1
|
Mikacenic C, Fussner LA, Bell J, Burnham EL, Chlan LL, Cook SK, Dickson RP, Almonor F, Luo F, Madan K, Morales-Nebreda L, Mould KJ, Simpson AJ, Singer BD, Stapleton RD, Wendt CH, Files DC. Research Bronchoscopies in Critically Ill Research Participants: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc 2023; 20:621-631. [PMID: 37125997 PMCID: PMC10174130 DOI: 10.1513/annalsats.202302-106st] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Bronchoscopy for research purposes is a valuable tool to understand lung-specific biology in human participants. Despite published reports and active research protocols using this procedure in critically ill patients, no recent document encapsulates the important safety considerations and downstream applications of this procedure in this setting. The objectives were to identify safe practices for patient selection and protection of hospital staff, provide recommendations for sample procurement to standardize studies, and give guidance on sample preparation for novel research technologies. Seventeen international experts in the management of critically ill patients, bronchoscopy in clinical and research settings, and experience in patient-oriented clinical or translational research convened for a workshop. Review of relevant literature, expert presentations, and discussion generated the findings presented herein. The committee concludes that research bronchoscopy with bronchoalveolar lavage in critically ill patients on mechanical ventilation is valuable and safe in appropriately selected patients. This report includes recommendations on standardization of this procedure and prioritizes the reporting of sample management to produce more reproducible results between laboratories. This document serves as a resource to the community of researchers who endeavor to include bronchoscopy as part of their research protocols and highlights key considerations for the inclusion and safety of research participants.
Collapse
|
2
|
Martin TR, Zemans RL, Ware LB, Schmidt EP, Riches DWH, Bastarache L, Calfee CS, Desai TJ, Herold S, Hough CL, Looney MR, Matthay MA, Meyer N, Parikh SM, Stevens T, Thompson BT. New Insights into Clinical and Mechanistic Heterogeneity of the Acute Respiratory Distress Syndrome: Summary of the Aspen Lung Conference 2021. Am J Respir Cell Mol Biol 2022; 67:284-308. [PMID: 35679511 PMCID: PMC9447141 DOI: 10.1165/rcmb.2022-0089ws] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/09/2022] [Indexed: 12/15/2022] Open
Abstract
Clinical and molecular heterogeneity are common features of human disease. Understanding the basis for heterogeneity has led to major advances in therapy for many cancers and pulmonary diseases such as cystic fibrosis and asthma. Although heterogeneity of risk factors, disease severity, and outcomes in survivors are common features of the acute respiratory distress syndrome (ARDS), many challenges exist in understanding the clinical and molecular basis for disease heterogeneity and using heterogeneity to tailor therapy for individual patients. This report summarizes the proceedings of the 2021 Aspen Lung Conference, which was organized to review key issues related to understanding clinical and molecular heterogeneity in ARDS. The goals were to review new information about ARDS phenotypes, to explore multicellular and multisystem mechanisms responsible for heterogeneity, and to review how best to account for clinical and molecular heterogeneity in clinical trial design and assessment of outcomes. The report concludes with recommendations for future research to understand the clinical and basic mechanisms underlying heterogeneity in ARDS to advance the development of new treatments for this life-threatening critical illness.
Collapse
Affiliation(s)
- Thomas R. Martin
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington
| | - Rachel L. Zemans
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine and Program in Cellular and Molecular Biology, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Lorraine B. Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine and
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Eric P. Schmidt
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - David W. H. Riches
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
- Program in Cell Biology, Department of Pediatrics, National Jewish Health, Denver, Colorado
| | - Lisa Bastarache
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Carolyn S. Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Anesthesia
| | - Tushar J. Desai
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Stem Cell Institute, Stanford University School of Medicine, Stanford, California
| | - Susanne Herold
- Department of Internal Medicine VI and Cardio-Pulmonary Institute (CPI), Universities of Giessen and Marburg Lung Center (UGMLC), Giessen, Germany
| | - Catherine L. Hough
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health & Science University, Portland, Oregon
| | | | - Michael A. Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Nuala Meyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samir M. Parikh
- Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
- Division of Nephrology, University of Texas Southwestern, Dallas, Texas
| | - Troy Stevens
- Department of Physiology and Cell Biology, College of Medicine, Center for Lung Biology, University of South Alabama, Mobile, Alabama; and
| | - B. Taylor Thompson
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
3
|
Huang D, Ju F, Du L, Liu T, Zuo Y, Abbott GW, Hu Z. Empagliflozin Protects against Pulmonary Ischemia/Reperfusion Injury via an ERK1/2-Dependent Mechanism. J Pharmacol Exp Ther 2021; 380:230-241. [PMID: 34893552 DOI: 10.1124/jpet.121.000956] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023] Open
Abstract
Ischemia/reperfusion (I/R) injury of the lung can lead to extensive pulmonary damage. Sodium-glucose cotransporter-2 (SGLT2) inhibitors are insulin-independent, oral anti-hyperglycemic agents used for treating type 2 diabetes mellitus (T2DM). Their cardioprotective properties have been reported, however, their potential roles in pulmonary protection in vivo are poorly characterized. Here, we tested an hypothesis that empagliflozin, an SGLT2 inhibitor, can protect lungs in a mouse model of lung I/R injury induced by pulmonary hilum ligation in vivo We assigned C57/BL6 mice to sham-operated, non-empagliflozin-treated control, or empagliflozin-treated groups. Pulmonary I/R injury was induced by 1-hour left hilum ligation followed by 2-hour reperfusion. Using q-PCR and western blot analysis, we demonstrate that SGLT2 is highly expressed in mouse kidney but is weakly expressed in mouse lung (n=5-6 per group, P<0.01 or P<0.001). Empagliflozin improved respiratory function, attenuated I/R-induced lung edema, lessened structural damage, inhibited apoptosis, and reduced inflammatory cytokine production and protein concentration in bronchoalveolar lavage (BAL) fluid (P<0.05 or P<0.001 vs. CON). In addition, empagliflozin enhanced phosphorylation of pulmonary ERK1/2 post-I/R injury in vivo (P<0.001, vs. CON, n=5 per group). We further showed that pharmacological inhibition of ERK1/2 activity reversed these beneficial effects of empagliflozin. In conclusion, we showed that empagliflozin exerts strong lung protective effects against pulmonary I/R injury in vivo, at least in part via the ERK1/2-mediated signaling pathway. Significance Statement Pulmonary ischemia-reperfusion (I/R) can exacerbate lung injury. Empagliflozin is a new anti-diabetic agent for type 2 diabetes mellitus. This study shows that empagliflozin attenuates lung damage after pulmonary I/R injury in vivo This protective phenomenon was mediated at least in part via the ERK1/2-mediated signaling pathway. This opens a new avenue of research for SGLT2 inhibitors in the treatment of reperfusion-induced acute pulmonary injury.
Collapse
Affiliation(s)
- Dou Huang
- West China Hospital Sichuan University, China
| | - Feng Ju
- West China Hospital Sichuan University, China
| | - Lei Du
- West China Hospital Sichuan University, China
| | - Ting Liu
- West China Hospital Sichuan University, China
| | - Yunxia Zuo
- West China Hospital Sichuan University, China
| | - Geoffrey W Abbott
- Department of Pharmacology, University of California, Irvine, United States
| | - Zhaoyang Hu
- West China Hospital, Sichuan University, China
| |
Collapse
|
4
|
Smith RE, Shifrin MM. Critical Care Considerations in Adult Patients With Influenza-Induced ARDS. Crit Care Nurse 2021; 40:15-24. [PMID: 33000130 DOI: 10.4037/ccn2020746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
TOPIC Acute respiratory distress syndrome is a complex respiratory disease that can be induced by influenza virus infection. Critical care providers are uniquely positioned to manage this pathological progression in adult patients through evidence-based practice. CLINICAL RELEVANCE Influenza and subsequent acute respiratory distress syndrome are associated with extremely high morbidity and mortality in adult patients in the United States. Although evidence-based medical management strategies can alter the clinical trajectory of acute respiratory distress syndrome and improve outcomes, critical care providers do not always implement these measures. PURPOSE To provide critical care providers with an overview of the pathological progression of influenza-induced acute respiratory distress syndrome and the current evidence-based strategies for management. CONTENT COVERED This article reviews the epidemiology and pathophysiology associated with influenza-induced acute respiratory distress syndrome, the criteria for diagnosis, and the evidence-based medical management.
Collapse
Affiliation(s)
- Rachel E Smith
- Rachel E. Smith is an acute care nurse practitioner in the medical intensive care unit at Saint Thomas West Hospital, Nashville, Tennessee
| | - Megan M Shifrin
- Megan M. Shifrin is an assistant professor and the coordinator of the Adult-Gerontology Acute Care Nurse Practitioner Intensivist Focus at Vanderbilt University School of Nursing, Nashville, Tennessee
| |
Collapse
|
5
|
Wick KD, Leligdowicz A, Zhuo H, Ware LB, Matthay MA. Mesenchymal stromal cells reduce evidence of lung injury in patients with ARDS. JCI Insight 2021; 6:148983. [PMID: 33974564 PMCID: PMC8262503 DOI: 10.1172/jci.insight.148983] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/05/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Whether airspace biomarkers add value to plasma biomarkers in studying acute respiratory distress syndrome (ARDS) is not well understood. Mesenchymal stromal cells (MSCs) are an investigational therapy for ARDS, and airspace biomarkers may provide mechanistic evidence for MSCs’ impact in patients with ARDS. METHODS We carried out a nested cohort study within a phase 2a safety trial of treatment with allogeneic MSCs for moderate-to-severe ARDS. Nonbronchoscopic bronchoalveolar lavage and plasma samples were collected 48 hours after study drug infusion. Airspace and plasma biomarker concentrations were compared between the MSC (n = 17) and placebo (n = 10) treatment arms, and correlation between the two compartments was tested. Airspace biomarkers were also tested for associations with clinical and radiographic outcomes. RESULTS Compared with placebo, MSC treatment significantly reduced airspace total protein, angiopoietin-2 (Ang-2), IL-6, and soluble TNF receptor-1 concentrations. Plasma biomarkers did not differ between groups. Each 10-fold increase in airspace Ang-2 was independently associated with 6.7 fewer days alive and free of mechanical ventilation (95% CI, –12.3 to –1.0, P = 0.023), and each 10-fold increase in airspace receptor for advanced glycation end-products (RAGE) was independently associated with a 6.6-point increase in day 3 radiographic assessment of lung edema score (95% CI, 2.4 to 10.8, P = 0.004). CONCLUSION MSCs reduced biological evidence of lung injury in patients with ARDS. Biomarkers from the airspaces provide additional value for studying pathogenesis, treatment effects, and outcomes in ARDS. TRIAL REGISTRATION ClinicalTrials.gov NCT02097641. FUNDING National Heart, Lung, and Blood Institute.
Collapse
Affiliation(s)
- Katherine D Wick
- Departments of Medicine and Anesthesia and.,Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
| | - Aleksandra Leligdowicz
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hanjing Zhuo
- Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
| | - Lorraine B Ware
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, and.,Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael A Matthay
- Departments of Medicine and Anesthesia and.,Cardiovascular Research Institute, University of California, San Francisco, San Francisco, California, USA
| |
Collapse
|
6
|
Bastarache JA, McNeil JB, Plosa EJ, Sucre JS, Kerchberger VE, Habegger LE, Weddle E, Sullivan B, Meegan JE, Wickersham NE, Shaver CM, Ware LB. Standardization of methods for sampling the distal airspace in mechanically ventilated patients using heat moisture exchange filter fluid. Am J Physiol Lung Cell Mol Physiol 2021; 320:L785-L790. [PMID: 33655765 PMCID: PMC8174823 DOI: 10.1152/ajplung.00595.2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Noninvasive sampling of the distal airspace in patients with acute respiratory distress syndrome (ARDS) has long eluded clinical and translational researchers. We recently reported that fluid collected from heat moisture exchange (HME) filters closely mirrors fluid directly aspirated from the distal airspace. In the current study, we sought to determine fluid yield from different HME types, optimal HME circuit dwell time, and reliability of HME fluid in reflecting the distal airspace. We studied fluid yield from four different filter types by loading increasing volumes of saline and measuring volumes of fluid recovered. We collected filters after 1, 2, and 4 h of dwell time for measurement of fluid volume and total protein from 13 subjects. After identifying 4 h as the optimal dwell time, we measured total protein and IgM in HME fluid from 42 subjects with ARDS and nine with hydrostatic pulmonary edema (HYDRO). We found that the fluid yield varies greatly by filter type. With timed sample collection, fluid recovery increased with increasing circuit dwell time with a median volume of 2.0 mL [interquartile range (IQR) 1.2-2.7] after 4 h. Total protein was higher in the 42 subjects with ARDS compared with nine with HYDRO [median 708 µg/mL (IQR 244-2017) vs. 364 µg/mL (IQR 136-578), P = 0.047], confirming that total protein concentration in HME is higher in ARDS compared with hydrostatic edema. These studies establish a standardized HME fluid collection protocol and confirm that HME fluid analysis is a novel noninvasive tool for the study of the distal airspace in ARDS.
Collapse
Affiliation(s)
- Julie A. Bastarache
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,2Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee,3Department of Cell and Developmental Biology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J. Brennan McNeil
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Erin J. Plosa
- 4Department of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer S. Sucre
- 4Department of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - V. Eric Kerchberger
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Luke E. Habegger
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth Weddle
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Briana Sullivan
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jamie E. Meegan
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nancy E. Wickersham
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ciara M. Shaver
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lorraine B. Ware
- 1Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee,2Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| |
Collapse
|
7
|
Current Updates On the In vivo Assessment of Zinc Oxide Nanoparticles Toxicity Using Animal Models. BIONANOSCIENCE 2021. [DOI: 10.1007/s12668-021-00845-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
8
|
Mu X, Wang H, Li H. Silencing of long noncoding RNA H19 alleviates pulmonary injury, inflammation, and fibrosis of acute respiratory distress syndrome through regulating the microRNA-423-5p/FOXA1 axis. Exp Lung Res 2021; 47:183-197. [PMID: 33629893 DOI: 10.1080/01902148.2021.1887967] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE This study aimed to explore the regulatory effects and mechanisms of long noncoding RNA H19 (H19) on pulmonary injury, inflammation, and fibrosis of acute respiratory distress syndrome (ARDS). MATERIALS AND METHODS A rat model of ARDS was established by intratracheal instillation of 2 mg/kg lipopolysaccharide (LPS). qRT-PCR was performed to detect the expression of H19, miR-423-5p, tumor necrosis factor-α (TNF-α), interleukin (IL)-1β, IL-6, monocyte chemoattractant protein (MCP)-1, and vascular endothelial growth factor (VEGF). Histology score was assessed by hematoxylin-eosin (HE) staining. Enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of proinflammatory cytokines and the content of VEGF in bronchoalveolar lavage fluid (BALF). The lung fibrosis was evaluated using western blot and Masson's trichrome staining. Dual-luciferase reporter gene assay was used for confirming the relationship between miR-423-5p and H19/FOXA1 in alveolar macrophage cells (MH-S) and alveolar epithelial cells (MLE-12). The regulatory effects of H19/miR-423-5p/FOXA1 axis on the inflammation and fibrosis were further analyzed in LPS-induced MH-S cells. RESULTS The expression of H19 and FOXA1 was significantly up-regulated, while the expression of miR-423-5p was down-regulated in LPS-induced ARDS rats. Silencing of H19 decreased the mRNA expression of TNF-α, IL-1β, IL-6, MCP-1, and VEGF, the contents of TNF-α, IL-1β, IL-6, and VEGF in BALF, and histology score in LPS-induced ARDS rats. H19 knockdown also reduced the fibrosis scores and the protein expression of vimentin and α-SMA, and elevated the protein expression of E-cadherin in LPS-induced ARDS rats. Furthermore, silencing of miR-423-5p and overexpression of FOXA1 reversed the inhibitory effects of si-H19 on the inflammation and fibrosis of LPS-induced MH-S cells. CONCLUSIONS Silencing of H19 relieved the pulmonary injury, inflammation and fibrosis of LPS-induced ARDS in rats. Silencing of H19 also alleviated the inflammation and fibrosis of LPS-induced MH-S cells through regulating the miR-423-5p/FOXA1 axis.
Collapse
Affiliation(s)
- Xianyu Mu
- Department of Emergency, Yantai Yuhuangding Hospital, Yantai City, China Shandong Province, China
| | - Hongrong Wang
- Department of Emergency, Yantai Yuhuangding Hospital, Yantai City, China Shandong Province, China
| | - Haiyong Li
- Department of Emergency, Yantai Yuhuangding Hospital, Yantai City, China Shandong Province, China
| |
Collapse
|
9
|
Wagener BM, Anjum N, Evans C, Brandon A, Honavar J, Creighton J, Traber MG, Stuart RL, Stevens T, Pittet JF. α-Tocopherol Attenuates the Severity of Pseudomonas aeruginosa-induced Pneumonia. Am J Respir Cell Mol Biol 2020; 63:234-243. [PMID: 32243761 DOI: 10.1165/rcmb.2019-0185oc] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pseudomonas aeruginosa is a lethal pathogen that causes high mortality and morbidity in immunocompromised and critically ill patients. The type III secretion system (T3SS) of P. aeruginosa mediates many of the adverse effects of infection with this pathogen, including increased lung permeability in a Toll-like receptor 4/RhoA/PAI-1 (plasminogen activator inhibitor-1)-dependent manner. α-Tocopherol has antiinflammatory properties that may make it a useful adjunct in treatment of this moribund infection. We measured transendothelial and transepithelial resistance, RhoA and PAI-1 activation, stress fiber formation, P. aeruginosa T3SS exoenzyme (ExoY) intoxication into host cells, and survival in a murine model of pneumonia in the presence of P. aeruginosa and pretreatment with α-tocopherol. We found that α-tocopherol alleviated P. aeruginosa-mediated alveolar endothelial and epithelial paracellular permeability by inhibiting RhoA, in part, via PAI-1 activation, and increased survival in a mouse model of P. aeruginosa pneumonia. Furthermore, we found that α-tocopherol decreased the activation of RhoA and PAI-1 by blocking the injection of T3SS exoenzymes into alveolar epithelial cells. P. aeruginosa is becoming increasingly antibiotic resistant. We provide evidence that α-tocopherol could be a useful therapeutic agent for individuals who are susceptible to infection with P. aeruginosa, such as those who are immunocompromised or critically ill.
Collapse
Affiliation(s)
- Brant M Wagener
- Department of Anesthesiology and Perioperative Medicine.,Center for Free Radical Biology, and
| | - Naseem Anjum
- Department of Anesthesiology and Perioperative Medicine
| | - Cilina Evans
- Department of Anesthesiology and Perioperative Medicine
| | | | | | | | - Maret G Traber
- Linus Pauling Institute, Oregon State University, Corvallis, Oregon
| | | | - Troy Stevens
- Department of Pharmacology and Medicine and the Center for Lung Biology, University of South Alabama, Mobile, Alabama
| | - Jean-Francois Pittet
- Department of Anesthesiology and Perioperative Medicine.,Center for Lung Injury and Repair, University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
10
|
Ashley SL, Sjoding MW, Popova AP, Cui TX, Hoostal MJ, Schmidt TM, Branton WR, Dieterle MG, Falkowski NR, Baker JM, Hinkle KJ, Konopka KE, Erb-Downward JR, Huffnagle GB, Dickson RP. Lung and gut microbiota are altered by hyperoxia and contribute to oxygen-induced lung injury in mice. Sci Transl Med 2020; 12:eaau9959. [PMID: 32801143 PMCID: PMC7732030 DOI: 10.1126/scitranslmed.aau9959] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 06/14/2019] [Accepted: 01/21/2020] [Indexed: 12/27/2022]
Abstract
Inhaled oxygen, although commonly administered to patients with respiratory disease, causes severe lung injury in animals and is associated with poor clinical outcomes in humans. The relationship between hyperoxia, lung and gut microbiota, and lung injury is unknown. Here, we show that hyperoxia conferred a selective relative growth advantage on oxygen-tolerant respiratory microbial species (e.g., Staphylococcus aureus) as demonstrated by an observational study of critically ill patients receiving mechanical ventilation and experiments using neonatal and adult mouse models. During exposure of mice to hyperoxia, both lung and gut bacterial communities were altered, and these communities contributed to oxygen-induced lung injury. Disruption of lung and gut microbiota preceded lung injury, and variation in microbial communities correlated with variation in lung inflammation. Germ-free mice were protected from oxygen-induced lung injury, and systemic antibiotic treatment selectively modulated the severity of oxygen-induced lung injury in conventionally housed animals. These results suggest that inhaled oxygen may alter lung and gut microbial communities and that these communities could contribute to lung injury.
Collapse
Affiliation(s)
- Shanna L Ashley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
- Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA
| | - Antonia P Popova
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Tracy X Cui
- Division of Pediatric Pulmonology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Matthew J Hoostal
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas M Schmidt
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William R Branton
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael G Dieterle
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nicole R Falkowski
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer M Baker
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kevin J Hinkle
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Kristine E Konopka
- Department of Pathology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - John R Erb-Downward
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Gary B Huffnagle
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Molecular, Cellular, and Developmental Biology, University of Michigan, Ann Arbor, MI, USA
- Mary H. Weiser Food Allergy Center, University of Michigan, Ann Arbor, MI, USA
| | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
- Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| |
Collapse
|
11
|
Ross JT, Nesseler N, Leligdowicz A, Zemans RL, Mahida RY, Minus E, Langelier C, Gotts JE, Matthay MA. The ex vivo perfused human lung is resistant to injury by high-dose S. pneumoniae bacteremia. Am J Physiol Lung Cell Mol Physiol 2020; 319:L218-L227. [PMID: 32519893 DOI: 10.1152/ajplung.00053.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Few patients with bacteremia from a nonpulmonary source develop acute respiratory distress syndrome (ARDS). However, the mechanisms that protect the lung from injury in bacteremia have not been identified. We simulated bacteremia by adding Streptococcus pneumoniae to the perfusate of the ex vivo perfused human lung model. In contrast to a pneumonia model in which bacteria were instilled into the distal air spaces of one lobe, injection of high doses of S. pneumoniae into the perfusate was not associated with alveolar epithelial injury as demonstrated by low protein permeability of the alveolar epithelium, intact alveolar fluid clearance, and the absence of alveolar edema. Unexpectedly, the ex vivo human lung rapidly cleared large quantities of S. pneumoniae even though the perfusate had very few intravascular phagocytes and lacked immunoglobulins or complement. The bacteria were cleared in part by the small number of neutrophils in the perfusate, alveolar macrophages in the airspaces, and probably by interstitial pathways. Together, these findings identify one mechanism by which the lung and the alveolar epithelium are protected from injury in bacteremia.
Collapse
Affiliation(s)
- James T Ross
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Nicolas Nesseler
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California.,Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France.,University Rennes, CHU de Rennes, Inra, Inserm, Institut NUMECAN-UMR_A 1341, UMR_S 1241, Rennes, France.,University Rennes, CHU Rennes, Inserm, CIC 1414 (Centre d'Investigation Clinique de Rennes), Rennes, France
| | - Aleksandra Leligdowicz
- Cardiovascular Research Institute, University of California San Francisco, San Francisco, California.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rachel L Zemans
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Rahul Y Mahida
- Birmingham Acute Care Research Group, Institute of Inflammation and Aging, University of Birmingham, Birmingham, United Kingdom
| | | | - Chaz Langelier
- Division of Infectious Diseases, Department of Medicine, University of California San Francisco, San Francisco, California
| | - Jeffrey E Gotts
- Department of Medicine, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| | - Michael A Matthay
- Departments of Medicine and Anesthesia, Cardiovascular Research Institute, University of California San Francisco, San Francisco, California
| |
Collapse
|
12
|
Schmidt J, Wenzel C, Spassov S, Borgmann S, Lin Z, Wollborn J, Weber J, Haberstroh J, Meckel S, Eiden S, Wirth S, Schumann S. Flow-Controlled Ventilation Attenuates Lung Injury in a Porcine Model of Acute Respiratory Distress Syndrome: A Preclinical Randomized Controlled Study. Crit Care Med 2020; 48:e241-e248. [PMID: 31856000 PMCID: PMC7017946 DOI: 10.1097/ccm.0000000000004209] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Lung-protective ventilation for acute respiratory distress syndrome aims for providing sufficient oxygenation and carbon dioxide clearance, while limiting the harmful effects of mechanical ventilation. "Flow-controlled ventilation", providing a constant expiratory flow, has been suggested as a new lung-protective ventilation strategy. The aim of this study was to test whether flow-controlled ventilation attenuates lung injury in an animal model of acute respiratory distress syndrome. DESIGN Preclinical, randomized controlled animal study. SETTING Animal research facility. SUBJECTS Nineteen German landrace hybrid pigs. INTERVENTION Flow-controlled ventilation (intervention group) or volume-controlled ventilation (control group) with identical tidal volume (7 mL/kg) and positive end-expiratory pressure (9 cm H2O) after inducing acute respiratory distress syndrome with oleic acid. MEASUREMENTS AND MAIN RESULTS PaO2 and PaCO2, minute volume, tracheal pressure, lung aeration measured via CT, alveolar wall thickness, cell infiltration, and surfactant protein A concentration in bronchoalveolar lavage fluid. Five pigs were excluded leaving n equals to 7 for each group. Compared with control, flow-controlled ventilation elevated PaO2 (154 ± 21 vs 105 ± 9 torr; 20.5 ± 2.8 vs 14.0 ± 1.2 kPa; p = 0.035) and achieved comparable PaCO2 (57 ± 3 vs 54 ± 1 torr; 7.6 ± 0.4 vs 7.1 ± 0.1 kPa; p = 0.37) with a lower minute volume (6.4 ± 0.5 vs 8.7 ± 0.4 L/min; p < 0.001). Inspiratory plateau pressure was comparable in both groups (31 ± 2 vs 34 ± 2 cm H2O; p = 0.16). Flow-controlled ventilation increased normally aerated (24% ± 4% vs 10% ± 2%; p = 0.004) and decreased nonaerated lung volume (23% ± 6% vs 38% ± 5%; p = 0.033) in the dependent lung region. Alveolar walls were thinner (5.5 ± 0.1 vs 7.8 ± 0.2 µm; p < 0.0001), cell infiltration was lower (20 ± 2 vs 32 ± 2 n/field; p < 0.0001), and normalized surfactant protein A concentration was higher with flow-controlled ventilation (1.1 ± 0.04 vs 1.0 ± 0.03; p = 0.039). CONCLUSIONS Flow-controlled ventilation enhances lung aeration in the dependent lung region and consequently improves gas exchange and attenuates lung injury. Control of the expiratory flow may provide a novel option for lung-protective ventilation.
Collapse
Affiliation(s)
- Johannes Schmidt
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christin Wenzel
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sashko Spassov
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Silke Borgmann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ziwei Lin
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jakob Wollborn
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jonas Weber
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jörg Haberstroh
- Experimental Surgery, Center for Experimental Models and Transgenic Service, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stephan Meckel
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sebastian Eiden
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Steffen Wirth
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| |
Collapse
|
13
|
Carlton EF, Flori HR. Biomarkers in pediatric acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:505. [PMID: 31728358 DOI: 10.21037/atm.2019.09.29] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Pediatric acute respiratory distress syndrome (PARDS) is a heterogenous process resulting in a severe acute lung injury. A single indicator does not exist for PARDS diagnosis. Rather, current diagnosis requires a combination of clinical and physiologic variables. Similarly, there is little ability to predict the path of disease, identify those at high risk of poor outcomes or target therapies specific to the underlying pathophysiology. Biomarkers, a measured indicator of a pathologic state or response to intervention, have been studied in PARDS due to their potential in diagnosis, prognostication and measurement of therapeutic response. Additionally, PARDS biomarkers show great promise in furthering our understanding of specific subgroups or endotypes in this highly variable disease, and thereby predict which patients may benefit and which may be harmed by PARDS specific therapies. In this chapter, we review the what, when, why and how of biomarkers in PARDS and discuss future directions in this quickly changing landscape.
Collapse
Affiliation(s)
- Erin F Carlton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Heidi R Flori
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| |
Collapse
|
14
|
Fowler AA, Truwit JD, Hite RD, Morris PE, DeWilde C, Priday A, Fisher B, Thacker LR, Natarajan R, Brophy DF, Sculthorpe R, Nanchal R, Syed A, Sturgill J, Martin GS, Sevransky J, Kashiouris M, Hamman S, Egan KF, Hastings A, Spencer W, Tench S, Mehkri O, Bindas J, Duggal A, Graf J, Zellner S, Yanny L, McPolin C, Hollrith T, Kramer D, Ojielo C, Damm T, Cassity E, Wieliczko A, Halquist M. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial. JAMA 2019; 322:1261-1270. [PMID: 31573637 PMCID: PMC6777268 DOI: 10.1001/jama.2019.11825] [Citation(s) in RCA: 546] [Impact Index Per Article: 109.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Experimental data suggest that intravenous vitamin C may attenuate inflammation and vascular injury associated with sepsis and acute respiratory distress syndrome (ARDS). OBJECTIVE To determine the effect of intravenous vitamin C infusion on organ failure scores and biological markers of inflammation and vascular injury in patients with sepsis and ARDS. DESIGN, SETTING, AND PARTICIPANTS The CITRIS-ALI trial was a randomized, double-blind, placebo-controlled, multicenter trial conducted in 7 medical intensive care units in the United States, enrolling patients (N = 167) with sepsis and ARDS present for less than 24 hours. The study was conducted from September 2014 to November 2017, and final follow-up was January 2018. INTERVENTIONS Patients were randomly assigned to receive intravenous infusion of vitamin C (50 mg/kg in dextrose 5% in water, n = 84) or placebo (dextrose 5% in water only, n = 83) every 6 hours for 96 hours. MAIN OUTCOMES AND MEASURES The primary outcomes were change in organ failure as assessed by a modified Sequential Organ Failure Assessment score (range, 0-20, with higher scores indicating more dysfunction) from baseline to 96 hours, and plasma biomarkers of inflammation (C-reactive protein levels) and vascular injury (thrombomodulin levels) measured at 0, 48, 96, and 168 hours. RESULTS Among 167 randomized patients (mean [SD] age, 54.8 years [16.7]; 90 men [54%]), 103 (62%) completed the study to day 60. There were no significant differences between the vitamin C and placebo groups in the primary end points of change in mean modified Sequential Organ Failure Assessment score from baseline to 96 hours (from 9.8 to 6.8 in the vitamin C group [3 points] and from 10.3 to 6.8 in the placebo group [3.5 points]; difference, -0.10; 95% CI, -1.23 to 1.03; P = .86) or in C-reactive protein levels (54.1 vs 46.1 μg/mL; difference, 7.94 μg/mL; 95% CI, -8.2 to 24.11; P = .33) and thrombomodulin levels (14.5 vs 13.8 ng/mL; difference, 0.69 ng/mL; 95% CI, -2.8 to 4.2; P = .70) at 168 hours. CONCLUSIONS AND RELEVANCE In this preliminary study of patients with sepsis and ARDS, a 96-hour infusion of vitamin C compared with placebo did not significantly improve organ dysfunction scores or alter markers of inflammation and vascular injury. Further research is needed to evaluate the potential role of vitamin C for other outcomes in sepsis and ARDS. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02106975.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Rahul Nanchal
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | - Aamer Syed
- Virginia Commonwealth University, Richmond
| | | | | | | | | | | | | | | | | | | | | | | | | | - Jeanette Graf
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | | | - Lynda Yanny
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | | | - Tonya Hollrith
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | - David Kramer
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | - Charles Ojielo
- Froedtert Hospital and the Medical College of Wisconsin, Milwaukee
| | - Tessa Damm
- Aurora St. Luke's Medical Center, Milwaukee, Wisconsin
| | | | | | | |
Collapse
|
15
|
Blázquez-Prieto J, López-Alonso I, Amado-Rodríguez L, Huidobro C, González-López A, Kuebler WM, Albaiceta GM. Impaired lung repair during neutropenia can be reverted by matrix metalloproteinase-9. Thorax 2017; 73:321-330. [PMID: 28947666 DOI: 10.1136/thoraxjnl-2017-210105] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 07/26/2017] [Accepted: 09/04/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Neutrophils may cause tissue disruption during migration and by releasing cytotoxic molecules. However, the benefits of neutrophil depletion observed in experimental models of lung injury do not correspond with the poor outcome of neutropenic patients. METHODS To clarify the role of neutrophils during repair, mice with ventilator induced lung injury (VILI) were rendered neutropenic after damage, and followed for 48 hours of spontaneous breathing. Lungs were harvested and inflammatory mediators and matrix metalloproteinases measured. Bronchoalveolar lavage fluid (BALF) from ventilated patients with acute respiratory distress syndrome, with or without neutropenia, was collected, the same mediators measured and their effects in an ex vivo model of alveolar repair studied. Finally, neutropenic mice were treated after VILI with exogenous matrix metalloproteinase-9 (MMP-9). RESULTS Lungs from neutropenic animals showed delayed repair and displayed higher levels of tumour necrosis factor α, interferon γ and macrophage inflammatory protein 2, and absence of MMP-9. BALF from ventilated neutropenic patients with acute respiratory distress syndrome showed similar results. BALFs from neutropenic patients yielded a delayed closure rate of epithelial wounds ex vivo, which was improved by removal of collagen or addition of exogenous MMP-9. Lastly, treatment of neutropenic mice with exogenous MMP-9 after VILI reduced tissue damage without modifying cytokine concentrations. CONCLUSION Release of MMP-9 from neutrophils is required for adequate matrix processing and lung repair.
Collapse
Affiliation(s)
- Jorge Blázquez-Prieto
- Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.,Unidad de Cuidados Intensivos Cardiológicos, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Biosanitaria del Principado de Asturias, Oviedo, Spain
| | - Inés López-Alonso
- Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.,Unidad de Cuidados Intensivos Cardiológicos, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Biosanitaria del Principado de Asturias, Oviedo, Spain
| | - Laura Amado-Rodríguez
- Unidad de Cuidados Intensivos Cardiológicos, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Biosanitaria del Principado de Asturias, Oviedo, Spain
| | - Covadonga Huidobro
- Unidad de Cuidados Intensivos Cardiológicos, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Biosanitaria del Principado de Asturias, Oviedo, Spain
| | - Adrián González-López
- Instituto de Investigación Biosanitaria del Principado de Asturias, Oviedo, Spain.,Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin, Berlin, Germany
| | | | - Guillermo M Albaiceta
- Departamento de Biología Funcional, Instituto Universitario de Oncología del Principado de Asturias, Universidad de Oviedo, Oviedo, Spain.,Unidad de Cuidados Intensivos Cardiológicos, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, Spain.,Instituto de Investigación Biosanitaria del Principado de Asturias, Oviedo, Spain
| |
Collapse
|