Article Text

Download PDFPDF
Pleural and transpulmonary pressures to tailor protective ventilation in children
  1. Meryl Vedrenne-Cloquet1,2,3,
  2. Sonia Khirani3,4,
  3. Robinder Khemani5,
  4. Fabrice Lesage1,
  5. Mehdi Oualha1,
  6. Sylvain Renolleau1,
  7. Davide Chiumello6,
  8. Alexandre Demoule7,8,
  9. Brigitte Fauroux2,3
  1. 1 Pediatric intensive care unit, Necker-Enfants Malades Hospitals, Paris, France
  2. 2 Université de Paris Cité, VIFASOM, Paris, France
  3. 3 Pediatric Non Invasive Ventilation Unit, Necker-Enfants Malades Hospitals, Paris, France
  4. 4 ASV Santé, Genevilliers, France
  5. 5 Children’s Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
  6. 6 Dipartimento di Anestesia, Rianimazione e Terapia del Dolore, Fondazione, IRCCS Ca’ Granda – Ospedale Maggiore Policlinico, Milan, Italy
  7. 7 Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
  8. 8 UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, Sorbonne Université, INSERM, Paris, France
  1. Correspondence to Dr Meryl Vedrenne-Cloquet, Necker-Enfants Malades Hospitals, Paris, Île-de-France, France; meryl_vedrenne{at}


This review aims to: (1) describe the rationale of pleural (PPL) and transpulmonary (PL) pressure measurements in children during mechanical ventilation (MV); (2) discuss its usefulness and limitations as a guide for protective MV; (3) propose future directions for paediatric research. We conducted a scoping review on PL in critically ill children using PubMed and Embase search engines. We included peer-reviewed studies using oesophageal (PES) and PL measurements in the paediatric intensive care unit (PICU) published until September 2021, and excluded studies in neonates and patients treated with non-invasive ventilation. PL corresponds to the difference between airway pressure and PPL. Oesophageal manometry allows measurement of PES, a good surrogate of PPL, to estimate PL directly at the bedside. Lung stress is the PL, while strain corresponds to the lung deformation induced by the changing volume during insufflation. Lung stress and strain are the main determinants of MV-related injuries with PL and PPL being key components. PL-targeted therapies allow tailoring of MV: (1) Positive end-expiratory pressure (PEEP) titration based on end-expiratory PL (direct measurement) may be used to avoid lung collapse in the lung surrounding the oesophagus. The clinical benefit of such strategy has not been demonstrated yet. This approach should consider the degree of recruitable lung, and may be limited to patients in which PEEP is set to achieve an end-expiratory PL value close to zero; (2) Protective ventilation based on end-inspiratory PL (derived from the ratio of lung and respiratory system elastances), might be used to limit overdistention and volutrauma by targeting lung stress values < 20–25 cmH2O; (3) PPL may be set to target a physiological respiratory effort in order to avoid both self-induced lung injury and ventilator-induced diaphragm dysfunction; (4) PPL or PL measurements may contribute to a better understanding of cardiopulmonary interactions. The growing cardiorespiratory system makes children theoretically more susceptible to atelectrauma, myotrauma and right ventricle failure. In children with acute respiratory distress, PPL and PL measurements may help to characterise how changes in PEEP affect PPL and potentially haemodynamics. In the PICU, PPL measurement to estimate respiratory effort is useful during weaning and ventilator liberation. Finally, the use of PPL tracings may improve the detection of patient ventilator asynchronies, which are frequent in children. Despite these numerous theoritcal benefits in children, PES measurement is rarely performed in routine paediatric practice. While the lack of robust clincal data partially explains this observation, important limitations of the existing methods to estimate PPL in children, such as their invasiveness and technical limitations, associated with the lack of reference values for lung and chest wall elastances may also play a role. PPL and PL monitoring have numerous potential clinical applications in the PICU to tailor protective MV, but its usefulness is counterbalanced by technical limitations. Paediatric evidence seems currently too weak to consider oesophageal manometry as a routine respiratory monitoring. The development and validation of a noninvasive estimation of PL and multimodal respiratory monitoring may be worth to be evaluated in the future.

  • ARDS
  • Critical Care
  • Paediatric Physician
  • Respiratory Measurement

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.


  • Contributors MV-C, SK and BF conceptualised and designed the study. MV-C performed the initial search and classification for the articles. All the authors checked classification and inclusion of the selected articles (collection of data). MV-C drafted the first manuscript, supervised by BF, and was helped by AD, DC and RK, for specific sections. MO, FL, SR, SK, RK, DC, AD and BF reviewed, edited and approved the final version to be published.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests AD reports personal fees from Medtronic, grants, personal fees and non-financial support from Philips, personal fees from Baxter, personal fees from Hamilton, personal fees and non-financial support from Fisher & Paykel, grants from French Ministry of Health, personal fees from Getinge, grants and personal fees from Respinor, grants and non-financial support from Lungpacer, outside the submitted work. MV-C reports non-financial support from Sentec, outside the submitted work. RK reports personal fees from OrangeMed Nihon Kohden, and grants from Masimo outside the submitted work.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.