• Zhong-Hua Shi, Annemijn Jonkman, Heder de Vries, Diana Jansen, Coen Ottenheijm, Armand Girbes, Angelique Spoelstra-de Man, Jian-Xin Zhou, Laurent Brochard, and Leo Heunks.
• Department of Intensive Care Medicine, Amsterdam UMC, Location VUmc, Postbox 7057, 1007 MB,, Amsterdam, The Netherlands.
• Intensive Care Med. 2019 Aug 1; 45 (8): 106110711061-1071.

IntroductionThis narrative review summarizes current knowledge on the physiology and pathophysiology of expiratory muscle function in ICU patients, as shared by academic professionals from multidisciplinary, multinational backgrounds, who include clinicians, clinical physiologists and basic physiologists.ResultsThe expiratory muscles, which include the abdominal wall muscles and some of the rib cage muscles, are an important component of the respiratory muscle pump and are recruited in the presence of high respiratory load or low inspiratory muscle capacity. Recruitment of the expiratory muscles may have beneficial effects, including reduction in end-expiratory lung volume, reduction in transpulmonary pressure and increased inspiratory muscle capacity. However, severe weakness of the expiratory muscles may develop in ICU patients and is associated with worse outcomes, including difficult ventilator weaning and impaired airway clearance. Several techniques are available to assess expiratory muscle function in the critically ill patient, including gastric pressure and ultrasound.ConclusionThe expiratory muscles are the "neglected component" of the respiratory muscle pump. Expiratory muscles are frequently recruited in critically ill ventilated patients, but a fundamental understanding of expiratory muscle function is still lacking in these patients.

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