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End-expiratory esophageal pressure versus lower inflection point in acute lung injury


No recommendations available concerning protocols of static PV loop and esophageal pressure measurements use set positive end-expiratory pressure (PEEP). The aim of the study was evaluation of the significance of the lower inflection point (LIP) and esophageal pressure monitoring for PEEP adjustment in ALI and ARDS.


A prospective study performed in one general ICU. We include 72 patients who received mechanical ventilation before evaluation and met ARDS criteria by AECC (1994) - acute onset, PaO2/FiO2 lower than 250 Torr, bilateral infiltrates on chest X-ray. Exclusion criteria were age <15 years and pregnancy. We drew a static pressure-volume loop with sustained inflation 40×30 (PV loop) for all patients using a lowflow technique (Hamilton G5) and measured the esophageal pressure (Avea) in 36 of 72 patients. After that PEEP was set according to zero end-expiratory transpulmonary pressure. We compare PV loop data with esophageal pressure measurements.


The low inflection point median was 8 (95% CI = 5 to 10.5) mbar, which does not correspond to the empirically set optimal PEEP of 13 (95% CI = 12 to 15) mbar (P < 0.001, Wilcoxon test). End-expiratory esophageal pressure (EEEP) median was 14 (95% CI = 12 to 18) mbar, the correlation between LIP and EEEP was poor (ρ = 0.279, P = 0.049). We find significant correlation between static compliance and EEEP (ρ = -0.421, P = 0.005). Sustained inflation did not lead to improved oxygenation (P > 0.05). PEEP adjustment by EEEP led to an increase in PaO2/FiO2 - median 107 mmHg (95% CI = 18 to 147, P < 0.001). EEEP was similar to empirically set PEEP (P > 0.05).


LIP has poor correlation with EEEP. PEEP adjustment by esophageal pressure was close to empirically set PEEP and can improve oxygenation.

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Correspondence to A Yaroshetskiy.

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Yaroshetskiy, A., Protsenko, D., Larin, E. et al. End-expiratory esophageal pressure versus lower inflection point in acute lung injury. Crit Care 17, P103 (2013).

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  • Acute Lung Injury
  • Static Compliance
  • Point Median
  • Transpulmonary Pressure
  • Esophageal Pressure