Chengda Zhang, MD

Esophageal balloon manometry

Evidence assembled by Chengda Zhang, MD

1. Evidence supporting titration of ventilator using esophageal balloon manometry

Mechanical Ventilation Strategy Guided by Transpulmonary Pressure in Severe Acute Respiratory Distress Syndrome Treated With Venovenous Extracorporeal Membrane Oxygenation

Crit Care Med. 2020 Sep;48(9):1280-1288

This trial was done in Chaoyang Hospital 朝阳医院, China's top academic hospital for critical care. The trial was designed to randomly assign VV-ECMO patients to two different ventilation strategy. The patient population is similar to most ECMO ARDS patients in US. 52 patients in each arm. Intervention was PEEP titration based on esophageal pressure, to maintain transpulmonary pressure of 0-5 cmH2O. Control group received conventional lung protective ventilation with PEEP between 10-15cmH2O.

Transpulmonary pressure guidance was associated with significantly higher successful ECMO decannulation (71.2% vs 48.0%, p=0.017)

This result makes sense physiologically: Keeping lung open and preventing atelectrauma could facilitate lung recovery.

Conclusion: It's time to consider esophageal balloon for VV-ECMO patients. Especially for those with obesity or other risk factors for increased intrathoracic pressure.

2. Verification of esophageal balloon placement

Collected from Hamilton Medical, author: Jean-Michel Arnal, Senior Intensivist, Hopital Sainte Musse, Toulon, France

• Cardiac oscillations are typical pressure waveform when balloon is present in the esophagus:

Intra-gastric position Intra-esophagus position

• To further verify the placement of balloon, occlusion test can be performed:


At expiratory hold, apply external thoracic pressure, the esophageal pressure and airway pressure should increase together, so that patient's transpulmonary pressure is unchanged.



With expiratory hold, patient will attempt to initiate inspiration, generating negative esophageal pressure and airway pressure at the same time, while patient's transpulmonary pressure remain unchanged.

• Balloon inflation

The balloon usually require 0.5-3cc of air to inflate. According to the method proposed by Mojoli et al (2016), the balloon is inflated from 0.5 to 3 ml in gradual steps of 0.5 ml for a Cooper Surgical catheter, and from 1 to 8 ml in steps of 1 ml for a Nutrivent catheter. During progressive inflation of the balloon, the baseline of esophageal pressure increases and the magnitude of the esophageal pressure deflection changes. The adequate inflation volume is the one associated with the largest deflection of esophageal pressure. If two different inflation volumes show the same magnitude of esophageal pressure deflection, the lowest inflation volume is selected.