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• W1963670425 abstract "To the Editor: Shasby et al (Chest 1981; 80:666-70), in an admirable study, emphasize the importance of location of the Swan-Ganz catheter tip below the left atrium for a reliable wedge pressure, especially when left atrial pressure is low and PEEP is high. Positioning the tip below the left atrium keeps it in West's zone 31West JB Dollery CT Naimark A Distribution of blood flow in isolated lung.Relation of vascular and alveolar pressure. J Appl Physiol. 1964; 19: 713-724PubMed Google Scholar where capillary distending pressure is greater than alveolar pressure so that left atrial pressure rather than alveolar pressure is transmitted when the catheter is wedged. As the authors point out, artifactual elevation of wedge pressure with the catheter tip in a higher position could also be avoided by briefly eliminating PEEP. A second source of error exists in the measurement of wedge pressure with PEEP (or in any circumstances with elevated mean pleural pressure, eg, COPD2Rice DL Awe RJ Gaasch WH Alexander JK Jenkins DE Wedge pressure measurement in chronic obstructive lung disease.Chest. 1974; 66: 628-632Crossref PubMed Scopus (39) Google Scholar or intermittent positive pressure ventilation). To the extent that positive airway pressure is transmitted to the pleural space, all pressures referenced to atmospheric will be artifactually elevated, including both wedge and left atrial pressures. This error would not be detected by direct measurement of left atrial pressure.2Rice DL Awe RJ Gaasch WH Alexander JK Jenkins DE Wedge pressure measurement in chronic obstructive lung disease.Chest. 1974; 66: 628-632Crossref PubMed Scopus (39) Google Scholar, 3Pace NL A critique of flow-directed pulmonary arterial catheterization.Anesthesiology. 1977; 47: 455-465Crossref PubMed Scopus (47) Google Scholar The left atrial transmural distending pressure and the effective wedge pressure are referenced to pleural (or pericardial, in the case of the atrium), not atmospheric, pressure. There are two clinical ways to correct the second error: either by measuring esophageal4Leatherman NE An improved balloon system for monitoring intraesophageal pressure in acutely ill patients.Crit Care Med. 1978; 6: 189-192Crossref PubMed Scopus (2) Google Scholar or pleural5Downs JB A technique for direct measurement of intrapleural pressure.Crit Care Med. 1976; 4: 207-210Crossref PubMed Scopus (21) Google Scholar pressure directly, or by periodically measuring pressures with the patient briefly off PEEP. The latter would correct for both PEEP-induced artifacts. Hypoxemia from brief removal from mechanical ventilation with PEEP is of short duration.6DeCampo T Civetta JM The effect of short-term discontinuation of high-level PEEP in patients with acute respiratory failure.Crit Care Med. 1979; 7: 47-49Crossref PubMed Google Scholar Such separation occurs periodically anyway for suctioning and other maneuvers. I know of no study demonstrating an ill effect on patient outcome from this, which may also be more practical than possibly prolonged repositioning of the Swan-Ganz catheter until the tip is below the left atrium. Therefore, I must disagree with the authors' statement that “discontinuing PEEP … cannot be recommended in seriously ill patients.” On the contrary, it would be prudent to disconnect the patient briefly from the ventilator every 8 to 12 hours to allow for the discrepancy between wedge pressures measured on and off PEEP." @default.
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• W1963670425 date "1982-09-01" @default.
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• W1963670425 title "Wedge Pressure with PEEP" @default.
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• W1963670425 doi "https://doi.org/10.1378/chest.82.3.390-c" @default.
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