muscle function. Clin Chest Med
as a function of posture in man. J Appl Physiol 1964;19:212–216.
1988;9(2):249–261.
7. Milic-Emili J. Measumement of pressures in respiratory physiology:
27. Miller JM, Moxham J, Green M. The maximal sniff in the assessment
techniques in the life sciences. Shannon, Ireland: Elsevier Scientific
of diaphragm function in man. Clin Sci (London) 1985;69(1):91–96.
1984:1–22.
8. Mead J, McIlroy MB, Selverstone NJ, Kriete BC. Measurement of 28. Heritier F, Perret C, Fitting JW. Esophageal and mouth pressure
intraesophageal pressure. J Appl Physiol 1955;7(5):491–495. during sniffs with and without nasal occlusion. Respir Physiol 1991;
9. Ferris BJ, Mead J, Frank N. Effect of body position on esophageal 86(3):305–313.
pressure and measurement of pulmonary compliance. J Appl Physiol 29. Heritier F, Rahm F, Pasche P, Fitting JW. Sniff nasal inspiratory
1959;14:521–524. pressure: a noninvasive assessment of inspiratory muscle strength.
10. Sutherland PW, Katsura T, Milic-Emili J. Previous volume history of Am J Respir Crit Care Med 1994;150(6 Pt 1):1678–1683.
the lung and regional distribution of gas. J Appl Physiol 1968;25(5): 30. Koulouris N, Mulvey DA, Laroche CM, Sawicka EH, Green M,
566–574. Moxham J. The measurement of inspiratory muscle strength by sniff
11. Baydur A, Behrakis PK, Zin WA, Jaeger M, Milic-Emili J. A simple esophageal, nasopharyngeal, and mouth pressures. Am Rev Respir
method for assessing the validity of the esophageal balloon tech- Dis 1989;139(3):641–646.
nique. Am Rev Respir Dis 1982;126(5):788–791. 31. Laporta D, Grassino A. Assessment of transdiaphragmatic pressure
12. Milner AD, Saunders RA, Hopkin LE. Relationship of intra-oesoph- in humans. J Appl Physiol 1985;58(5):1469–1476.
ageal pressure to mouth pressure during the measurement of thoracic 32. Tobin MJ. Essentials of critical care medicine. New York: Churchill
gas volume in the newborn. Biol Neonate 1978;33(5–6):314–319. Livingstone; 1989:232.
13. Blanch PB, Banner MJ. A new respiratory monitor that enables 33. Marini JJ, O’Quin R, Culver BH, Butler J. Estimation of transmural
accurate measurement of work of breathing: a validation study. Re- cardiac pressures during ventilation with PEEP. J Appl Physiol 1982;
spir Care 1994;39(9):897–905. 53(2):384–391.
14. Petros AJ, Lamond CT, Bennett D. The Bicore pulmonary monitor: 34. Kingma I, Smiseth OA, Frais MA, Smith ER, Tyberg JV. Left
a device to assess the work of breathing while weaning from me- ventricular external constraint: relationship between pericardial,
chanical ventilation. Anaesthesia 1993;48(11):985–988. pleural and esophageal pressures during positve end-expiratory
15. Campbell E. The respiratory muscles and the mechanics of breath- pressure and volume loading in dogs. Ann Biomed Eng 1987;
ing. London: Lloyd-Luke; 1958. 15(3–4):331–346.
16. Fiastro JF, Habib MP, Shon BY, Campbell SC. Comparison of stan- 35. Kron IL, Harman PK, Nolan SP. The measurement of intra-abdom-
dard weaning parameters and the mechanical work of breathing in inal pressure as a criterion for abdominal re-exploration. Ann Surg
mechanically ventilated patients. Chest 1988;94(2):232–238. 1984;199(1):28–30.
17. Henning RJ, Shubin H, Weil MH. The measurement of the work of 36. Cullen DJ, Coyle JP, Teplick R, Long MC. Cardiovascular, pul-
breathing for the clinical assessment of ventilator dependence. Crit monary, and renal effects of massively increased intra-abdominal
Care Med 1977;5(6):264–268. pressure in critically ill patients. Crit Care Med 1989;17(2):118–
18. Proctor HJ, Woolson R. Prediction of respiratory muscle fatigue by 121.
measurements of the work of breathing. Surg Gynecol Obstet 1973; 37. Obeid F, Saba A, Fath J, Guslits B, Chung R, Sorensen V, et al.
136(3):367–370. Increases in intra-abdominal pressure affect pulmonary compliance.
19. Peters RM, Hilberman M, Hogan JS, Crawford DA. Objective indi- Arch Surg 1995;130(5):544-547; discussion 547–548.
cations for respiratory therapy in post-trauma and postoperative pa- 38. Cheatham ML, Safcsak K. Intraabdominal pressure: a revised method
tients. Am J Surg 1972;124(2):262–269. for measurement. J Am Coll Surg 1998;186(5):594–595.
20. Marini JJ, Rodriguez RM, Lamb V. The inspiratory workload of 39. Fusco MA, Martin RS, Chang MC. Estimation of intra-abdominal
patient-initiated mechanical ventilation. Am Rev Respir Dis 1986; pressure by bladder pressure measurement: validity and methodol-
134(5):902–909. ogy. J Trauma 2001;50(2):297–302.
Discussion Ganz catheter equivalent for the pulmo- of breathing, as you pointed out, is only
nologists, and they were going to give one determinant of a ventilator-depen-
MacIntyre: In the late 1980s and us all kinds of information. And they dent patient. The work only looks at the
early 1990s, these esophageal and gas- did give us lots of data, but I think the loads; it doesn’t look at the capabilities,
tric pressure measurement devices were problem was that the data didn’t help us the cardiac function, the muscle func-
thought to be, as you put it, the Swan- make decisions. For instance, the work tion, or the nutritional status. So it’s only
one discrete variable. Indeed, that’s Bigatello: Regarding the partition of technique” for assessing the accuracy
probably why the tension time index is lung and chest wall during the mea- of the relationship between airway and
a little bit better— because it considers surement of compliance, I think there esophageal pressure changes known,
muscle function as well. is an important technical question. but that technique does not ensure that
The role of this device, I think, in When you put in an esophageal bal- the absolute value is correct. So far
the chest wall issues is perhaps more loon, or when you look at an occlu- there are no really good studies on
important. I think perhaps we’re not sion pressure at end-expiration, you how to predict juxtacardiac pressure
using esophageal pressure measure- can measure transpulmonary pressure from esophageal pressure in humans.
ment as much as we should; there are and use it for the measurement of com-
a lot of obese and edematous patients, pliance that way, by subtracting the
as you pointed out. With all this new pressure at the airway minus the esoph- REFERENCE
emphasis to do compliance curves, ageal pressure. However, as you have 1. Baydur A, Behrakis PK, Zin WA, Jaeger
pressure-volume curves, and plateau pointed out, the esophageal pressure M, Milic-Emili J. A simple method for as-
pressure measurements to protect the measurements are not that reliable; sessing the validity of the esophageal bal-
lung, this issue of chest wall compli- measuring changes rather than abso- loon technique. Am Rev Respir Dis 1982;
lute values of esophageal pressure is 126(5):788–791.
ance becomes, in my opinion, very
important. So esophageal pressure much more reliable. So is this the tech-
nique you use and do you think it is Hess: So you’re not taking a num-
might actually find more utility in that ber and subtracting that from the
environment. And, you’re right, they the correct one? Or would you rather
do 2 measurements of esophageal pres- wedge pressure?
do not sell stand-alone systems today,
but one ventilator manufacturer has it sures—sort of a chest wall chord com-
pliance—and measure chest wall com- Benditt: I’m not subtracting the
as a feature on one of their devices, so esophageal pressure from the wedge
pliance that way, then calculate in
you don’t necessarily have to go to pressure. I’m saying, yes, there’s a very
reverse the lung compliance?
eBay to get it. large, positive, integral, pleural pressure.
Benditt: That’s a great point, and I
Benditt: I do think that chest wall Hess: And what makes it even more
think it underlines the fact that in unco-
compliance is going to be very im- confusing is that you’re measuring it
operative patients, when you can’t do
portant. I get into little arguments in cm H2O, whereas the vascular pres-
the dynamic occlusion method, gener-
with the ARDS Network folks when sure values are in mm Hg.
ating an absolute value for esophageal
they’re talking about plateau pres-
pressure is difficult, and that is very im-
sure levels less than 30 cm H2O, and Benditt: Right. You have to correct
portant for chest wall compliance. In
that is the respiratory system pla- for that.
terms of using a sort of a “delta” [ie,
teau pressure, not the lung plateau
change in esophageal pressure] and
pressure. It’s always bothered me a back-calculating, I haven’t done that Durbin: My talk will address some
little bit that there was no clear eval- myself, and so I can’t attest to its of these issues in heart/lung interac-
uation of how much the chest wall accuracy. But I can see the logic be- tions. This was a nice lead-in to that.
was contributing to these pressures, hind that. The questions Dean [Hess] asked I’d
and I can imagine a huge or very, like to answer in 2 ways. First, the
very edematous ICU patient in whom Hess: How do you use the esopha- pressure is helpful in understanding
the chest wall would make a big con- geal pressure, then, to correct the the cardiovascular system effects
tribution but the lung is in good wedge pressure, if the esophageal pres- only if you know the geometry and
shape, or a little thin COPD [chronic sure does not reflect the absolute pleu- the size of the ventricle. It’s really
obstructive pulmonary disease] pa- ral pressure? end-diastolic volume and geometry
tient who maybe has developed that we’re interested in. Pressure is
ARDS but in whom it may not be Benditt: That’s a big question. Ba- a surrogate (and a very poor one) for
contributing, and I’ve always sically, I try to ensure, as much as volume, so even having an accurate,
thought it would be great to get a possible, the correct positioning of the corrected number for wedge pres-
balloon down those people so we catheters; I look for cardiac pulsations sure doesn’t help you understand the
could really measure the lung pres- in the balloon. I’m the stingiest about cardiac physiology in many condi-
sure, just that variable, not the total filling it with only 0.5 mL, which I tions. Second, there are methods for
respiratory system pressure. I agree- think is very important. Baydur et al1 looking at pleural pressure distribu-
that it may be more useful. described the “dynamic occlusion tion from the lung to the cardiovas-
cular system. If the thorax were con- The clinical impact of these pressure function, inspiratory rise time, and ter-
sidered homogeneous or not homo- interactions creates variations in heart mination criteria; so it has been very
geneous, these effects could be con- volume that cause respiratory-induced useful in the evaluation of patient-
sidered in the model as well. systolic and diastolic blood pressure ventilator synchrony. It is unfortunate
The cardiovascular system, which variations (so called “delta down” and that esophageal pressure measurement
is complicated enough, with the cor- “delta up”), which are reflected in di- is no longer commercially available,
rections you’ve brought up, becomes rect arterial-pressure waveforms. except in combination with the Avea
even more complicated when placed These pressure-induced changes may ventilator [Viasys Healthcare, Con-
inside a human being, where interac- actually be better indicators of an in- shohocken, Pennsylvania].
tions with the nervous system and cor- dividual patient’s responses to ther-
rections are occurring continually. It apy. Hess: What about the use of respi-
probably isn’t worth the effort to try ratory variation and the central venous
to do what you’re suggesting, other Nilsestuen: I want to comment on pressure as inflection of pleural pres-
than to recognize where obvious er- the usefulness of having esophageal sure? Scott [Harris] and Luca [Big-
rors do exist. It may be more impor- pressure waveforms. In all the articles atello] will tell you that that is sort of
tant to look at the outcome of an in- I reviewed in preparation for the pa- our “poor man’s” way of looking at
tervention. For instance, the effect on tient-ventilator-synchrony discussion, these things sometimes in the ICU.
cardiac output of giving a fluid bolus esophageal pressure was almost al-
is more important than the change in ways used as the evaluative tool in Benditt: I’ll leave that discussion to
wedge or corrected wedge pressure. clinical situations, to look at trigger Dr Durbin.