The correlation between esophageal and abdominal pressures in mechanically ventilated patients undergoing laparoscopic surgery.

BACKGROUND: Intrathoracic pressure in patients undergoing laparoscopic surgery may be affected by intra-abdominal pressure during surgery. We investigated the relationship between intra-abdominal pressure (Pabd) and esophageal pressure (Pes) in mechanically ventilated patients undergoing laparoscopic surgery. METHODS: We prospectively studied 43 consenting patients over 18 y of age who were scheduled for elective laparoscopic surgery with plans for intra-operative intubation and paralysis. After establishing a good level of inter-observer agreement on Pes measurements, Pes was measured by one observer for each patient using an esophageal catheter. Pabd and Pes were recorded before and after abdominal insufflation. We used regression analysis to model the relationship between Pabd and Pes. RESULTS: Patients' ages varied from 22 to 78 y, with a mean of 53.2 ± 14.6 y. Body mass index (BMI) varied from 13.7 to 60.5 kg/m2, with a mean of 33.7 ± 10.5. PEEP was 5-7 cm H2O for 19 patients and 0 cm H2O for the remainder. Most patients underwent gastric bypass surgery (n = 11); others underwent hernia repair (n = 9), colon resection (n = 7), cholecystectomy (n = 6), and various other surgeries (n = 10). Using univariate analyses, baseline Pabd was significantly correlated with baseline Pes (estimate of model coefficient [95% CI]: 0.79 [0.36-1.21], R2 = 0.24, P = .001), as was BMI (0.29 [0.19-0.40], R(2) = 0.41, P < .001). However, a multivariable analysis showed no significant correlation with baseline Pabd (0.10 [-0.46 to 0.65], P = .73), whereas BMI remained highly significant (0.27 [0.11-00.43], P = .001) with R2 = 0.40. Due to unexpected uniformity of abdominal inflation pressures (generally 20.4 cm H2O) during surgery, data were not amenable to assessment of correlation between changes in abdominal and esophageal pressures after inflation. CONCLUSION: There was a limited correlation between baseline Pes and Pabd in patients undergoing elective laparoscopic surgery, suggesting a limited value of Pabd measurements in the management of mechanically ventilated patients.

Optimal PEEP guided by esophageal balloon manometry.

A 45-year-old female was admitted to our ICU with severe ascites, and septic shock due to an obstructive ureteric stone. Despite an F(IO(2)) of 1.0, high PEEP, and multiple recruitment maneuvers, it was challenging to obtain an S(pO(2)) > 85% after the patient was turned. We inserted an esophageal balloon to determine whether the abdominal pressure was affecting lung compliance. PEEP was guided to a level of 32 cm H(2)O to achieve a transpulmonary pressure of 0 cm H(2)O. Within 6 hours there was significant oxygenation improvement: P(aO(2))/F(IO(2)) increased from 80 mm Hg to 244 mm Hg, and oxygenation index decreased from 35 to 18. At 48 hours, P(aO(2))/F(IO(2)) was 382 mm Hg and oxygenation index was 7. Paracentesis of approximately 5 L assisted with weaning. Subsequent PEEP changes were guided by transpulmonary pressure. She was weaned from mechanical ventilation within 10 days, with no adverse sequelae associated with very high PEEP.