How to quantify respiratory effort and drive in critically ill children?

Abstract The emergence of the concepts of patient self-inflicted lung injury and lung and diaphragm-protective ventilation has renewed interest in quantifying respiratory drive, respiratory effort, and work of breathing in real-time and at the bedside. Measurements derived from electromyography of respiratory muscles and esophageal manometry are the gold standard, but their current use in pediatric ICUs is scarce. There are other direct and indirect methods to quantify respiratory drive and effort that have been validated in critically ill pediatric patients. Direct methods have been adequately tested, specifically to customize the level of support provided from the acute phase to weaning from mechanical ventilation. Promising indirect methods may be the first step, and some of them have been adequately validated. Given the heterogeneity of the pediatric population and the scarcity of cut-off thresholds, decisions must be based on the trajectory of drive and effort, preferably using a multimodal approach. In this review, we summarize the current state of the art regarding direct methods and new tools for quantifying respiratory drive and effort, including their relevance and limitations in decision-making.