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Bayraktutan Z, Dincer B, Keskin H, Kose D, Bilen A, Toktay E, Sirin B, Halici Z. Roflumilast as a Potential Therapeutic Agent for Cecal Ligation and Puncture-Induced Septic Lung Injury. J INVEST SURG 2021; 35:605-613. [PMID: 33843406 DOI: 10.1080/08941939.2021.1908462] [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: 10/21/2022]
Abstract
PURPOSE/AIMS This study focused on delineating the possible effects of roflumilast (ROF), a selective phosphodiesterase 4 (PDE4) inhibitor, in rats with cecal ligation and puncture (CLP)-induced polymicrobial sepsis, and investigated whether ROF can act as a protective agent in sepsis-induced lung damage. MATERIAL AND METHODS Four experimental groups were organized, each comprising eight rats: Control, Sepsis, Sepsis + ROF 0.5 mgkg-1, and Sepsis + ROF 1 mgkg-1 groups. A polymicrobial sepsis model was induced in the rats by cecal ligation and puncture under anesthesia. Twelve hours after sepsis induction, the lungs were obtained for biochemical, molecular, and histopathological analyses. RESULTS In the sepsis group's lungs, the TNF-α, IL-1β, and IL-6 mRNA expression levels peaked in the sepsis group's lung tissues, and ROF significantly decreased these levels compared with the sepsis group dose-dependently. ROF also significantly decreased MDA levels in septic lungs and increased antioxidant parameters (SOD and GSH) compared with the sepsis group. Histopathological analysis results supported biochemical and molecular results. CONCLUSIONS ROF, a PDE4 inhibitor, suppressed the expression levels of pro-inflammatory cytokines, alleviated lung damage (probably by blocking neutrophil infiltration), and increased the capacity of the antioxidant system.
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Affiliation(s)
| | - Busra Dincer
- Department of Pharmacology, Erzincan Binali Yildirim University, Erzincan, Turkey
| | - Halil Keskin
- Department of Child Health and Diseases, Ataturk University, Erzurum, Turkey
| | - Duygu Kose
- Department of Pharmacology, Ataturk University, Erzurum, Turkey
| | - Arzu Bilen
- Department of Internal Medicine, Ataturk University, Erzurum, Turkey
| | - Erdem Toktay
- Department of Histology and Embryology, Kafkas University, Kars, Turkey
| | - Busra Sirin
- Clinical Research, Development and Design Application and Research Center, Ataturk University, Erzurum, Turkey
| | - Zekai Halici
- Department of Pharmacology, Ataturk University, Erzurum, Turkey.,Department of Internal Medicine, Ataturk University, Erzurum, Turkey.,Department of Histology and Embryology, Kafkas University, Kars, Turkey.,Clinical Research, Development and Design Application and Research Center, Ataturk University, Erzurum, Turkey
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Domnik NJ, Walsted ES, Langer D. Clinical Utility of Measuring Inspiratory Neural Drive During Cardiopulmonary Exercise Testing (CPET). Front Med (Lausanne) 2020; 7:483. [PMID: 33043023 PMCID: PMC7530180 DOI: 10.3389/fmed.2020.00483] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/16/2020] [Indexed: 12/18/2022] Open
Abstract
Cardiopulmonary exercise testing (CPET) has traditionally included ventilatory and metabolic measurements alongside electrocardiographic characterization; however, research increasingly acknowledges the utility of also measuring inspiratory neural drive (IND) through its surrogate measure of diaphragmatic electromyography (EMGdi). While true IND also encompasses the activation of non-diaphragmatic respiratory muscles, the current review focuses on diaphragmatic measurements, providing information about additional inspiratory muscle groups for context where appropriate. Evaluation of IND provides mechanistic insight into the origins of dyspnea and exercise limitation across pathologies; yields valuable information reflecting the integration of diverse mechanical, chemical, locomotor, and metabolic afferent signals; and can help assess the efficacy of therapeutic interventions. Further, IND measurement during the physiologic stress of exercise is uniquely poised to reveal the underpinnings of physiologic limitations masked during resting and unloaded breathing, with important information provided not only at peak exercise, but throughout exercise protocols. As our understanding of IND presentation across varying conditions continues to grow and methods for its measurement become more accessible, the translation of these principles into clinical settings is a logical next step in facilitating appropriate and nuanced management tailored to each individual's unique physiology. This review provides an overview of the current state of understanding of IND measurement during CPET: its origins, known patterns of behavior and links with dyspnea in health and major respiratory diseases, and the possibility of expanding this approach to applications beyond exercise.
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Affiliation(s)
- Nicolle J Domnik
- Department of Medicine, Queen's University, Kingston, ON, Canada
| | - Emil S Walsted
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Daniel Langer
- Research Group for Rehabilitation in Internal Disorders, Respiratory Rehabilitation and Respiratory Division, Department of Rehabilitation Sciences, University Hospital Leuven, KU Leuven, Leuven, Belgium
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Luo YM, Qiu ZH, Wang Y, He BT, Qin H, Xiao SC, Luo YM, Steier J, Moxham J, Polkey MI. Absence of dynamic hyperinflation during exhaustive exercise in severe COPD reflects submaximal IC maneuvers rather than a nonhyperinflator phenotype. J Appl Physiol (1985) 2020; 128:586-595. [DOI: 10.1152/japplphysiol.00695.2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Approximately 20% of chronic obstructive pulmonary disease (COPD) patients have been considered to have a “nonhyperinflator phenotype.” However, this judgment depends on patients making a fully maximal inspiratory capacity (IC) maneuver at rest, since the IC during exercise is compared with this baseline measurement. We hypothesized that IC maneuvers at rest are sometimes submaximal and tested this hypothesis by measuring IC and associated neural respiratory drive at rest and during inhalation of CO2 and exercise in patients with COPD. Twenty-six COPD patients [age 66 ± 6 yr, mean forced expiratory volume in 1 s (FEV1) 40 ± 11% predicted] and 39 healthy subjects (age 39 ± 14 yr, FEV1 98 ± 12% predicted) were studied. IC and the diaphragm electromyogram (EMGdi) associated with it (EMGdi-IC) and forced inspiratory vital capacity (FIVC) and its corresponding EMGdi (EMGdi-FIVC) were measured during inhalation of 8% CO2 (8% CO2-92% O2) and room air. Incremental exhaustive cycle ergometer exercise was also performed in both patients with COPD and healthy subjects. IC, EMGdi-IC, FIVC, and EMGdi-FIVC during breathing 8% CO2 were significantly greater than those during breathing room air in both patients with COPD and healthy subjects (all P < 0.001). EMGdi-IC in patients with COPD constantly increased during exercise from 145 ± 40 µV at rest to 185 ± 52 µV at the end of exercise but change in IC was variable. Neural respiratory drive and its relevant IC increased during hypercapnia. Exercise-related hypercapnia in patients with COPD raises neural respiratory drives, which compensate for IC reduction, leading to underestimation of dynamic hyperinflation measured by IC at rest breathing room air. NEW & NOTEWORTHY Inspiratory capacity measured during hypercapnia is higher than that during eucapnia. Thus total lung capacity is not always be achieved by a standard inspiratory capacity maneuver, leading to risk of underestimation of dynamic hyperinflation in patients with severe chronic obstructive pulmonary disease after exhaustive exercise.
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Affiliation(s)
- Yuan-Ming Luo
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
- Department of Respiratory Medicine, King’s College London School of Medicine, London, United Kingdom
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Zhi-Hui Qiu
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Yuan Wang
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Bai-Ting He
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Hua Qin
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Si-chang Xiao
- National Clinical Research Center for Respiratory Disease, State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China
| | - Ying-mei Luo
- Respiratory Muscle Laboratory, Heart and Lung Institute, Imperial College and the Royal Brompton Hospital, London, United Kingdom
| | - Joerg Steier
- Department of Respiratory Medicine, King’s College London School of Medicine, London, United Kingdom
| | - John Moxham
- Department of Respiratory Medicine, King’s College London School of Medicine, London, United Kingdom
| | - Michael I Polkey
- Respiratory Muscle Laboratory, Heart and Lung Institute, Imperial College and the Royal Brompton Hospital, London, United Kingdom
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Oppersma E, Doorduin J, van der Hoeven JG, Veltink PH, van Hees HWH, Heunks LMA. The effect of metabolic alkalosis on the ventilatory response in healthy subjects. Respir Physiol Neurobiol 2018; 249:47-53. [PMID: 29307724 DOI: 10.1016/j.resp.2018.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 12/07/2017] [Accepted: 01/03/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with acute respiratory failure may develop respiratory acidosis. Metabolic compensation by bicarbonate production or retention results in posthypercapnic alkalosis with an increased arterial bicarbonate concentration. The hypothesis of this study was that elevated plasma bicarbonate levels decrease respiratory drive and minute ventilation. METHODS In an intervention study in 10 healthy subjects the ventilatory response using a hypercapnic ventilatory response (HCVR) test was assessed, before and after administration of high dose sodium bicarbonate. Total dose of sodiumbicarbonate was 1000 ml 8.4% in 3 days. RESULTS Plasma bicarbonate increased from 25.2 ± 2.2 to 29.2 ± 1.9 mmol/L. With increasing inspiratory CO2 pressure during the HCVR test, RR, Vt, Pdi, EAdi and VE increased. The clinical ratio ΔVE/ΔPetCO2 remained unchanged, but Pdi, EAdi and VE were significantly lower after bicarbonate administration for similar levels of inspired CO2. CONCLUSION This study demonstrates that in healthy subjects metabolic alkalosis decreases the neural respiratory drive and minute ventilation, as a response to inspiratory CO2.
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Affiliation(s)
- E Oppersma
- MIRA - Institute for Biomedical Technology & Technical Medicine, University of Twente, Enschede, The Netherlands; Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J Doorduin
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Neurology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - J G van der Hoeven
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P H Veltink
- MIRA - Institute for Biomedical Technology & Technical Medicine, University of Twente, Enschede, The Netherlands
| | - H W H van Hees
- Department of Pulmonary Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - L M A Heunks
- Department of Critical Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands; Department of Intensive Care Medicine, VU University Medical Center, Amsterdam, The Netherlands.
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Abstract
Purpose of review The present review summarizes developments in the field of respiratory muscle monitoring, in particular in critically ill patients. Recent findings Patients admitted to the ICU may develop severe respiratory muscle dysfunction in a very short time span. Among other factors, disuse and sepsis have been associated with respiratory muscle dysfunction in these patients. Because weakness is associated with adverse outcome, including prolonged mechanical ventilation and mortality, it is surprising that respiratory muscle dysfunction largely develops without being noticed by the clinician. Respiratory muscle monitoring is not standard of care in most ICUs. Improvements in technology have opened windows for monitoring the respiratory muscles in critically ill patients. Diaphragm electromyography and esophageal pressure measurement are feasible techniques for respiratory muscle monitoring, although the effect on outcome remains to be investigated. Summary Respiratory muscle dysfunction develops rapidly in selected critically ill patients and is associated with adverse outcome. Recent technological advances allow real-time monitoring of respiratory muscle activity in these patients. Although this field is in its infancy, from a physiological perspective, it is reasonable to assume that monitoring respiratory muscle activity improves outcome in these patients.
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Abstract
Neurally adjusted ventilatory assist (NAVA) uses the electrical activity of the diaphragm (Edi) as a neural trigger to synchronize mechanical ventilatory breaths with the patient's neural respiratory drive. Using this signal enables the ventilator to proportionally support the patient's instantaneous drive on a breath-by-breath basis. Synchrony can be achieved even in the presence of significant air leaks, which make this an attractive choice for invasive and non-invasive ventilation of the neonate. This paper describes the Edi signal, neuroventilatory coupling, and patient-ventilator synchrony including the functional concept of NAVA. Safety features, NAVA terminology, and clinical application of NAVA to unload respiratory musculature are presented. The use of the Edi signal as a respiratory vital sign for conventional ventilation is discussed. The results of animal and adult studies are briefly summarized and detailed descriptions of all NAVA-related research in pediatric and neonatal patients are provided. Further studies are needed to determine whether NAVA will have significant impact on the overall outcomes of neonates.
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Schmidt M, Banzett RB, Raux M, Morélot-Panzini C, Dangers L, Similowski T, Demoule A. Unrecognized suffering in the ICU: addressing dyspnea in mechanically ventilated patients. Intensive Care Med 2013; 40:1-10. [PMID: 24132382 DOI: 10.1007/s00134-013-3117-3] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 09/15/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intensive care unit (ICU) patients are exposed to many sources of discomfort. Although increasing attention is being given to the detection and treatment of pain, very little is given to the detection and treatment of dyspnea (defined as "breathing discomfort"). METHODS Published information on the prevalence, mechanisms, and potential negative impacts of dyspnea in mechanically ventilated patients are reviewed. The most appropriate tools to detect and quantify dyspnea in ICU patients are also assessed. RESULTS/CONCLUSIONS Growing evidence suggests that dyspnea is a frequent issue in mechanically ventilated ICU patients, is highly associated with anxiety and pain, and is improved in many patients by altering the ventilator settings. CONCLUSIONS Future studies are needed to better delineate the impact of dyspnea in the ICU and to define diagnostic, monitoring and therapeutic protocols.
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Stein H, Hall R, Davis K, White DB. Electrical activity of the diaphragm (Edi) values and Edi catheter placement in non-ventilated preterm neonates. J Perinatol 2013; 33:707-11. [PMID: 23636099 DOI: 10.1038/jp.2013.45] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 03/23/2013] [Accepted: 03/26/2013] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The electrical activity of the diaphragm (Edi) reflects neural respiratory drive. Edi peak correlates with inspiratory drive and Edi minimum (Edi min) correlates with the tonic activity of the diaphragm. Edi data in non-ventilated preterm neonates have not been determined.The primary aim of this study was to determine Edi values in non-ventilated preterm neonates throughout postnatal maturation and with various types of noninvasive respiratory support. The secondary aim was to evaluate the success or complications of placement of the Edi catheter in premature neonates. STUDY DESIGN This was a prospective observational study of non-ventilated neonates <33 weeks gestation. Data were collected weekly using an Edi catheter placed in neonates on highflow nasal cannula (HFNC), nasal cannula (NC) or room air (RA). Clinical stability was determined by measuring heart rate (HR), respiratory rate (RR) and oxygen saturation (Sats). Success and adverse events of Edi catheter placement was monitored. Statistics were obtained by analysis of variance, P<0.05 was considered significant. RESULT Seventeen neonates were enrolled at 26 to 33 weeks postmenstrual age and studied from 1 to 10 weeks in duration. Overall Edi peak was 10.8±3.7 mcV (range 3.7 to 18.7) and Edi min was 2.8±1.1 mcV (range 0.8 to 7.6). There was no difference in Edi peak and min over postmenstrual ages within or between neonates, and no difference between those neonates on HFNC, NC or RA. HR, RR and Sats were not different over postmenstrual age or between any groups. The Edi catheter was placed successfully in 100% of these neonates. There were no adverse events noted. CONCLUSION In clinically stable neonates, the inspiratory drive (Edi peak) and tonic activity (Edi min) do not change with postnatal maturation or with the level of noninvasive respiratory support. The Edi catheter can be placed successfully in these premature neonates. These Edi data have the potential to guide ventilatory management of premature neonates.
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Affiliation(s)
- H Stein
- Department of Neonatology, Toledo Children's Hospital, Toledo, OH 43606, USA.
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Synchronized mechanical ventilation using electrical activity of the diaphragm in neonates. Clin Perinatol 2012; 39:525-42. [PMID: 22954267 DOI: 10.1016/j.clp.2012.06.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
The electrical activity of the diaphragm (Edi) is measured by a specialized nasogastric/orogastric tube positioned in the esophagus at the level of the crural diaphragm. Neurally adjusted ventilatory assist (NAVA) uses the Edi signal as a neural trigger and intrabreath controller to synchronize mechanical ventilatory breaths with the patient's respiratory drive and to proportionally support the patient's respiratory efforts on a breath-by-breath basis. NAVA improves patient-ventilator interaction and synchrony even in the presence of large air leaks, and might therefore be an optimal option for noninvasive ventilation in neonates.
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Moga AM, de Marchie M, Saey D, Spahija J. Mechanisms of non-pharmacologic adjunct therapies used during exercise in COPD. Respir Med 2012; 106:614-26. [PMID: 22341681 DOI: 10.1016/j.rmed.2012.01.006] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Revised: 01/04/2012] [Accepted: 01/12/2012] [Indexed: 11/16/2022]
Abstract
Individuals with chronic obstructive pulmonary disease (COPD) are often limited in their ability to perform exercise due to a heightened sense of dyspnea and/or the occurrence of leg fatigue associated with a reduced ventilatory capacity and peripheral skeletal muscle dysfunction, respectively. Pulmonary rehabilitation programs have been shown to improve exercise tolerance and health related quality of life. Additional therapeutic approaches such as non-invasive ventilatory support (NIVS), heliox (He-O(2)) and supplemental oxygen have been used as non-pharmacologic adjuncts to exercise to enhance the ability of patients with COPD to exercise at a higher exercise-intensity and thus improve the physiological benefits of exercise. The purpose of the current review is to examine the pathophysiology of exercise limitation in COPD and to explore the physiological mechanisms underlying the effect of the adjunct therapies on exercise in patients with COPD. This review indicates that strategies that aim to unload the respiratory muscles and enhance oxygen saturation during exercise alleviate exercise limiting factors and improve exercise performance in patients with COPD. However, available data shows significant variability in the effectiveness across patients. Further research is needed to identify the most appropriate candidates for these forms of therapies.
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Affiliation(s)
- A M Moga
- School of Physical and Occupational Therapy, McGill University, 3654 Promenade Sir William Osler, Montreal, Quebec H3G 1Y5, Canada
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Doorduin J, Sinderby CA, Beck J, Stegeman DF, van Hees HWH, van der Hoeven JG, Heunks LMA. The Calcium Sensitizer Levosimendan Improves Human Diaphragm Function. Am J Respir Crit Care Med 2012; 185:90-5. [DOI: 10.1164/rccm.201107-1268oc] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Neurally adjusted ventilatory assist in patients with critical illness-associated polyneuromyopathy. Intensive Care Med 2011; 37:1951-61. [PMID: 22048718 DOI: 10.1007/s00134-011-2376-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2011] [Accepted: 08/03/2011] [Indexed: 10/16/2022]
Abstract
PURPOSE Diaphragmatic electrical activity (EA(di)), reflecting respiratory drive, and its feedback control might be impaired in critical illness-associated polyneuromyopathy (CIPM). We aimed to evaluate whether titration and prolonged application of neurally adjusted ventilatory assist (NAVA), which delivers pressure (P (aw)) in proportion to EA(di), is feasible in CIPM patients. METHODS Peripheral and phrenic nerve electrophysiology studies were performed in 15 patients with clinically suspected CIPM and in 14 healthy volunteers. In patients, an adequate NAVA level (NAVAal) was titrated daily and was implemented for a maximum of 72 h. Changes in tidal volume (V (t)) generation per unit of EA(di) (V (t)/EA(di)) were assessed daily during standardized tests of neuro-ventilatory efficiency (NVET). RESULTS In patients (median [range], 66 [44-80] years), peripheral electrophysiology studies confirmed CIPM. Phrenic nerve latency (PNL) was prolonged and diaphragm compound muscle action potential (CMAP) was reduced compared with healthy volunteers (p < 0.05 for both). NAVAal could be titrated in all but two patients. During implementation of NAVAal for 61 (37-64) h, the EA(di) amplitude was 9.0 (4.4-15.2) μV, and the V (t) was 6.5 (3.7-14.3) ml/kg predicted body weight. V (t), respiratory rate, EA(di), PaCO(2), and hemodynamic parameters remained unchanged, while PaO(2)/FiO(2) increased from 238 (121-337) to 282 (150-440) mmHg (p = 0.007) during NAVAal. V (t)/EA(di) changed by -10 (-46; +31)% during the first NVET and by -0.1 (-26; +77)% during the last NVET (p = 0.048). CONCLUSION In most patients with CIPM, EA(di) and its feedback control are sufficiently preserved to titrate and implement NAVA for up to 3 days. Whether monitoring neuro-ventilatory efficiency helps inform the weaning process warrants further evaluation.
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Balkissoon R, Lommatzsch S, Carolan B, Make B. Chronic obstructive pulmonary disease: a concise review. Med Clin North Am 2011; 95:1125-41. [PMID: 22032431 DOI: 10.1016/j.mcna.2011.08.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Globally, chronic obstructive pulmonary disease (COPD) is a major cause of significant morbidity and mortality, and is now the third leading cause of death in the United States. Over the past 15 years there has been a surge of bench and translational research regarding the genetics and pathogenesis of COPD, and several large-scale clinical trials have introduced new treatment paradigms for COPD. Current research also demonstrates that COPD is not just a lung disease and that there are several potential extrapulmonary manifestations and comorbidities that should be evaluated and treated when one identifies an individual as having COPD.
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Affiliation(s)
- Ron Balkissoon
- National Jewish Health, Pulmonary Division, Department of Medicine, Denver, CO 80206, USA.
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Rabe KF. Roflumilast for the treatment of chronic obstructive pulmonary disease. Expert Rev Respir Med 2011; 4:543-55. [PMID: 20649375 DOI: 10.1586/ers.10.56] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Roflumilast is a new phosphodiesterase 4 inhibitor that has recently completed Phase III trials for the treatment of chronic obstructive pulmonary disease (COPD). Preclinical studies have shown that roflumilast targets inflammatory processes in COPD, with beneficial effects on tobacco-induced lung inflammation, lung fibrosis and remodeling, mucociliary malfunction and oxidative stress. Two recent, 1-year Phase III trials in COPD have shown that roflumilast reduces exacerbations and improves lung function in patients with COPD who have symptoms of chronic bronchitis and a history of exacerbations. Two other 6-month Phase III trials have demonstrated the beneficial effects of roflumilast in patients already receiving treatment with the long-acting β-agonist salmeterol or the long-acting muscarinic antagonist tiotropium. This article reviews the pharmacology, pharmacokinetics and preclinical pharmacology of roflumilast, the clinical studies supporting its use in COPD and its side-effect profile.
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Affiliation(s)
- Klaus F Rabe
- Leiden University Medical Center, Department of Pulmonology, Albinusdreef 2, 2333 ZA Leiden, The Netherlands.
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Passath C, Takala J, Tuchscherer D, Jakob SM, Sinderby C, Brander L. Physiologic Response to Changing Positive End-Expiratory Pressure During Neurally Adjusted Ventilatory Assist in Sedated, Critically Ill Adults. Chest 2010; 138:578-87. [DOI: 10.1378/chest.10-0286] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Neurally adjusted ventilatory assist decreases ventilator-induced lung injury and non-pulmonary organ dysfunction in rabbits with acute lung injury. Intensive Care Med 2009; 35:1979-89. [DOI: 10.1007/s00134-009-1626-x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 05/25/2009] [Indexed: 10/20/2022]
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Lecomte F, Brander L, Jalde F, Beck J, Qui H, Elie C, Slutsky AS, Brunet F, Sinderby C. Physiological response to increasing levels of neurally adjusted ventilatory assist (NAVA). Respir Physiol Neurobiol 2009; 166:117-24. [DOI: 10.1016/j.resp.2009.02.015] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Revised: 02/21/2009] [Accepted: 02/25/2009] [Indexed: 10/21/2022]
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Brander L, Leong-Poi H, Beck J, Brunet F, Hutchison SJ, Slutsky AS, Sinderby C. Titration and Implementation of Neurally Adjusted Ventilatory Assist in Critically Ill Patients. Chest 2009; 135:695-703. [DOI: 10.1378/chest.08-1747] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Moerer O, Barwing J, Quintel M. [Neurally adjusted ventilatory assist (NAVA). A new mode of assisted mechanical ventilation]. Anaesthesist 2009; 57:998-1005. [PMID: 18663419 DOI: 10.1007/s00101-008-1412-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The aim of mechanical ventilation is to assure gas exchange while efficiently unloading the respiratory muscles and mechanical ventilation is an integral part of the care of patients with acute respiratory failure. Modern lung protective strategies of mechanical ventilation include low-tidal-volume ventilation and the continuation of spontaneous breathing which has been shown to be beneficial in reducing atelectasis and improving oxygenation. Poor patient-ventilator interaction is a major issue during conventional assisted ventilation. Neurally adjusted ventilator assist (NAVA) is a new mode of mechanical ventilation that uses the electrical activity of the diaphragm (EAdi) to control the ventilator. First experimental studies showed an improved patient-ventilator synchrony and an efficient unloading of the respiratory muscles. Future clinical studies will have to show that NAVA is of clinical advantage when compared to conventional modes of assisted mechanical ventilation. This review characterizes NAVA according to current publications on this topic.
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Affiliation(s)
- O Moerer
- Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität, Göttingen, Deutschland.
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Sinderby C, Beck J, Spahija J, de Marchie M, Lacroix J, Navalesi P, Slutsky AS. Inspiratory muscle unloading by neurally adjusted ventilatory assist during maximal inspiratory efforts in healthy subjects. Chest 2007; 131:711-717. [PMID: 17356084 DOI: 10.1378/chest.06-1909] [Citation(s) in RCA: 116] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Neurally adjusted ventilatory assist (NAVA) is a mode of mechanical ventilation in which the ventilator is controlled by the electrical activity of the diaphragm (EAdi). During maximal inspirations, the pressure delivered can theoretically reach extreme levels that may cause harm to the lungs. The aims of this study were to evaluate whether NAVA could efficiently unload the respiratory muscles during maximal inspiratory efforts, and if a high level of NAVA would suppress EAdi without increasing lung-distending pressures. METHOD In awake healthy subjects (n = 9), NAVA was applied at increasing levels in a stepwise fashion during quiet breathing and maximal inspirations. EAdi and airway pressure (Paw), esophageal pressure (Pes), and gastric pressure, flow, and volume were measured. RESULTS During maximal inspirations with a high NAVA level, peak Paw was 37.1 +/- 11.0 cm H(2)O (mean +/- SD). This reduced Pes deflections from - 14.2 +/- 2.7 to 2.3 +/- 2.3 cm H(2)O (p < 0.001) and EAdi to 43 +/- 7% (p < 0.001), compared to maximal inspirations with no assist. At high NAVA levels, inspiratory capacity showed a modest increase of 11 +/- 11% (p = 0.024). CONCLUSION In healthy subjects, NAVA can safely and efficiently unload the respiratory muscles during maximal inspiratory maneuvers, without failing to cycle-off ventilatory assist and without causing excessive lung distention. Despite maximal unloading of the diaphragm at high levels of NAVA, EAdi is still present and able to control the ventilator.
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Affiliation(s)
- Christer Sinderby
- Department of Critical Care Medicine, St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Jennifer Beck
- Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Department of Pediatrics, University of Toronto, Toronto, ON, Canada
| | - Jadranka Spahija
- Sacré-Coeur Hospital Research Center, Department of Medicine, University of Montreal, Montreal, QC, Canada
| | - Michel de Marchie
- Sir Mortimer B. Davis Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Jacques Lacroix
- Pediatric Intensive Care Unit, Department of Pediatrics, Hôpital Sainte-Justine Research Center, Université de Montréal, Montreal, QC, Canada
| | - Paolo Navalesi
- Pulmonary Rehabilitation and Respiratory Intensive Care Unit, Fondazione S. Maugeri, Pavia, Italy
| | - Arthur S Slutsky
- Department of Critical Care Medicine, St. Michael's Hospital, Department of Medicine, University of Toronto, Toronto, ON, Canada
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Spahija J, Beck J, Lindström L, Bégin P, de Marchie M, Sinderby C. Effect of increased diaphragm activation on diaphragm power spectrum center frequency. Respir Physiol Neurobiol 2005; 146:67-76. [PMID: 15733780 DOI: 10.1016/j.resp.2004.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2004] [Indexed: 11/17/2022]
Abstract
Increased transdiaphragmatic pressure, reduced muscle blood flow, and increased duty cycle have all been associated with a reduction in the center frequency (CFdi) of the diaphragm's electrical activity (EAdi). However, the specific influence of diaphragm activation on CFdi is unknown. We evaluated whether increased diaphragm activation would result in a greater decline in the CFdi when pressure-time product (PTPdi) was kept constant. Five healthy subjects performed periods of intermittent quasi-static diaphragmatic contractions with a fixed duty cycle. In separate runs, subjects targeted transdiaphragmatic pressures (Pdi) by performing end-inspiratory holds with the glottis open and expulsive maneuvers at end-expiratory lung volume (EELV). Diaphragm activation and pressures were measured with an electrode array and balloons mounted on an esophago-gastric catheter, respectively. The EAdi, which was 25+/-8%(S.D.) of maximum at EELV, increased to 61+/-8% (P<0.001) when an identical Pdi (averaging 31+/-13 cmH2O) was generated at a higher lung volume (77% of inspiratory capacity). The latter was associated with a 17% greater decline in CFdi (P=0.012). In order to reproduce at EELV, the decrease in CFdi observed at the increased lung volume, a two-fold increase in PTPdi was required. We conclude that CFdi responds specifically to increased diaphragm activation when pressure-time product remains constant.
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Affiliation(s)
- Jadranka Spahija
- Research Center, Respiratory Health Research Unit, Sacré-Coeur Hospital of Montréal, Montreal, Que., Canada H4J 1C5.
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Lin YS, Gu Q, Lee LY. Activation of dopamine D2-like receptors attenuates pulmonary C-fiber hypersensitivity in rats. Am J Respir Crit Care Med 2003; 167:1096-101. [PMID: 12531778 DOI: 10.1164/rccm.200210-1171oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
This study was performed to determine whether activation of dopamine D2-like receptors inhibits the hyperresponsiveness of pulmonary C fibers induced by inflammatory mediators such as prostaglandin E2 (PGE2). In anesthetized, open-chest rats, constant infusion of PGE2 (1.5-4.5 microg/kg per minute, 2 minutes) significantly enhanced the C-fiber response to capsaicin injection. At 20 minutes after pretreatment with quinpirole (3 mg/kg, intravenous), a D2-like receptor agonist, the hyperresponsiveness to capsaicin of the same C fibers induced by PGE2 infusion was markedly attenuated, and this inhibitory effect lasted for more than 90 minutes. The effect of quinpirole was dose dependent and was antagonized by pretreatment with domperidone (5 mg/kg, intravenous), a D2-like receptor antagonist, administrated 10 minutes before the quinpirole injection. In a separate series of experiments, C-fiber responses to injections of phenyl biguanide and lactic acid and to constant-pressure lung inflation were augmented by PGE2; these potentiating responses were also significantly reduced by quinpirole. Furthermore, the effect of quinpirole was equally effective in inhibiting the increase in excitability of pulmonary C fibers induced by alveolar hypercapnia or constant infusion of adenosine. In conclusion, these results clearly show that activation of the dopamine D2-like receptors attenuates the hyperresponsiveness of pulmonary C fibers to both chemical stimuli and lung inflation.
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Affiliation(s)
- You Shuei Lin
- Department of Physiology, University of Kentucky Medical Center, Lexington 40536-0298, USA
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Respiratory Muscle Unloading during Mechanical Ventilation. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_27] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tobin MJ. Sleep-disordered breathing, control of breathing, respiratory muscles, and pulmonary function testing in AJRCCM 2001. Am J Respir Crit Care Med 2002; 165:584-97. [PMID: 11874806 DOI: 10.1164/ajrccm.165.5.2201061] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Hines Veterans Affairs Hospital, Route 11N, Hines, Illinois 60141, USA.
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Beck J, Gottfried SB, Navalesi P, Skrobik Y, Comtois N, Rossini M, Sinderby C. Electrical activity of the diaphragm during pressure support ventilation in acute respiratory failure. Am J Respir Crit Care Med 2001; 164:419-24. [PMID: 11500343 DOI: 10.1164/ajrccm.164.3.2009018] [Citation(s) in RCA: 121] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
We compared crural diaphragm electrical activity (EAdi) with transdiaphragmatic pressure (Pdi) during varying levels of pressure support ventilation (PS) in 13 intubated patients. With changing PS, we found no evidence for changes in neuromechanical coupling of the diaphragm. From lowest to highest PS (2 cm H(2)O +/- 4 to 20 cm H(2)O +/- 7), tidal volume increased from 430 ml +/- 180 to 527 ml +/- 180 (p < 0.001). The inspiratory volume calculated during the period when EAdi increased to its peak did not change from 276 +/- 147 to 277 +/- 162 ml, p = 0.976. Respiratory rate decreased from 23.9 (+/- 7) to 21.3 (+/- 7) breaths/min (p = 0.015). EAdi and Pdi decreased proportionally by adding PS (r = 0.84 and r = 0.90, for mean and peak values, respectively). Mean and peak EAdi decreased (p < 0.001) by 33 +/- 21% (mean +/- SD) and 37 +/- 23% with the addition of 10 cm H(2)O of PS, similar to the decrease in the mean and peak Pdi (p < 0.001) observed (34 +/- 36 and 35 +/- 23%). We also found that ventilator assist continued during the diaphragm deactivation period, a phenomenon that was further exaggerated at higher PS levels. We conclude that EAdi is a valid measurement of neural drive to the diaphragm in acute respiratory failure.
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Affiliation(s)
- J Beck
- Hôpital Ste-Justine, Department of Pediatrics, Montreal, Quebec, Canada.
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Sinderby C, Spahija J, Beck J, Kaminski D, Yan S, Comtois N, Sliwinski P. Diaphragm activation during exercise in chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2001; 163:1637-41. [PMID: 11401887 DOI: 10.1164/ajrccm.163.7.2007033] [Citation(s) in RCA: 124] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Although it has been postulated that central inhibition of respiratory drive may prevent development of diaphragm fatigue in patients with chronic obstructive pulmonary disease (COPD) during exercise, this premise has not been validated. We evaluated diaphragm electrical activation (EAdi) relative to maximum in 10 patients with moderately severe COPD at rest and during incremental exhaustive bicycle exercise. Flow was measured with a pneumotachograph and volume by integration of flow. EAdi and transdiaphragmatic pressures (Pdi) were measured using an esophageal catheter. End-expiratory lung volume (EELV) was assessed by inspiratory capacity (IC) maneuvers, and maximal voluntary EAdi was obtained during these maneuvers. Minute ventilation (V E) was 12.2 +/- 1.9 L/min (mean +/- SD) at rest, and increased progressively (p < 0.001) to 31.0 +/- 7.8 L/min at end-exercise. EELV increased during exercise (p < 0.001) causing end-inspiratory lung volume to attain 97 +/- 3% of TLC at end-exercise. Pdi at rest was 9.4 +/- 3.2 cm H(2)O and increased during the first two thirds of exercise (p < 0.001) to plateau at about 13 cm H(2)O. EAdi was 24 +/- 6% of voluntary maximal at rest and increased progressively during exercise (p < 0.001) to reach 81 +/- 7% at end-exercise. In conclusion, dynamic hyperinflation during exhaustive exercise in patients with COPD reduces diaphragm pressure-generating capacity, promoting high levels of diaphragm activation.
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Affiliation(s)
- C Sinderby
- Guy-Bernier Research Center, Maisonneuve-Rosemont Hospital, Department of Medicine, and Ste Justine Research Center, Ste Justine Hospital, Montreal, Quebec, Canada.
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