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Critical Care Research and Practice
Volume 2012, Article ID 597932, 9 pages
Review Article

Goal-Directed Mechanical Ventilation: Are We Aiming at the Right Goals? A Proposal for an Alternative Approach Aiming at Optimal Lung Compliance, Guided by Esophageal Pressure in Acute Respiratory Failure

1Intensive Care Unit, E. Wolfson Medical Center, Halohamim st 62, 58100 Holon, Israel
2Sackler Faculty of Medicine, University of Tel Aviv, 69978 Tel Aviv, Israel
3Intensive Care Unit, Hospital Morales Meseguer, Avenida Marqués de Los Velez s/n, 30500 Murcia, Spain

Received 30 June 2012; Revised 12 August 2012; Accepted 13 August 2012

Academic Editor: Mikhail Y. Kirov

Copyright © 2012 Arie Soroksky and Antonio Esquinas. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


Patients with acute respiratory failure and decreased respiratory system compliance due to ARDS frequently present a formidable challenge. These patients are often subjected to high inspiratory pressure, and in severe cases in order to improve oxygenation and preserve life, we may need to resort to unconventional measures. The currently accepted ARDSNet guidelines are characterized by a generalized approach in which an algorithm for PEEP application and limited plateau pressure are applied to all mechanically ventilated patients. These guidelines do not make any distinction between patients, who may have different chest wall mechanics with diverse pathologies and different mechanical properties of their respiratory system. The ability of assessing pleural pressure by measuring esophageal pressure allows us to partition the respiratory system into its main components of lungs and chest wall. Thus, identifying the dominant factor affecting respiratory system may better direct and optimize mechanical ventilation. Instead of limiting inspiratory pressure by plateau pressure, PEEP and inspiratory pressure adjustment would be individualized specifically for each patient's lung compliance as indicated by transpulmonary pressure. The main goal of this approach is to specifically target transpulmonary pressure instead of plateau pressure, and therefore achieve the best lung compliance with the least transpulmonary pressure possible.