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van den Berg M, Shi Z, Claassen WJ, Hooijman P, Lewis CTA, Andersen JL, van der Pijl RJ, Bogaards SJP, Conijn S, Peters EL, Begthel LPL, Uijterwijk B, Lindqvist J, Langlais PR, Girbes ARJ, Stapel S, Granzier H, Campbell KS, Ma W, Irving T, Hwee DT, Hartman JJ, Malik FI, Paul M, Beishuizen A, Ochala J, Heunks L, Ottenheijm CAC. Super-relaxed myosins contribute to respiratory muscle hibernation in mechanically ventilated patients. Sci Transl Med 2024; 16:eadg3894. [PMID: 39083588 DOI: 10.1126/scitranslmed.adg3894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 02/12/2024] [Accepted: 07/11/2024] [Indexed: 08/02/2024]
Abstract
Patients receiving mechanical ventilation in the intensive care unit (ICU) frequently develop contractile weakness of the diaphragm. Consequently, they may experience difficulty weaning from mechanical ventilation, which increases mortality and poses a high economic burden. Because of a lack of knowledge regarding the molecular changes in the diaphragm, no treatment is currently available to improve diaphragm contractility. We compared diaphragm biopsies from ventilated ICU patients (N = 54) to those of non-ICU patients undergoing thoracic surgery (N = 27). By integrating data from myofiber force measurements, x-ray diffraction experiments, and biochemical assays with clinical data, we found that in myofibers isolated from the diaphragm of ventilated ICU patients, myosin is trapped in an energy-sparing, super-relaxed state, which impairs the binding of myosin to actin during diaphragm contraction. Studies on quadriceps biopsies of ICU patients and on the diaphragm of previously healthy mechanically ventilated rats suggested that the super-relaxed myosins are specific to the diaphragm and not a result of critical illness. Exposing slow- and fast-twitch myofibers isolated from the diaphragm biopsies to small-molecule compounds activating troponin restored contractile force in vitro. These findings support the continued development of drugs that target sarcomere proteins to increase the calcium sensitivity of myofibers for the treatment of ICU-acquired diaphragm weakness.
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Affiliation(s)
- Marloes van den Berg
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
- Bispebjerg Hospital, Institute of Sports Medicine, Copenhagen 2400, Denmark
| | - Zhonghua Shi
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
- Amsterdam UMC, Location VUmc, Department of Intensive Care Medicine, Amsterdam 1081, HV, Netherlands
- Sanbo Brain Hospital, Capital Medical University, Intensive Care Medicine, Beijing 100093, China
| | - Wout J Claassen
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Pleuni Hooijman
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Christopher T A Lewis
- University of Copenhagen, Department of Biomedical Sciences, Copenhagen 2200, Denmark
- Research and Early Development, Novo Nordisk A/S, Måløv 2760, Denmark
| | - Jesper L Andersen
- Bispebjerg Hospital, Institute of Sports Medicine, Copenhagen 2400, Denmark
| | - Robbert J van der Pijl
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
| | - Sylvia J P Bogaards
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Stefan Conijn
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Eva L Peters
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
| | - Leon P L Begthel
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge CB2 0RE, UK
| | - Bas Uijterwijk
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
| | - Johan Lindqvist
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
| | - Paul R Langlais
- Department of Endocrinology, University of Arizona, Tucson, AZ 85721, USA
| | - Armand R J Girbes
- Amsterdam UMC, Location VUmc, Department of Intensive Care Medicine, Amsterdam 1081, HV, Netherlands
| | - Sandra Stapel
- Amsterdam UMC, Location VUmc, Department of Intensive Care Medicine, Amsterdam 1081, HV, Netherlands
| | - Henk Granzier
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
| | - Kenneth S Campbell
- Division of Cardiovascular Medicine, University of Kentucky College of Medicine, Lexington, KY 40536, USA
| | - Weikang Ma
- BioCAT, Illinois Institute of Technology, Lemont, IL 60439, USA
| | - Thomas Irving
- BioCAT, Illinois Institute of Technology, Lemont, IL 60439, USA
| | - Darren T Hwee
- Research and Early Development, Cytokinetics Inc., South San Francisco, CA 94080, USA
| | - James J Hartman
- Research and Early Development, Cytokinetics Inc., South San Francisco, CA 94080, USA
| | - Fady I Malik
- Research and Early Development, Cytokinetics Inc., South San Francisco, CA 94080, USA
| | - Marinus Paul
- Amsterdam UMC, Location VUmc, Department of Cardiothoracic Surgery, Amsterdam 1081, HV, Netherlands
| | - Albertus Beishuizen
- Medisch Spectrum Twente, Intensive Care Center, Enschede 7511, HN, Netherlands
| | - Julien Ochala
- University of Copenhagen, Department of Biomedical Sciences, Copenhagen 2200, Denmark
| | - Leo Heunks
- Radboud UMC, Department of Intensive Care, Nijmegen 6525, GA, Netherlands
| | - Coen A C Ottenheijm
- Amsterdam UMC, Location VUmc, Department of Physiology, Amsterdam 1081, HV, Netherlands
- Department of Cellular and Molecular Medicine, University of Arizona, Tucson AZ 85721, USA
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Kuitunen I, Uimonen M. Noninvasive respiratory support preventing reintubation after pediatric cardiac surgery-A systematic review. Paediatr Anaesth 2024; 34:204-211. [PMID: 38041510 DOI: 10.1111/pan.14808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 12/03/2023]
Abstract
OBJECTIVE To analyze the optimal postextubation respiratory support in pediatric cardiac surgery patients. DESIGN Systematic review of randomized controlled trials. SETTING Pediatric or neonatal intensive care units. PARTICIPANTS All aged children (<16 years) having cardiac surgery and postoperative invasive ventilation. INTERVENTION Noninvasive respiratory support, including high flow nasal cannula (HFNC), conventional oxygen therapy (COT), noninvasive positive pressure ventilation (NIPPV), continuous positive pressure (CPAP), and noninvasive high-frequency oscillatory ventilation (NHFOV). MEASUREMENT AND MAIN RESULTS Studies were not pooled for statistical synthesis due to the limited number and quality of the included studies. Risk ratios with 95% confidence intervals were calculated for individual studies. A total of 167 studies were screened and six were included. The risk of bias was low in one, high in one, and had some concerns in four of the studies. Extubation failure (defined as reintubation) was the main outcome of interest. Risk ratio for reintubation was 0.10 (CI 0.02-0.40) and 1.07 (CI 0.16-7.26) in HFNC versus COT, 0.49 (CI 0.05-5.28) in HFNC versus NIPPV, 0.40 (CI 0.08-1.94) in HFNOV versus CPAP, 0.75 (CI 0.26-2.18) in HFNOV versus NIPPV, and 1.37 (CI 0.33-5.73) in CPAP versus NIPPV. Treatment durations did not differ between the groups. CONCLUSION We did not find clear evidence of a difference in reintubation rates and other clinical outcomes between different noninvasive ventilation strategies. Evidence certainty was assessed to be very low due to the risk of bias, the small number of included studies, and high imprecision. Future quality studies are needed to determine the optimal postextubation support in pediatric cardiac surgery patients.
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Affiliation(s)
- Ilari Kuitunen
- University of Eastern Finland, Institute of Clinical Medicine and Department of Pediatrics, Kuopio, Finland
- Department of Pediatrics, Kuopio University Hospital, Kuopio, Finland
| | - Mikko Uimonen
- Department of Cardiothoracic Surgery, Tampere Heart Hospital, Tampere, Finland
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Panelli A, Verfuß MA, Dres M, Brochard L, Schaller SJ. Phrenic nerve stimulation to prevent diaphragmatic dysfunction and ventilator-induced lung injury. Intensive Care Med Exp 2023; 11:94. [PMID: 38109016 PMCID: PMC10728426 DOI: 10.1186/s40635-023-00577-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/06/2023] [Indexed: 12/19/2023] Open
Abstract
Side effects of mechanical ventilation, such as ventilator-induced diaphragmatic dysfunction (VIDD) and ventilator-induced lung injury (VILI), occur frequently in critically ill patients. Phrenic nerve stimulation (PNS) has been a valuable tool for diagnosing VIDD by assessing respiratory muscle strength in response to magnetic PNS. The detection of pathophysiologically reduced respiratory muscle strength is correlated with weaning failure, longer mechanical ventilation time, and mortality. Non-invasive electromagnetic PNS designed for diagnostic use is a reference technique that allows clinicians to measure transdiaphragm pressure as a surrogate parameter for diaphragm strength and functionality. This helps to identify diaphragm-related issues that may impact weaning readiness and respiratory support requirements, although lack of lung volume measurement poses a challenge to interpretation. In recent years, therapeutic PNS has been demonstrated as feasible and safe in lung-healthy and critically ill patients. Effects on critically ill patients' VIDD or diaphragm atrophy outcomes are the subject of ongoing research. The currently investigated application forms are diverse and vary from invasive to non-invasive and from electrical to (electro)magnetic PNS, with most data available for electrical stimulation. Increased inspiratory muscle strength and improved diaphragm activity (e.g., excursion, thickening fraction, and thickness) indicate the potential of the technique for beneficial effects on clinical outcomes as it has been successfully used in spinal cord injured patients. Concerning the potential for electrophrenic respiration, the data obtained with non-invasive electromagnetic PNS suggest that the induced diaphragmatic contractions result in airway pressure swings and tidal volumes remaining within the thresholds of lung-protective mechanical ventilation. PNS holds significant promise as a therapeutic intervention in the critical care setting, with potential applications for ameliorating VIDD and the ability for diaphragm training in a safe lung-protective spectrum, thereby possibly reducing the risk of VILI indirectly. Outcomes of such diaphragm training have not been sufficiently explored to date but offer the perspective for enhanced patient care and reducing weaning failure. Future research might focus on using PNS in combination with invasive and non-invasive assisted ventilation with automatic synchronisation and the modulation of PNS with spontaneous breathing efforts. Explorative approaches may investigate the feasibility of long-term electrophrenic ventilation as an alternative to positive pressure-based ventilation.
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Affiliation(s)
- Alessandro Panelli
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Michael A Verfuß
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany
| | - Martin Dres
- Sorbonne Université, INSERM UMRS 1158, Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- Service de Médecine Intensive et Réanimation, Département R3S, APHP, Sorbonne Université, Hôpital Pitie Salpêtrière, Paris, France
| | - Laurent Brochard
- Unity Health Toronto, Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Stefan J Schaller
- Charité - Universitätsmedizin Berlin, Department of Anesthesiology and Intensive Care Medicine (CCM/CVK), Berlin, Germany.
- Technical University of Munich, School of Medicine and Health, Klinikum Rechts der Isar, Department of Anesthesiology and Intensive Care Medicine, Munich, Germany.
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Mnuskina S, Bauer J, Wirth-Hücking A, Schneidereit D, Nübler S, Ritter P, Cacciani N, Li M, Larsson L, Friedrich O. Single fibre cytoarchitecture in ventilator-induced diaphragm dysfunction (VIDD) assessed by quantitative morphometry second harmonic generation imaging: Positive effects of BGP-15 chaperone co-inducer and VBP-15 dissociative corticosteroid treatment. Front Physiol 2023; 14:1207802. [PMID: 37440999 PMCID: PMC10333583 DOI: 10.3389/fphys.2023.1207802] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 06/01/2023] [Indexed: 07/15/2023] Open
Abstract
Ventilator-induced diaphragm dysfunction (VIDD) is a common sequela of intensive care unit (ICU) treatment requiring mechanical ventilation (MV) and neuromuscular blockade (NMBA). It is characterised by diaphragm weakness, prolonged respirator weaning and adverse outcomes. Dissociative glucocorticoids (e.g., vamorolone, VBP-15) and chaperone co-inducers (e.g., BGP-15) previously showed positive effects in an ICU-rat model. In limb muscle critical illness myopathy, preferential myosin loss prevails, while myofibrillar protein post-translational modifications are more dominant in VIDD. It is not known whether the marked decline in specific force (force normalised to cross-sectional area) is a pure consequence of altered contractility signaling or whether diaphragm weakness also has a structural correlate through sterical remodeling of myofibrillar cytoarchitecture, how quickly it develops, and to which extent VBP-15 or BGP-15 may specifically recover myofibrillar geometry. To address these questions, we performed label-free multiphoton Second Harmonic Generation (SHG) imaging followed by quantitative morphometry in single diaphragm muscle fibres from healthy rats subjected to five or 10 days of MV + NMBA to simulate ICU treatment without underlying confounding pathology (like sepsis). Rats received daily treatment of either Prednisolone, VBP-15, BGP-15 or none. Myosin-II SHG signal intensities, fibre diameters (FD) as well as the parameters of myofibrillar angular parallelism (cosine angle sum, CAS) and in-register of adjacent myofibrils (Vernier density, VD) were computed from SHG images. ICU treatment caused a decline in FD at day 10 as well as a significant decline in CAS and VD from day 5. Vamorolone effectively recovered FD at day 10, while BGP-15 was more effective at day 5. BGP-15 was more effective than VBP-15 in recovering CAS at day 10 although not to control levels. In-register VD levels were restored at day 10 by both compounds. Our study is the first to provide quantitative insights into VIDD-related myofibrillar remodeling unravelled by SHG imaging, suggesting that both VBP-15 and BGP-15 can effectively ameliorate the structure-related dysfunction in VIDD.
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Affiliation(s)
- Sofia Mnuskina
- Department of Chemical and Biological Engineering (CBI), Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Julian Bauer
- Department of Chemical and Biological Engineering (CBI), Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Anette Wirth-Hücking
- Department of Chemical and Biological Engineering (CBI), Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Dominik Schneidereit
- Department of Chemical and Biological Engineering (CBI), Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Stefanie Nübler
- Department of Chemical and Biological Engineering (CBI), Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Paul Ritter
- Department of Chemical and Biological Engineering (CBI), Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | - Nicola Cacciani
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Meishan Li
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lars Larsson
- Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
- Department of Clinical Neuroscience, Clinical Neurophysiology, Karolinska Institutet, Stockholm, Sweden
- Viron Molecular Medicine Institute, Boston, MA, United States
| | - Oliver Friedrich
- Department of Chemical and Biological Engineering (CBI), Institute of Medical Biotechnology, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- Muscle Research Center Erlangen (MURCE), Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
- School of Medical Sciences, University of New South Wales, Kensington Campus, Sydney, NSW, Australia
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5
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Eksombatchai D, Sukkratok C, Sutherasan Y, Junhasavasdikul D, Theerawit P. The ratio of respiratory rate to diaphragm thickening fraction for predicting extubation success. BMC Pulm Med 2023; 23:109. [PMID: 37016339 PMCID: PMC10071651 DOI: 10.1186/s12890-023-02392-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/17/2023] [Indexed: 04/06/2023] Open
Abstract
BACKGROUND Several parameters are used to predict successful extubation but their accuracy varies among studies. We hypothesized that combining conventional and diaphragmatic parameters would be more effective than using just one. Our primary objective was to evaluate the performance of the respiratory rate in relation to the diaphragm thickening fraction (RR/DTF) ratio to predict the success of extubation. METHODS We enrolled 130 adult patients who required invasive mechanical ventilation, planned to be extubated, and used a spontaneous breathing trial (SBT) in the intensive care unit from July 2020 to April 2022. We measured the conventional parameters and the diaphragmatic parameters 2 h after SBT. The RR/DTF was calculated by dividing the respiratory rate (RR) by the diaphragm thickening fraction (DTF). The definition of weaning success is successful extubation within 48 h. RESULTS Of 130 patients, 8 patients (6.2%) were reintubated within 48 h. The RR/DTF was significantly lower in the successful extubation group than in the extubation failure group (right hemidiaphragm; 0.47 (0.33-0.64) vs 1.1 (0.6-2.32), p < 0.001 and left hemidiaphragm; 0.45 (0.31-0.65) vs 0.78 (0.48-1.75), p < 0.001). The right RR/DTF using a cut-off point at ≤ 0.81 had a sensitivity of 87.7%, a specificity of 75%, and areas under the receiver operating characteristic curve (AUROC) of 0.762 for predicting successful extubation (p = 0.013). The sensitivity, specificity, and AUROC for predicting extubation success of right DTF at a cut-off point of ≥ 26.2% were 84.3%, 62.5%, and 0.775, respectively (p = 0.009). CONCLUSION The RR/DTF ratio is a promising tool for predicting extubation outcome. Additionally, using RR/DTF was more reliable than conventional or diaphragmatic parameters alone in predicting extubation success.
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Affiliation(s)
- Dararat Eksombatchai
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Ramathibodi Hospital, Rama VI Road, Bangkok, 10400, Ratchathewi, Thailand
| | - Chalermwut Sukkratok
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Ramathibodi Hospital, Rama VI Road, Bangkok, 10400, Ratchathewi, Thailand
| | - Yuda Sutherasan
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Ramathibodi Hospital, Rama VI Road, Bangkok, 10400, Ratchathewi, Thailand
| | - Detajin Junhasavasdikul
- Division of Pulmonary and Pulmonary Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Ramathibodi Hospital, Rama VI Road, Bangkok, 10400, Ratchathewi, Thailand
| | - Pongdhep Theerawit
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Ramathibodi Hospital, Rama VI Road, Bangkok, 10400, Ratchathewi, Thailand.
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Santana PV, Cardenas LZ, de Albuquerque ALP. Diaphragm Ultrasound in Critically Ill Patients on Mechanical Ventilation—Evolving Concepts. Diagnostics (Basel) 2023; 13:diagnostics13061116. [PMID: 36980423 PMCID: PMC10046995 DOI: 10.3390/diagnostics13061116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 03/11/2023] [Accepted: 03/13/2023] [Indexed: 03/18/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving respiratory support therapy, but MV can lead to diaphragm muscle injury (myotrauma) and induce diaphragmatic dysfunction (DD). DD is relevant because it is highly prevalent and associated with significant adverse outcomes, including prolonged ventilation, weaning failures, and mortality. The main mechanisms involved in the occurrence of myotrauma are associated with inadequate MV support in adapting to the patient’s respiratory effort (over- and under-assistance) and as a result of patient-ventilator asynchrony (PVA). The recognition of these mechanisms associated with myotrauma forced the development of myotrauma prevention strategies (MV with diaphragm protection), mainly based on titration of appropriate levels of inspiratory effort (to avoid over- and under-assistance) and to avoid PVA. Protecting the diaphragm during MV therefore requires the use of tools to monitor diaphragmatic effort and detect PVA. Diaphragm ultrasound is a non-invasive technique that can be used to monitor diaphragm function, to assess PVA, and potentially help to define diaphragmatic effort with protective ventilation. This review aims to provide clinicians with an overview of the relevance of DD and the main mechanisms underlying myotrauma, as well as the most current strategies aimed at minimizing the occurrence of myotrauma with special emphasis on the role of ultrasound in monitoring diaphragm function.
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Affiliation(s)
- Pauliane Vieira Santana
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
| | - Letícia Zumpano Cardenas
- Intensive Care Unit, Physical Therapy Department, AC Camargo Cancer Center, São Paulo 01509-011, Brazil
| | - Andre Luis Pereira de Albuquerque
- Pulmonary Division, Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
- Sírio-Libanês Teaching and Research Institute, Hospital Sírio Libanês, São Paulo 01308-060, Brazil
- Correspondence: (P.V.S.); (A.L.P.d.A.)
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De Rosa S, Umbrello M, Pelosi P, Battaglini D. Update on Lean Body Mass Diagnostic Assessment in Critical Illness. Diagnostics (Basel) 2023; 13:diagnostics13050888. [PMID: 36900032 PMCID: PMC10000858 DOI: 10.3390/diagnostics13050888] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 02/23/2023] [Accepted: 02/24/2023] [Indexed: 03/03/2023] Open
Abstract
Acute critical illnesses can alter vital functions with profound biological, biochemical, metabolic, and functional modifications. Despite etiology, patient's nutritional status is pivotal to guide metabolic support. The assessment of nutritional status remains complex and not completely elucidated. Loss of lean body mass is a clear marker of malnutrition; however, the question of how to investigate it still remains unanswered. Several tools have been implemented to measure lean body mass, including a computed tomography scan, ultrasound, and bioelectrical impedance analysis, although such methods unfortunately require validation. A lack of uniform bedside measurement tools could impact the nutrition outcome. Metabolic assessment, nutritional status, and nutritional risk have a pivotal role in critical care. Therefore, knowledge about the methods used to assess lean body mass in critical illnesses is increasingly required. The aim of the present review is to update the scientific evidence regarding lean body mass diagnostic assessment in critical illness to provide the diagnostic key points for metabolic and nutritional support.
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Affiliation(s)
- Silvia De Rosa
- Centre for Medical Sciences—CISMed, University of Trento, Via S. Maria Maddalena 1, 38122 Trento, Italy
- Anesthesia and Intensive Care, Santa Chiara Regional Hospital, APSS, 38123 Trento, Italy
| | - Michele Umbrello
- S.C. Anestesia e Rianimazione II, Ospedale San Carlo Borromeo, ASST dei Santi Paolo e Carlo, 20142 Milano, Italy
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, 16132 Genova, Italy
| | - Denise Battaglini
- IRCCS Ospedale Policlinico San Martino, 16132 Genova, Italy
- Correspondence:
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Ribeiro F, Alves PKN, Bechara LRG, Ferreira JCB, Labeit S, Moriscot AS. Small-Molecule Inhibition of MuRF1 Prevents Early Disuse-Induced Diaphragmatic Dysfunction and Atrophy. Int J Mol Sci 2023; 24:ijms24043637. [PMID: 36835047 PMCID: PMC9965746 DOI: 10.3390/ijms24043637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
In clinical conditions such as diaphragm paralysis or mechanical ventilation, disuse-induced diaphragmatic dysfunction (DIDD) is a condition that poses a threat to life. MuRF1 is a key E3-ligase involved in regulating skeletal muscle mass, function, and metabolism, which contributes to the onset of DIDD. We investigated if the small-molecule mediated inhibition of MuRF1 activity (MyoMed-205) protects against early DIDD after 12 h of unilateral diaphragm denervation. Wistar rats were used in this study to determine the compound's acute toxicity and optimal dosage. For potential DIDD treatment efficacy, diaphragm contractile function and fiber cross-sectional area (CSA) were evaluated. Western blotting investigated potential mechanisms underlying MyoMed-205's effects in early DIDD. Our results indicate 50 mg/kg bw MyoMed-205 as a suitable dosage to prevent early diaphragmatic contractile dysfunction and atrophy following 12 h of denervation without detectable signs of acute toxicity. Mechanistically, treatment did not affect disuse-induced oxidative stress (4-HNE) increase, whereas phosphorylation of (ser632) HDAC4 was normalized. MyoMed-205 also mitigated FoxO1 activation, inhibited MuRF2, and increased phospho (ser473) Akt protein levels. These findings may suggest that MuRF1 activity significantly contributes to early DIDD pathophysiology. Novel strategies targeting MuRF1 (e.g., MyoMed-205) have potential therapeutic applications for treating early DIDD.
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Affiliation(s)
- Fernando Ribeiro
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Paula K. N. Alves
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Luiz R. G. Bechara
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Julio C. B. Ferreira
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
| | - Siegfried Labeit
- DZHK Partner Site Mannheim-Heidelberg, Medical Faculty Mannheim, University of Heidelberg, 68169 Mannheim, Germany
- Myomedix GmbH, 69151 Neckargemünd, Germany
| | - Anselmo S. Moriscot
- Department of Anatomy, Institute of Biomedical Sciences, University of São Paulo, São Paulo 05508-000, Brazil
- Correspondence: ; Tel.: +55-11-3091-0946
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9
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Intensive Care Unit Acquired Weakness Is Associated with Rapid Changes to Skeletal Muscle Proteostasis. Cells 2022; 11:cells11244005. [PMID: 36552769 PMCID: PMC9776723 DOI: 10.3390/cells11244005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/21/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Intensive care unit (ICU)-acquired weakness is a frequent consequence of critical illness that impacts both the limb and respiratory muscles. The cause of ICU-acquired weakness is multifactorial, but both prolonged limb muscle inactivity and mechanical ventilation are risk factors for muscle wasting, which predisposes ICU patients to both short-term complications and long-term disabilities resulting from muscle weakness. Unfortunately, the current research does not provide a detailed understanding of the cellular etiology of ICU-acquired weakness, and no standard treatment exists. Therefore, improving knowledge of the mechanisms promoting muscle atrophy in critically ill patients is essential to developing therapeutic strategies to protect against ICU-induced skeletal muscle wasting. To advance our understanding of the mechanism(s) responsible for ICU-acquired weakness, we tested the hypothesis that ICU-induced muscle inactivity promotes a rapid decrease in anabolic signaling/protein synthesis and accelerates proteolysis in both limb and respiratory muscles. To investigate ICU-induced changes in skeletal muscle proteostasis, adult Sprague Dawley rats were anesthetized and mechanically ventilated for 12 h to simulate ICU care. Measurements of anabolic signaling, protein synthesis, and proteolytic activity in the limb muscles (plantaris and soleus) and respiratory muscles (parasternal and intercostal) revealed ICU-induced reductions in both anabolic signaling (i.e., AKT/mTOR pathway) and muscle protein synthesis. Moreover, simulated ICU care resulted in increased biomarkers of accelerated proteolysis in both limb and respiratory muscles. These novel findings reveal that disturbances in limb and respiratory muscle proteostasis occur rapidly during ICU-induced muscle inactivity, irrespective of the muscle function or muscle fiber type.
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Rbm20 ΔRRM Mice, Expressing a Titin Isoform with Lower Stiffness, Are Protected from Mechanical Ventilation-Induced Diaphragm Weakness. Int J Mol Sci 2022; 23:ijms232415689. [PMID: 36555335 PMCID: PMC9779751 DOI: 10.3390/ijms232415689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 12/06/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022] Open
Abstract
Diaphragm weakness frequently develops in mechanically ventilated critically ill patients and is associated with increased morbidity, including ventilator weaning failure, mortality, and health care costs. The mechanisms underlying diaphragm weakness are incompletely understood but may include the elastic properties of titin, a giant protein whose layout in the muscle's sarcomeres makes it an ideal candidate to sense ventilation-induced diaphragm unloading, resulting in downstream signaling through titin-binding proteins. In the current study, we investigated whether modulating titin stiffness affects the development of diaphragm weakness during mechanical ventilation. To this end, we ventilated genetically engineered mice with reduced titin stiffness (Rbm20ΔRRM), and robust (TtnΔIAjxn) or severely (TtnΔ112-158) increased titin stiffness for 8 h, and assessed diaphragm contractility and protein expression of titin-binding proteins. Mechanical ventilation reduced the maximum active tension of the diaphragm in WT, TtnΔIAjxn and TtnΔ112-158 mice. However, in Rbm20ΔRRM mice maximum active tension was preserved after ventilation. Analyses of titin binding proteins suggest that muscle ankyrin repeat proteins (MARPs) 1 and 2 may play a role in the adaptation of the diaphragm to mechanical ventilation, and the preservation of diaphragm contractility in Rbm20ΔRRM mice. Thus, Rbm20ΔRRM mice, expressing titin isoforms with lower stiffness, are protected from mechanical ventilation-induced diaphragm weakness, suggesting that titin elasticity may modulate the diaphragm's response to unloading during mechanical ventilation.
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Villelabeitia-Jaureguizar K, Calvo-Lobo C, Rodríguez-Sanz D, Vicente-Campos D, Castro-Portal JA, López-Cañadas M, Becerro-de-Bengoa-Vallejo R, Chicharro JL. Low Intensity Respiratory Muscle Training in COVID-19 Patients after Invasive Mechanical Ventilation: A Retrospective Case-Series Study. Biomedicines 2022; 10:2807. [PMID: 36359327 PMCID: PMC9687222 DOI: 10.3390/biomedicines10112807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Worldwide, healthcare systems had to respond to an exponential increase in COVID-19 patients with a noteworthy increment in intensive care units (ICU) admissions and invasive mechanical ventilation (IMV). The aim was to determine low intensity respiratory muscle training (RMT) effects in COVID-19 patients upon medical discharge and after an ICU stay with IMV. A retrospective case-series study was performed. Forty COVID-19 patients were enrolled and divided into twenty participants who received IMV during ICU stay (IMV group) and 20 participants who did not receive IMV nor an ICU stay (non-IMV group). Maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), COPD assessment test (CAT) and Medical Research Council (MRC) dyspnea scale were collected at baseline and after 12 weeks of low intensity RMT. A greater MRC dyspnea score and lower PImax were shown at baseline in the IMV group versus the non-IMV group (p < 0.01). RMT effects on the total sample improved all outcome measurements (p < 0.05; d = 0.38−0.98). Intragroup comparisons after RMT improved PImax, CAT and MRC scores in the IMV group (p = 0.001; d = 0.94−1.09), but not for PImax in the non-IMV group (p > 0.05). Between-groups comparison after RMT only showed MRC dyspnea improvements (p = 0.020; d = 0.74) in the IMV group versus non-IMV group. Furthermore, PImax decrease was only predicted by the IMV presence (R2 = 0.378). Low intensity RMT may improve respiratory muscle strength, health related quality of life and dyspnea in COVID-19 patients. Especially, low intensity RMT could improve dyspnea level and maybe PImax in COVID-19 patients who received IMV in ICU.
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Affiliation(s)
| | - César Calvo-Lobo
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - David Rodríguez-Sanz
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Davinia Vicente-Campos
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
| | | | | | | | - José López Chicharro
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
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12
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Doerr V, Montalvo RN, Nguyen BL, Boeno FP, Sunshine MD, Bindi VE, Fuller DD, Smuder AJ. Effects of Hyperbaric Oxygen Preconditioning on Doxorubicin Cardiorespiratory Toxicity. Antioxidants (Basel) 2022; 11:antiox11102073. [PMID: 36290796 PMCID: PMC9598583 DOI: 10.3390/antiox11102073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/29/2022] Open
Abstract
Cardiorespiratory dysfunction resulting from doxorubicin (DOX) chemotherapy treatment is a debilitating condition affecting cancer patient outcomes and quality of life. DOX treatment promotes cardiac and respiratory muscle pathology due to enhanced reactive oxygen species (ROS) production, mitochondrial dysfunction and impaired muscle contractility. In contrast, hyperbaric oxygen (HBO) therapy is considered a controlled oxidative stress that can evoke a substantial and sustained increase in muscle antioxidant expression. This HBO-induced increase in antioxidant capacity has the potential to improve cardiac and respiratory (i.e., diaphragm) muscle redox balance, preserving mitochondrial function and preventing muscle dysfunction. Therefore, we determined whether HBO therapy prior to DOX treatment is sufficient to enhance muscle antioxidant expression and preserve muscle redox balance and cardiorespiratory muscle function. To test this, adult female Sprague Dawley rats received HBO therapy (2 or 3 atmospheres absolute (ATA), 100% O2, 1 h/day) for 5 consecutive days prior to acute DOX treatment (20 mg/kg i.p.). Our data demonstrate that 3 ATA HBO elicits a greater antioxidant response compared to 2 ATA HBO. However, these effects did not correspond with beneficial adaptations to cardiac systolic and diastolic function or diaphragm muscle force production in DOX treated rats. These findings suggest that modulating muscle antioxidant expression with HBO therapy is not sufficient to prevent DOX-induced cardiorespiratory dysfunction.
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Affiliation(s)
- Vivian Doerr
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA
| | - Ryan N. Montalvo
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA
| | - Branden L. Nguyen
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL 32610, USA
| | - Franccesco P. Boeno
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA
| | - Michael D. Sunshine
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL 32610, USA
- Department of Physical Therapy, University of Florida, Gainesville, FL 32611, USA
- McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
| | - Victoria E. Bindi
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL 32610, USA
- Department of Physical Therapy, University of Florida, Gainesville, FL 32611, USA
- McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
| | - David D. Fuller
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL 32610, USA
- Department of Physical Therapy, University of Florida, Gainesville, FL 32611, USA
- McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
| | - Ashley J. Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA
- Breathing Research and Therapeutics Center, University of Florida, Gainesville, FL 32610, USA
- Correspondence:
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Steinberg I, Bisciaio A, Rosboch GL, Ceraolo E, Guerrera F, Ruffini E, Brazzi L. Impact of intubated vs. non-intubated anesthesia on postoperative diaphragmatic function: Results from a prospective observational study. Front Physiol 2022; 13:953951. [PMID: 36003644 PMCID: PMC9393254 DOI: 10.3389/fphys.2022.953951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/14/2022] [Indexed: 12/02/2022] Open
Abstract
Background: An altered diaphragmatic function was associated with the development of postoperative pulmonary complications following thoracic surgery. Methods: To evaluate the impact of different anesthetic techniques on postoperative diaphragmatic dysfunction, patients undergoing video-assisted thoracoscopic surgery (VATS) lung biopsy for interstitial lung disease were enrolled in a monocentric observational prospective study. Patients received intubated or non-intubated anesthesia according to risk assessment and preferences following multidisciplinary discussion. Ultrasound measured diaphragmatic excursion (DIA) and Thickening Fraction (TF) were recorded together with arterial blood gases and pulmonary function tests (PFT) immediately before and 12 h after surgery. Pain control and postoperative nausea and vomiting (PONV) were also evaluated. Results: From February 2019 to September 2020, 41 consecutive patients were enrolled. Five were lost due to difficulties in collecting postoperative data. Of the remaining 36 patients, 25 underwent surgery with a non-intubated anesthesia approach whereas 11 underwent intubated general anesthesia. The two groups had similar baseline characteristics. On the operated side, DIA and TF showed a lower residual postoperative function in the intubated group compared to the non-intubated group (54 vs. 82% of DIA and 36 vs. 97% of TF; p = 0.001 for both). The same was observed on the non-operated side (58 vs. 82% and 62 vs. 94%; p = 0.005 and p = 0.045, respectively, for DIA and TF). No differences were observed between groups in terms of pain control, PONV, gas exchange and PFT. Conclusion: This study suggests that maintenance of spontaneous breathing during VATS lung biopsy is associated with better diaphragmatic residual function after surgery.
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Affiliation(s)
- Irene Steinberg
- Department of Surgical Sciences, University of Turin, Turin, Italy
- *Correspondence: Irene Steinberg,
| | - Agnese Bisciaio
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Giulio Luca Rosboch
- Department of Anaesthesia, Intensive Care and Emergency—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Edoardo Ceraolo
- Department of Anaesthesia, Intensive Care and Emergency—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Francesco Guerrera
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Thoracic Surgery—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Enrico Ruffini
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Thoracic Surgery—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
| | - Luca Brazzi
- Department of Surgical Sciences, University of Turin, Turin, Italy
- Department of Anaesthesia, Intensive Care and Emergency—‘Città Della Salute e Della Scienza University Hospital, Turin, Italy
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14
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Effect of Acupuncture on Diaphragm Function in Healthy Volunteers: A Pilot Clinical Study. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:6608200. [PMID: 35677369 PMCID: PMC9168091 DOI: 10.1155/2022/6608200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/28/2022] [Accepted: 05/14/2022] [Indexed: 11/18/2022]
Abstract
Introduction In western medicine, the diaphragm is the main inspiratory muscle. It is involved in the postural control of the trunk and contributes to balance performance. In traditional Chinese medicine (TCM), the diaphragm represents a gateway between the lower and upper parts of the body, and it regulates the descending and ascending functions of the whole organism. The aim of this study was to assess the effect of acupuncture on diaphragm function. Methods A proof-of-concept, prospective, controlled, pilot trial in healthy volunteers. Respiratory rate, inspired volume, diaphragm excursion, and thickening were measured during tidal and maximal breathing at baseline and after sham or real acupuncture. Acupuncture was performed on Yanglingquan (GB34), Tai Chong (LV3), Danzhong (CV17), Geshu (BL17), and Geguan (BL46). Results Ten participants were enrolled (6 males, weight 71 ± 12 kg, height 173 ± 9 cm, BMI 21 ± 1.3 kg/m2). During tidal breathing, tidal volume, diaphragm displacement, and end-expiratory diaphragm thickness did not change with sham or real acupuncture as compared to baseline; thickening ratio was 43.5 ± 16.6 vs. 31.3 ± 14.9 (sham) vs. 30.8 ± 15.3% (baseline), p=0.1066. During breaths at vital capacity, the acupuncture group, as compared to both baseline and sham acupuncture, had a trend toward a larger tidal volume (3840 ± 690 vs. 3110 ± 880 vs. 3230 ± 750 ml, p=0.1247) and showed a significantly higher thickening ratio (270.6 ± 136.4 vs. 172.4 ± 57.4 vs. 188.6 ± 41.7%, p=0.0414). Conclusions Acupuncture significantly influenced diaphragm function in healthy volunteers, improving its inspiratory thickening fraction during breaths at vital capacity, as compared to no or sham acupuncture.
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Horn AG, Kunkel ON, Schulze KM, Baumfalk DR, Weber RE, Poole DC, Behnke BJ. Supplemental oxygen administration during mechanical ventilation reduces diaphragm blood flow and oxygen delivery. J Appl Physiol (1985) 2022; 132:1190-1200. [PMID: 35323060 PMCID: PMC9054262 DOI: 10.1152/japplphysiol.00021.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 11/22/2022] Open
Abstract
During mechanical ventilation (MV), supplemental oxygen (O2) is commonly administered to critically ill patients to combat hypoxemia. Previous studies demonstrate that hyperoxia exacerbates MV-induced diaphragm oxidative stress and contractile dysfunction. Whereas normoxic MV (i.e., 21% O2) diminishes diaphragm perfusion and O2 delivery in the quiescent diaphragm, the effect of MV with 100% O2 is unknown. We tested the hypothesis that MV supplemented with hyperoxic gas (100% O2) would increase diaphragm vascular resistance and reduce diaphragmatic blood flow and O2 delivery to a greater extent than MV alone. Female Sprague-Dawley rats (4-6 mo) were randomly divided into two groups: 1) MV + 100% O2 followed by MV + 21% O2 (n = 9) or 2) MV + 21% O2 followed by MV + 100% O2 (n = 10). Diaphragmatic blood flow (mL/min/100 g) and vascular resistance were determined, via fluorescent microspheres, during spontaneous breathing (SB), MV + 100% O2, and MV + 21% O2. Compared with SB, total diaphragm vascular resistance was increased, and blood flow was decreased with both MV + 100% O2 and MV + 21% O2 (all P < 0.05). Medial costal diaphragmatic blood flow was lower with MV + 100% O2 (26 ± 6 mL/min/100 g) versus MV + 21% O2 (51 ± 15 mL/min/100 g; P < 0.05). Second, the addition of 100% O2 during normoxic MV exacerbated the MV-induced reductions in medial costal diaphragm perfusion (23 ± 7 vs. 51 ± 15 mL/min/100 g; P < 0.05) and O2 delivery (3.4 ± 0.2 vs. 6.4 ± 0.3 mL O2/min/100 g; P < 0.05). These data demonstrate that administration of supplemental 100% O2 during MV increases diaphragm vascular resistance and diminishes perfusion and O2 delivery to a significantly greater degree than normoxic MV. This suggests that prolonged bouts of MV (i.e., 6 h) with hyperoxia may accelerate MV-induced vascular dysfunction in the quiescent diaphragm and potentially exacerbate downstream contractile dysfunction.NEW & NOTEWORTHY This is the first study, to our knowledge, demonstrating that supplemental oxygen (i.e., 100% O2) during mechanical ventilation (MV) augments the MV-induced reductions in diaphragmatic blood flow and O2 delivery. The accelerated reduction in diaphragmatic blood flow with hyperoxic MV would be expected to potentiate MV-induced diaphragm vascular dysfunction and consequently, downstream contractile dysfunction. The data presented herein provide a putative mechanism for the exacerbated oxidative stress and diaphragm dysfunction reported with prolonged hyperoxic MV.
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Affiliation(s)
- Andrew G Horn
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Olivia N Kunkel
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Kiana M Schulze
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Dryden R Baumfalk
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Ramona E Weber
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
- Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas
| | - Bradley J Behnke
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
- Johnson Cancer Research Center, Kansas State University, Manhattan, Kansas
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16
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Zhang D, Hao W, Li X, Han P, Niu Q. Aldh1a1 and Scl25a30 in diaphragmatic dysfunction. Exp Biol Med (Maywood) 2022; 247:1013-1029. [PMID: 35410502 DOI: 10.1177/15353702221085201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
New methods to prevent ventilator-induced diaphragmatic dysfunction (VIDD) are urgently needed, and the cellular basis of VIDD is poorly understood. This study evaluated whether transvenous phrenic nerve stimulation (PNS) could prevent VIDD in rabbits undergoing mechanical ventilation (MV) and explored whether oxidative stress-related genes might be candidate molecular markers for VIDD. Twenty-four adult male New Zealand white rabbits were allocated to control, MV, and PNS groups (n = 8 in each group). Rabbits in the MV and PNS groups underwent MV for 24 h. Intermittent bilateral transvenous PNS was performed in rabbits in the PNS group. Transdiaphragmatic pressure was recorded using balloon catheters. The diameters and cross-sectional areas (CSAs) of types I and II diaphragmatic fibers were measured using immunohistochemistry (IHC) techniques. Genes associated with VIDD were identified by RNA sequencing (RNA-seq), differentially expressed gene (DEG) analysis, and weighted gene co-expression network analysis (WGCNA). Reverse transcription polymerase chain reaction (RT-PCR), Western blotting, and IHC analyses were carried out to verify the transcriptome profile. Pdi60Hz, Pdi80Hz, and Pdi100Hz were significantly higher in the PNS group than in the MV group at 12 and 24 h (P < 0.05 at both time points). The diameters and CSAs of types I (slow-twitch) and II (fast-twitch) fibers were significantly larger in the PNS group than in the MV group (P < 0.05). RNA-seq, RT-PCR, Western blotting, and IHC experiments identified two candidate genes associated with VIDD: Aldh1a1 and Scl25a30. The MV group had significantly higher mRNA and protein expressions of Aldh1a1/ALDH1A1 and significantly lower mRNA and protein expressions of Scl25a30/SCL25A30 than the control or PNS groups (P < 0.05). We have identified two candidate genes involved in the prevention of VIDD by transvenous PNS. These two key genes may provide a theoretical basis for targeted therapy against VIDD.
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Affiliation(s)
- Dong Zhang
- Department of Critical Care Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi 046000, China
| | - Wenyan Hao
- Department of Biomedical Engineering, Changzhi Medical College, Changzhi 046000, China
| | - Xujiong Li
- Department of Physiology, Changzhi Medical College, Changzhi 046000, China
| | - Pengyong Han
- The Central Lab, Changzhi Medical College, Changzhi 046000, China
| | - Qi Niu
- Department of Critical Care Medicine, Heping Hospital Affiliated to Changzhi Medical College, Changzhi 046000, China
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Itagaki T. Diaphragm-protective mechanical ventilation in acute respiratory failure. THE JOURNAL OF MEDICAL INVESTIGATION 2022; 69:165-172. [DOI: 10.2152/jmi.69.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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Abstract
While the traditional lung function tests are used to assess lung capacity and pulmonary function, they cannot evaluate respiratory driving function and the integrity of the conduction pathway from the central nervous system to the respiratory motor neuron in the spinal cord and to the diaphragm. The inspiratory trigger is sent from the central nervous system through the phrenic nerve and drives the diaphragm to generate inspiratory movement. Therefore, phrenic nerve stimulation and diaphragmatic electromyography are two fundamental methods to assess respiratory function. There are several useful tools to assess respiratory motor system including electrical or magnetic phrenic nerve stimulation, diaphragmatic needle electromyography, and diaphragmatic ultrasound. By these means, physicians can assess current respiratory status in different neurological diseases that affect respiratory muscles, follow-up of the severity of respiratory impairment, help to predict the chance of successfully weaning from ventilatory support, and confirm clinical diagnoses such as diaphragmatic myoclonus. Although some of these tests require special training, applying these neurophysiological assessments in clinical practice is highly recommended.
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Affiliation(s)
- Yih-Chih Jacinta Kuo
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Kai-Hsiang Stanley Chen
- Department of Neurology, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan.
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Horn AG, Kunkel ON, Baumfalk DR, Simon ME, Schulze KM, Hsu WW, Muller-Delp J, Poole DC, Behnke BJ. Prolonged mechanical ventilation increases diaphragm arteriole circumferential stretch without changes in stress/stretch: Implications for the pathogenesis of ventilator-induced diaphragm dysfunction. Microcirculation 2021; 28:e12727. [PMID: 34467606 DOI: 10.1111/micc.12727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 05/31/2021] [Accepted: 08/24/2021] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Prolonged mechanical ventilation (MV; ≥6 h) results in large, time-dependent reductions in diaphragmatic blood flow and shear stress. We tested the hypothesis that MV would impair the structural and material properties (ie, increased stress/stretch relation and/or circumferential stretch) of first-order arterioles (1A) from the medial costal diaphragm. METHODS Shear stress was estimated from isolated arterioles and prior blood flow data from the diaphragm during spontaneous breathing (SB) and prolonged MV (6 h MV). Thereafter, female Sprague-Dawley rats (~5 months) were randomly divided into two groups, SB (n = 6) and 6 h MV (n = 6). Following SB and 6 h MV, 1A medial costal diaphragm arterioles were isolated, cannulated, and subjected to stepwise (0-140 cmH2 O) increases in intraluminal pressure in calcium-free Ringer's solution. Inner diameter and wall thickness were measured at each pressure step and used to calculate wall:lumen ratio, Cauchy-stress, and circumferential stretch. RESULTS Compared to SB, there was a ~90% reduction in arteriolar shear stress with prolonged MV (9 ± 2 vs 78 ± 20 dynes/cm2 ; p ≤ .05). In the unloaded condition (0 cmH2 O), the arteriolar intraluminal diameter was reduced (37 ± 8 vs 79 ± 13 μm) and wall:lumen ratio was increased (120 ± 18 vs 46 ± 10%) compared to SB (p ≤ .05). There were no differences in the passive diameter responses or the circumferential stress/stretch relationship between groups (p > .05), but at each pressure step, circumferential stretch was increased with 6 h MV vs SB (p ≤ .05). CONCLUSION During prolonged MV, medial costal diaphragm arteriolar shear stress is severely diminished. Despite no change in the material behavior (stress/stretch), prolonged MV resulted in altered structural and mechanical properties (ie, elevated circumferential stretch) of medial costal diaphragm arterioles. This provides important novel mechanistic insights into the impaired diaphragm blood flow capacity and vascular dysfunction following prolonged MV.
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Affiliation(s)
- Andrew G Horn
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - Olivia N Kunkel
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - Dryden R Baumfalk
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - Mikaela E Simon
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - Kiana M Schulze
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
| | - Wei-Wen Hsu
- Division of Biostatistics and Bioinformations, Department of Environmental and Public Health Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - Judy Muller-Delp
- Department of Biomedical Sciences, Florida State University, Tallahassee, FL, USA
| | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
- Department of Anatomy and Physiology, Kansas State University, Manhattan, KS, USA
| | - Bradley J Behnke
- Department of Kinesiology, Kansas State University, Manhattan, KS, USA
- Johnson Cancer Research Center, Kansas State University, Manhattan, KS, USA
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Jhou HJ, Chen PH, Ou-Yang LJ, Lin C, Tang SE, Lee CH. Methods of Weaning From Mechanical Ventilation in Adult: A Network Meta-Analysis. Front Med (Lausanne) 2021; 8:752984. [PMID: 34671629 PMCID: PMC8521009 DOI: 10.3389/fmed.2021.752984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 09/13/2021] [Indexed: 12/16/2022] Open
Abstract
Background/Objective: The aim of study is to assess the efficacy of each ventilator weaning method for ventilated patients in intensive care units (ICUs). Methods: A systematic search was conducted using PubMed, Embase, and China National Knowledge Infrastructure to identify randomized control studies on ventilated patients regarding extubation associated outcomes (weaning success or failure, proportion requiring re-intubation, or mortality) from inception until April 01, 2020. Commonly used ventilation modes involved pressure support ventilation, synchronized intermittent mandatory ventilation, automatic tube compensation, continuous positive airway pressure, adaptive support ventilation, neurally adjusted ventilatory assist, proportional assisted ventilation, and SmartCare. Pooled estimates regarding extubation associated outcomes were calculated using network meta-analysis. Results: Thirty-nine randomized controlled trials including 5,953 patients met inclusion criteria. SmartCare and proportional assist ventilation were found to be effective methods in increasing weaning success (odds ratio, 2.72, 95% confidence interval (CI), 1.33–5.58, P-score: 0.84; odds ratio, 2.56, 95% CI, 1.60–4.11, P-score: 0.83; respectively). Besides, proportional assist ventilation had superior in reducing proportion requiring re-intubation rate (odds ratio, 0.48, 95% CI, 0.25–0.92, P-score: 0.89) and mortality (odds ratio, 0.48, 95% CI, 0.26–0.92, P-score: 0.91) than others. Conclusion: In general consideration, our study provided evidence that weaning with proportional assist ventilation has a high probability of being the most effective ventilation mode for patients with mechanical ventilation regarding a higher rate of weaning success, a lower proportion requiring reintubation, and a lower mortality rate than other ventilation modes.
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Affiliation(s)
- Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan.,School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Huang Chen
- Department of General Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan.,Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
| | - Liang-Jun Ou-Yang
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chin Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan.,Department of Research and Development, National Defense Medical Center, Taipei, Taiwan
| | - Shih-En Tang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan.,National Defense Medical Center, Graduate Institute of Aerospace and Undersea Medicine, Taipei, Taiwan
| | - Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, National Defense Medical Center, Tri-Service General Hospital, Taipei, Taiwan
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21
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Randelman M, Zholudeva LV, Vinit S, Lane MA. Respiratory Training and Plasticity After Cervical Spinal Cord Injury. Front Cell Neurosci 2021; 15:700821. [PMID: 34621156 PMCID: PMC8490715 DOI: 10.3389/fncel.2021.700821] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 08/11/2021] [Indexed: 12/30/2022] Open
Abstract
While spinal cord injuries (SCIs) result in a vast array of functional deficits, many of which are life threatening, the majority of SCIs are anatomically incomplete. Spared neural pathways contribute to functional and anatomical neuroplasticity that can occur spontaneously, or can be harnessed using rehabilitative, electrophysiological, or pharmacological strategies. With a focus on respiratory networks that are affected by cervical level SCI, the present review summarizes how non-invasive respiratory treatments can be used to harness this neuroplastic potential and enhance long-term recovery. Specific attention is given to "respiratory training" strategies currently used clinically (e.g., strength training) and those being developed through pre-clinical and early clinical testing [e.g., intermittent chemical stimulation via altering inhaled oxygen (hypoxia) or carbon dioxide stimulation]. Consideration is also given to the effect of training on non-respiratory (e.g., locomotor) networks. This review highlights advances in this area of pre-clinical and translational research, with insight into future directions for enhancing plasticity and improving functional outcomes after SCI.
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Affiliation(s)
- Margo Randelman
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States.,Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, PA, United States
| | - Lyandysha V Zholudeva
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States.,Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, PA, United States.,Gladstone Institutes, San Francisco, CA, United States
| | - Stéphane Vinit
- INSERM, END-ICAP, Université Paris-Saclay, UVSQ, Versailles, France
| | - Michael A Lane
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, PA, United States.,Marion Murray Spinal Cord Research Center, Drexel University College of Medicine, Philadelphia, PA, United States
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22
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Assessment of magnetic flux density properties of electromagnetic noninvasive phrenic nerve stimulations for environmental safety in an ICU environment. Sci Rep 2021; 11:16317. [PMID: 34381086 PMCID: PMC8357944 DOI: 10.1038/s41598-021-95489-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 07/26/2021] [Indexed: 12/02/2022] Open
Abstract
Diaphragm weakness affects up to 60% of ventilated patients leading to muscle atrophy, reduction of muscle fiber force via muscle fiber injuries and prolonged weaning from mechanical ventilation. Electromagnetic stimulation of the phrenic nerve can induce contractions of the diaphragm and potentially prevent and treat loss of muscular function. Recommended safety distance of electromagnetic coils is 1 m. The aim of this study was to investigate the magnetic flux density in a typical intensive care unit (ICU) setting. Simulation of magnetic flux density generated by a butterfly coil was performed in a Berlin ICU training center with testing of potential disturbance and heating of medical equipment. Approximate safety distances to surrounding medical ICU equipment were additionally measured in an ICU training center in Bern. Magnetic flux density declined exponentially with advancing distance from the stimulation coil. Above a coil distance of 300 mm with stimulation of 100% power the signal could not be distinguished from the surrounding magnetic background noise. Electromagnetic stimulation of the phrenic nerve for diaphragm contraction in an intensive care unit setting seems to be safe and feasible from a technical point of view with a distance above 300 mm to ICU equipment from the stimulation coil.
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23
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Crulli B, Kawaguchi A, Praud JP, Petrof BJ, Harrington K, Emeriaud G. Evolution of inspiratory muscle function in children during mechanical ventilation. Crit Care 2021; 25:229. [PMID: 34193216 PMCID: PMC8243304 DOI: 10.1186/s13054-021-03647-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 06/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is no universally accepted method to assess the pressure-generating capacity of inspiratory muscles in children on mechanical ventilation (MV), and no study describing its evolution over time in this population. METHODS In this prospective observational study, we have assessed the function of the inspiratory muscles in children on various modes of MV. During brief airway occlusion maneuvers, we simultaneously recorded airway pressure depression at the endotracheal tube (ΔPaw, force generation) and electrical activity of the diaphragm (EAdi, central respiratory drive) over five consecutive inspiratory efforts. The neuro-mechanical efficiency ratio (NME, ΔPaw/EAdimax) was also computed. The evolution over time of these indices in a group of children in the pediatric intensive care unit (PICU) was primarily described. As a secondary objective, we compared these values to those measured in a group of children in the operating room (OR). RESULTS In the PICU group, although median NMEoccl decreased over time during MV (regression coefficient - 0.016, p = 0.03), maximum ΔPawmax remained unchanged (regression coefficient 0.109, p = 0.50). Median NMEoccl at the first measurement in the PICU group (after 21 h of MV) was significantly lower than at the only measurement in the OR group (1.8 cmH2O/µV, Q1-Q3 1.3-2.4 vs. 3.7 cmH2O/µV, Q1-Q3 3.5-4.2; p = 0.015). Maximum ΔPawmax in the PICU group was, however, not significantly different from the OR group (35.1 cmH2O, Q1-Q3 21-58 vs. 31.3 cmH2O, Q1-Q3 28.5-35.5; p = 0.982). CONCLUSIONS The function of inspiratory muscles can be monitored at the bedside of children on MV using brief airway occlusions. Inspiratory muscle efficiency was significantly lower in critically ill children than in children undergoing elective surgery, and it decreased over time during MV in critically ill children. This suggests that both critical illness and MV may have an impact on inspiratory muscle efficiency.
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Affiliation(s)
- Benjamin Crulli
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Atsushi Kawaguchi
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
- Pediatric Intensive Care Unit, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
- Department of Intensive Care Medicine, Tokyo Women's Medical University, Tokyo, Japan
| | - Jean-Paul Praud
- Neonatal Respiratory Research Unit, Departments of Pediatrics and Pharmacology-Physiology, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, QC, J1H 5N4, Canada
| | - Basil J Petrof
- Meakins-Christie Laboratories and Translational Research in Respiratory Diseases Program, McGill University Health Centre and Research Institute, 1001 Boulevard Décarie, Montreal, QC, H4A 3J1, Canada
| | - Karen Harrington
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada
| | - Guillaume Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte-Justine, Université de Montréal, 3175 chemin de la Côte-Sainte-Catherine, Montreal, QC, H3T 1C5, Canada.
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24
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Yoshihara T, Deminice R, Hyatt HW, Ozdemir M, Nguyen BL, Powers SK. Angiotensin 1-7 protects against ventilator-induced diaphragm dysfunction. Clin Transl Sci 2021; 14:1512-1523. [PMID: 33742769 PMCID: PMC8301547 DOI: 10.1111/cts.13015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/29/2021] [Accepted: 02/20/2021] [Indexed: 12/24/2022] Open
Abstract
Mechanical ventilation (MV) is a life‐saving instrument used to provide ventilatory support for critically ill patients and patients undergoing surgery. Unfortunately, an unintended consequence of prolonged MV is the development of inspiratory weakness due to both diaphragmatic atrophy and contractile dysfunction; this syndrome is labeled ventilator‐induced diaphragm dysfunction (VIDD). VIDD is clinically important because diaphragmatic weakness is an important contributor to problems in weaning patients from MV. Investigations into the pathogenesis of VIDD reveal that oxidative stress is essential for the rapid development of VIDD as redox disturbances in diaphragm fibers promote accelerated proteolysis. Currently, no standard treatment exists to prevent VIDD and, therefore, developing a strategy to avert VIDD is vital. Guided by evidence indicating that activation of the classical axis of the renin‐angiotensin system (RAS) in diaphragm fibers promotes oxidative stress and VIDD, we hypothesized that activation of the nonclassical RAS signaling pathway via angiotensin 1‐7 (Ang1‐7) will protect against VIDD. Using an established animal model of prolonged MV, our results disclose that infusion of Ang1‐7 protects the diaphragm against MV‐induced contractile dysfunction and fiber atrophy in both fast and slow muscle fibers. Further, Ang1‐7 shielded diaphragm fibers against MV‐induced mitochondrial damage, oxidative stress, and protease activation. Collectively, these results reveal that treatment with Ang1‐7 protects against VIDD, in part, due to diminishing oxidative stress and protease activation. These important findings provide robust evidence that Ang1‐7 has the therapeutic potential to protect against VIDD by preventing MV‐induced contractile dysfunction and atrophy of both slow and fast muscle fibers.
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Affiliation(s)
- Toshinori Yoshihara
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA.,Graduate School of Health and Sports Science, Juntendo University, Inzai, Japan
| | - Rafael Deminice
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA.,Department of Physical Education, State University of Londrina, Londrina, Brazil
| | - Hayden W Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Mustafa Ozdemir
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Branden L Nguyen
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
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25
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Liu J, Wang CJ, Ran JH, Lin SH, Deng D, Ma Y, Xu F. The predictive value of brain natriuretic peptide or N-terminal pro-brain natriuretic peptide for weaning outcome in mechanical ventilation patients: Evidence from SROC. J Renin Angiotensin Aldosterone Syst 2021; 22:1470320321999497. [PMID: 33678076 PMCID: PMC8880489 DOI: 10.1177/1470320321999497] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE Mechanical ventilation is an important treatment for critically ill patients. Physicians generally perform a spontaneous breathing trial (SBT) to determine whether the patients can be weaned from mechanical ventilation, but almost 17% of the patients who pass the SBT still require respiratory support. Cardiac dysfunction is an important cause of weaning failure. The use of brain natriuretic peptide or N-terminal pro-BNP is a simple method to assess cardiac function. We performed a systematic review of investigations of brain natriuretic peptide or N-terminal pro-BNP as predictors of weaning from mechanical ventilation. DATA SOURCES PubMed (1950 to December 2020), Cochrane, and Embase (1974 to December 2020), and some Chinese databases for additional articles (China Biology Medicine (CBM), China Science and Technology Journal Database (CSTJ), and Wanfang Data and China National Knowledge Infrastructure (CNKI)). STUDY SELECTION We systematically searched observation studies investigating the predictive value of brain natriuretic peptide or N-terminal pro-brain natriuretic peptide in weaning outcome of patients with mechanical ventilation. DATA EXTRACTION Two independent reviewers extracted data. The differences are resolved through consultation. DATA SYNTHESIS We included 18 articles with 1416 patients and extracted six index tests with pooled sensitivity and specificity for each index test. For the BNP change rate predicting weaning success, the pooled sensitivity was 89% (83%-94%) and the pooled specificity was 82% (72%-89%) with the highest pooled AUC of 0.9511. CONCLUSIONS The brain natriuretic peptide change rate is a reliable predictor of weaning outcome from mechanical ventilation.
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Affiliation(s)
- Jian Liu
- Department of Intensive Care Unit, Youyang Hospital, A Branch of The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China.,Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Chuan-Jiang Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Jun-Huai Ran
- Department of Intensive Care Unit, Youyang Hospital, A Branch of The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Shi-Hui Lin
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| | - Dan Deng
- School of Public Health and Management, Chongqing Medical University, Chongqing, China
| | - Yu Ma
- Department of Critical Care Medicine, Chongqing Emergency Medical Center, Chongqing, China
| | - Fang Xu
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
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26
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Hyatt HW, Ozdemir M, Yoshihara T, Nguyen BL, Deminice R, Powers SK. Calpains play an essential role in mechanical ventilation-induced diaphragmatic weakness and mitochondrial dysfunction. Redox Biol 2020; 38:101802. [PMID: 33279868 PMCID: PMC7724197 DOI: 10.1016/j.redox.2020.101802] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving intervention for many critically ill patients. Unfortunately, an unintended consequence of prolonged MV is the rapid development of diaphragmatic atrophy and contractile dysfunction, known as ventilator-induced diaphragm dysfunction (VIDD). Although the mechanism(s) responsible for VIDD are not fully understood, abundant evidence reveals that oxidative stress leading to the activation of the major proteolytic systems (i.e., autophagy, ubiquitin-proteasome, caspase, and calpain) plays a dominant role. Of the proteolytic systems involved in VIDD, calpain has received limited experimental attention due to the longstanding dogma that calpain plays a minor role in inactivity-induced muscle atrophy. Guided by preliminary experiments, we tested the hypothesis that activation of calpains play an essential role in MV-induced oxidative stress and the development of VIDD. This premise was rigorously tested by transgene overexpression of calpastatin, an endogenous inhibitor of calpains. Animals with/without transfection of the calpastatin gene in diaphragm muscle fibers were exposed to 12 h of MV. Results confirmed that overexpression of calpastatin barred MV-induced activation of calpain in diaphragm fibers. Importantly, deterrence of calpain activation protected the diaphragm against MV-induced oxidative stress, fiber atrophy, and contractile dysfunction. Moreover, prevention of calpain activation in the diaphragm forstalled MV-induced mitochondrial dysfunction and prevented MV-induced activation of caspase-3 along with the transcription of muscle specific E3 ligases. Collectively, these results support the hypothesis that calpain activation plays an essential role in the early development of VIDD. Further, these findings provide the first direct evidence that calpain plays an important function in inactivity-induced mitochondrial dysfunction and oxidative stress in skeletal muscle fibers. Inhibiting calpains during mechanical ventilation protects the diaphragm. Calpains play an important role in muscle atrophy and contractile dysfunction. Calpain inhibition during mechanical ventilation prevents mitochondrial dysfunction. Calpain-cleaved molecules may play important signaling roles. Calpain activation cross-talks with other proteolytic systems.
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Affiliation(s)
- Hayden W Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA.
| | - Mustafa Ozdemir
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Exercise and Sport Sciences, Hacettepe University, Ankara, Turkey
| | - Toshinori Yoshihara
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Exercise Physiology, Juntendo University, Tokyo, Japan
| | - Branden L Nguyen
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Rafael Deminice
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Physical Education, State University of Londrina, Londrina, Brazil
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
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27
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Hall SE, Ahn B, Smuder AJ, Morton AB, Hinkley JM, Wiggs MP, Sollanek KJ, Hyatt H, Powers SK. Comparative Efficacy of Angiotensin II Type 1 Receptor Blockers Against Ventilator-Induced Diaphragm Dysfunction in Rats. Clin Transl Sci 2020; 14:481-486. [PMID: 33222389 PMCID: PMC7993256 DOI: 10.1111/cts.12916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/29/2020] [Indexed: 12/16/2022] Open
Abstract
Mechanical ventilation (MV) is a life‐saving intervention for many critically ill patients. Unfortunately, prolonged MV results in the rapid development of inspiratory muscle weakness due to diaphragmatic atrophy and contractile dysfunction (termed ventilator‐induced diaphragm dysfunction (VIDD)). Although VIDD is a major risk factor for problems in weaning patients from MV, a standard therapy to prevent VIDD does not exist. However, emerging evidence suggests that pharmacological blockade of angiotensin II type 1 receptors (AT1Rs) protects against VIDD. Nonetheless, the essential characteristics of AT1R blockers (ARBs) required to protect against VIDD remain unclear. To determine the traits of ARBs that are vital for protection against VIDD, we compared the efficacy of two clinically relevant ARBs, irbesartan and olmesartan; these ARBs differ in molecular structure and effects on AT1Rs. Specifically, olmesartan blocks both angiotensin II (AngII) binding and mechanical activation of AT1Rs, whereas irbesartan prevents only AngII binding to AT1Rs. Using a well‐established preclinical model of prolonged MV, we tested the hypothesis that compared with irbesartan, olmesartan provides greater protection against VIDD. Our results reveal that irbesartan does not protect against VIDD whereas olmesartan defends against both MV‐induced diaphragmatic atrophy and contractile dysfunction. These findings support the hypothesis that olmesartan is superior to irbesartan in protecting against VIDD and are consistent with the concept that blockade of mechanical activation of AT1Rs is a required property of ARBs to shield against VIDD. These important findings provide a foundation for future clinical trials to evaluate ARBs as a therapy to protect against VIDD.
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Affiliation(s)
- Stephanie E Hall
- Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas, USA
| | - Bumsoo Ahn
- Aging and Metabolism Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Ashley J Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | | | - J Matthew Hinkley
- Advent Health Translational Research Institute, Orlando, Florida, USA
| | | | | | - Hayden Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
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28
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Ogura Y, Kakehashi C, Yoshihara T, Kurosaka M, Kakigi R, Higashida K, Fujiwara SE, Akema T, Funabashi T. Ketogenic diet feeding improves aerobic metabolism property in extensor digitorum longus muscle of sedentary male rats. PLoS One 2020; 15:e0241382. [PMID: 33125406 PMCID: PMC7598508 DOI: 10.1371/journal.pone.0241382] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 10/13/2020] [Indexed: 12/01/2022] Open
Abstract
Recent studies of the ketogenic diet, an extremely high-fat diet with extremely low carbohydrates, suggest that it changes the energy metabolism properties of skeletal muscle. However, ketogenic diet effects on muscle metabolic characteristics are diverse and sometimes countervailing. Furthermore, ketogenic diet effects on skeletal muscle performance are unknown. After male Wistar rats (8 weeks of age) were assigned randomly to a control group (CON) and a ketogenic diet group (KD), they were fed for 4 weeks respectively with a control diet (10% fat, 10% protein, 80% carbohydrate) and a ketogenic diet (90% fat, 10% protein, 0% carbohydrate). After the 4-week feeding period, the extensor digitorum longus (EDL) muscle was evaluated ex vivo for twitch force, tetanic force, and fatigue. We also analyzed the myosin heavy chain composition, protein expression of metabolic enzymes and regulatory factors, and citrate synthase activity. No significant difference was found between CON and KD in twitch or tetanic forces or muscle fatigue. However, the KD citrate synthase activity and the protein expression of Sema3A, citrate synthase, succinate dehydrogenase, cytochrome c oxidase subunit 4, and 3-hydroxyacyl-CoA dehydrogenase were significantly higher than those of CON. Moreover, a myosin heavy chain shift occurred from type IIb to IIx in KD. These results demonstrated that the 4-week ketogenic diet improves skeletal muscle aerobic capacity without obstructing muscle contractile function in sedentary male rats and suggest involvement of Sema3A in the myosin heavy chain shift of EDL muscle.
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Affiliation(s)
- Yuji Ogura
- Department of Physiology, St. Marianna University of School of Medicine, Miyamae-ku, Kawasaki, Japan
| | - Chiaki Kakehashi
- Department of Physiology, St. Marianna University of School of Medicine, Miyamae-ku, Kawasaki, Japan
| | - Toshinori Yoshihara
- Graduate School of Health and Sports Science, Juntendo University, Inzai, Chiba, Japan
| | - Mitsutoshi Kurosaka
- Department of Physiology, St. Marianna University of School of Medicine, Miyamae-ku, Kawasaki, Japan
| | - Ryo Kakigi
- Faculty of Management & Information Science, Josai International University, Togane, Chiba, Japan
| | - Kazuhiko Higashida
- Department of Nutrition, University of Shiga Prefecture, Hikone, Shiga, Japan
| | - Sei-Etsu Fujiwara
- Department of Physiology, St. Marianna University of School of Medicine, Miyamae-ku, Kawasaki, Japan
| | - Tatsuo Akema
- Department of Physiology, St. Marianna University of School of Medicine, Miyamae-ku, Kawasaki, Japan
| | - Toshiya Funabashi
- Department of Physiology, St. Marianna University of School of Medicine, Miyamae-ku, Kawasaki, Japan
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29
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Smuder AJ, Turner SM, Schuster CM, Morton AB, Hinkley JM, Fuller DD. Hyperbaric Oxygen Treatment Following Mid-Cervical Spinal Cord Injury Preserves Diaphragm Muscle Function. Int J Mol Sci 2020; 21:ijms21197219. [PMID: 33007822 PMCID: PMC7582297 DOI: 10.3390/ijms21197219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 09/24/2020] [Accepted: 09/27/2020] [Indexed: 12/17/2022] Open
Abstract
Oxidative damage to the diaphragm as a result of cervical spinal cord injury (SCI) promotes muscle atrophy and weakness. Respiratory insufficiency is the leading cause of morbidity and mortality in cervical spinal cord injury (SCI) patients, emphasizing the need for strategies to maintain diaphragm function. Hyperbaric oxygen (HBO) increases the amount of oxygen dissolved into the blood, elevating the delivery of oxygen to skeletal muscle and reactive oxygen species (ROS) generation. It is proposed that enhanced ROS production due to HBO treatment stimulates adaptations to diaphragm oxidative capacity, resulting in overall reductions in oxidative stress and inflammation. Therefore, we tested the hypothesis that exposure to HBO therapy acutely following SCI would reduce oxidative damage to the diaphragm muscle, preserving muscle fiber size and contractility. Our results demonstrated that lateral contusion injury at C3/4 results in a significant reduction in diaphragm muscle-specific force production and fiber cross-sectional area, which was associated with augmented mitochondrial hydrogen peroxide emission and a reduced mitochondrial respiratory control ratio. In contrast, rats that underwent SCI followed by HBO exposure consisting of 1 h of 100% oxygen at 3 atmospheres absolute (ATA) delivered for 10 consecutive days demonstrated an improvement in diaphragm-specific force production, and an attenuation of fiber atrophy, mitochondrial dysfunction and ROS production. These beneficial adaptations in the diaphragm were related to HBO-induced increases in antioxidant capacity and a reduction in atrogene expression. These findings suggest that HBO therapy may be an effective adjunctive therapy to promote respiratory health following cervical SCI.
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Affiliation(s)
- Ashley J. Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA; (A.B.M.); (J.M.H.)
- Breathing Research and Therapeutics, University of Florida, Gainesville, FL 32610, USA;
- Correspondence:
| | - Sara M. Turner
- Department of Physical Therapy, University of Florida, Gainesville, FL 32610, USA; (S.M.T.); (C.M.S.)
| | - Cassandra M. Schuster
- Department of Physical Therapy, University of Florida, Gainesville, FL 32610, USA; (S.M.T.); (C.M.S.)
| | - Aaron B. Morton
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA; (A.B.M.); (J.M.H.)
| | - J. Matthew Hinkley
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA; (A.B.M.); (J.M.H.)
| | - David D. Fuller
- Breathing Research and Therapeutics, University of Florida, Gainesville, FL 32610, USA;
- Department of Physical Therapy, University of Florida, Gainesville, FL 32610, USA; (S.M.T.); (C.M.S.)
- McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA
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30
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Respiratory Neurophysiology in Intensive Care Unit. J Clin Neurophysiol 2020; 37:208-210. [PMID: 32358247 DOI: 10.1097/wnp.0000000000000663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Patients with intensive care unit-acquired weakness have an increased risk of prolonged mechanical ventilation, which is a risk factor for prolonged stay and mortality. The most common cause of this problem is weakness of the diaphragm, which can derive from phrenic nerve injury associated with critical neuropathy, or with the complex multiorgan failure/systemic respiratory response syndrome causing muscle fiber lesion. Two conventional neurophysiological techniques are useful to investigate the respiratory muscles, phrenic nerve conduction, and needle electromyography of the accessory respiratory muscles and diaphragm. Phrenic nerve stimulation is a standard noninvasive technique; amplitude of the motor response can be reduced because of muscle fiber inexcitability or axonal loss. Electromyography of the diaphragm is an invasive method but is safe if performed as indicated. It can reveal neurogenic or myopathic motor units. Although these neurophysiological methods have limitations in the investigation of intensive care unit patients with severe respiratory involvement, normal phrenic nerve responses should exclude marked axonal loss and indicate a better prognosis.
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31
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Horn AG, Baumfalk DR, Schulze KM, Kunkel ON, Colburn TD, Weber RE, Bruells CS, Musch TI, Poole DC, Behnke BJ. Effects of elevated positive end-expiratory pressure on diaphragmatic blood flow and vascular resistance during mechanical ventilation. J Appl Physiol (1985) 2020; 129:626-635. [PMID: 32730173 PMCID: PMC7517429 DOI: 10.1152/japplphysiol.00320.2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although mechanical ventilation (MV) is a life-saving intervention, prolonged MV can lead to deleterious effects on diaphragm function, including vascular incompetence and weaning failure. During MV, positive end-expiratory pressure (PEEP) is used to maintain small airway patency and mitigate alveolar damage. We tested the hypothesis that increased intrathoracic pressure with high levels of PEEP would increase diaphragm vascular resistance and decrease perfusion. Female Sprague-Dawley rats (~6 mo) were randomly divided into two groups receiving low PEEP (1 cmH2O; n = 10) or high PEEP (9 cmH2O; n = 9) during MV. Blood flow, via fluorescent microspheres, was determined during spontaneous breathing (SB), low-PEEP MV, high-PEEP MV, low-PEEP MV + surgical laparotomy (LAP), and high-PEEP MV + pneumothorax (PTX). Compared with SB, both low-PEEP MV and high-PEEP MV increased total diaphragm and medial costal vascular resistance (P ≤ 0.05) and reduced total and medial costal diaphragm blood flow (P ≤ 0.05). Also, during MV medial costal diaphragm vascular resistance was greater and blood flow lower with high-PEEP MV vs. low-PEEP MV (P ≤ 0.05). Diaphragm perfusion with high-PEEP MV+PTX and low-PEEP MV were not different (P > 0.05). The reduced total and medial costal diaphragmatic blood flow with low-PEEP MV appears to be independent of intrathoracic pressure changes and is attributed to increased vascular resistance and diaphragm quiescence. Mechanical compression of the diaphragm vasculature may play a role in the lower diaphragmatic blood flow at higher levels of PEEP. These reductions in blood flow to the quiescent diaphragm during MV could predispose critically ill patients to weaning complications. NEW & NOTEWORTHY This is the first study, to our knowledge, demonstrating that mechanical ventilation, with low and high positive-end expiratory pressure (PEEP), increases vascular resistance and reduces total and regional diaphragm perfusion. The rapid reduction in diaphragm perfusion and increased vascular resistance may initiate a cascade of events that predispose the diaphragm to vascular and thus contractile dysfunction with prolonged mechanical ventilation.
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Affiliation(s)
- Andrew G Horn
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Dryden R Baumfalk
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Kiana M Schulze
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Olivia N Kunkel
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Trenton D Colburn
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Ramona E Weber
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Christian S Bruells
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Timothy I Musch
- Department of Kinesiology, Kansas State University, Manhattan, Kansas.,Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas
| | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, Kansas.,Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas
| | - Bradley J Behnke
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
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Is Mitochondrial Oxidative Stress the Key Contributor to Diaphragm Atrophy and Dysfunction in Critically Ill Patients? Crit Care Res Pract 2020; 2020:8672939. [PMID: 32377432 PMCID: PMC7191397 DOI: 10.1155/2020/8672939] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/10/2020] [Accepted: 03/27/2020] [Indexed: 02/08/2023] Open
Abstract
Diaphragm dysfunction is prevalent in the progress of respiratory dysfunction in various critical illnesses. Respiratory muscle weakness may result in insufficient ventilation, coughing reflection suppression, pulmonary infection, and difficulty in weaning off respirators. All of these further induce respiratory dysfunction and even threaten the patients' survival. The potential mechanisms of diaphragm atrophy and dysfunction include impairment of myofiber protein anabolism, enhancement of myofiber protein degradation, release of inflammatory mediators, imbalance of metabolic hormones, myonuclear apoptosis, autophagy, and oxidative stress. Among these contributors, mitochondrial oxidative stress is strongly implicated to play a key role in the process as it modulates diaphragm protein synthesis and degradation, induces protein oxidation and functional alteration, enhances apoptosis and autophagy, reduces mitochondrial energy supply, and is regulated by inflammatory cytokines via related signaling molecules. This review aims to provide a concise overview of pathological mechanisms of diaphragmatic dysfunction in critically ill patients, with special emphasis on the role and modulating mechanisms of mitochondrial oxidative stress.
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33
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Lung- and Diaphragm-protective Ventilation in Acute Respiratory Distress Syndrome: Rationale and Challenges. Anesthesiology 2020; 130:620-633. [PMID: 30844950 DOI: 10.1097/aln.0000000000002605] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A novel approach to ventilation aims to be both lung- and diaphragm-protective. This strategy integrates concerns over excessive lung stress during spontaneous breathing while avoiding both insufficient and excessive inspiratory effort.
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34
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Supinski GS, Wang L, Schroder EA, Callahan LAP. SS31, a mitochondrially targeted antioxidant, prevents sepsis-induced reductions in diaphragm strength and endurance. J Appl Physiol (1985) 2020; 128:463-472. [PMID: 31944887 PMCID: PMC7099438 DOI: 10.1152/japplphysiol.00240.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 01/14/2020] [Accepted: 01/14/2020] [Indexed: 12/12/2022] Open
Abstract
Sepsis-induced diaphragm dysfunction contributes to respiratory failure and mortality in critical illness. There are no treatments for this form of diaphragm weakness. Studies show that sepsis-induced muscle dysfunction is triggered by enhanced mitochondrial free radical generation. We tested the hypothesis that SS31, a mitochondrially targeted antioxidant, would attenuate sepsis-induced diaphragm dysfunction. Four groups of mice were studied: 1) sham-operated controls, 2) sham-operated+SS31 (10 mg·kg-1·day-1), 3) cecal ligation puncture (CLP), and 4) CLP+SS31. Forty-eight hours postoperatively, diaphragm strips with attached phrenic nerves were isolated, and the following were assessed: muscle-field-stimulated force-frequency curves, nerve-stimulated force-frequency curves, and muscle fatigue. We also measured calpain activity, 20S proteasomal activity, myosin heavy chain (MHC) levels, mitochondrial function, and aconitase activity, an index of mitochondrial superoxide generation. Sepsis markedly reduced diaphragm force generation; SS31 prevented these decrements. Diaphragm-specific force generation averaged 30.2 ± 1.4, 9.4 ± 1.8, 25.5 ± 2.3, and 27.9 ± 0.6 N/cm2 for sham, CLP, sham+SS31, and CLP+SS31 groups (P < 0.001). Similarly, with phrenic nerve stimulation, CLP depressed diaphragm force generation, effects prevented by SS31. During endurance trials, force was significantly reduced with CLP, and SS31 prevented these reductions (P < 0.001). Sepsis also increased diaphragm calpain activity, increased 20S proteasomal activity, decreased MHC levels, reduced mitochondrial function (state 3 rates and ATP generation), and reduced aconitase activity; SS31 prevented each of these sepsis-induced alterations (P ≤ 0.017 for all indices). SS31 prevents sepsis-induced diaphragm dysfunction, preserving force generation, endurance, and mitochondrial function. Compounds with similar mechanisms of action may be useful therapeutically to preserve diaphragm function in patients who are septic and critically ill.NEW & NOTEWORTHY Sepsis-induced diaphragm dysfunction is a major contributor to mortality and morbidity in patients with critical illness in intensive care units. Currently, there is no proven pharmacological treatment for this problem. This study provides the novel finding that administration of SS31, a mitochondrially targeted antioxidant, preserves diaphragm myosin heavy chain content and mitochondrial function, thereby preventing diaphragm weakness and fatigue in sepsis.
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Affiliation(s)
- Gerald S Supinski
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Lin Wang
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Elizabeth A Schroder
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
| | - Leigh Ann P Callahan
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kentucky, Lexington, Kentucky
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35
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Ni YN, Xu H, Li WJ, Sun JK, Liang BM, Liang ZA. Could the loss of diaphragm thickness measured by computer tomography predict the rate of reintubation? J Thorac Dis 2020; 12:581-591. [PMID: 32274124 PMCID: PMC7138965 DOI: 10.21037/jtd.2019.12.125] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Diaphragm function loss is very common in the intensive care unit (ICU) and can predict the success of weaning. However, whether diaphragm thickness loss during mechanical ventilation (MV) as measured by computed tomography (CT) can predict the rate of reintubation remains unclear. Therefore, we hypothesized that a loss of diaphragm thickness would impact the outcome of weaning. Methods A retrospective study was performed on patients who received MV in the ICU of West China Hospital, Sichuan University. The diaphragm thickness of each patient on the CT scans within 48 hours after MV and 24 hours before weaning were measured by at least two independent investigators. The primary outcome was the rate of reintubation, and the second outcomes included hospital mortality and the length of ICU stay (ICU LOS) after extubation. Results A total of 145 patients were included in the analysis. According to the receiver operating characteristic curve, all patients were divided into two groups (less or more than 1.55 mm diaphragm thickness loss in reintubation). As a result, less loss of diaphragm thickness was a protective factor for the rate of reintubation [33% vs. 12%; adjusted odds ratio (aOR) 0.001; 95% confidence interval (CI), 0.001–0.271; P=0.018] and hospital mortality (18% vs. 4%; aOR 0.001; 95% CI, 0.001–0.035; P=0.007). However, no significant difference was found in the ICU LOS after extubation between the two groups. Conclusions Less diaphragm thickness loss was related to a lower rate of reintubation and hospital mortality.
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Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory and Critical Care, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hui Xu
- Department of Radiology, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China
| | - Wei-Jing Li
- Department of Respiratory and Critical Care, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China
| | - Ji-Kui Sun
- State Key Laboratory of Oral Diseases, West China School of Stomatology, Sichuan University, Chengdu 610041, China
| | - Bin-Miao Liang
- Department of Respiratory and Critical Care, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China
| | - Zong-An Liang
- Department of Respiratory and Critical Care, West China School of Medicine and West China Hospital, Sichuan University, Chengdu 610041, China
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36
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Itagaki T, Nakanishi N, Takashima T, Ueno Y, Tane N, Tsunano Y, Nunomura T, Oto J. Effect of controlled ventilation during assist-control ventilation on diaphragm thickness : a post hoc analysis of an observational study. THE JOURNAL OF MEDICAL INVESTIGATION 2020; 67:332-337. [PMID: 33148911 DOI: 10.2152/jmi.67.332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Background : Since diaphragm passivity induces oxidative stress that leads to rapid atrophy of diaphragm, we investigated the effect of controlled ventilation on diaphragm thickness during assist-control ventilation (ACV). Methods : Previously, we measured end-expiratory diaphragm thickness (Tdiee) of patients mechanically ventilated for more than 48 hours on days 1, 3, 5 and 7 after the start of ventilation. We retrospectively investigated the proportion of controlled ventilation during the initial 48-hour ACV (CV48%). Patients were classified according to CV48% : Low group, less than 25% ; High group, higher than 25%. Results : Of 56 patients under pressure-control ACV, Tdiee increased more than 10% in 6 patients (11%), unchanged in 8 patients (14%) and decreased more than 10% in 42 patients (75%). During the first week of ventilation, Tdiee decreased in both groups : Low (difference, -7.4% ; 95% confidence interval [CI], -10.1% to -4.6% ; p < 0.001) and High group (difference, -5.2% ; 95% CI, -8.5% to -2.0% ; p = 0.049). Maximum Tdiee variation from baseline did not differ between Low (-15.8% ; interquartile range [IQR], -22.3 to -1.5) and High group (-16.7% ; IQR, -22.6 to -11.1, p = 0.676). Conclusions : During ACV, maximum variation in Tdiee was not associated with proportion of controlled ventilation higher than 25%. J. Med. Invest. 67 : 332-337, August, 2020.
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Affiliation(s)
- Taiga Itagaki
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Nobuto Nakanishi
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Takuya Takashima
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Yoshitoyo Ueno
- Department of Emergency and Critical Care Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Natsuki Tane
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, Tokushima, Japan
| | - Yumiko Tsunano
- Department of Emergency and Critical Care Medicine, Tokushima University Graduate School, Tokushima, Japan
| | - Toshiyuki Nunomura
- Division of Critical Care Center, Kochi Red Cross Hospital, Kochi, Japan
| | - Jun Oto
- Department of Emergency and Disaster Medicine, Tokushima University Hospital, Tokushima, Japan
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37
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Shimatani T, Shime N, Nakamura T, Ohshimo S, Hotz J, Khemani RG. Neurally adjusted ventilatory assist mitigates ventilator-induced diaphragm injury in rabbits. Respir Res 2019; 20:293. [PMID: 31870367 PMCID: PMC6929282 DOI: 10.1186/s12931-019-1265-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022] Open
Abstract
Background Ventilator-induced diaphragmatic dysfunction is a serious complication associated with higher ICU mortality, prolonged mechanical ventilation, and unsuccessful withdrawal from mechanical ventilation. Although neurally adjusted ventilatory assist (NAVA) could be associated with lower patient-ventilator asynchrony compared with conventional ventilation, its effects on diaphragmatic dysfunction have not yet been well elucidated. Methods Twenty Japanese white rabbits were randomly divided into four groups, (1) no ventilation, (2) controlled mechanical ventilation (CMV) with continuous neuromuscular blockade, (3) NAVA, and (4) pressure support ventilation (PSV). Ventilated rabbits had lung injury induced, and mechanical ventilation was continued for 12 h. Respiratory waveforms were continuously recorded, and the asynchronous events measured. Subsequently, the animals were euthanized, and diaphragm and lung tissue were removed, and stained with Hematoxylin-Eosin to evaluate the extent of lung injury. The myofiber cross-sectional area of the diaphragm was evaluated under the adenosine triphosphatase staining, sarcomere disruptions by electron microscopy, apoptotic cell numbers by the TUNEL method, and quantitative analysis of Caspase-3 mRNA expression by real-time polymerase chain reaction. Results Physiological index, respiratory parameters, and histologic lung injury were not significantly different among the CMV, NAVA, and PSV. NAVA had lower asynchronous events than PSV (median [interquartile range], NAVA, 1.1 [0–2.2], PSV, 6.8 [3.8–10.0], p = 0.023). No differences were seen in the cross-sectional areas of myofibers between NAVA and PSV, but those of Type 1, 2A, and 2B fibers were lower in CMV compared with NAVA. The area fraction of sarcomere disruptions was lower in NAVA than PSV (NAVA vs PSV; 1.6 [1.5–2.8] vs 3.6 [2.7–4.3], p < 0.001). The proportion of apoptotic cells was lower in NAVA group than in PSV (NAVA vs PSV; 3.5 [2.5–6.4] vs 12.1 [8.9–18.1], p < 0.001). There was a tendency in the decreased expression levels of Caspase-3 mRNA in NAVA groups. Asynchrony Index was a mediator in the relationship between NAVA and sarcomere disruptions. Conclusions Preservation of spontaneous breathing using either PSV or NAVA can preserve the cross sectional area of the diaphragm to prevent atrophy. However, NAVA may be superior to PSV in preventing sarcomere injury and apoptosis of myofibrotic cells of the diaphragm, and this effect may be mediated by patient-ventilator asynchrony.
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Affiliation(s)
- Tatsutoshi Shimatani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Tomohiko Nakamura
- Division of Neonatology, Nagano Children's Hospital, 3100 Toyoshina, Azumino City, Nagano, 399-8288, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Justin Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, United States
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, United States.,Department of Pediatrics, University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA, 90033, United States
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38
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Hemorrhagic Shock Sensitized the Diaphragm to Ventilator-Induced Dysfunction through the Activation of IL-6/JAK/STAT Signaling-Mediated Autophagy in Rats. Mediators Inflamm 2019; 2019:3738409. [PMID: 31814800 PMCID: PMC6878811 DOI: 10.1155/2019/3738409] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/03/2019] [Indexed: 01/15/2023] Open
Abstract
Mechanical ventilation (MV) is a major life support technique for the management of trauma-associated hemorrhagic shock (HS). Ventilator-induced diaphragm dysfunction (VIDD), one of the most common complications of MV, has been well demonstrated in animal and human studies. However, few data are available concerning the effects of MV on diaphragm function in HS victims. In the present study, we found diaphragm muscle atrophy and weakness in HS but not in healthy animals after 4 hours of MV. The inhibition of autophagy resulted in reduced muscle fiber atrophy and improved forces. In addition, we observed diaphragmatic interleukin- (IL-) 6 overexpression and activation of its downstream signaling JAK/STAT in HS animals after MV, and either the neutralization of IL-6 or the inhibition of the JAK/STAT pathway attenuated autophagy, diaphragm atrophy, and weakness. Importantly, treatment with nonselective antioxidant exerted no protective effects against VIDD in HS animals. In addition, in vitro study showed that exogenous IL-6 was able to induce activation of JAK/STAT signaling and to increase autophagy in C2C12 cells. Moreover, the inhibition of JAK/STAT signaling abolished IL-6-induced cell autophagy. Together, our results suggested that HS sensitized the diaphragm to ventilator-induced atrophy and weakness through the activation of IL-6/JAK/STAT signaling-mediated autophagy in rats.
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39
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Dexmedetomidine Impairs Diaphragm Function and Increases Oxidative Stress but Does Not Aggravate Diaphragmatic Atrophy in Mechanically Ventilated Rats. Anesthesiology 2019; 128:784-795. [PMID: 29346133 DOI: 10.1097/aln.0000000000002081] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anesthetics in ventilated patients are critical as any cofactor hampering diaphragmatic function may have a negative impact on the weaning progress and therefore on patients' mortality. Dexmedetomidine may display antioxidant and antiproteolytic properties, but it also reduced glucose uptake by the muscle, which may impair diaphragm force production. This study tested the hypothesis that dexmedetomidine could inhibit ventilator-induced diaphragmatic dysfunction. METHODS Twenty-four rats were separated into three groups (n = 8/group). Two groups were mechanically ventilated during either dexmedetomidine or pentobarbital exposure for 24 h, referred to as interventional groups. A third group of directly euthanized rats served as control. Force generation, fiber dimensions, proteolysis markers, protein oxidation and lipid peroxidation, calcium homeostasis markers, and glucose transporter-4 (Glut-4) translocation were measured in the diaphragm. RESULTS Diaphragm force, corrected for cross-sectional area, was significantly decreased in both interventional groups compared to controls and was significantly lower with dexmedetomidine compared to pentobarbital (e.g., 100 Hz: -18%, P < 0.0001). In contrast to pentobarbital, dexmedetomidine did not lead to diaphragmatic atrophy, but it induced more protein oxidation (200% vs. 73% in pentobarbital, P = 0.0015), induced less upregulation of muscle atrophy F-box (149% vs. 374% in pentobarbital, P < 0.001) and impaired Glut-4 translocation (-73%, P < 0.0005). It activated autophagy, the calcium-dependent proteases, and caused lipid peroxidation similarly to pentobarbital. CONCLUSIONS Twenty-four hours of mechanical ventilation during dexmedetomidine sedation led to a worsening of ventilation-induced diaphragm dysfunction, possibly through impaired Glut-4 translocation. Although dexmedetomidine prevented diaphragmatic fiber atrophy, it did not inhibit oxidative stress and activation of the proteolytic pathways.
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40
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Smuder AJ, Morton AB, Hall SE, Wiggs MP, Ahn B, Wawrzyniak NR, Sollanek KJ, Min K, Kwon OS, Nelson WB, Powers SK. Effects of exercise preconditioning and HSP72 on diaphragm muscle function during mechanical ventilation. J Cachexia Sarcopenia Muscle 2019; 10:767-781. [PMID: 30972953 PMCID: PMC6711411 DOI: 10.1002/jcsm.12427] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Accepted: 02/19/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is a life-saving measure for patients in respiratory failure. However, prolonged MV results in significant diaphragm atrophy and contractile dysfunction, a condition referred to as ventilator-induced diaphragm dysfunction (VIDD). While there are currently no clinically approved countermeasures to prevent VIDD, increased expression of heat shock protein 72 (HSP72) has been demonstrated to attenuate inactivity-induced muscle wasting. HSP72 elicits cytoprotection via inhibition of NF-κB and FoxO transcriptional activity, which contribute to VIDD. In addition, exercise-induced prevention of VIDD is characterized by an increase in the concentration of HSP72 in the diaphragm. Therefore, we tested the hypothesis that increased HSP72 expression is required for the exercise-induced prevention of VIDD. We also determined whether increasing the abundance of HSP72 in the diaphragm, independent of exercise, is sufficient to prevent VIDD. METHODS Cause and effect was determined by inhibiting the endurance exercise-induced increase in HSP72 in the diaphragm of exercise trained animals exposed to prolonged MV via administration of an antisense oligonucleotide targeting HSP72. Additional experiments were performed to determine if increasing HSP72 in the diaphragm via genetic (rAAV-HSP72) or pharmacological (BGP-15) overexpression is sufficient to prevent VIDD. RESULTS Our results demonstrate that the exercise-induced increase in HSP72 protein abundance is required for the protective effects of exercise against VIDD. Moreover, both rAAV-HSP72 and BGP-15-induced overexpression of HSP72 were sufficient to prevent VIDD. In addition, modification of HSP72 in the diaphragm is inversely related to the expression of NF-κB and FoxO target genes. CONCLUSIONS HSP72 overexpression in the diaphragm is an effective intervention to prevent MV-induced oxidative stress and the transcriptional activity of NF-κB and FoxO. Therefore, overexpression of HSP72 in the diaphragm is a potential therapeutic target to protect against VIDD.
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Affiliation(s)
- Ashley J Smuder
- Department of Exercise Science, University of South Carolina, Columbia, USA
| | - Aaron B Morton
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
| | - Stephanie E Hall
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
| | - Michael P Wiggs
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
| | - Bumsoo Ahn
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
| | - Nicholas R Wawrzyniak
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
| | - Kurt J Sollanek
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
| | - Kisuk Min
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
| | - Oh Sung Kwon
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
| | - W Bradley Nelson
- Department of Natural Sciences, Ohio Dominican University, Columbus, USA
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, USA
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41
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Peñuelas O, Keough E, López-Rodríguez L, Carriedo D, Gonçalves G, Barreiro E, Lorente JÁ. Ventilator-induced diaphragm dysfunction: translational mechanisms lead to therapeutical alternatives in the critically ill. Intensive Care Med Exp 2019; 7:48. [PMID: 31346802 PMCID: PMC6658639 DOI: 10.1186/s40635-019-0259-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023] Open
Abstract
Mechanical ventilation [MV] is a life-saving technique delivered to critically ill patients incapable of adequately ventilating and/or oxygenating due to respiratory or other disease processes. This necessarily invasive support however could potentially result in important iatrogenic complications. Even brief periods of MV may result in diaphragm weakness [i.e., ventilator-induced diaphragm dysfunction [VIDD]], which may be associated with difficulty weaning from the ventilator as well as mortality. This suggests that VIDD could potentially have a major impact on clinical practice through worse clinical outcomes and healthcare resource use. Recent translational investigations have identified that VIDD is mainly characterized by alterations resulting in a major decline of diaphragmatic contractile force together with atrophy of diaphragm muscle fibers. However, the signaling mechanisms responsible for VIDD have not been fully established. In this paper, we summarize the current understanding of the pathophysiological pathways underlying VIDD and highlight the diagnostic approach, as well as novel and experimental therapeutic options.
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Affiliation(s)
- Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain.
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.
| | - Elena Keough
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Lucía López-Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Demetrio Carriedo
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Gesly Gonçalves
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain
- Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department [CEXS], Barcelona, Spain
- Universitat Pompeu Fabra [UPF], Barcelona Biomedical Research Park [PRBB], Barcelona, Spain
| | - José Ángel Lorente
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain
- Universidad Europea, Madrid, Spain
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42
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Horn AG, Davis RT, Baumfalk DR, Kunkel ON, Bruells CS, McCullough DJ, Opoku-Acheampong AB, Poole DC, Behnke BJ. Impaired diaphragm resistance vessel vasodilation with prolonged mechanical ventilation. J Appl Physiol (1985) 2019; 127:423-431. [PMID: 31161883 DOI: 10.1152/japplphysiol.00189.2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving intervention, yet with prolonged MV (i.e., ≥6 h) there are time-dependent reductions in diaphragm blood flow and an impaired hyperemic response of unknown origin. Female Sprague-Dawley rats (4-8 mo, n = 118) were randomized into two groups; spontaneous breathing (SB) and 6-h (prolonged) MV. After MV or SB, vasodilation (flow-induced, endothelium-dependent and -independent agonists) and constriction (myogenic and α-adrenergic) responses were measured in first-order (1A) diaphragm resistance arterioles in vitro, and endothelial nitric oxide synthase (eNOS) mRNA expression was quantified. Following prolonged MV, there was a significant reduction in diaphragm arteriolar flow-induced (SB, 34.7 ± 3.8% vs. MV, 22.6 ± 2.0%; P ≤ 0.05), endothelium-dependent (via acetylcholine; SB, 64.3 ± 2.1% vs. MV, 36.4 ± 2.3%; P ≤ 0.05) and -independent (via sodium nitroprusside; SB, 65.0 ± 3.1% vs. MV, 46.0 ± 4.6%; P ≤ 0.05) vasodilation. Compared with SB, there was reduced eNOS mRNA expression (P ≤ 0.05). Prolonged MV diminished phenylephrine-induced vasoconstriction (SB, 37.3 ± 6.7% vs. MV, 19.0 ± 1.9%; P ≤ 0.05) but did not alter myogenic or passive pressure responses. The severe reductions in diaphragmatic blood flow at rest and during contractions, with prolonged MV, are associated with diaphragm vascular dysfunction which occurs through both endothelium-dependent and endothelium-independent mechanisms.NEW & NOTEWORTHY Following prolonged mechanical ventilation, vascular alterations occur through both endothelium-dependent and -independent pathways. This is the first study, to our knowledge, demonstrating that diaphragm arteriolar dysfunction occurs consequent to prolonged mechanical ventilation and likely contributes to the severe reductions in diaphragmatic blood flow and weaning difficulties.
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Affiliation(s)
- Andrew G Horn
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Robert T Davis
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, Florida
| | - Dryden R Baumfalk
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Olivia N Kunkel
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Christian S Bruells
- Department of Anesthesiology, RWTH Aachen University, Faculty of Medicine, Aachen, Germany
| | - Danielle J McCullough
- Department of Anatomy and Physiology, Edward Via College of Osteopathic Medicine, Auburn Campus, Auburn, Alabama
| | | | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, Kansas.,Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas
| | - Bradley J Behnke
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
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43
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van der Pijl RJ, Granzier HL, Ottenheijm CAC. Diaphragm contractile weakness due to reduced mechanical loading: role of titin. Am J Physiol Cell Physiol 2019; 317:C167-C176. [PMID: 31042425 DOI: 10.1152/ajpcell.00509.2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The diaphragm, the main muscle of inspiration, is constantly subjected to mechanical loading. Only during controlled mechanical ventilation, as occurs during thoracic surgery and in the intensive care unit, is mechanical loading of the diaphragm arrested. Animal studies indicate that the diaphragm is highly sensitive to unloading, causing rapid muscle fiber atrophy and contractile weakness; unloading-induced diaphragm atrophy and contractile weakness have been suggested to contribute to the difficulties in weaning patients from ventilator support. The molecular triggers that initiate the rapid unloading atrophy of the diaphragm are not well understood, although proteolytic pathways and oxidative signaling have been shown to be involved. Mechanical stress is known to play an important role in the maintenance of muscle mass. Within the muscle's sarcomere, titin is considered to play an important role in the stress-response machinery. Titin is a giant protein that acts as a mechanosensor regulating muscle protein expression in a sarcomere strain-dependent fashion. Thus titin is an attractive candidate for sensing the sudden mechanical arrest of the diaphragm when patients are mechanically ventilated, leading to changes in muscle protein expression. Here, we provide a novel perspective on how titin and its biomechanical sensing and signaling might be involved in the development of mechanical unloading-induced diaphragm weakness.
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Affiliation(s)
- Robbert J van der Pijl
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Henk L Granzier
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona
| | - Coen A C Ottenheijm
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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Interactions between Cytosolic Phospholipase A2 Activation and Mitochondrial Reactive Oxygen Species Production in the Development of Ventilator-Induced Diaphragm Dysfunction. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:2561929. [PMID: 31178955 PMCID: PMC6501131 DOI: 10.1155/2019/2561929] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/13/2019] [Indexed: 12/29/2022]
Abstract
Cytosolic phospholipase A2 (cPLA2) has been reported to be critical for infection-induced mitochondrial reactive oxygen species (ROS) production and diaphragm dysfunction (DD). In the present study, we aim to investigate whether cPLA2 was involved in ventilator-induced diaphragm dysfunction (VIDD). Our results showed that mechanical ventilation (MV) induced cPLA2 activation in the diaphragm with excessive mitochondrial ROS generation and muscle weakness. Specific inhibition of cPLA2 with CDIBA resulted in decreased mitochondrial ROS levels and improved diaphragm forces. In addition, mitochondria-targeted antioxidant MitoTEMPO attenuated ventilator-induced mitochondrial oxidative stress and downregulated cPLA2 activation in vivo. Both CDIBA and MitoTEMPO were able to attenuate protein degradation, muscle atrophy, and weakness following prolonged MV. Furthermore, laser Doppler imaging showed that MV decreased diaphragm tissue perfusion and induced subsequent hypoxia. An in vitro study also demonstrated a positive association between cPLA2 activation and mitochondrial ROS generation in C2C12 cells cultured under hypoxic condition. Collectively, our study showed that cPLA2 activation positively interacts with mitochondrial ROS generation in the development of VIDD, and ventilator-induced diaphragm hypoxia serves as a possible contributor to this positive feedback loop.
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45
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Tang H, Shrager JB. The Signaling Network Resulting in Ventilator-induced Diaphragm Dysfunction. Am J Respir Cell Mol Biol 2019; 59:417-427. [PMID: 29768017 DOI: 10.1165/rcmb.2018-0022tr] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving measure for those incapable of adequately ventilating or oxygenating without assistance. Unfortunately, even brief periods of MV result in diaphragm weakness (i.e., ventilator-induced diaphragm dysfunction [VIDD]) that may render it difficult to wean the ventilator. Prolonged MV is associated with cascading complications and is a strong risk factor for death. Thus, prevention of VIDD may have a dramatic impact on mortality rates. Here, we summarize the current understanding of the pathogenic events underlying VIDD. Numerous alterations have been proven important in both human and animal MV diaphragm. These include protein degradation via the ubiquitin proteasome system, autophagy, apoptosis, and calpain activity-all causing diaphragm muscle fiber atrophy, altered energy supply via compromised oxidative phosphorylation and upregulation of glycolysis, and also mitochondrial dysfunction and oxidative stress. Mitochondrial oxidative stress in fact appears to be a central factor in each of these events. Recent studies by our group and others indicate that mitochondrial function is modulated by several signaling molecules, including Smad3, signal transducer and activator of transcription 3, and FoxO. MV rapidly activates Smad3 and signal transducer and activator of transcription 3, which upregulate mitochondrial oxidative stress. Additional roles may be played by angiotensin II and leaky ryanodine receptors causing elevated calcium levels. We present, here, a hypothetical scaffold for understanding the molecular pathogenesis of VIDD, which links together these elements. These pathways harbor several drug targets that could soon move toward testing in clinical trials. We hope that this review will shape a short list of the most promising candidates.
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Affiliation(s)
- Huibin Tang
- Stanford University School of Medicine, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford, California; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
| | - Joseph B Shrager
- Stanford University School of Medicine, Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford, California; and Veterans Affairs Palo Alto Healthcare System, Palo Alto, California
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46
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Zambelli V, Sigurtà A, Rizzi L, Zucca L, Delvecchio P, Bresciani E, Torsello A, Bellani G. Angiotensin-(1-7) exerts a protective action in a rat model of ventilator-induced diaphragmatic dysfunction. Intensive Care Med Exp 2019; 7:8. [PMID: 30659381 PMCID: PMC6338614 DOI: 10.1186/s40635-018-0218-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 12/25/2018] [Indexed: 12/11/2022] Open
Abstract
Background Ventilator-induced diaphragmatic dysfunction (VIDD) is a common event during mechanical ventilation (MV) leading to rapid muscular atrophy and contractile dysfunction. Recent data show that renin-angiotensin system is involved in diaphragmatic skeletal muscle atrophy after MV. In particular, angiotensin-II can induce marked diaphragm muscle wasting, whereas angiotensin-(1–7) (Ang-(1–7)) could counteract this activity. This study was designed to evaluate the effects of the treatment with Ang-(1–7) in a rat model of VIDD with neuromuscular blocking agent infusion. Moreover, we studied whether the administration of A-779, an antagonist of Ang-(1–7) receptor (Mas), alone or in combination with PD123319, an antagonist of AT2 receptor, could antagonize the effects of Ang-(1–7). Methods Sprague-Dawley rats underwent prolonged MV (8 h), while receiving an iv infusion of sterile saline 0.9% (vehicle) or Ang-(1–7) or Ang-(1–7) + A-779 or Ang-(1–7) + A-779 + PD123319. Diaphragms were collected for ex vivo contractility measurement (with electric stimulation), histological analysis, quantitative real-time PCR, and Western blot analysis. Results MV resulted in a significant reduction of diaphragmatic contractility in all groups of treatment. Ang-(1–7)-treated rats showed higher muscular fibers cross-sectional area and lower atrogin-1 and myogenin mRNA levels, compared to vehicle treatment. Treatment with the antagonists of Mas and Ang-II receptor 2 (AT2R) caused a significant reduction of muscular contractility and an increase of atrogin-1 and MuRF-1 mRNA levels, not affecting the cross-sectional fiber area and myogenin mRNA levels. Conclusions Systemic Ang-(1–7) administration during MV exerts a protective role on the muscular fibers of the diaphragm preserving muscular fibers anatomy, and reducing atrophy. The involvement of Mas and AT2R in the mechanism of action of Ang-(1–7) still remains controversial.
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Affiliation(s)
- Vanessa Zambelli
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Anna Sigurtà
- Anesthesia and Critical Care, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Laura Rizzi
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Letizia Zucca
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Paolo Delvecchio
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Elena Bresciani
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Antonio Torsello
- Department of Medicine, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Bellani
- Department of Medicine, University of Milano-Bicocca, Monza, Italy.
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Abstract
Respiratory failure is common during acute exacerbation of chronic obstructive pulmonary disease (AE-COPD). Phrenic nerve conduction (PNC), transcranial magnetic stimulation (TMS), and cervical magnetic stimulation (CMS) are of great value in identifying the feature and site of AE-COPD.PNC, TMS, and CMS were performed in 20 AE-COPD patients with respiratory failure, and re-examined after weaning. Latencies and amplitudes of the diaphragmatic compound muscle action potential (dCMAP), motor evoked potential of the diaphragm (dMEP) evoked by TMS and CMS, and central motor conduction time (CMCT) were measured. Blood gas analysis and serum electrolyte levels were also evaluated. The results were compared with those from 20 healthy subjects.AE-COPD patients showed prolonged CMCT and latencies of dCMAP and dMEP, decreased amplitudes of dCMAP and dMEP evoked by CMS, while CMCT and the latency of dMEP evoked by TMS were shortened after weaning. Significant correlation was identified between arterial blood gas analysis, serum electrolyte levels, disease duration, the duration of mechanical ventilation and the electrophysiological findings in AE-COPD patients prior to weaning.The central and peripheral respiratory pathway is involved in AE-COPD. Central respiratory pathway function is improved after weaning in AE-COPD patients with respiratory failure.
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Affiliation(s)
- Yu Wang
- Department of Neurology, Third Central Hospital of Tianjin
- Tianjin Institute of Hepatobiliary Disease
- Tianjin Key Laboratory of Artificial Cell
- Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
| | - Na Liu
- Department of Neurology, Third Central Hospital of Tianjin
- Tianjin Institute of Hepatobiliary Disease
- Tianjin Key Laboratory of Artificial Cell
- Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
| | - Zhecheng Zhang
- Department of Neurology, Third Central Hospital of Tianjin
- Tianjin Institute of Hepatobiliary Disease
- Tianjin Key Laboratory of Artificial Cell
- Artificial Cell Engineering Technology Research Center of Public Health Ministry, Tianjin, China
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48
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Yu TJ, Liu YC, Chu CM, Hu HC, Kao KC. Effects of theophylline therapy on respiratory muscle strength in patients with prolonged mechanical ventilation: A retrospective cohort study. Medicine (Baltimore) 2019; 98:e13982. [PMID: 30633180 PMCID: PMC6336648 DOI: 10.1097/md.0000000000013982] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Mechanical ventilation may cause diaphragm weakness an effect termed ventilator-induced diaphragm dysfunction (VIDD). The prevalence of VIDD among patients receiving mechanical ventilation is very high, with the degree of diaphragmatic atrophy being associated with the length of mechanical ventilation. Theophylline is known to increase diaphragmatic contractility and reduce fatigue, so in this study, we evaluated the effect of theophylline in patients with prolonged mechanical ventilation.Patients who depended on mechanical ventilation were included in the study. We compared the maximum inspiratory pressure (PImax) values, rapid shallow breathing index (RSBI) values, and successful weaning rates of theophylline-treated and non-theophylline-treated patients.Eighty-four patients received theophylline and 76 patients did not. These 2 groups' clinical characteristics, including their PImax and RSBI at initial admission, were similar. The results showed that the theophylline-treated group had significantly better PImax and RSBI, with a higher last PImax (30.1 ± 9.7 cmH2O vs 26.9 ± 9.1 cmH2O; P = .034) and lower last RSBI (107.0 ± 68.4 vs 131.4 ± 77.7; P = .036). The improvements to each respective patient's PImax and RSBI were also significantly higher in the theophylline-treated group (PImax: 20.1 ± 5.7% vs 3.2 ± 1.1%, P = .005; RSBI: 11.2 ± 3.0% vs 2.7 ± 1.6%, P = .015). The weaning success rate of the theophylline-treated group was also higher, but not significantly so.Theophylline might improve respiratory muscle strength in patients with prolonged mechanical ventilation and it needs further prospective studies to confirm.
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Affiliation(s)
- Teng-Jen Yu
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Memorial Hospital, Keelung
| | - Yu-Chih Liu
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Memorial Hospital, Keelung
| | - Chien-Min Chu
- Department of Pulmonary and Critical Care Medicine, Chang-Gung Memorial Hospital, Keelung
| | - Han-Chung Hu
- Department of Thoracic Medicine, Chang-Gung Memorial Hospital
- Department of Respiratory Therapy, Chang-Gung University, Taoyuan, Taiwan
| | - Kuo-Chin Kao
- Department of Thoracic Medicine, Chang-Gung Memorial Hospital
- Department of Respiratory Therapy, Chang-Gung University, Taoyuan, Taiwan
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49
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Schreiber A, Bertoni M, Goligher EC. Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization. Crit Care Clin 2018; 34:357-381. [PMID: 29907270 DOI: 10.1016/j.ccc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. Limb muscle weakness persists for months after discharge from intensive care and results in poor long-term functional status and quality of life. Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.
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Affiliation(s)
- Annia Schreiber
- Respiratory Intensive Care Unit and Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili 1, Brescia 25123, Italy
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, 585 University Avenue, Peter Munk Building, 11th Floor Room 192, Toronto, ON M5G 2N2, Canada.
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50
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Powers SK, Morton AB, Hyatt H, Hinkley MJ. The Renin-Angiotensin System and Skeletal Muscle. Exerc Sport Sci Rev 2018; 46:205-214. [PMID: 30001274 DOI: 10.1249/jes.0000000000000158] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The renin-angiotensin system (RAS) plays a key role in the control of blood pressure and fluid homeostasis. Emerging evidence also reveals that hyperactivity of the RAS contributes to skeletal muscle wasting. This review discusses the key role that the RAS plays in skeletal muscle wasting due to congestive heart failure, chronic kidney disease, and ventilator-induced diaphragmatic wasting.
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Affiliation(s)
- Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL
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