Perfluorochemicals as a treatment of decompression sickness in rats

Perfluorocarbon-based oxygen carriers: from physics to physiology

Developing biocompatible, synthetic oxygen carriers is a consistently challenging task that researchers have been pursuing for decades. Perfluorocarbons (PFC) are fascinating compounds with a huge capacity to dissolve gases, where the respiratory gases are of special interest for current investigations. Although largely chemically and biologically inert, pure PFCs are not suitable for injection into the vascular system. Extensive research created stable PFC nano-emulsions that avoid (i) fast clearance from the blood and (ii) long organ retention time, which leads to undesired transient side effects. PFC-based oxygen carriers (PFOCs) show a variety of application fields, which are worthwhile to investigate. To understand the difficulties that challenge researchers in creating formulations for clinical applications, this review provides the physical background of PFCs’ properties and then illuminates the reasons for instabilities of PFC emulsions. By linking the unique properties of PFCs and PFOCs to physiology, it elaborates on the response, processing and dysregulation, which the body experiences through intravascular PFOCs. Thereby the reader will receive a scientific and easily comprehensible overview why PFOCs are precious tools for so many diverse application areas from cancer therapeutics to blood substitutes up to organ preservation and diving disease.

Perfluorocarbons for the treatment of decompression illness: how to bridge the gap between theory and practice

Decompression illness (DCI) is a complex clinical syndrome caused by supersaturation of respiratory gases in blood and tissues after abrupt reduction in ambient pressure. The resulting formation of gas bubbles combined with pulmonary barotrauma leads to venous and arterial gas embolism. Severity of DCI depends on the degree of direct tissue damage caused by growing bubbles or indirect cell injury by impaired oxygen transport, coagulopathy, endothelial dysfunction, and subsequent inflammatory processes. The standard therapy of DCI requires expensive and not ubiquitously accessible hyperbaric chambers, so there is an ongoing search for alternatives. In theory, perfluorocarbons (PFC) are ideal non-recompressive therapeutics, characterized by high solubility of gases. A dual mechanism allows capturing of excess nitrogen and delivery of additional oxygen. Since the 1980s, numerous animal studies have proven significant benefits concerning survival and reduction in DCI symptoms by intravenous application of emulsion-based PFC preparations. However, limited shelf-life, extended organ retention and severe side effects have prevented approval for human usage by regulatory authorities. These negative characteristics are mainly due to emulsifiers, which provide compatibility of PFC to the aqueous medium blood. The encapsulation of PFC with amphiphilic biopolymers, such as albumin, offers a new option to achieve the required biocompatibility avoiding toxic emulsifiers. Recent studies with PFC nanocapsules, which can also be used as artificial oxygen carriers, show promising results. This review summarizes the current state of research concerning DCI pathology and the therapeutic use of PFC including the new generation of non-emulsified formulations based on nanocapsules.

Treatment of micro air bubbles in rat adipose tissue at 25 kPa altitude exposures with perfluorocarbon emulsions and nitric oxide

INTRODUCTION

Perfluorocarbon emulsions (PFC) and nitric oxide (NO) releasing agents have on experimental basis demonstrated therapeutic properties in treating and preventing the formation of venous gas embolism as well as increased survival rate during decompression sickness from diving. The effect is ascribed to an increased solubility and transport capacity of respiratory gases in the PFC emulsion and possibly enhanced nitrogen washout through NO-increased blood flow rate and/or the removal of endothelial micro bubble nuclei precursors. Previous reports have shown that metabolic gases (i.e., oxygen in particular) and water vapor contribute to bubble growth and stabilization during altitude exposures. Accordingly, we hypothesize that the administration of PFC and NO donors upon hypobaric pressure exposures either (1) enhance the bubble disappearance rate through faster desaturation of nitrogen, or in contrast (2) promote bubble growth and stabilization through an increased oxygen supply.

METHODS

In anesthetized rats, micro air bubbles (containing 79% nitrogen) of 4-500 nl were injected into exposed abdominal adipose tissue. Rats were decompressed in 36 min to 25 kPa (~10,376 m above sea level) and bubbles studied for 210 min during continued oxygen breathing (FIO2 = 1). Rats were administered PFC, NO, or combined PFC and NO.

RESULTS

In all groups, most bubbles grew transiently, followed by a stabilization phase. There were no differences in the overall bubble growth or decay between groups or when compared with previous data during oxygen breathing alone at 25 kPa.

CONCLUSION

During extreme altitude exposures, the contribution of metabolic gases to bubble growth compromises the therapeutic effects of PFC and NO, but PFC and NO do not induce additional bubble growth.

Blood substitutes: evolution from noncarrying to oxygen- and gas-carrying fluids

The development of oxygen (O2)-carrying blood substitutes has evolved from the goal of replicating blood O2 transport properties to that of preserving microvascular and organ function, reducing the inherent or potential toxicity of the material used to carry O2, and treating pathologies initiated by anemia and hypoxia. Furthermore, the emphasis has shifted from blood replacement fluid to "O2 therapeutics" that restore tissue oxygenation to specific tissues regions. This review covers the different alternatives, potential and limitations of hemoglobin-based O2 carriers (HBOCs) and perfluorocarbon-based O2 carriers (PFCOCs), with emphasis on the physiologic conditions disturbed in the situation that they will be used. It describes how concepts learned from plasma expanders without O2-carrying capacity can be applied to maintain O2 delivery and summarizes the microvascular responses due to HBOCs and PFCOCs. This review also presents alternative applications of HBOCs and PFCOCs namely: 1) How HBOC O2 affinity can be engineered to target O2 delivery to hypoxic tissues; and 2) How the high gas solubility of PFCOCs provides new opportunities for carrying, dissolving, and delivering gases with biological activity. It is concluded that the development of current blood substitutes has amplified their applications horizon by devising therapeutic functions for O2 carriers requiring limited O2 delivery capacity restoration. Conversely, full, blood-like O2-carrying capacity reestablishment awaits the control of O2 carrier toxicity.

Brain oxygenation and CNS oxygen toxicity after infusion of perfluorocarbon emulsion

Intravenous perfluorocarbon (PFC) emulsions, administered with supplemental inspired O(2), are being evaluated for their ability to eliminate N(2) from blood and tissue prior to submarine escape, but these agents can increase the incidence of central nervous system (CNS) O(2) toxicity, perhaps by enhancing O(2) delivery to the brain. To assess this, we infused a PFC emulsion (Oxycyte, 6 ml/kg iv) into anesthetized rats and measured cerebral Po(2) and regional cerebral blood flow (rCBF) in cortex, hippocampus, hypothalamus, and striatum with 100% O(2) at 1, 3, or 5 atmospheres absolute (ATA). At 1 ATA, brain Po(2) stabilized at >20 mmHg higher in animals infused with PFC emulsion than in control animals infused with saline, and rCBF fell by ~10%. At 3 ATA, PFC emulsion raised brain Po(2) >70 mmHg above control levels, and rCBF decreased by as much as 25%. At 5 ATA, brain Po(2) was ≥159 mmHg above levels in control animals for the first 40 min but then rose sharply; rCBF showed a similar profile, reflecting vasoconstriction followed by hyperemia. Conscious rats were also pretreated with PFC emulsion at 3 or 6 ml/kg iv and exposed to 100% O(2) at 5 ATA. At the lower dose, 80% of the animals experienced seizures by 33 min compared with 50% of the control animals. At the higher dose, seizures occurred in all rats within 25 min. At these doses, administration of PFC emulsion poses a clear risk of CNS O(2) toxicity in conscious rats exposed to hyperbaric O(2) at 5 ATA.

Venous gas embolism as a predictive tool for improving CNS decompression safety

A key process in the pathophysiological steps leading to decompression sickness (DCS) is the formation of inert gas bubbles. The adverse effects of decompression are still not fully understood, but it seems reasonable to suggest that the formation of venous gas emboli (VGE) and their effects on the endothelium may be the central mechanism leading to central nervous system (CNS) damage. Hence, VGE might also have impact on the long-term health effects of diving. In the present review, we highlight the findings from our laboratory related to the hypothesis that VGE formation is the main mechanism behind serious decompression injuries. In recent studies, we have determined the impact of VGE on endothelial function in both laboratory animals and in humans. We observed that the damage to the endothelium due to VGE was dose dependent, and that the amount of VGE can be affected both by aerobic exercise and exogenous nitric oxide (NO) intervention prior to a dive. We observed that NO reduced VGE during decompression, and pharmacological blocking of NO production increased VGE formation following a dive. The importance of micro-nuclei for the formation of VGE and how it can be possible to manipulate the formation of VGE are discussed together with the effects of VGE on the organism. In the last part of the review we introduce our thoughts for the future, and how the enigma of DCS should be approached.

Effect of oxygen breathing and perfluorocarbon emulsion treatment on air bubbles in adipose tissue during decompression sickness

Decompression sickness (DCS) after air diving has been treated with success by means of combined normobaric oxygen breathing and intravascular perfluorocarbon (PFC) emulsions causing increased survival rate and faster bubble clearance from the intravascular compartment. The beneficial PFC effect has been explained by the increased transport capacity of oxygen and inert gases in blood. However, previous reports have shown that extravascular bubbles in lipid tissue of rats suffering from DCS will initially grow during oxygen breathing at normobaric conditions. We hypothesize that the combined effect of normobaric oxygen breathing and intravascular PFC infusion could lead to either enhanced extravascular bubble growth on decompression due to the increased oxygen supply, or that PFC infusion could lead to faster bubble elimination due to the increased solubility and transport capacity in blood for nitrogen causing faster nitrogen tissue desaturation. In anesthetized rats decompressed from a 60-min hyperbaric exposure breathing air at 385 kPa, we visually followed the resolution of micro-air bubbles injected into abdominal adipose tissue while the rats breathed either air, oxygen, or oxygen breathing combined with PFC infusion. All bubble observations were done at 101.3 kPa pressure. During oxygen breathing with or without combined PFC infusion, bubbles disappeared faster compared with air breathing. Combined oxygen breathing and PFC infusion caused faster bubble disappearance compared with oxygen breathing. The combined effect of oxygen breathing and PFC infusion neither prevented nor increased transient bubble growth time, rate, or growth ratio compared with oxygen breathing alone. We conclude that oxygen breathing in combination with PFC infusion causes faster bubble disappearance and does not exacerbate transient bubble growth. PFC infusion may be a valuable adjunct therapy during the first-aid treatment of DCS at normobaric conditions.

Gas embolism: pathophysiology and treatment

Based on a literature search, an overview is presented of the pathophysiology of venous and arterial gas embolism in the experimental and clinical environment, as well as the relevance and aims of diagnostics and treatment of gas embolism. The review starts with a few historical observations and then addresses venous air embolism by discussing pulmonary vascular filtration, entrapment, and the clinical occurrence of venous air emboli. The section on arterial gas embolism deals with the main mechanisms involved, coronary and cerebral air embolism (CAE), and the effects of bubbles on the blood-brain barrier. The diagnosis of CAE uses various techniques including ultrasound, perioperative monitoring, computed tomography, brain magnetic resonance imaging and other modalities. The section on therapy starts by addressing the primary treatment goals and the roles of adequate oxygenation and ventilation. Then the rationale for hyperbaric oxygen as a therapy for CAE based on its physiological mode of action is discussed, as well as some aspects of adjuvant drug therapy. A few animal studies are presented, which emphasize the importance of the timing of therapy, and the outcome of patients with air embolism (including clinical patients, divers and submariners) is described.

Degassed liquids to prevent/treat decompression sickness

Recompression and oxygen breathing constitute the primary treatments for decompression sickness (DCS). Increasing the volume of distribution of dissolved gas with high-volume liquid therapy represents an alternative strategy to prevent or treat DCS. Furthermore, degassing of ingested and infused liquids would increase their potential to keep supersaturated tissue gases in solution after decompression. We hypothesize that administration of degassed liquids will prevent or reverse mild-moderate DCS by increasing the volume of distribution of dissolved gas in DCS victims. Degassed perfluorocarbon ingestion offers particularly attractive potential: one liter theoretically dissolves approximately 300ml of N(2) in vivo at 1atm. One could speculate that degassed liquids may adequately treat mild DCS in lieu of recompression, particularly DCS expressed in 'fast compartment' (well-perfused) tissues. Furthermore, degassed liquid administration should prove to be even more effective adjunct therapy for severe DCS than present gas-saturated liquids.

Perfluorocarbons: future clinical possibilities

Perfluorocarbons are now being used as oxygen carriers in clinical settings. Because these chemicals may have a role as a blood substitute, in organ preservation, and in the management of respiratory failure, we have reviewed some of the research leading to these applications.

Removal of dissolved O2 by a fluid membrane of Fomblin Y (perfluoro polyether): fluorescence of diphenylhexatriene in Fomblin Y

O2 can be gently removed from solutions by contact with a "bulk fluid membrane" of the viscous and nearly inert perfluoro polyether Fomblin Y. A volume of Fomblin dissolves approximately 20 times more O2 than an equal volume of water. Hence, when a volume of aqueous solution which was in equilibrium with air is enclosed with an equal volume of Fomblin which had been flushed with argon, oxygen would diffuse into the Fomblin, leaving in the water only 5% of the oxygen that was there. When the Fomblin is stirred, diffusion is rather rapid. The residue can be removed either by placing an oxygen scavenger on the other side of the Fomblin or by flowing a trickle of deoxygenated Fomblin through the sample. Diphenylhexatriene, a fluorescent probe of cell membranes, can be dissolved in Fomblin Y and has a fluorescence lifetimes extending from 12 ns in O2 saturation to 30 ns (!) in the absence of oxygen. Stern-Volmer plots calibrated against a Clark electrode validate this system for oximetry. A general purpose anaerobic cuvette for fluorescence spectroscopy, containing the sample solution, a Fomblin compartment and the oxygen scavenger Na-dithionite is demonstrated.

Potential clinical applications for blood substitutes

In the coming decade, it is likely that oxygen-carrying alternatives to red blood cells will become available for clinical use. The driving force behind their development is the risk of transfusion of homologous blood, which includes transmission of viral disease (HIV and hepatitis) and transfusion reactions as well as the expense of collecting and storing human blood. A number of clinical applications for these products can be anticipated now, but when available, it is likely that the list will grow. How widely these products will be used depends on their safety. In addition to these clinical applications, blood substitutes will be useful in furthering our understanding of basic oxygen transport physiology.

Overview of progress in the fluorocarbon approach to in vivo oxygen delivery

The development of fluorocarbon-based oxygen carriers has experienced rapid progress over the past few years. Fluosol has been approved for use during percutaneous transluminal coronary angioplasty (PTCA) for high-risk patients. Its clinical evaluation is being pursued as an adjunct to cancer therapy and for treatment of myocardial infarction in conjunction with thrombolytic therapy. O2-delivery efficacy has been achieved with the development of the new highly concentrated (4 to 5 times more concentrated than Fluosol), fluid, emulsions of perfluorooctyl bromide (perflubron), trade-named Oxygen. The stability of fluorocarbon emulsions has also improved considerably and the new emulsions can be stored unfrozen and are ready for use. The side-effect profile of these emulsions has been characterized as being the normal response of the body's phagocytes to the injection of particles, a response that is considered physiological rather than pathological in nature; it involves some products of arachidonic acid metabolism and can be controlled pharmacologically. Means of further stabilizing fluorocarbon emulsions, involving molecular-diffusion-controlling additives or fluorinated surfactants, including mixed fluorocarbon-hydrocarbon compounds, have been devised. Increased control over in vivo particle recognition, intravascular persistence and side effects, and at adapting emulsion characteristics to specific applications, is being investigated. The range of therapeutic applications is expanding. The concentrated emulsions will be able to serve as a temporary red blood cell substitute in many situations. Acute normovolemic hemodilution with fluorocarbon emulsions, used in conjunction with homologous predonation and other blood-sparing techniques, should afford greater flexibility, increase the margin of safety, and reduce or alleviate the need for autologous blood transfusion during surgical procedures. Fluorocarbon applications in the cardiovascular field include use during PTCA, for cardioplegia and reperfusion, and the treatment of myocardial infarction. Significant tumor growth delay has been achieved when concentrated emulsions are used in conjunction with cancer radio- or chemotherapy. Liquid ventilation has potential as a unique treatment for the adult and infant respiratory distress syndromes and for drug delivery. The radiopaque and versatile perflubron can also be used in contrast agents for diagnosis with computed X-ray tomography, magnetic resonance imaging and ultrasound, allowing the early detection and staging of cancer. Other potential applications investigated include the treatment of cerebral ischemia, organ and limb preservation, use as a tamponade during retinal repair, etc.

Combination of treatment with perfluorochemicals and free radical scavengers

P-cyclohexylmorpholine, given as oxygen carrier of second generation, was tested in two experimental models: the ischemic intestine and the lung under hyperbaric oxygen condition. In both instances in separated groups either alpha-tocopherol or allopurinol was additionally given as oxygen free radical scavenger. The thiobarbituric acid reaction (TBAR) was used as screening test for the occurrence of lipid peroxidation in organ probes; further the content of glutathione in reduced (GSH) and oxidized form (GSSG) was determined. Whereas only slight increases of TBAR substances and GSSG could be found compared to controls, the effect of the administrated scavenging drugs was very impressive: they could suppress nearly totally the effect of an enhanced oxidative stress.

Synthetic oxygen transport fluids based on perfluorochemicals: applications in medicine and biology

Recent advances in the development and assessment of synthetic oxygen transport fluids based on perfluorochemicals (PFCs) are reviewed. The basic properties of PFCs are outlined, together with the selection criteria for biomedical applications. PFCs must be emulsified for intravascular use and attention is focussed on the formulation and biocompatibility testing of both first- and second-generation emulsions and their components in man and other species. The multidisciplinary applications for PFCs in medicine and basic biomedical research are described, including the clinical use of Fluosol-DA 20% as an oxygen-carrying perfusate in percutaneous transluminal coronary angioplasty.

Perfluorochemical erythrocyte substitutes: disposition and effects on drug distribution and elimination

As a result of their ability to transport oxygen, PFC emulsions are being investigated for possible use in a wide variety of conditions. The recent FDA approval of F-DA to diminish myocardial ischemia during angioplasty is the first marketing approval for such a product in the world. The many potential uses of such products may result in their common application in the future, especially as new and better products are developed. The elimination, distribution, and tissue retention of PFC emulsions as well as the physiological changes that occur upon their administration have been the subject of many investigations. The results indicate that these agents may influence the pharmacokinetic properties of other drugs by a wide variety of mechanisms. Several studies have shown significant, but not necessarily consistent, changes in drug elimination and distribution following PFC emulsion infusion. Changes appear dependent on the drug examined, emulsion utilized, degree of blood exchange, species utilized, and the controls chosen for comparison. Often, the changes are time dependent indicating the importance of conducting long-term studies. While PFC emulsions do not appear to alter renal elimination of drugs, several studies have demonstrated that these agents have the potential to induce drug metabolism from several days to possibly months after exposure. Observed changes in drug volumes of distribution, which are often time dependent, may be due to changes in normal drug transport throughout the circulation and/or changes in membrane permeability and cell transport mechanisms. Changes in drug transport may result from depletion of plasma proteins or increases in alpha 1-acid glycoprotein levels due to trauma or PFC emulsion effects. The binding of drugs by PFC emulsion droplets varies greatly and PFC emulsion components displace some plasma protein bound drugs. The wide variability in the results and conclusions of the pharmacokinetic studies conducted to date emphasize the importance of utilizing adequate controls to identify which alterations are PFC emulsion specific.

Perfluorochemicals as oxygen transport vehicles

Perfluorochemical liquids (PFC's) are good solvents for gases and as such, have significant relevance to the field of biology. Approximately 40 ml of oxygen will dissolve in 100 ml of most PFC's, and carbon dioxide is at least twice as soluble. This makes these compounds attractive as vehicles for these and other gases in-vivo and in-vitro. Although many have low viscosities and surface tensions, it is necessary to emulsify them for intravenous use and organ perfusion. The emulsion particles must be very fine, usually about 150 nanometers in diameter, and stable in the presence of blood and other biological fluids. Presently the two most used emulsifying agents are Pluronic F68 and phospholipids. Emulsions made with the former are now known to cause complement activation with accompanying transient decreases in circulating leukocytes and oxygen tension. This phenomenon is reversible and usually not severe. Phospholipid-stabilized PFC emulsions do not activate complement and should therefore, be advantageous. Areas of current research utilizing PFC emulsions are in tumor therapy, by increasing the oxygenation of otherwise hypoxic cells, in ischemic heart treatment, and in alleviating the effects of cerebral ischemia. Many other applications of PFC's are being pursued, and even more research activity in this field is likely.

Perfluorocarbon blood substitutes

The salient physicochemical properties of the fluorocarbons are briefly reviewed, including their solubility for the physiologically important gases and their properties relevant to formulation (nonmiscibility with water). The preparations used to date are described, including their properties and compositions, with some comment about the available knowledge of the properties of the constituents. A critical review of the biological aspects and the possible uses of fluorocarbon emulsions constitutes the main body of the manuscript. Gas-transporting capabilities are considered quantitatively. The biological effects of these preparations are reviewed in in vivo, whole body systems, with some in vitro evidence where appropriate. The usefulness of these preparations investigated to date are reviewed under the broad headings of cardiovascular system, radiology, intoxications, and organ preservation. Finally, the shortcomings and potential usefulness are discussed, with recommendations for potential modifications.

Perfluorocarbons as oxygen-transport fluids

1. An overview of the proposed biological applications of perfluorocarbons and their emulsions as oxygen-transport fluids is presented. 2. Aspects of the properties, preparation, composition and physiological assessment of perfluorocarbon emulsions are discussed. 3. The experimental basis for some of the potential therapeutic uses of PFCs in liquid ventilation, treatment of decompression sickness, organ perfusion, oxygenation of ischaemic and malignant tissues, and as contrast media for NMR imaging is described. 4. The extent to which emulsified perfluorocarbons may have value as substitutes for red blood cells is discussed in detail. Data from both animal and human studies with such emulsions is reviewed. Brief consideration is also given to the possible use of native and modified haemoglobin in blood replacement together with recent work on the preparation of so-called "synthetic red cells".

The influence of oxygenation on the 19F spin-lattice relaxation rates of fluosol-DA

The spin-lattice relaxation rates (1/T1) were measured at 94.1 MHz for six peaks in the 19F NMR spectrum of the perfluorochemical blood substitute fluosol-DA, which contains a mixed emulsion of perfluorodecalin and perfluorotripropylamine. Each of these rates increased linearly with the percentage of oxygen dissolved in the emulsion. Relative values of the linear increase for different peaks established that, for perfluorotripropylamine in the mixed emulsion, the oxygen-fluorocarbon interaction is loosely but preferentially oriented in a manner similar to that previously established for other pure fluorocarbons. The uncertainty in the oxygen level estimated from T1 measurements is somewhat less than 5% O2 and it is thus established that quantitative non-invasive oxygenation measurements can be made to sufficient precision by this approach, using fluosol-DA and 19F spin-lattice relaxation.