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Silva PL, Scharffenberg M, Rocco PRM. Understanding the mechanisms of ventilator-induced lung injury using animal models. Intensive Care Med Exp 2023; 11:82. [PMID: 38010595 PMCID: PMC10682329 DOI: 10.1186/s40635-023-00569-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Abstract
Mechanical ventilation is a life-saving therapy in several clinical situations, promoting gas exchange and providing rest to the respiratory muscles. However, mechanical ventilation may cause hemodynamic instability and pulmonary structural damage, which is known as ventilator-induced lung injury (VILI). The four main injury mechanisms associated with VILI are as follows: barotrauma/volutrauma caused by overstretching the lung tissues; atelectrauma, caused by repeated opening and closing of the alveoli resulting in shear stress; and biotrauma, the resulting biological response to tissue damage, which leads to lung and multi-organ failure. This narrative review elucidates the mechanisms underlying the pathogenesis, progression, and resolution of VILI and discusses the strategies that can mitigate VILI. Different static variables (peak, plateau, and driving pressures, positive end-expiratory pressure, and tidal volume) and dynamic variables (respiratory rate, airflow amplitude, and inspiratory time fraction) can contribute to VILI. Moreover, the potential for lung injury depends on tissue vulnerability, mechanical power (energy applied per unit of time), and the duration of that exposure. According to the current evidence based on models of acute respiratory distress syndrome and VILI, the following strategies are proposed to provide lung protection: keep the lungs partially collapsed (SaO2 > 88%), avoid opening and closing of collapsed alveoli, and gently ventilate aerated regions while keeping collapsed and consolidated areas at rest. Additional mechanisms, such as subject-ventilator asynchrony, cumulative power, and intensity, as well as the damaging threshold (stress-strain level at which tidal damage is initiated), are under experimental investigation and may enhance the understanding of VILI.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil
| | - Martin Scharffenberg
- Department of Anesthesiology and Intensive Care Medicine, Pulmonary Engineering Group, University Hospital Carl Gustav Carus at Technische Universität Dresden, Dresden, Germany
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Centro de Ciências da Saúde, Avenida Carlos Chagas Filho, 373, Bloco G-014, Ilha Do Fundão, Rio de Janeiro, RJ, 21941-902, Brazil.
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Hamlington KL, Smith BJ, Dunn CM, Charlebois CM, Roy GS, Bates JHT. Linking lung function to structural damage of alveolar epithelium in ventilator-induced lung injury. Respir Physiol Neurobiol 2018; 255:22-29. [PMID: 29742448 DOI: 10.1016/j.resp.2018.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 05/02/2018] [Accepted: 05/05/2018] [Indexed: 12/21/2022]
Abstract
Understanding how the mechanisms of ventilator-induced lung injury (VILI), namely atelectrauma and volutrauma, contribute to the failure of the blood-gas barrier and subsequent intrusion of edematous fluid into the airspace is essential for the design of mechanical ventilation strategies that minimize VILI. We ventilated mice with different combinations of tidal volume and positive end-expiratory pressure (PEEP) and linked degradation in lung function measurements to injury of the alveolar epithelium observed via scanning electron microscopy. Ventilating with both high inspiratory plateau pressure and zero PEEP was necessary to cause derangements in lung function as well as visually apparent physical damage to the alveolar epithelium of initially healthy mice. In particular, the epithelial injury was tightly associated with indicators of alveolar collapse. These results support the hypothesis that mechanical damage to the epithelium during VILI is at least partially attributed to atelectrauma-induced damage of alveolar type I epithelial cells.
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Affiliation(s)
- Katharine L Hamlington
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05405, USA.
| | - Bradford J Smith
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05405, USA.
| | - Celia M Dunn
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05405, USA
| | - Chantel M Charlebois
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05405, USA
| | - Gregory S Roy
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05405, USA
| | - Jason H T Bates
- Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT 05405, USA.
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Cruz FF, Ball L, Rocco PRM, Pelosi P. Ventilator-induced lung injury during controlled ventilation in patients with acute respiratory distress syndrome: less is probably better. Expert Rev Respir Med 2018; 12:403-414. [PMID: 29575957 DOI: 10.1080/17476348.2018.1457954] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Mechanical ventilation is required to support respiratory function in the acute respiratory distress syndrome (ARDS), but it may promote lung damage, a phenomenon known as ventilator-induced lung injury (VILI). Areas covered: Several mechanisms of VILI have been described, such as: inspiratory and/or expiratory stress inducing overdistension (volutrauma); interfaces between collapsed or edema-filled alveoli with surrounding open alveoli, acting as stress raisers; alveoli that repetitively open and close during tidal breathing (atelectrauma); and peripheral airway dynamics. In this review, we discuss: the definition and classification of ARDS; ventilatory parameters that act as VILI determinants (tidal volume, respiratory rate, positive end-expiratory pressure, peak, plateau, driving and transpulmonary pressures, energy, mechanical power, and intensity); and the roles of prone positioning and muscle paralysis. We seek to provide an up-to-date overview of the evidence in the field from a clinical perspective. Expert commentary: To prevent VILI, mechanical ventilation strategies should minimize inspiratory/expiratory stress, dynamic/static strain, energy, mechanical power, and intensity, as well as mitigate the hemodynamic consequences of positive-pressure ventilation. In patients with moderate to severe ARDS, prone positioning can reduce lung damage and improve survival. Overall, volutrauma seems to be more harmful than atelectrauma. Extracorporeal support should be considered in selected cases.
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Affiliation(s)
- Fernanda Ferreira Cruz
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil
| | - Lorenzo Ball
- b Department of Surgical Sciences and Integrated Diagnostics , Ospedale Policlinico San Martino, IRCCS for Oncology, University of Genoa , Genoa , Italy
| | - Patricia Rieken Macedo Rocco
- a Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics , Federal University of Rio de Janeiro , Rio de Janeiro , Brazil
| | - Paolo Pelosi
- b Department of Surgical Sciences and Integrated Diagnostics , Ospedale Policlinico San Martino, IRCCS for Oncology, University of Genoa , Genoa , Italy
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Loverdos K, Toumpanakis D, Litsiou E, Karavana V, Glynos C, Magkou C, Theocharis S, Vassilakopoulos T. The differential effects of inspiratory, expiratory, and combined resistive breathing on healthy lung. Int J Chron Obstruct Pulmon Dis 2016; 11:1623-38. [PMID: 27499619 PMCID: PMC4959591 DOI: 10.2147/copd.s106337] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Combined resistive breathing (CRB) is the hallmark of obstructive airway disease pathophysiology. We have previously shown that severe inspiratory resistive breathing (IRB) induces acute lung injury in healthy rats. The role of expiratory resistance is unknown. The possibility of a load-dependent type of resistive breathing-induced lung injury also remains elusive. Our aim was to investigate the differential effects of IRB, expiratory resistive breathing (ERB), and CRB on healthy rat lung and establish the lowest loads required to induce injury. Anesthetized tracheostomized rats breathed through a two-way valve. Varying resistances were connected to the inspiratory, expiratory, or both ports, so that the peak inspiratory pressure (IRB) was 20%-40% or peak expiratory (ERB) was 40%-70% of maximum. CRB was assessed in inspiratory/expiratory pressures of 30%/50%, 40%/50%, and 40%/60% of maximum. Quietly breathing animals served as controls. At 6 hours, respiratory system mechanics were measured, and bronchoalveolar lavage was performed for measurement of cell and protein concentration. Lung tissue interleukin-6 and interleukin-1β levels were estimated, and a lung injury histological score was determined. ERB produced significant, load-independent neutrophilia, without mechanical or permeability derangements. IRB 30% was the lowest inspiratory load that provoked lung injury. CRB increased tissue elasticity, bronchoalveolar lavage total cell, macrophage and neutrophil counts, protein and cytokine levels, and lung injury score in a dose-dependent manner. In conclusion, CRB load dependently deranges mechanics, increases permeability, and induces inflammation in healthy rats. ERB is a putative inflammatory stimulus for the lung.
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Affiliation(s)
- Konstantinos Loverdos
- Department of Critical Care, Pulmonary Unit and Marianthi Simou Applied Biomedical Research and Training Center, Evangelismos General Hospital, University of Athens Medical School
| | - Dimitrios Toumpanakis
- Department of Critical Care, Pulmonary Unit and Marianthi Simou Applied Biomedical Research and Training Center, Evangelismos General Hospital, University of Athens Medical School
| | - Eleni Litsiou
- Department of Critical Care, Pulmonary Unit and Marianthi Simou Applied Biomedical Research and Training Center, Evangelismos General Hospital, University of Athens Medical School
| | - Vassiliki Karavana
- Department of Critical Care, Pulmonary Unit and Marianthi Simou Applied Biomedical Research and Training Center, Evangelismos General Hospital, University of Athens Medical School
| | - Constantinos Glynos
- Department of Critical Care, Pulmonary Unit and Marianthi Simou Applied Biomedical Research and Training Center, Evangelismos General Hospital, University of Athens Medical School
| | | | - Stamatios Theocharis
- 1st Department of Pathology, University of Athens Medical School, Athens, Greece
| | - Theodoros Vassilakopoulos
- Department of Critical Care, Pulmonary Unit and Marianthi Simou Applied Biomedical Research and Training Center, Evangelismos General Hospital, University of Athens Medical School
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Dreyfuss D, Ricard JD, Gaudry S. Did studies on HFOV fail to improve ARDS survival because they did not decrease VILI? On the potential validity of a physiological concept enounced several decades ago. Intensive Care Med 2015; 41:2076-86. [PMID: 26438222 DOI: 10.1007/s00134-015-4062-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 09/06/2015] [Indexed: 02/06/2023]
Abstract
High frequency oscillatory ventilation (HFOV) has been the subject of extensive physiological research for 30 years and even more so of an intense debate on its potential usefulness in the treatment of acute respiratory distress syndrome (ARDS). This technique has been enthusiastically promoted by some teams until two high-quality randomized clinical trials in adults with ARDS showed that HFOV did not decrease and might have even increased mortality. As a consequence of these results, physiological concepts such as atelectrauma and biotrauma on which ARDS management with HFOV were based should be reexamined. In contrast, the concept of volutrauma, i.e., end-inspiratory overdistension, as the cause for ventilator-induced lung injury might help explain excess mortality during mechanical ventilation of ARDS when inspiratory volumes are too high. This is what might have happened during one of the recent studies on HFOV. Failure of this complex technique must be put in perspective with the dramatic improvement of ARDS prognosis with very simple interventions such as tidal volume reduction, early pharmacological paralysis, and prone positioning which all limited end-inspiratory volume.
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Affiliation(s)
- Didier Dreyfuss
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, AP-HP, 92700, Colombes, France. .,UMR 1137, IAME, INSERM, 75018, Paris, France. .,UMR 1137, IAME, Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.
| | - Jean-Damien Ricard
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, AP-HP, 92700, Colombes, France.,UMR 1137, IAME, INSERM, 75018, Paris, France.,UMR 1137, IAME, Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France
| | - Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, AP-HP, 92700, Colombes, France.,UMR 1137, IAME, INSERM, 75018, Paris, France.,UMR 1123, ECEVE, Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France
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Walsh BK, Davis MD, Hunt JF, Kheir JN, Smallwood CD, Arnold JH. The effects of lung recruitment maneuvers on exhaled breath condensate pH. J Breath Res 2015; 9:036009. [PMID: 26333431 DOI: 10.1088/1752-7155/9/3/036009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Exhaled breath condensate (EBC) pH serves as a surrogate marker of airway lining fluid (ALF) pH and can be used to evaluate airway acidification (AA). AA is known to be present in acute respiratory distress syndrome (ARDS) and can be evaluated via continuous EBC pH measurement during mechanical ventilation. Lung recruitment maneuvers (LRMs) are utilized in the treatment of ARDS, however, their impact on EBC pH has never been explored. Here we described the acute effects of two commonly used LRMs on EBC pH. In a prospective, non-randomized, serial exposure study, 10 intubated pediatric subjects with acute respiratory distress syndrome sequentially underwent: a period of baseline ventilation, sustained inflation (SI) maneuver of 40 cm H2O for 40 s, open lung ventilation, staircase recruitment strategy (SRS) (which involves a systematic ramping of plateau pressures in 5 cm H2O increments, starting at 30 cm H2O), and PEEP titration. Maximum lung recruitment during the SRS is defined as a PaO2 + PaCO2 of >400 mmHg. Following lung recruitment, PEEP titration was conducted from 20 cm H2O in 2 cm H2O decrements until a PaO2 + PaCO2 was <380 and then increased by 2 cm H2O. EBC pH, arterial blood gases, lung mechanics, hemodynamics, and function residual capacity were obtained following each phase of the LRM and observational period. Seven out of 10 patients were able to reach maximum lung recruitment. Baseline EBC pH (6.38 ± 0.37) did not correlate with disease severity defined by PaO2/FiO2 ratio or oxygenation index (OI). Average EBC pH differed between phases and decreased after LRM (p = 0.001). EBC pH is affected by LRMs. EBC acidification following LRMs may represent a washout effect of opening acidic lung units and ventilating them or acute AA resulting from LRM.
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Affiliation(s)
- Brian K Walsh
- Boston Children's Hospital, 300 Longwood Ave, Farley 019, Boston, MA 02115, USA
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Effects of a recruitment maneuver on plasma levels of soluble RAGE in patients with diffuse acute respiratory distress syndrome: a prospective randomized crossover study. Intensive Care Med 2015; 41:846-55. [PMID: 25792206 DOI: 10.1007/s00134-015-3726-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 02/27/2015] [Indexed: 01/11/2023]
Abstract
PURPOSE The soluble form of the receptor for advanced glycation end-products (sRAGE) is a promising marker for epithelial dysfunction, but it has not been fully characterized as a biomarker of acute respiratory distress syndrome (ARDS). Whether sRAGE could inform on the response to ventilator settings has been poorly investigated, and whether a recruitment maneuver (RM) may influence plasma sRAGE remains unknown. METHODS Twenty-four patients with moderate/severe, nonfocal ARDS were enrolled in this prospective monocentric crossover study and randomized into a "RM-SHAM" group when a 6-h-long RM sequence preceded a 6-h-long sham evaluation period, or a "SHAM-RM" group (inverted sequences). Protective ventilation was applied, and RM consisted of the application of 40 cmH2O airway pressure for 40 s. Arterial blood was sampled for gas analyses and sRAGE measurements, 5 min pre-RM (or 40-s-long sham period), 5, 30 min, 1, 4, and 6 h after the RM (or 40-s-long sham period). RESULTS Mean PaO2/FiO2, tidal volume, PEEP, and plateau pressure were 125 mmHg, 6.8 ml/kg (ideal body weight), and 13 and 26 cmH2O, respectively. Median baseline plasma sRAGE levels were 3,232 pg/ml. RM induced a significant decrease in sRAGE (-1,598 ± 859 pg/ml) in 1 h (p = 0.043). At 4 and 6 h post-RM, sRAGE levels increased back toward baseline values. Pre-RM sRAGE was associated with RM-induced oxygenation improvement (AUC 0.84). CONCLUSIONS We report the first kinetics study of plasma sRAGE after RM in ARDS. Our findings reinforce the value of plasma sRAGE as a biomarker of ARDS.
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Abstract
This review documents important progress made in 2013 in the field of critical care respirology, in particular with regard to acute respiratory failure and acute respiratory distress syndrome. Twenty-five original articles published in the respirology and critical care sections of Critical Care are discussed in the following categories: pre-clinical studies, protective lung ventilation – how low can we go, non-invasive ventilation for respiratory failure, diagnosis and prognosis in acute respiratory distress syndrome and respiratory failure, and promising interventions for acute respiratory distress syndrome.
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9
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Recruitment maneuvers modulate epithelial and endothelial cell response according to acute lung injury etiology. Crit Care Med 2013; 41:e256-65. [PMID: 23887231 DOI: 10.1097/ccm.0b013e31828a3c13] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To investigate the effects of the rate of increase in airway pressure and duration of lung recruitment maneuvers in experimental pulmonary and extrapulmonary acute lung injury. DESIGN Prospective, randomized, controlled experimental study. SETTINGS University research laboratory. SUBJECTS Fifty adult male Wistar rats. INTERVENTIONS Acute lung injury was induced by Escherichia coli lipopolysaccharide either intratracheally (pulmonary acute lung injury) or intraperitoneally (extrapulmonary acute lung injury). After 24 hours, animals were assigned to one of three different recruitment maneuvers, targeted to maximal airway pressure of 30 cm H2O: 1) continuous positive airway pressure for 30 seconds (CPAP-30); 2) stepwise airway pressure increase (5 cm H2O/step, 8.5 s at each step) over 51 seconds (STEP-51) to achieve a pressure-time product similar to that of CPAP-30; and 3) stepwise airway pressure increase (5 cm H2O/step, 5 s at each step) over 30 seconds with maximum pressure sustained for a further 30 seconds (STEP-30/30). MEASUREMENTS AND MAIN RESULTS All recruitment maneuvers reduced static lung elastance independent of acute lung injury etiology. In pulmonary acute lung injury, CPAP-30 yielded lower surfactant protein-B and higher type III procollagen expressions compared with STEP-30/30. In extrapulmonary acute lung injury, CPAP-30 and STEP-30/30 increased vascular cell adhesion molecule-1 expression, but the type of recruitment maneuver did not influence messenger ribonucleic acid expression of receptor for advanced glycation end products, surfactant protein-B, type III procollagen, and pro-caspase 3. CONCLUSIONS CPAP-30 worsened markers of potential epithelial cell damage in pulmonary acute lung injury, whereas both CPAP-30 and STEP-30/30 yielded endothelial injury in extrapulmonary acute lung injury. In both acute lung injury groups, recruitment maneuvers improved respiratory mechanics, but stepwise recruitment maneuver without sustained airway pressure appeared to associate with less biological impact on lungs.
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Parker JC. Acute lung injury and pulmonary vascular permeability: use of transgenic models. Compr Physiol 2013; 1:835-82. [PMID: 23737205 DOI: 10.1002/cphy.c100013] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Acute lung injury is a general term that describes injurious conditions that can range from mild interstitial edema to massive inflammatory tissue destruction. This review will cover theoretical considerations and quantitative and semi-quantitative methods for assessing edema formation and increased vascular permeability during lung injury. Pulmonary edema can be quantitated directly using gravimetric methods, or indirectly by descriptive microscopy, quantitative morphometric microscopy, altered lung mechanics, high-resolution computed tomography, magnetic resonance imaging, positron emission tomography, or x-ray films. Lung vascular permeability to fluid can be evaluated by measuring the filtration coefficient (Kf) and permeability to solutes evaluated from their blood to lung clearances. Albumin clearances can then be used to calculate specific permeability-surface area products (PS) and reflection coefficients (σ). These methods as applied to a wide variety of transgenic mice subjected to acute lung injury by hyperoxic exposure, sepsis, ischemia-reperfusion, acid aspiration, oleic acid infusion, repeated lung lavage, and bleomycin are reviewed. These commonly used animal models simulate features of the acute respiratory distress syndrome, and the preparation of genetically modified mice and their use for defining specific pathways in these disease models are outlined. Although the initiating events differ widely, many of the subsequent inflammatory processes causing lung injury and increased vascular permeability are surprisingly similar for many etiologies.
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Affiliation(s)
- James C Parker
- Department of Physiology, University of South Alabama, Mobile, Alabama, USA.
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Kumar Mahto S, Tenenbaum-Katan J, Sznitman J. Respiratory physiology on a chip. SCIENTIFICA 2012; 2012:364054. [PMID: 24278686 PMCID: PMC3820443 DOI: 10.6064/2012/364054] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 06/21/2012] [Indexed: 05/12/2023]
Abstract
Our current understanding of respiratory physiology and pathophysiological mechanisms of lung diseases is often limited by challenges in developing in vitro models faithful to the respiratory environment, both in cellular structure and physiological function. The recent establishment and adaptation of microfluidic-based in vitro devices (μFIVDs) of lung airways have enabled a wide range of developments in modern respiratory physiology. In this paper, we address recent efforts over the past decade aimed at advancing in vitro models of lung structure and airways using microfluidic technology and discuss their applications. We specifically focus on μFIVDs covering four major areas of respiratory physiology, namely, artificial lungs (AL), the air-liquid interface (ALI), liquid plugs and cellular injury, and the alveolar-capillary barrier (ACB).
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Affiliation(s)
- Sanjeev Kumar Mahto
- Department of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | - Janna Tenenbaum-Katan
- Department of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa 32000, Israel
| | - Josué Sznitman
- Department of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa 32000, Israel
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de Prost N, Saumon G, Dreyfuss D. Modeling the time-course of ventilator-induced lung injury: what can we learn from interspecies discrepancies? Intensive Care Med 2011; 37:1901-3. [PMID: 22052187 DOI: 10.1007/s00134-011-2394-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2011] [Accepted: 08/22/2011] [Indexed: 10/15/2022]
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de Prost N, Ricard JD, Saumon G, Dreyfuss D. Ventilator-induced lung injury: historical perspectives and clinical implications. Ann Intensive Care 2011; 1:28. [PMID: 21906379 PMCID: PMC3224506 DOI: 10.1186/2110-5820-1-28] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 07/23/2011] [Indexed: 01/17/2023] Open
Abstract
Mechanical ventilation can produce lung physiological and morphological alterations termed ventilator-induced lung injury (VILI). Early experimental studies demonstrated that the main determinant of VILI is lung end-inspiratory volume. The clinical relevance of these experimental findings received resounding confirmation with the results of the acute respiratory distress syndrome (ARDS) Network study, which showed a 22% reduction in mortality in patients with the acute respiratory distress syndrome through a simple reduction in tidal volume. In contrast, the clinical relevance of low lung volume injury remains debated and the application of high positive end-expiratory pressure levels can contribute to lung overdistension and thus be deleterious. The significance of inflammatory alterations observed during VILI is debated and has not translated into clinical application. This review examines seminal experimental studies that led to our current understanding of VILI and contributed to the current recommendations in the respiratory support of ARDS patients.
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Affiliation(s)
- Nicolas de Prost
- Assistance Publique - Hôpitaux de Paris, Hôpital Henri Mondor, Service de Réanimation Médicale, 51, Avenue de Tassigny, 94010, Créteil, France
| | - Jean-Damien Ricard
- Université Paris-Diderot and PRES Sorbonne Paris Cité, Site Xavier Bichat, 75018 Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital Louis Mourier, Service de Réanimation Médicale, F-92700, 178, rue des Renouillers - 92701 Colombes Cedex, France
- INSERM U722, F-75018 Paris, France
| | - Georges Saumon
- Université Paris-Diderot and PRES Sorbonne Paris Cité, Site Xavier Bichat, 75018 Paris, France
| | - Didier Dreyfuss
- Université Paris-Diderot and PRES Sorbonne Paris Cité, Site Xavier Bichat, 75018 Paris, France
- Assistance Publique - Hôpitaux de Paris, Hôpital Louis Mourier, Service de Réanimation Médicale, F-92700, 178, rue des Renouillers - 92701 Colombes Cedex, France
- INSERM U722, F-75018 Paris, France
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Silva PL, Cruz FF, Fujisaki LC, Oliveira GP, Samary CS, Ornellas DS, Maron-Gutierrez T, Rocha NN, Goldenberg R, Garcia CSNB, Morales MM, Capelozzi VL, Gama de Abreu M, Pelosi P, Rocco PRM. Hypervolemia induces and potentiates lung damage after recruitment maneuver in a model of sepsis-induced acute lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R114. [PMID: 20546573 PMCID: PMC2911760 DOI: 10.1186/cc9063] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Revised: 04/21/2010] [Accepted: 06/14/2010] [Indexed: 01/02/2023]
Abstract
Introduction Recruitment maneuvers (RMs) seem to be more effective in extrapulmonary acute lung injury (ALI), caused mainly by sepsis, than in pulmonary ALI. Nevertheless, the maintenance of adequate volemic status is particularly challenging in sepsis. Since the interaction between volemic status and RMs is not well established, we investigated the effects of RMs on lung and distal organs in the presence of hypovolemia, normovolemia, and hypervolemia in a model of extrapulmonary lung injury induced by sepsis. Methods ALI was induced by cecal ligation and puncture surgery in 66 Wistar rats. After 48 h, animals were anesthetized, mechanically ventilated and randomly assigned to 3 volemic status (n = 22/group): 1) hypovolemia induced by blood drainage at mean arterial pressure (MAP)≈70 mmHg; 2) normovolemia (MAP≈100 mmHg), and 3) hypervolemia with colloid administration to achieve a MAP≈130 mmHg. In each group, animals were further randomized to be recruited (CPAP = 40 cm H2O for 40 s) or not (NR) (n = 11/group), followed by 1 h of protective mechanical ventilation. Echocardiography, arterial blood gases, static lung elastance (Est,L), histology (light and electron microscopy), lung wet-to-dry (W/D) ratio, interleukin (IL)-6, IL-1β, caspase-3, type III procollagen (PCIII), intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) mRNA expressions in lung tissue, as well as lung and distal organ epithelial cell apoptosis were analyzed. Results We observed that: 1) hypervolemia increased lung W/D ratio with impairment of oxygenation and Est,L, and was associated with alveolar and endothelial cell damage and increased IL-6, VCAM-1, and ICAM-1 mRNA expressions; and 2) RM reduced alveolar collapse independent of volemic status. In hypervolemic animals, RM improved oxygenation above the levels observed with the use of positive-end expiratory pressure (PEEP), but increased lung injury and led to higher inflammatory and fibrogenetic responses. Conclusions Volemic status should be taken into account during RMs, since in this sepsis-induced ALI model hypervolemia promoted and potentiated lung injury compared to hypo- and normovolemia.
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Affiliation(s)
- Pedro L Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Av Carlos Chagas Filho, Rio de Janeiro 21949-902, Brazil.
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In vivo intravital endoscopic confocal fluorescence microscopy of normal and acutely injured rat lungs. J Transl Med 2010; 90:824-34. [PMID: 20386539 DOI: 10.1038/labinvest.2010.76] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
We present a new lung imaging technique based on endoscopic confocal fluorescence microscopy (ECFM), which is a new method that is able to provide cellular and structural assessment of living tissue using a small confocal probe in direct contact with the visceral pleura. To observe distal airspace structure and cellular condition in normal and injured lungs (hyperoxic and bleomycin challenged), we used fluorescent-specific marker contrast and ECFM. Alveolar space ECFM with spectral analyses were performed at 488-nm excitation using FITC-labeled markers or naturally fluorescent dyes. The normal lung was compared with the sick lung, where our in vivo imaging experiments correlated well with results obtained with corresponding ex vivo conventional assays. Four main elements pertaining to the acute lung injury/acute respiratory distress syndrome (ALI/ARDS) pathophysiology and established early key events were specifically studied: alveolar epithelial membrane phenotype, lung cell apoptosis, neutrophil recruitment, and edema. ECFM allowed visualization of (i) fine-tuned ultrastructural lectin (RCA-1) and sialoglycoprotein (RTI40) epithelial cell membrane expression, (ii) YO-PRO-1-related DNA linking of lung cell apoptosis, (iii) PKH2 green fluorescent cell linker-labeled neutrophil tracking in lung microcirculatory network and airspaces, (iv) FITC-dextran plasma contrast and extravasation with edema formation. ECFM provides reliable results to corresponding ex vivo fluorescent methods. ECFM, using the minimally invasive Five-1(R) optical instrument and specific fluorescent markers, is able to provide real-time potentially useful imaging of live unfixed normal and injured lung tissue with promising developments for improving bedside diagnostic and decision-making therapeutic strategy in patients with ALI.
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Loss of airway pressure during HFOV results in an extended loss of oxygenation: a retrospective animal study. J Surg Res 2009; 162:250-7. [PMID: 19560160 DOI: 10.1016/j.jss.2009.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Revised: 04/03/2009] [Accepted: 04/13/2009] [Indexed: 01/11/2023]
Abstract
BACKGROUND Patients with acute respiratory distress syndrome (ARDS) are often ventilated with high airway pressure. Brief loss of airway pressure may lead to an extended loss of oxygenation. While using high frequency oscillatory ventilation (HFOV) in a porcine acute lung injury model, two animals became disconnected from the ventilator with subsequent loss of airway pressure. We compared the two disconnected animals to the two animals that remained connected to determine causes for the extended reduction in oxygenation. METHODS ARDS was induced using 5% Tween. Thirty min of nonprotective ventilation (NPV) followed before placing the pigs on HFOV. Measurements were made at baseline, after lung injury, and every 30min during the 6-h study. Disconnections were treated by hand-ventilation and a recruitment maneuver before being placed back on HFOV. The lungs were histologically analyzed and wet/dry weights were measured to determine lung edema. RESULTS Hemodynamics and lung function were similar in all pigs at baseline, after injury, and following NPV. The animals that remained connected to the oscillator showed a continued improvement in PaO(2)/FiO(2) (P/F) ratio throughout the study. The animals that experienced the disconnection had a significant loss of lung function that never recovered. The disconnect animals had more diffuse alveolar disease on histologic analysis. CONCLUSIONS A significant fall in lung function results following disconnection from HFOV, which remains depressed for a substantial period of time despite efforts to reopen the lung. Dispersion of edema fluid is a possible mechanism for the protracted loss of lung function.
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Do airway secretions play an underappreciated role in acute respiratory distress syndrome? Curr Opin Crit Care 2008; 14:44-9. [PMID: 18195625 DOI: 10.1097/mcc.0b013e3282f2f4cb] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW We review the evidence that airway secretions may have an underappreciated role in acute respiratory distress syndrome, contributing to physiologic disarrangements, ventilator dependence and perhaps to injury generation. As common manipulations of ventilator settings, position and fluid status have the potential to influence these problems, explorations into the secretion dynamics of acute lung injury may be fertile ground for developing therapeutic advances. RECENT FINDINGS Principles that govern the interaction of airflow and airway fluids suggest that mobile fluids and secretions are pumped by well-selected ventilatory patterns toward the airway opening. Conversely, other selections may inhibit these fluids from clearance or encourage their translocation between lung regions. Recent laboratory work demonstrates that choices for tidal volume and positive end-expiratory pressure may localize or disperse proteinaceous lung edema or bacteria. Gravitational factors may interact with ventilatory pattern for benefit or harm. SUMMARY Capability of ventilation and positioning to mobilize secretions implies the potential for clearance or containment of inflammatory mediators and infection. Ventilatory and positional prescriptions could be designed to meet one of either conflicting targets. Additional experimental and clinical investigations are required before adopting these proposed therapeutic principles into practice.
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Bouadma L, Dreyfuss D, Ricard JD, Martet G, Saumon G. Mechanical ventilation and hemorrhagic shock-resuscitation interact to increase inflammatory cytokine release in rats. Crit Care Med 2008; 35:2601-6. [PMID: 17828032 DOI: 10.1097/01.ccm.0000286398.78243.ce] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether hemorrhagic shock and resuscitation (HSR) and high lung stress during mechanical ventilation interact to augment lung and systemic inflammatory responses and whether their sequence affects these responses. DESIGN Prospective, randomized, controlled animal study. SETTING Research laboratory. SUBJECTS Fifty-six male Wistar rats. INTERVENTIONS Controls were immediately killed after anesthesia. High lung stress was produced by mechanical ventilation with high tidal volume of 30 mL/kg and no positive end-expiratory pressure (HV) for 2 hrs. HSR consisted of lessening systemic arterial pressure to 30 mm Hg for 1 hr followed by reinjection of the withdrawn blood. Experimental groups consisted of HSR only and HSR preceded or followed by HV or conventional mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Interleukin-1beta, interleukin-6, and macrophage inhibitory protein 2 were determined in lung homogenate, bronchoalveolar lavage fluid, and plasma. HV ventilation alone did not increase plasma or lung cytokine content compared with controls. HSR significantly increased all mediators in lungs and plasma but not macrophage inhibitory protein 2 in plasma. Conventional ventilation, applied either before or after HSR, did not influence lung or systemic mediator release, whereas HV significantly increased mediator release when combined with HSR whatever the sequence of injuries. Lung mediator content was significantly higher in animals ventilated with HV before the HSR stress than in animals submitted to HSR and then ventilated with HV. Plasma macrophage inhibitory protein 2 concentrations followed the same pattern. CONCLUSIONS This study shows that HSR and high lung tissue stress interact to increase lung and systemic release of inflammatory mediators in a way that depends on their sequence. Previous injury may sensitize lungs to inadequate mechanical ventilation, but inadequate mechanical ventilation may also sensitize lungs to postoperative complications.
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Affiliation(s)
- Lila Bouadma
- INSERM, U773, Centre de Recherche Bichat Beaujon CRB3, Paris
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Dolinay T, Wu W, Kaminski N, Ifedigbo E, Kaynar AM, Szilasi M, Watkins SC, Ryter SW, Hoetzel A, Choi AMK. Mitogen-activated protein kinases regulate susceptibility to ventilator-induced lung injury. PLoS One 2008; 3:e1601. [PMID: 18270588 PMCID: PMC2223071 DOI: 10.1371/journal.pone.0001601] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2007] [Accepted: 01/17/2008] [Indexed: 01/09/2023] Open
Abstract
Background Mechanical ventilation causes ventilator-induced lung injury in animals and humans. Mitogen-activated protein kinases have been implicated in ventilator-induced lung injury though their functional significance remains incomplete. We characterize the role of p38 mitogen-activated protein kinase/mitogen activated protein kinase kinase-3 and c-Jun-NH2-terminal kinase-1 in ventilator-induced lung injury and investigate novel independent mechanisms contributing to lung injury during mechanical ventilation. Methodology and Principle Findings C57/BL6 wild-type mice and mice genetically deleted for mitogen-activated protein kinase kinase-3 (mkk-3−/−) or c-Jun-NH2-terminal kinase-1 (jnk1−/−) were ventilated, and lung injury parameters were assessed. We demonstrate that mkk3−/− or jnk1−/− mice displayed significantly reduced inflammatory lung injury and apoptosis relative to wild-type mice. Since jnk1−/− mice were highly resistant to ventilator-induced lung injury, we performed comprehensive gene expression profiling of ventilated wild-type or jnk1−/− mice to identify novel candidate genes which may play critical roles in the pathogenesis of ventilator-induced lung injury. Microarray analysis revealed many novel genes differentially expressed by ventilation including matrix metalloproteinase-8 (MMP8) and GADD45α. Functional characterization of MMP8 revealed that mmp8−/− mice were sensitized to ventilator-induced lung injury with increased lung vascular permeability. Conclusions We demonstrate that mitogen-activated protein kinase pathways mediate inflammatory lung injury during ventilator-induced lung injury. C-Jun-NH2-terminal kinase was also involved in alveolo-capillary leakage and edema formation, whereas MMP8 inhibited alveolo-capillary protein leakage.
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Affiliation(s)
- Tamás Dolinay
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, Unites States of America
- Department of Pulmonology, University of Debrecen Medical and Health Science Center, Debrecen, Hungary
| | - Wei Wu
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, Unites States of America
| | - Naftali Kaminski
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, Unites States of America
| | - Emeka Ifedigbo
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, Unites States of America
| | - A. Murat Kaynar
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mária Szilasi
- Department of Pulmonology, University of Debrecen Medical and Health Science Center, Debrecen, Hungary
| | - Simon C. Watkins
- Department of Cell Biology and Physiology, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Stefan W. Ryter
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, Unites States of America
| | - Alexander Hoetzel
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, Unites States of America
- Department of Anesthesiology and Critical Care Medicine, University of Freiburg, Freiburg, Germany
| | - Augustine M. K. Choi
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, Unites States of America
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America
- * To whom correspondence should be addressed. E-mail:
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Terbutaline lessens protein fluxes across the alveolo-capillary barrier during high-volume ventilation. Intensive Care Med 2007; 34:763-70. [DOI: 10.1007/s00134-007-0954-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2007] [Accepted: 10/25/2007] [Indexed: 01/11/2023]
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de Prost N, Roux D, Dreyfuss D, Ricard JD, Le Guludec D, Saumon G. Alveolar edema dispersion and alveolar protein permeability during high volume ventilation: effect of positive end-expiratory pressure. Intensive Care Med 2007; 33:711-7. [PMID: 17333114 DOI: 10.1007/s00134-007-0575-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2006] [Accepted: 02/01/2007] [Indexed: 01/11/2023]
Abstract
OBJECTIVES To evaluate whether PEEP affects intrapulmonary alveolar edema liquid movement and alveolar permeability to proteins during high volume ventilation. DESIGN AND SETTING Experimental study in an animal research laboratory. SUBJECTS 46 male Wistar rats. INTERVENTIONS A (99m)Tc-labeled albumin solution was instilled in a distal airway to produce a zone of alveolar flooding. Conventional ventilation (CV) was applied for 30 min followed by various ventilation strategies for 3 h: CV, spontaneous breathing, and high volume ventilation with different PEEP levels (0, 6, and 8 cmH(2)O) and different tidal volumes. Dispersion of the instilled liquid and systemic leakage of (99m)Tc-albumin from the lungs were studied by scintigraphy. MEASUREMENTS AND RESULTS The instillation protocol produced a zone of alveolar flooding that stayed localized during CV or spontaneous breathing. High volume ventilation dispersed alveolar liquid in the lungs. This dispersion was prevented by PEEP even when tidal volume was the same and thus end-inspiratory pressure higher. High volume ventilation resulted in the leakage of instilled (99m)Tc-albumin from the lungs. This increase in alveolar albumin permeability was reduced by PEEP. Albumin permeability was more affected by the amplitude of tidal excursions than by overall lung distension. CONCLUSIONS PEEP prevents the dispersion of alveolar edema liquid in the lungs and lessens the increase in alveolar albumin permeability due to high volume ventilation.
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Affiliation(s)
- Nicolas de Prost
- Centre de Recherche Bichat Beaujon CRB3, INSERM U773, site Bichat BP 416, Université Paris 7, Denis Diderot, 75018, Paris, France
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de Prost N, Saumon G. Glucose transport in the lung and its role in liquid movement. Respir Physiol Neurobiol 2007; 159:331-7. [PMID: 17369109 DOI: 10.1016/j.resp.2007.02.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2006] [Revised: 02/16/2007] [Accepted: 02/17/2007] [Indexed: 11/24/2022]
Abstract
Glucose concentration in the liquid present in the alveolar/airway lumen is the consequence of the balance between removal by lung epithelial cells and entry from the plasma or lung interstitium through the paracellular pathway. Glucose removal is mediated by active, Na(+) -dependent, cotransport and results in transepithelial Na(+) transport and liquid absorption in animals with significant rates of luminal glucose uptake and when luminal glucose concentration is high enough. Cotransport kinetics predicted a low luminal glucose concentration at the steady state, and foetal lung fluid and adult alveolar epithelial lining fluid glucose concentrations were indeed found lower than plasma. When luminal glucose concentration is low, the glucose-dependent part of transepithelial Na(+) transport is abated and alveolar liquid clearance reduced. A means to refuel this mechanism of liquid absorption would be to increase glucose entry in alveolar spaces through an increase in paracellular permeability. This hypothesis was modelled, and experimental data were found to acceptably agree with predictions.
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Affiliation(s)
- Nicolas de Prost
- INSERM, U773, Centre de Recherche Bichat Beaujon CRB3, BP 416, F-75018, Paris, France
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Lee JW, Matthay MA. Protein permeability in lung injury: now in real time again? J Appl Physiol (1985) 2006; 102:508-9. [PMID: 17068211 DOI: 10.1152/japplphysiol.01180.2006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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