Esophageal Pressure Guideline in the Intensive Care Unit
CCCF ePoster library. and Michael Long S. 11/13/19; 283408; EP131
Samira Fard and Michael Long
Samira Fard and Michael Long
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Topic: Quality Assurance & Improvement

Samira Fard, Michael Long, Lorenzo Del Sorbo, Jenna Wong, Maria Kobylianski, Ewan Goligher
Critical Care, Toronto General Hospital,Toronto, Canada

Introduction:Esophageal manometry enables partitioning of the pressures applied to the chest wall and lung (transpulmonary pressure, PL) [1]. It also permits direct measurements of patient inspiratory effort under mechanical ventilation and detection of patient-ventilator dyssynchrony [2]. Hence, esophageal manometry might be used to prevent ventilator-induced lung injury, self-induced lung injury, and ventilator-induced diaphragm dysfunction, thus improving clinical outcomes.Clinical uptake has been limited by a number of technical obstacles, such as clinician expertise in catheter insertion and placement, collecting accurate measurements, as well as the knowledge requirement for interpretation of the findings. At our hospital, there was no standard guideline for the use of esophageal manometry. We undertook to develop a guideline for local clinical implementation. In this abstract we describe the process and resulting guideline.
Methods: This guideline was created based on extensive literature reviews supporting the techniques and clinically relevant evidence to date.  Additionally, expert user experiences and an intensive care unit (ICU) interdisciplinary team perspective was incorporated in order to enhance the success of implementation [3-4]. 
Results: The guideline includes criteria for consideration of insertion and contraindication for use and how to check the integrity of the catheter, the method of insertion and verifying placement. The clinical application of esophageal manometry is outlined. The guideline was designed to incorporate multiple measures of both lung stress and respiratory effort with the goal of monitoring risk for ventilator-induced lung injury and diaphragm myotrauma. Routine measurements mandated by the guideline include: End-expiratory esophageal pressure (Pes), peak inspiratory Pes, end-expiratory PL, peak inspiratory PL, plateau PL, inspiratory swing in Pes, inspiratory swing in PL, and the elastance-derived plateau PL.
Conclusions:We have developed a local practice guideline for the use of esophageal manometry with the aim of enhancing the safety of mechanical ventilation. Our goal is to improve comfort and address many of the barriers to the integration of esophageal manometry into the assessment of patients in the ICU. Ongoing assessments of clinician knowledge and comfort and monitoring the use of esophageal manometry in eligible patients will determine the effectiveness of the guideline implementation. 

References: 1. Grieco, D. L., Chen, L., & Brochard, L. (2017). Transpulmonary pressure: importance and limits. Annals of translational medicine5(14)..Akoumianaki, E. et al.  
2. The Application of Esophageal Pressure Measurement in Patients with Respiratory Failure.  Am J Respir Crit Care Med 2014; 189(5):  520-531. 

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