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Comparative effects of neurally adjusted ventilatory assist and variable pressure support on lung and diaphragmatic function in a model of acute respiratory distress syndrome: A randomised animal study. Eur J Anaesthesiol 2021; 38:32-40. [PMID: 32657806 DOI: 10.1097/eja.0000000000001261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Variable assisted mechanical ventilation has been shown to improve lung function and reduce lung injury. However, differences between extrinsic and intrinsic variability are unknown. OBJECTIVE To investigate the effects of neurally adjusted ventilatory assist (NAVA, intrinsic variability), variable pressure support ventilation (Noisy PSV, extrinsic variability) and conventional pressure-controlled ventilation (PCV) on lung and diaphragmatic function and damage in experimental acute respiratory distress syndrome (ARDS). DESIGN Randomised controlled animal study. SETTING University Hospital Research Facility. SUBJECTS A total of 24 juvenile female pigs. INTERVENTIONS ARDS was induced by repetitive lung lavage and injurious ventilation. Animals were randomly assigned to 24 h of either: 1) NAVA, 2) Noisy PSV or 3) PCV (n=8 per group). Mechanical ventilation settings followed the ARDS Network recommendations. MEASUREMENTS The primary outcome was histological lung damage. Secondary outcomes were respiratory variables and patterns, subject-ventilator asynchrony (SVA), pulmonary and diaphragmatic biomarkers, as well as diaphragmatic muscle atrophy and myosin isotypes. RESULTS Global alveolar damage did not differ between groups, but NAVA resulted in less interstitial oedema in dorsal lung regions than Noisy PSV. Gas exchange and SVA incidence did not differ between groups. Compared with Noisy PSV, NAVA generated higher coefficients of variation of tidal volume and respiratory rate. During NAVA, only 40.4% of breaths were triggered by the electrical diaphragm signal. The IL-8 concentration in lung tissue was lower after NAVA compared with PCV and Noisy PSV, whereas Noisy PSV yielded lower type III procollagen mRNA expression than NAVA and PCV. Diaphragmatic muscle fibre diameters were smaller after PCV compared with assisted modes, whereas expression of myosin isotypes did not differ between groups. CONCLUSION Noisy PSV and NAVA did not reduce global lung injury compared with PCV but affected different biomarkers and attenuated diaphragmatic atrophy. NAVA increased the respiratory variability; however, NAVA yielded a similar SVA incidence as Noisy PSV. TRIAL REGISTRATION This trial was registered and approved by the Landesdirektion Dresden, Germany (AZ 24-9168.11-1/2012-2).
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Abstract
WHAT WE ALREADY KNOW ABOUT THIS TOPIC Diaphragm dysfunction and atrophy develop during controlled mechanical ventilation. Although oxidative stress injures muscle during controlled mechanical ventilation, it is unclear whether it causes autophagy or fiber atrophy. WHAT THIS ARTICLE TELLS US THAT IS NEW Pretreatment of rats undergoing 24 h of mechanical ventilation with N-acetylcysteine prevents decreases in diaphragm contractility, inhibits the autophagy and proteasome pathways, but has no influence on the development of diaphragm fiber atrophy. BACKGROUND Diaphragm dysfunction and atrophy develop during prolonged controlled mechanical ventilation. Fiber atrophy has been attributed to activation of the proteasome and autophagy proteolytic pathways. Oxidative stress activates the proteasome during controlled mechanical ventilation, but it is unclear whether it also activates autophagy. This study investigated whether pretreatment with the antioxidant N-acetylcysteine affects controlled mechanical ventilation-induced diaphragm contractile dysfunction, fiber atrophy, and proteasomal and autophagic pathway activation. The study also explored whether proteolytic pathway activity during controlled mechanical ventilation is mediated by microRNAs that negatively regulate ubiquitin E3 ligases and autophagy-related genes. METHODS Three groups of adult male rats were studied (n = 10 per group). The animals in the first group were anesthetized and allowed to spontaneously breathe. Animals in the second group were pretreated with saline before undergoing controlled mechanical ventilation for 24 h. The animals in the third group were pretreated with N-acetylcysteine (150 mg/kg) before undergoing controlled mechanical ventilation for 24 h. Diaphragm contractility and activation of the proteasome and autophagy pathways were measured. Expressions of microRNAs that negatively regulate ubiquitin E3 ligases and autophagy-related genes were measured with quantitative polymerase chain reaction. RESULTS Controlled mechanical ventilation decreased diaphragm twitch force from 428 ± 104 g/cm (mean ± SD) to 313 ± 50 g/cm and tetanic force from 2,491 ± 411 g/cm to 1,618 ± 177 g/cm. Controlled mechanical ventilation also decreased diaphragm fiber size, increased expression of several autophagy genes, and augmented Atrogin-1, MuRF1, and Nedd4 expressions by 36-, 41-, and 8-fold, respectively. Controlled mechanical ventilation decreased the expressions of six microRNAs (miR-20a, miR-106b, miR-376, miR-101a, miR-204, and miR-93) that regulate autophagy genes. Pretreatment with N-acetylcysteine prevented diaphragm contractile dysfunction, attenuated protein ubiquitination, and downregulated E3 ligase and autophagy gene expression. It also reversed controlled mechanical ventilation-induced microRNA expression decreases. N-Acetylcysteine pretreatment had no affect on fiber atrophy. CONCLUSIONS Prolonged controlled mechanical ventilation activates the proteasome and autophagy pathways in the diaphragm through oxidative stress. Pathway activation is accomplished, in part, through inhibition of microRNAs that negatively regulate autophagy-related genes.
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Molina Peña ME, Sánchez CM, Rodríguez-Triviño CY. Physiopathological mechanisms of diaphragmatic dysfunction associated with mechanical ventilation. ACTA ACUST UNITED AC 2020; 67:195-203. [PMID: 31982168 DOI: 10.1016/j.redar.2019.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 12/06/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
Ventilator-induced diaphragm dysfunction (VIDD) is the loss of diaphragmatic muscle strength'related to of mechanical ventilation, noticed during the first day or 48hours after initiating controlled mechanical ventilation. This alteration has been related to disruption on the insulin growth factor/phosphoinositol 3-kinase/kinase B protein pathway (IGF/PI3K/AKT), in addition to an overexpression of FOXO, expression of NF-kB signaling, increase function of muscular ubiquitin ligase and activation of caspasa-3. VIDD has a negative impact on quality of life, duration of mechanical ventilation, and hospitalization stance and cost. More studies are necessary to understated the process and impact of VIDD. This is a narrative review of non-systematic literature, aiming to explain the molecular pathways involved in VIDD.
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Affiliation(s)
- M E Molina Peña
- Semillero de Fisiología Pr ctica aplicada, Grupo Navarra Medicina, Departamento de Ciencias Fisiológicas, Facultad de Ciencias de la Salud, Fundación Universitaria Navarra-UNINAVARRA, Neiva, Huila, Colombia.
| | - C M Sánchez
- Semillero de Fisiología Pr ctica aplicada, Grupo Navarra Medicina, Departamento de Ciencias Fisiológicas, Facultad de Ciencias de la Salud, Fundación Universitaria Navarra-UNINAVARRA, Neiva, Huila, Colombia
| | - C Y Rodríguez-Triviño
- Grupo Navarra Medicina, Departamento de Ciencias Fisiológicas, Facultad de Ciencias de la Salud, Fundación Universitaria Navarra-UNINAVARRA, Neiva, Huila, Colombia; Grupo Cuidar, Facultad de Ciencias de la Salud, Universidad Surcolombiana, Neiva, Huila, Colombia
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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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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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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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Magalhães PA, Camillo CA, Langer D, Andrade LB, Duarte MDCM, Gosselink R. Weaning failure and respiratory muscle function: What has been done and what can be improved? Respir Med 2018; 134:54-61. [DOI: 10.1016/j.rmed.2017.11.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 09/18/2017] [Accepted: 11/28/2017] [Indexed: 02/03/2023]
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Vassilakopoulos T, Petrof BJ. A Stimulating Approach to Ventilator-induced Diaphragmatic Dysfunction. Am J Respir Crit Care Med 2017; 169:336-41. [PMID: 14739134 DOI: 10.1164/rccm.200304-489cp] [Citation(s) in RCA: 288] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Acceleration sensors in abdominal wall position as a non-invasive approach to detect early breathing alterations induced by intolerance of increased airway resistance. J Cardiothorac Surg 2017; 12:96. [PMID: 29126451 PMCID: PMC5681836 DOI: 10.1186/s13019-017-0658-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 11/01/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early detection of respiratory overload is crucial to mechanically ventilated patients, especially during phases of spontaneous breathing. Although a diversity of methods and indices has been established, there is no highly specific approach to predict respiratory failure. This study aimed to evaluate acceleration sensors in abdominal and thoracic wall positions to detect alterations in breathing excursions in a setting of gradual increasing airway resistance. METHODS Twenty-nine healthy volunteers were committed to a standardized protocol of a two-minutes step-down spontaneous breathing on a 5 mm, 4 mm and then 3 mm orally placed endotracheal tube. Accelerator sensors in thoracic and abdominal wall position monitored breathing excursions. 15 participants passed the breathing protocol ("completed" group), 14 individuals cancelled the protocol due to subjective intolerance to the increasing airway resistance ("abandoned" group). RESULTS Gradual increased respiratory workload led to a significant decrease of acceleration in abdominal wall position in the "abandoned" group compared to the "completed" group (p < 0.001), while these gradual accelerating changes were not observed in thoracic wall position (p = 0.484). Thoracic acceleration sensors did not detect any time- and group-specific changes (p = 0.746). CONCLUSIONS The abdominal wall position of the acceleration sensors may be a non-invasive, economical and practical approach to detect early breathing alterations prior to respiratory failure. TRIAL REGISTRATION EK 309-15; by the Ethics Committee of the Faculty of Medicine, RWTH Aachen, Aachen, Germany. Retrospectively registered 28th of December 2015.
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Berger D, Bloechlinger S, von Haehling S, Doehner W, Takala J, Z'Graggen WJ, Schefold JC. Dysfunction of respiratory muscles in critically ill patients on the intensive care unit. J Cachexia Sarcopenia Muscle 2016; 7:403-12. [PMID: 27030815 PMCID: PMC4788634 DOI: 10.1002/jcsm.12108] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Revised: 12/18/2015] [Accepted: 01/27/2016] [Indexed: 12/13/2022] Open
Abstract
Muscular weakness and muscle wasting may often be observed in critically ill patients on intensive care units (ICUs) and may present as failure to wean from mechanical ventilation. Importantly, mounting data demonstrate that mechanical ventilation itself may induce progressive dysfunction of the main respiratory muscle, i.e. the diaphragm. The respective condition was termed 'ventilator-induced diaphragmatic dysfunction' (VIDD) and should be distinguished from peripheral muscular weakness as observed in 'ICU-acquired weakness (ICU-AW)'. Interestingly, VIDD and ICU-AW may often be observed in critically ill patients with, e.g. severe sepsis or septic shock, and recent data demonstrate that the pathophysiology of these conditions may overlap. VIDD may mainly be characterized on a histopathological level as disuse muscular atrophy, and data demonstrate increased proteolysis and decreased protein synthesis as important underlying pathomechanisms. However, atrophy alone does not explain the observed loss of muscular force. When, e.g. isolated muscle strips are examined and force is normalized for cross-sectional fibre area, the loss is disproportionally larger than would be expected by atrophy alone. Nevertheless, although the exact molecular pathways for the induction of proteolytic systems remain incompletely understood, data now suggest that VIDD may also be triggered by mechanisms including decreased diaphragmatic blood flow or increased oxidative stress. Here we provide a concise review on the available literature on respiratory muscle weakness and VIDD in the critically ill. Potential underlying pathomechanisms will be discussed before the background of current diagnostic options. Furthermore, we will elucidate and speculate on potential novel future therapeutic avenues.
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Affiliation(s)
- David Berger
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
| | - Stefan Bloechlinger
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland; Department of Clinical Cardiology, Inselspital University Hospital of Bern Bern Switzerland
| | - Stephan von Haehling
- Department of Cardiology and Center for Innovative Clinical Trials University of Göttingen Göttingen Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin Charite Universitätsmedizin Berlin Berlin Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
| | - Werner J Z'Graggen
- Department of Neurosurgery and Dept. of Neurology, Inselspital University Hospital of Bern Bern Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital University Hospital of Bern Bern Switzerland
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Bruells CS, Breuer T, Maes K, Bergs I, Bleilevens C, Marx G, Weis J, Gayan-Ramirez G, Rossaint R. Influence of weaning methods on the diaphragm after mechanical ventilation in a rat model. BMC Pulm Med 2016; 16:127. [PMID: 27558126 PMCID: PMC4997706 DOI: 10.1186/s12890-016-0285-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 08/11/2016] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Mechanical ventilation (MV) is associated with diaphragm weakness, a phenomenon termed ventilator-induced diaphragmatic dysfunction. Weaning should balance diaphragmatic loading as well as prevention of overload after MV. The weaning methods pressure support ventilation (PSV) and spontaneous breathing trials (SBT) lead to gradual or intermittent reloading of a weak diaphragm, respectively. This study investigated which weaning method allows more efficient restoration of diaphragm homeostasis. METHODS Rats (n = 8 per group) received 12 h of MV followed by either 12 h of pressure support ventilation (PSV) or intermittent spontaneous breathing trials (SBT) and were compared to rats euthanized after 12 h MV (CMV) and to acutely euthanized rats (CON). Force generation, activity of calpain-1 and caspase-3, oxidative stress, and markers of protein synthesis (phosphorylated AKT to total AKT) were measured in the diaphragm. RESULTS Reduction of diaphragmatic force caused by CMV compared to CON was worsened with PSV and SBT (both p < 0.05 vs. CON and CMV). Both PSV and SBT reversed oxidative stress and calpain-1 activation caused by CMV. Reduced pAKT/AKT was observed after CMV and both weaning procedures. CONCLUSIONS MV resulted in a loss of diaphragmatic contractility, which was aggravated in SBT and PSV despite reversal of oxidative stress and proteolysis.
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Affiliation(s)
- Christian S Bruells
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Thomas Breuer
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany. .,Department of Anaesthesiology, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Karen Maes
- Laboratory of Pneumology, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Ingmar Bergs
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Christian Bleilevens
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Gernot Marx
- Department of Intensive and Intermediate Care, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Joachim Weis
- Institute of Neuropathology, University Hospital of the RWTH Aachen, Aachen, Germany
| | | | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Germany
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Hussain SNA, Cornachione AS, Guichon C, Al Khunaizi A, de Souza Leite F, Petrof BJ, Mofarrahi M, Moroz N, de Varennes B, Goldberg P, Rassier DE. Prolonged controlled mechanical ventilation in humans triggers myofibrillar contractile dysfunction and myofilament protein loss in the diaphragm. Thorax 2016; 71:436-45. [DOI: 10.1136/thoraxjnl-2015-207559] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Accepted: 01/06/2016] [Indexed: 12/16/2022]
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McCrory MC, Lee KJ, Scanlon MC, Wakeham MK. Predictors of need for mechanical ventilation at discharge after tracheostomy in the PICU. Pediatr Pulmonol 2016; 51:53-9. [PMID: 25823590 DOI: 10.1002/ppul.23195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 01/21/2015] [Accepted: 02/23/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The objective of this study was to determine factors predictive of need for mechanical ventilation (MV) upon discharge from the pediatric intensive care unit (PICU) among patients who receive a tracheostomy during their stay. METHODS This was a retrospective cohort study using the Virtual PICU Systems (VPS) database. Patients <18 years old admitted between 2009-2011 who required MV for at least 3 days and received a tracheostomy during their PICU stay were included. RESULTS A total of 680 pediatric patients from 74 PICUs were included, of whom 347 (51%) remained on MV at the time of PICU discharge. Neonates (30/38, 79%) and infants (129/203, 64%) required MV at PICU discharge after tracheostomy more often than adolescents (66/141, 47%) and children (122/298, 41%). Time on MV pre-tracheostomy was longer among those who required MV at discharge (median 18.3 vs. 13.8 days, P < 0.0001); however, number of failed extubations was similar (median 1 for both groups, P = 0.97). On mixed-effects multivariable regression analysis, the age categories of neonate (OR 2.9, 95%CI 1.1-7.6, P = 0.03), and infant (OR 1.7, 95%CI 1.1-2.8, P = 0.03), and ventilator days prior to tracheostomy (OR 1.01, 95%CI 1.0-1.02, P = 0.01) were significantly associated with increased odds of MV upon PICU discharge, while being a trauma admission was associated with decreased odds (OR 0.45, 95%CI 0.28-0.73, P = 0.001). CONCLUSIONS Younger patients and those with prolonged courses of MV prior to tracheostomy are more likely to continue to need MV upon PICU discharge.
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Affiliation(s)
- Michael C McCrory
- Section on Pediatric Critical Care Medicine, Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - K Jane Lee
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew C Scanlon
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Martin K Wakeham
- Department of Pediatrics, Division of Pediatric Critical Care, Medical College of Wisconsin, Milwaukee, Wisconsin
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Breuer T, Maes K, Rossaint R, Marx G, Scheers H, Bergs I, Bleilevens C, Gayan-Ramirez G, Bruells CS. Sevoflurane Exposure Prevents Diaphragmatic Oxidative Stress During Mechanical Ventilation but Reduces Force and Affects Protein Metabolism Even During Spontaneous Breathing in a Rat Model. Anesth Analg 2015; 121:73-80. [DOI: 10.1213/ane.0000000000000736] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Hooijman PE, Paul MA, Stienen GJM, Beishuizen A, Van Hees HWH, Singhal S, Bashir M, Budak MT, Morgen J, Barsotti RJ, Levine S, Ottenheijm CAC. Unaffected contractility of diaphragm muscle fibers in humans on mechanical ventilation. Am J Physiol Lung Cell Mol Physiol 2014; 307:L460-70. [PMID: 25038190 DOI: 10.1152/ajplung.00076.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Several studies have indicated that diaphragm dysfunction develops in patients on mechanical ventilation (MV). Here, we tested the hypothesis that the contractility of sarcomeres, i.e., the smallest contractile unit in muscle, is affected in humans on MV. To this end, we compared diaphragm muscle fibers of nine brain-dead organ donors (cases) that had been on MV for 26 ± 5 h with diaphragm muscle fibers from nine patients (controls) undergoing surgery for lung cancer that had been on MV for less than 2 h. In each diaphragm specimen we determined 1) muscle fiber cross-sectional area in cryosections by immunohistochemical methods and 2) the contractile performance of permeabilized single muscle fibers by means of maximum specific force, kinetics of cross-bridge cycling by rate of tension redevelopment, myosin heavy chain content and concentration, and calcium sensitivity of force of slow-twitch and fast-twitch muscle fibers. In case subjects, we noted no statistically significant decrease in outcomes compared with controls in slow-twitch or fast-twitch muscle fibers. These observations indicate that 26 h of MV of humans is not invariably associated with changes in the contractile performance of sarcomeres in the diaphragm.
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Affiliation(s)
| | | | - Ger J M Stienen
- Departments of Physiology, Faculty of Science, Department of Physics and Astronomy, Vrije Universiteit, Amsterdam, The Netherlands
| | - Albertus Beishuizen
- Intensive Care, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Hieronymus W H Van Hees
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Muhammad Bashir
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Murat T Budak
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Jacqueline Morgen
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Robert J Barsotti
- Department of Physiology, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Sanford Levine
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Gift of Life Donor Program, Philadelphia, Pennsylvania; and
| | - Coen A C Ottenheijm
- Departments of Physiology, Department of Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
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Sedation using propofol induces similar diaphragm dysfunction and atrophy during spontaneous breathing and mechanical ventilation in rats. Anesthesiology 2014; 120:665-72. [PMID: 24401770 DOI: 10.1097/aln.0000000000000125] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mechanical ventilation is crucial for patients with respiratory failure. The mechanical takeover of diaphragm function leads to diaphragm dysfunction and atrophy (ventilator-induced diaphragmatic dysfunction), with an increase in oxidative stress as a major contributor. In most patients, a sedative regimen has to be initiated to allow tube tolerance and ventilator synchrony. Clinical data imply a correlation between cumulative propofol dosage and diaphragm dysfunction, whereas laboratory investigations have revealed that propofol has some antioxidant properties. The authors hypothesized that propofol reduces markers of oxidative stress, atrophy, and contractile dysfunction in the diaphragm. METHODS Male Wistar rats (n = 8 per group) were subjected to either 24 h of mechanical ventilation or were undergone breathing spontaneously for 24 h under propofol sedation to test for drug effects. Another acutely sacrificed group served as controls. After sacrifice, diaphragm tissue was removed, and contractile properties, cross-sectional areas, oxidative stress, and proteolysis were examined. The gastrocnemius served as internal control. RESULTS Propofol did not protect against diaphragm atrophy, oxidative stress, and protease activation. The decrease in tetanic force compared with controls was similar in the spontaneous breathing group (31%) and in the ventilated group (34%), and both groups showed the same amount of muscle atrophy. The gastrocnemius muscle fibers did not show atrophy. CONCLUSIONS Propofol does not protect against ventilator-induced diaphragmatic dysfunction or oxidative injury. Notably, spontaneous breathing under propofol sedation resulted in the same amount of diaphragm atrophy and dysfunction although diaphragm activation per se protects against ventilator-induced diaphragmatic dysfunction. This makes a drug effect of propofol likely.
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Song Y, Demmer DL, Pinniger GJ, Lavin T, MacMillan MV, Pillow JJ, Bakker AJ. Effect of maternal steroid on developing diaphragm integrity. PLoS One 2014; 9:e93224. [PMID: 24681552 PMCID: PMC3969349 DOI: 10.1371/journal.pone.0093224] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2013] [Accepted: 03/03/2014] [Indexed: 01/21/2023] Open
Abstract
Antenatal steroids reduce the severity of initial respiratory distress of premature newborn babies but may have an adverse impact on other body organs. The study aimed to examine the effect of maternal steroids on postnatal respiratory muscle function during development and elucidate the mechanisms underlying the potential myopathy in newborn rats. Pregnant rats were treated with intramuscular injections of 0.5 mg/kg betamethasone 7 d and 3 d before birth. Newborn diaphragms were dissected for assessment of contractile function at 2 d, 7 d or 21 d postnatal age (PNA), compared with age-matched controls. The expression of myosin heavy chain (MHC) isoforms and atrophy-related genes and activity of intracellular molecular signalling were measured using quantitative PCR and/or Western blot. With advancing PNA, neonatal MHC gene expression decreased progressively while MHC IIb and IIx isoforms increased. Protein metabolic signalling showed high baseline activity at 2 d PNA, and significantly declined at 7 d and 21 d. Antenatal administration of betamethasone significantly decreased diaphragm force production, fatigue resistance, total fast fibre content and anabolic signalling activity (Akt and 4E-BP1) in 21 d diaphragm. These responses were not observed in 2 d or 7 d postnatal diaphragm. Results demonstrate that maternal betamethasone treatment causes postnatal diaphragmatic dysfunction at 21 d PNA, which is attributed to MHC II protein loss and impairment of the anabolic signalling pathway. Developmental modifications in MHC fibre composition and protein signalling account for the age-specific diaphragm dysfunction.
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Affiliation(s)
- Yong Song
- School of Anatomy, Physiology and Human Biology, The University of Western Australia, Perth, Western Australia, Australia
- Centre for Neonatal Research and Education, School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Denise L. Demmer
- School of Anatomy, Physiology and Human Biology, The University of Western Australia, Perth, Western Australia, Australia
| | - Gavin J. Pinniger
- School of Anatomy, Physiology and Human Biology, The University of Western Australia, Perth, Western Australia, Australia
| | - Tina Lavin
- School of Anatomy, Physiology and Human Biology, The University of Western Australia, Perth, Western Australia, Australia
- Centre for Neonatal Research and Education, School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Mia V. MacMillan
- School of Anatomy, Physiology and Human Biology, The University of Western Australia, Perth, Western Australia, Australia
| | - Jane J. Pillow
- School of Anatomy, Physiology and Human Biology, The University of Western Australia, Perth, Western Australia, Australia
- Centre for Neonatal Research and Education, School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
- Women and Newborns Health Service, c/-King Edward Memorial and Princess Margaret Hospitals, Perth, Western Australia, Australia
| | - Anthony J. Bakker
- School of Anatomy, Physiology and Human Biology, The University of Western Australia, Perth, Western Australia, Australia
- * E-mail:
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Bruells CS, Maes K, Rossaint R, Thomas D, Cielen N, Bleilevens C, Bergs I, Loetscher U, Dreier A, Gayan-Ramirez G, Behnke BJ, Weis J. Prolonged mechanical ventilation alters the expression pattern of angio-neogenetic factors in a pre-clinical rat model. PLoS One 2013; 8:e70524. [PMID: 23950950 PMCID: PMC3738548 DOI: 10.1371/journal.pone.0070524] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 06/19/2013] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Mechanical ventilation (MV) is a life saving intervention for patients with respiratory failure. Even after 6 hours of MV, diaphragm atrophy and dysfunction (collectively referred to as ventilator-induced diaphragmatic dysfunction, VIDD) occurs in concert with a blunted blood flow and oxygen delivery. The regulation of hypoxia sensitive factors (i.e. hypoxia inducible factor 1α, 2α (HIF-1α,-2α), vascular endothelial growth factor (VEGF)) and angio-neogenetic factors (angiopoietin 1-3, Ang) might contribute to reactive and compensatory alterations in diaphragm muscle. METHODS Male Wistar rats (n = 8) were ventilated for 24 hours or directly sacrificed (n = 8), diaphragm and mixed gastrocnemius muscle tissue was removed. Quantitative real time PCR and western blot analyses were performed to detect changes in angio-neogenetic factors and inflammatory markers. Tissues were stained using Isolectin (IB 4) to determine capillarity and calculate the capillary/fiber ratio. RESULTS MV resulted in up-regulation of Ang 2 and HIF-1α mRNA in both diaphragm and gastrocnemius, while VEGF mRNA was down-regulated in both tissues. HIF-2α mRNA was reduced in both tissues, while GLUT 4 mRNA was increased in gastrocnemius and reduced in diaphragm samples. Protein levels of VEGF, HIF-1α, -2α and 4 did not change significantly. Additionally, inflammatory cytokine mRNA (Interleukin (IL)-6, IL-1β and TNF α) were elevated in diaphragm tissue. CONCLUSION The results demonstrate that 24 hrs of MV and the associated limb disuse induce an up-regulation of angio-neogenetic factors that are connected to HIF-1α. Changes in HIF-1α expression may be due to several interactions occurring during MV.
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Affiliation(s)
- Christian S Bruells
- Department of Anesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany.
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Oliveira ADSB, Costa LB, Assis TDO, Mota DLD, França EÉTD, Araújo Filho JCD, Rosas STP, Medeiros PLD. Effects of controlled and pressure support mechanical ventilation on rat diaphragm muscle. Acta Cir Bras 2013; 27:109-16. [PMID: 22378364 DOI: 10.1590/s0102-86502012000200003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2011] [Accepted: 12/20/2011] [Indexed: 11/22/2022] Open
Abstract
PURPOSE The objective of this study was to analyze the effects of Pressure Controlled Ventilation mode (PCV-C) and PSV mode in diaphragm muscle of rats. METHODS Wistar rats (n=18) were randomly assigned to the control group or to receive 6 hours of PCV and PSV. After this period, animals were euthanized and their diaphragms were excised, frozen in liquid nitrogen and stored in at -80º C for further histomorphometric analysis. RESULTS Results showed a 15% decrease in cross-sectional area of muscle fibers on the PCV-C group when compared to the control group (p<0.001) and by 10% when compared to the PSV group (p<0.05). Minor diameter was decreased in PCV-C group by 9% when compared with the control group (p<0.001) and by 6% when compared to the PSV group (p<0.05). When myonuclear area was analyzed, a 16% decrease was observed in the PCV-C group when compared to the PSV group (p<0.05). No significant difference between the groups was observed in myonuclear perimeter (p>0.05). CONCLUSION Short-term controlled mechanical ventilation seems to lead to muscular atrophy in diaphragm fibers. The PSV mode may attenuate the effects of VIDD.
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Abstract
Muscle plasticity is defined as the ability of a given muscle to alter its structural and functional properties in accordance with the environmental conditions imposed on it. As such, respiratory muscle is in a constant state of remodeling, and the basis of muscle's plasticity is its ability to change protein expression and resultant protein balance in response to varying environmental conditions. Here, we will describe the changes of respiratory muscle imposed by extrinsic changes in mechanical load, activity, and innervation. Although there is a large body of literature on the structural and functional plasticity of respiratory muscles, we are only beginning to understand the molecular-scale protein changes that contribute to protein balance. We will give an overview of key mechanisms regulating protein synthesis and protein degradation, as well as the complex interactions between them. We suggest future application of a systems biology approach that would develop a mathematical model of protein balance and greatly improve treatments in a variety of clinical settings related to maintaining both muscle mass and optimal contractile function of respiratory muscles.
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Affiliation(s)
- Heather M Gransee
- Department of Physiology & Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
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21
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Tang H, Lee M, Budak MT, Pietras N, Hittinger S, Vu M, Khuong A, Hoang CD, Hussain SNA, Levine S, Shrager JB. Intrinsic apoptosis in mechanically ventilated human diaphragm: linkage to a novel Fos/FoxO1/Stat3-Bim axis. FASEB J 2011; 25:2921-36. [PMID: 21597002 DOI: 10.1096/fj.11-183798] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Mechanical ventilation (MV) is a life-saving measure in many critically ill patients. However, prolonged MV results in diaphragm dysfunction that contributes to the frequent difficulty in weaning patients from the ventilator. The molecular mechanisms underlying ventilator-induced diaphragm dysfunction (VIDD) remain poorly understood. We report here that MV induces myonuclear DNA fragmentation (3-fold increase; P<0.01) and selective activation of caspase 9 (P<0.05) and Bcl2-interacting mediator of cell death (Bim; 2- to 7-fold increase; P<0.05) in human diaphragm. MV also statistically significantly down-regulates mitochondrial gene expression and induces oxidative stress. In cultured muscle cells, we show that oxidative stress activates each of the catabolic pathways thought to underlie VIDD: apoptotic (P<0.05), proteasomal (P<0.05), and autophagic (P<0.01). Further, silencing Bim expression blocks (P<0.05) oxidative stress-induced apoptosis. Overlapping the gene expression profiles of MV human diaphragm and H₂O₂-treated muscle cells, we identify Fos, FoxO1, and Stat3 as regulators of Bim expression as well as of expression of the catabolic markers atrogin and LC3. We thus identify a novel Fos/FoxO1/Stat3-Bim intrinsic apoptotic pathway and establish the centrality of oxidative stress in the development of VIDD. This information may help in the design of specific drugs to prevent this condition.
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Affiliation(s)
- Huibin Tang
- Division of Thoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
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Hussain SNA, Mofarrahi M, Sigala I, Kim HC, Vassilakopoulos T, Maltais F, Bellenis I, Chaturvedi R, Gottfried SB, Metrakos P, Danialou G, Matecki S, Jaber S, Petrof BJ, Goldberg P. Mechanical ventilation-induced diaphragm disuse in humans triggers autophagy. Am J Respir Crit Care Med 2010; 182:1377-86. [PMID: 20639440 DOI: 10.1164/rccm.201002-0234oc] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Controlled mechanical ventilation (CMV) results in atrophy of the human diaphragm. The autophagy-lysosome pathway (ALP) contributes to skeletal muscle proteolysis, but its contribution to diaphragmatic protein degradation in mechanically ventilated patients is unknown. OBJECTIVES To evaluate the autophagy pathway responses to CMV in the diaphragm and limb muscles of humans and to identify the roles of FOXO transcription factors in these responses. METHODS Muscle biopsies were obtained from nine control subjects and nine brain-dead organ donors. Subjects were mechanically ventilated for 2 to 4 hours and 15 to 276 hours, respectively. Activation of the ubiquitin-proteasome system was detected by measuring mRNA expressions of Atrogin-1, MURF1, and protein expressions of UBC2, UBC4, and the α subunits of the 20S proteasome (MCP231). Activation of the ALP was detected by electron microscopy and by measuring the expressions of several autophagy-related genes. Total carbonyl content and HNE-protein adduct formation were measured to assess oxidative stress. Total AKT, phosphorylated and total FOXO1, and FOXO3A protein levels were also measured. MEASUREMENTS AND MAIN RESULTS Prolonged CMV triggered activation of the ALP as measured by the appearance of autophagosomes in the diaphragm and increased expressions of autophagy-related genes, as compared with controls. Induction of autophagy was associated with increased protein oxidation and enhanced expression of the FOXO1 gene, but not the FOXO3A gene. CMV also triggered the inhibition of both AKT expression and FOXO1 phosphorylation. CONCLUSIONS We propose that prolonged CMV causes diaphragm disuse, which, in turn, leads to activation of the ALP through oxidative stress and the induction of the FOXO1 transcription factor.
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Abstract
OBJECTIVE To review current knowledge about the impact of prolonged mechanical ventilation on diaphragmatic function and biology. MEASUREMENTS Systematic literature review. CONCLUSIONS Prolonged mechanical ventilation can promote diaphragmatic atrophy and contractile dysfunction. As few as 18 hrs of mechanical ventilation results in diaphragmatic atrophy in both laboratory animals and humans. Prolonged mechanical ventilation is also associated with diaphragmatic contractile dysfunction. Studies using animal models revealed that mechanical ventilation-induced diaphragmatic atrophy is due to increased diaphragmatic protein breakdown and decreased protein synthesis. Recent investigations have identified calpain, caspase-3, and the ubiquitin-proteasome system as key proteases that contribute to mechanical ventilation-induced diaphragmatic proteolysis. The scientific challenge for the future is to delineate the mechanical ventilation-induced signaling pathways that activate these proteases and depress protein synthesis in the diaphragm. Future investigations that define the signaling mechanisms responsible for mechanical ventilation-induced diaphragmatic weakness will provide the knowledge required for the development of new medicines that can maintain diaphragmatic mass and function during prolonged mechanical ventilation.
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Abstract
In septic patients increased central drive and increased metabolic demands combine to increase energy demands on the ventilatory muscles. This occurs at a time when energy supplies are limited and energy production hindered, and it leads to an energy supply-demand imbalance and often ventilatory failure. Problems related to contractile function of the ventilatory muscles also contribute, especially when the clinical course is prolonged. The increased ventilatory activity increases interactions between the ventilatory and cardiovascular systems, and when ventilatory muscles fail and mechanical ventilatory support is required a new set of problems emerges. In this review I discuss factors related to ventilatory muscle failure, giving emphasis to mechanical and supply demand aspects. I also review the implications of changes in ventilatory patterns for heart-lung interactions.
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Affiliation(s)
- Sheldon Magder
- Department of Medicine, Division of Critical Care, McGill University Health Centre, Montreal, Quebec, Canada.
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26
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Lopes FDS, Carvalho RF, Campos GER, Sugizaki MM, Padovani CR, Nogueira CR, Cicogna AC, Pai-Silva MD. Down-regulation of MyoD gene expression in rat diaphragm muscle with heart failure. Int J Exp Pathol 2008; 89:216-22. [PMID: 18460074 DOI: 10.1111/j.1365-2613.2008.00587.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Diaphragm myopathy has been described in patients with heart failure (HF), with alterations in myosin heavy chains (MHC) expression. The pathways that regulate MHC expression during HF have not been described, and myogenic regulatory factors (MRFs) may be involved. The purpose of this investigation was to determine MRF mRNA expression levels in the diaphragm. Diaphragm muscle from both HF and control Wistar rats was studied when overt HF had developed, 22 days after monocrotaline administration. MyoD, myogenin and MRF4 gene expression were determined by RT-PCR and MHC isoforms by polyacrylamide gel electrophoresis. Heart failure animals presented decreased MHC IIa/IIx protein isoform and MyoD gene expression, without altering MHC I, IIb, myogenin and MRF4. Our results show that in HF, MyoD is selectively down-regulated, which might be associated with alterations in MHC IIa/IIx content. These changes are likely to contribute to the diaphragm myopathy caused by HF.
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Vassilakopoulos T. Ventilator-induced diaphragm dysfunction: the clinical relevance of animal models. Intensive Care Med 2007; 34:7-16. [DOI: 10.1007/s00134-007-0866-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 08/28/2007] [Indexed: 11/25/2022]
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Maes K, Testelmans D, Powers S, Decramer M, Gayan-Ramirez G. Leupeptin Inhibits Ventilator-induced Diaphragm Dysfunction in Rats. Am J Respir Crit Care Med 2007; 175:1134-8. [PMID: 17379854 DOI: 10.1164/rccm.200609-1342oc] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Controlled mechanical ventilation (CMV) has been shown to result in elevated diaphragmatic proteolysis and atrophy together with diaphragmatic contractile dysfunction. OBJECTIVES To test whether administration of leupeptin, an inhibitor of lysosomal proteases and calpain, concomitantly with 24 hours of CMV, would protect the diaphragm from the deleterious effects of mechanical ventilation. METHODS Rats were assigned to either a control group or 24 hours of CMV; animals in the ventilation group received either a single intramuscular injection of saline or 15 mg/kg of the protease inhibitor, leupeptin. MEASUREMENTS AND MAIN RESULTS Compared with control animals, mechanical ventilation resulted in a significant reduction of the in vitro diaphragm-specific force production at all stimulation frequencies. Leupeptin completely prevented this reduction in force generation. Atrophy of type IIx/b fibers was present after CMV, but not after treatment with leupeptin. Cathepsin B and calpain activities were significantly higher after CMV compared with the other groups; this was abolished by treatment with leupeptin. Significant inverse correlations were found between diaphragmatic force generation and cathepsin B and calpain activity, and illustrate the deleterious role of proteolysis in diminishing diaphragmatic force production after prolonged CMV. CONCLUSIONS Administration of the protease inhibitor leupeptin concomitantly with mechanical ventilation completely prevented ventilation-induced diaphragmatic contractile dysfunction and atrophy.
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Affiliation(s)
- Karen Maes
- Respiratory Muscle Research Unit, Laboratory of Pneumology, Katholieke Universiteit Leuven, Leuven, Belgium
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29
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Vassilakopoulos T, Zakynthinos S, Roussos C. Bench-to-bedside review: weaning failure--should we rest the respiratory muscles with controlled mechanical ventilation? Crit Care 2006; 10:204. [PMID: 16356210 PMCID: PMC1550863 DOI: 10.1186/cc3917] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The use of controlled mechanical ventilation (CMV) in patients who experience weaning failure after a spontaneous breathing trial or after extubation is a strategy based on the premise that respiratory muscle fatigue (requiring rest to recover) is the cause of weaning failure. Recent evidence, however, does not support the existence of low frequency fatigue (the type of fatigue that is long-lasting) in patients who fail to wean despite the excessive respiratory muscle load. This is because physicians have adopted criteria for the definition of spontaneous breathing trial failure and thus termination of unassisted breathing, which lead them to put patients back on the ventilator before the development of low frequency respiratory muscle fatigue. Thus, no reason exists to completely unload the respiratory muscles with CMV for low frequency fatigue reversal if weaning is terminated based on widely accepted predefined criteria. This is important, since experimental evidence suggests that CMV can induce dysfunction of the diaphragm, resulting in decreased diaphragmatic force generating capacity, which has been called ventilator-induced diaphragmatic dysfunction (VIDD). The mechanisms of VIDD are not fully elucidated, but include muscle atrophy, oxidative stress and structural injury. Partial modes of ventilatory support should be used whenever possible, since these modes attenuate the deleterious effects of mechanical ventilation on respiratory muscles. When CMV is used, concurrent administration of antioxidants (which decrease oxidative stress and thus attenuate VIDD) seems justified, since antioxidants may be beneficial (and are certainly not harmful) in critical care patients.
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Affiliation(s)
- Theodoros Vassilakopoulos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Spyros Zakynthinos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Charis Roussos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
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Gayan-Ramirez G, Testelmans D, Maes K, Rácz GZ, Cadot P, Zádor E, Wuytack F, Decramer M. Intermittent spontaneous breathing protects the rat diaphragm from mechanical ventilation effects. Crit Care Med 2006; 33:2804-9. [PMID: 16352963 DOI: 10.1097/01.ccm.0000191250.32988.a3] [Citation(s) in RCA: 107] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Short-term mechanical ventilation has been proven to reduce diaphragm force and fiber dimensions. We hypothesized that intermittent spontaneous breathing during the course of mechanical ventilation would minimize the effects of mechanical ventilation on diaphragm force and expression levels of transcription factors (MyoD and myogenin). DESIGN Randomized, controlled experiment. SETTING Animal basic science laboratory. SUBJECTS Male Wistar rats, weighing 350-500 g. INTERVENTIONS Anesthetized and tracheotomized rats were submitted to either 24 hrs of spontaneous breathing (SB, n = 5), 24 hrs of continuous controlled mechanical ventilation (CMV, n = 7), or controlled mechanical ventilation with intermittent spontaneous breathing: 60 mins every 5 hrs of mechanical ventilation repeated four times (ISB60, n = 8) or 5 mins every 5 hrs 55 mins of mechanical ventilation repeated four times (SB5, n = 9). They were compared with control animals free from intervention (C, n = 5). MEASUREMENTS AND MAIN RESULTS The profile of the diaphragm force-frequency curve of the controls and SB group was significantly different from that of the ISB and CMV groups; especially, the mean asymptotic force was less in the ISB and CMV compared with controls and SB. CMV resulted in a significant decrease in the diaphragm type I (-26%, p < .05 vs. C) and type IIx/b (-39%, p < .005 vs. C and SB) cross-sectional area, whereas this was not observed in the ISB groups. Diaphragm MyoD protein expression was significantly decreased after ISB60 (-35%, p < .0001 vs. C and SB) and even more after CMV (-73%, p < .0001 vs. others). The same pattern was observed with myogenin protein levels. Positive relationships between diaphragm MyoD and myogenin protein levels and diaphragm force were observed. CONCLUSIONS The data demonstrated that intermittent spontaneous breathing during the course of mechanical ventilation may minimize the deleterious effect of controlled mechanical ventilation on diaphragm force, fiber dimensions, and expression of transcription factors.
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Affiliation(s)
- Ghislaine Gayan-Ramirez
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, Leuven Belgium
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Rowley KL, Mantilla CB, Sieck GC. Respiratory muscle plasticity. Respir Physiol Neurobiol 2005; 147:235-51. [PMID: 15871925 DOI: 10.1016/j.resp.2005.03.003] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2005] [Revised: 03/21/2005] [Accepted: 03/22/2005] [Indexed: 11/23/2022]
Abstract
Plasticity of respiratory muscles must be considered in the context of their unique physiological demands. The continuous rhythmic activation of respiratory muscles makes them among the most active in the body. Respiratory muscles, especially the diaphragm, are non-weight-bearing, and thus, in contrast to limb muscles, are not exposed to gravitational effects. Perturbations in normal activation and load known to induce plasticity in limb muscles may not cause similar adaptations in respiratory muscles. In this review, we explore the structural and functional properties of the diaphragm muscle and their response to alterations in load and activity. Overall, relatively modest changes in diaphragm structural and functional properties occur in response to perturbations in load or activity. However, disruptions in the normal influence of phrenic innervation by frank denervation, tetrodotoxin nerve block and spinal hemisection, induce profound changes in the diaphragm, indicating the substantial trophic influence of phrenic motoneurons on diaphragm muscle.
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Affiliation(s)
- Katharine L Rowley
- Department of Physiology and Biomedical Engineering, Mayo Clinic College of Medicine, 200 First St. SW, Joseph 4-184W, Rochester, MN 55905, USA
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Jaber S, Sebbane M, Koechlin C, Hayot M, Capdevila X, Eledjam JJ, Prefaut C, Ramonatxo M, Matecki S. Effects of short vs. prolonged mechanical ventilation on antioxidant systems in piglet diaphragm. Intensive Care Med 2005; 31:1427-33. [PMID: 16041522 DOI: 10.1007/s00134-005-2694-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Accepted: 05/30/2005] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Prolonged controlled mechanical ventilation (MV) is known to induce diaphragmatic oxidative stress that seems to be an important factor reducing force-generating capacity. To better understand the cellular mechanisms involved, this work examined the effect of short vs. prolonged MV on antioxidant defense in the diaphragm. DESIGN AND SETTING Prospective, randomized, controlled animal study in a university laboratory. METHODS Eleven piglets (15-20 kg) were assigned to one of two groups: a long-MV group (n=6) ventilated for 3 days or a short-MV group (n=5) ventilated for 3 h. Force frequency curves of the transdiaphragmatic pressure (Pdi) were obtained in vivo by phrenic nerve pacing. Oxidative stress was evaluated by thiobarbituric reactive substance (TBARs) content and the enzymatic antioxidant activity of both superoxide dismutase (SOD) and glutathione peroxidase (GPx) in samples of diaphragm. RESULTS Pdi decreased in the long-MV group by 30-35% over the 3 days at all frequencies compared to the short-MV group. Diaphragm TBARs content was significantly higher and SOD activity lower in long-MV animals than in short-MV animals after 72 h. GPx activity tended to be lower in diaphragms from long-MV animals, but this difference was not significant. CONCLUSIONS This study shows that 3 days of MV in piglets is associated with a decrease in antioxidant activity which could emphasize oxidative stress and both contribute to the diaphragm dysfunction caused by MV.
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Affiliation(s)
- Samir Jaber
- Intensive Care Unit, Department of Anesthesiology: DAR B, CHU de Montpellier, Hôpital Saint Eloi, 80 avenue Augustin Fliche, 34295 Montpellier, France.
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Gayan-Ramirez GN, Decramer ML. Diaphragm antioxidant system in controlled mechanical ventilation in piglets: short term vs. prolonged mechanical ventilation response. Intensive Care Med 2005; 31:1303-5. [PMID: 16041523 DOI: 10.1007/s00134-005-2693-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2005] [Accepted: 06/27/2005] [Indexed: 11/29/2022]
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Decramer M, Gayan-Ramirez G. Ventilator-induced Diaphragmatic Dysfunction. Am J Respir Crit Care Med 2004; 170:1141-2. [PMID: 15563638 DOI: 10.1164/rccm.2409004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Affiliation(s)
- Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Loyola University of Chicago Stritch School of Medicine and Hines Veterans Affairs Hospital, Hines, IL 60141, USA.
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Tobin MJ. Sleep-Disordered Breathing, Control of Breathing, Respiratory Muscles, Pulmonary Function Testing inAJRCCM2003. Am J Respir Crit Care Med 2004; 169:254-64. [PMID: 14718239 DOI: 10.1164/rccm.2312010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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, Loyola University of Chicago Stritch School of Medicine and Hines Veterans Affairs Hospital, Hines, IL 60141, USA.
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