EFFECTIVENESS OF ESOPHAGEAL BALLOON MONITORING FOR OPTIMIZING PEEP IN ARDS: A SCOPING REVIEW

Abstract

Background: Acute Respiratory Distress Syndrome (ARDS) presents a significant clinical challenge due to severe hypoxemia and lung non-compliance. Positive End-Expiratory Pressure (PEEP) is critical in sustaining alveolar recruitment and improving oxygenation. Conventional PEEP strategies, such as those recommended by ARDSNet, do not account for individual pleural pressure variations, potentially leading to ventilation-induced lung injury (VILI). Esophageal balloon monitoring facilitates estimation of transpulmonary pressure, enabling personalized PEEP titration to optimize lung protection in ARDS patients.

Objective: To map and synthesize existing evidence on the effectiveness of esophageal balloon monitoring for optimizing PEEP in ARDS, focusing on clinical outcomes, comparisons with conventional ventilation strategies, technical challenges, and personalized ventilation approaches.

Methods: A scoping review was conducted following the Arksey and O’Malley framework. Three databases—PubMed, Scopus, and Web of Science—were systematically searched for studies from 2020 to 2025. Inclusion criteria comprised quantitative, qualitative, and mixed-method studies involving esophageal balloon monitoring targeting PEEP optimization in ARDS patients. Screening and data extraction were independently performed by two reviewers, culminating in 22 included studies. Data were summarized in a structured matrix covering study design, outcomes, comparisons, and limitations.

Results: The included studies comprised clinical trials, implementation studies, and mixed-method reviews. Evidence consistently showed improved oxygenation, increased lung compliance, and a reduction in VILI with esophageal balloon-guided PEEP compared to ARDSNet approaches. Notably, randomized controlled trials demonstrated improved PaO2/FiO2 ratios, decreased driving pressures, and mortality benefits in subgroups such as obese ARDS patients. Bench studies highlighted technical considerations regarding catheter design and calibration. Despite physiological benefits, barriers to clinical adoption include equipment costs, training needs, and protocol complexity.

Discussion: Esophageal balloon monitoring offers superior personalization in PEEP titration by addressing pleural pressure heterogeneity inherent in ARDS, yet clinical outcome improvements remain subgroup-dependent. Benefits are clear in oxygenation and lung protection but tempered by technical and practical challenges. The technique supports the evolution toward precision mechanical ventilation tailored to individual patient physiology, potentially improving outcomes in complex ARDS phenotypes.

Conclusion: Esophageal balloon monitoring effectively optimizes PEEP in ARDS, enhancing respiratory mechanics and reducing lung injury. Further large-scale randomized trials, cost-effectiveness analyses, and standardization of protocols are needed to facilitate broader clinical integration and validate long-term benefits.