Table 1

Summary of the rationale and clinical applications for PL and PPL monitoring in critically ill children undergoing invasive mechanical ventilation

Protective ventilationWhy?
Paediatric specificities and potential consequences
What’s known?
Actual evidence in critically ill children
What’s new?
Potential applications and future studies
PEEP titrationLow FRC
Lower diastolic function
Higher right afterload
  • Lung collapse

  • Right ventricle failure

  • Low PEEP is associated with mortality53

  • Cardiac index and BP are not changed55 when increasing PEEP in PARDS but BP decreases after recruitment manoeuvres during cardiac surgery59

  • No evidence about the benefits of a PL-targeted PEEP titration

  • To assess the effect of a PL-targeted PEEP titration on RV function

    • PARDS

    • Congenital heart defects

Target physiological respiratory effortPatient-ventilator asynchrony
  • Dynamic hyperinflation and diaphragm expiratory activation

  • High RR, low lung volume

Fatigable respiratory muscles
  • VIDD

  • VILI ? P-SILI ?

  • Trigger errors induce additional respiratory effort65

  • Usefulness of PPL swings analysis

    • PEEP titration to limit dynamic hyperinflation and improve asynchrony66

    • Detect reverse triggering30

  • To investigate the deleterious effects of patient-ventilator asynchrony

  • To assess if strenuous efforts leads to P-SILI in children

  • To validate the usefulness of PPL monitoring during active conditions as a guide for lung and diaphragmatic protective ventilation

Optimisation of weaningFatigable respiratory muscles
Post-extubation upper airway obstruction
  • VIDD

  • High risk of extubation failure

  • SBT is feasible without excessive respiratory effort26 62

  • A high postextubation respiratory effort predicts extubation failure26

  • To validate the usefulness of PPL monitoring to detect potentially difficult-to-wean patients and guide long-term ventilatory management

  • References are added in brackets.

  • BP, blood pressure; FRC, functional respiratory capacity; PARDS, paediatric acute respiratory distress syndrome; PEEP, positive end-expiratory pressure; PL, transpulmonary pressure; PPL, pleural pressure; P-SILI, patient self-induced lung injury; RR, respiratory rate; RV, Right ventricle; SBT, spontaneous breathing trial; VIDD, ventilator-induced diaphragm injury; VILI, ventilator-induced lung injury.