Esophageal manometry: a valuable tool for the comprehensive management of COVID-19-related hypoxic respiratory failure

Abstract

The optimal management of respiratory failure related to SARS-CoV-2 infection is a subject of heated debates in the scientific community. The lack of solid scientific evidence, combined with the unclear pathophysiology of COVID-19 pneumonia, means that the modalities and duration of ventilator assistance often rely on subjective assessments of the doctor on call. In establishing a suitable respiratory support, it is essential to evaluate the degree of activation of the respiratory muscles as objectively as possible. Among the various methods of evaluating the inspiratory effort, measurement of the phasic variations of esophageal pressure (intended as a surrogate of pleural pressure) represents the gold standard. Esophageal pressure measurement can be implemented in a minimally invasive way in every patient category, does not require sophisticated devices, and provides objective data about respiratory muscle activity. In patients with ongoing COVID-19-related respiratory failure, esophageal pressure monitoring allows i) optimizing the type and settings of noninvasive ventilation, ii) providing objective support in the delicate choice of establishing invasive ventilation in cases in which such an indication is unclear, and iii) monitoring the clinical evolution of COVID-19 pneumonia to allow early interception of cases with progressive worsening of lung function. Esophageal manometry provides a complete and objective assessment of respiratory muscle activity. Its clinical use in patients with respiratory failure in the course of COVID-19 would allow clarifying some pathophysiological aspects of the disease and customizing ventilatory support according to the needs of specific patients.