Role of transpulmonary pressure esophageal Balloon catheter-guided monitoring in the management of severe acute respiratory distress syndrome

ABSTRACT Acute respiratory distress syndrome (ARDS) is a life-threatening condition that often necessitates advanced ventilatory strategies. This case presents a 43-year-old female with severe ARDS who required invasive mechanical ventilation and individualized positive end-expiratory pressure (PEEP) titration guided by transpulmonary pressure (PL) monitoring by esophageal balloon catheter. A 43-year-old morbidly obese female (body mass index – 40) with a history of heavy smoking presented with a 2-day history of worsening shortness of breath, chest pain, and productive cough. She developed severe ARDS and required intubation within 12 h of hospital admission after failure of noninvasive ventilation. Lung-protective ventilation and prone positioning were initiated, PEEP increased up to 16 cmH2O, but oxygenation remained poor with PaO 2 /FiO 2 ratio < 00. The patient was considered for ECMO support as a last resort. But the treating team decided before ECMO to check the PL, esophageal balloon catheter was placed to guide further management. Based on PL monitoring, PEEP was titrated up to 28 cmH 2 O, leading to significant improvement in oxygenation and compliance. The patient was gradually weaned, discharged from the intensive care unit after 27 days, and later discharged home safely. An esophageal balloon catheter provided real-time data that was associated with improved outcomes in severe ARDS. This case underscores the role of esophageal balloon catheter monitoring in optimizing PEEP and improving outcomes in severe ARDS, particularly in patients with complex comorbidities such as morbid obesity.