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Umbrello M, Brogi E, Formenti P, Corradi F, Forfori F. Ultrasonographic Features of Muscular Weakness and Muscle Wasting in Critically Ill Patients. J Clin Med 2023; 13:26. [PMID: 38202033 PMCID: PMC10780243 DOI: 10.3390/jcm13010026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 12/12/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Muscle wasting begins as soon as in the first week of one's ICU stay and patients with multi-organ failure lose more muscle mass and suffer worse functional impairment as a consequence. Muscle wasting and weakness are mainly characterized by a generalized, bilateral lower limb weakness. However, the impairment of the respiratory and/or oropharyngeal muscles can also be observed with important consequences for one's ability to swallow and cough. Muscle wasting represents the result of the disequilibrium between breakdown and synthesis, with increased protein degradation relative to protein synthesis. It is worth noting that the resulting functional disability can last up to 5 years after discharge, and it has been estimated that up to 50% of patients are not able to return to work during the first year after ICU discharge. In recent years, ultrasound has played an increasing role in the evaluation of muscle. Indeed, ultrasound allows an objective evaluation of the cross-sectional area, the thickness of the muscle, and the echogenicity of the muscle. Furthermore, ultrasound can also estimate the thickening fraction of muscle. The objective of this review is to analyze the current understanding of the pathophysiology of acute skeletal muscle wasting and to describe the ultrasonographic features of normal muscle and muscle weakness.
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Affiliation(s)
- Michele Umbrello
- Department Intensive Care and Anesthesia, ASST Ovest Milanese, Ospedale Nuovo di Legnano, 20025 Legnano, Italy
| | - Etrusca Brogi
- Department Anaesthesia and Intensive Care, University of Pisa, 56126 Pisa, Italy
| | - Paolo Formenti
- Departement of Anesthesia and Intensive Care, ASST Nord Milano, Ospedale E Bassini, 20092 Cinisello Balsamo, Italy
| | - Francesco Corradi
- Department Anaesthesia and Intensive Care, University of Pisa, 56126 Pisa, Italy
| | - Francesco Forfori
- Department Anaesthesia and Intensive Care, University of Pisa, 56126 Pisa, Italy
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Shen W, Jiang Y, Xu Y, Qian X, Jia J, Ding Y, He Y, Pan Q, Zhuang J, Ge H, Xu P. Cellular senescence contributes to mechanical ventilation-induced diaphragm dysfunction by upregulating p53 signalling pathways. BMC Pulm Med 2023; 23:509. [PMID: 38097957 PMCID: PMC10722656 DOI: 10.1186/s12890-023-02662-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 09/15/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Mechanical ventilation can cause acute atrophy and injury in the diaphragm, which are related to adverse clinical results. However, the underlying mechanisms of ventilation-induced diaphragm dysfunction (VIDD) have not been well elucidated. The current study aimed to explore the role of cellular senescence in VIDD. METHODS A total of twelve New Zealand rabbits were randomly divided into 2 groups: (1) spontaneously breathing anaesthetized animals (the CON group) and (2) mechanically ventilated animals (for 48 h) in V-ACV mode (the MV group). Respiratory parameters were collected during ventilation. Diaphragm were collected for further analyses. RESULTS Compared to those in the CON group, the percentage and density of sarcomere disruption in the MV group were much higher (p < 0.001, both). The mRNA expression of MAFbx and MuRF1 was upregulated in the MV group (p = 0.003 and p = 0.006, respectively). Compared to that in the CON group, the expression of MAFbx and MuRF1 detected by western blotting was also upregulated (p = 0.02 and p = 0.03, respectively). Moreover, RNA-seq showed that genes associated with senescence were remarkably enriched in the MV group. The mRNA expression of related genes was further verified by q-PCR (Pai1: p = 0.009; MMP9: p = 0.008). Transverse cross-sections of diaphragm myofibrils in the MV group showed more intensive positive staining of SA-βGal than those in the CON group. p53-p21 axis signalling was elevated in the MV group. The mRNA expression of p53 and p21 was significantly upregulated (p = 0.02 and p = 0.05, respectively). The western blot results also showed upregulation of p53 and p21 protein expression (p = 0.03 and p = 0.05, respectively). Moreover, the p21-positive staining in immunofluorescence and immunohistochemistry in the MV group was much more intense than that in the CON group (p < 0.001, both). CONCLUSIONS In a rabbit model, we demonstrated that mechanical ventilation in A/C mode for 48 h can still significantly induce ultrastructural damage and atrophy of the diaphragm. Moreover, p53-dependent senescence might play a role in mechanical ventilation-induced dysfunction. These findings might provide novel therapeutic targets for VIDD.
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Affiliation(s)
- Weimin Shen
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China
| | - Ye Jiang
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China
| | - Ying Xu
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China
| | - Xiaoli Qian
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China
| | - Jianwei Jia
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China
| | - Yuejia Ding
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China
| | - Yuhan He
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China
| | - Qing Pan
- College of Information Engineering, Zhejiang University of Technology, Hangzhou, 310023, China
| | - Jinyang Zhuang
- Huashan Hospital affiliated to Fudan University, Shanghai, 200040, China
| | - Huiqing Ge
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China.
| | - Peifeng Xu
- Department of Respiratory Care, Regional Medical Center for National Institute of Respiratory Diseases, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Qingchun East Rd. 3, Hangzhou, 310016, China.
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Zhang J, Feng J, Jia J, Wang X, Zhou J, Liu L. Research progress on the pathogenesis and treatment of ventilator-induced diaphragm dysfunction. Heliyon 2023; 9:e22317. [PMID: 38053869 PMCID: PMC10694316 DOI: 10.1016/j.heliyon.2023.e22317] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 11/09/2023] [Accepted: 11/09/2023] [Indexed: 12/07/2023] Open
Abstract
Prolonged controlled mechanical ventilation (CMV) can cause diaphragm fiber atrophy and inspiratory muscle weakness, resulting in diaphragmatic contractile dysfunction, called ventilator-induced diaphragm dysfunction (VIDD). VIDD is associated with higher rates of in-hospital deaths, nosocomial pneumonia, difficulty weaning from ventilators, and increased costs. Currently, appropriate clinical strategies to prevent and treat VIDD are unavailable, necessitating the importance of exploring the mechanisms of VIDD and suitable treatment options to reduce the healthcare burden. Numerous animal studies have demonstrated that ventilator-induced diaphragm dysfunction is associated with oxidative stress, increased protein hydrolysis, disuse atrophy, and calcium ion disorders. Therefore, this article summarizes the molecular pathogenesis and treatment of ventilator-induced diaphragm dysfunction in recent years so that it can be better served clinically and is essential to reduce the duration of mechanical ventilation use, intensive care unit (ICU) length of stay, and the medical burden.
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Affiliation(s)
- Jumei Zhang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Jianguo Feng
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Jing Jia
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Xiaobin Wang
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Jun Zhou
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
| | - Li Liu
- Department of Anesthesiology, The Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan Province, 646000, China
- Anesthesiology and Critical Care Medicine Key Laboratory of Luzhou, Southwest Medical University, Luzhou, Sichuan Province, 646000, China
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Paolo F, Valentina DG, Silvia C, Tommaso P, Elena C, Martin D, Marini John J, Davide C. The possible predictive value of muscle ultrasound in the diagnosis of ICUAW in long-term critically ill patients. J Crit Care 2022; 71:154104. [DOI: 10.1016/j.jcrc.2022.154104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/09/2022] [Accepted: 06/20/2022] [Indexed: 12/25/2022]
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Hyatt HW, Ozdemir M, Bomkamp MP, Powers SK. Activation of Calpain Contributes to Mechanical Ventilation-Induced Depression of Protein Synthesis in Diaphragm Muscle. Cells 2022; 11:cells11061028. [PMID: 35326479 PMCID: PMC8947683 DOI: 10.3390/cells11061028] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 11/16/2022] Open
Abstract
Mechanical ventilation (MV) is a clinical tool that provides respiratory support to patients unable to maintain adequate alveolar ventilation on their own. Although MV is often a life-saving intervention in critically ill patients, an undesired side-effect of prolonged MV is the rapid occurrence of diaphragmatic atrophy due to accelerated proteolysis and depressed protein synthesis. Investigations into the mechanism(s) responsible for MV-induced diaphragmatic atrophy reveal that activation of the calcium-activated protease, calpain, plays a key role in accelerating proteolysis in diaphragm muscle fibers. Moreover, active calpain has been reported to block signaling events that promote protein synthesis (i.e., inhibition of mammalian target of rapamycin (mTOR) activation). While this finding suggests that active calpain can depress muscle protein synthesis, this postulate has not been experimentally verified. Therefore, we tested the hypothesis that active calpain plays a key role in the MV-induced depression of both anabolic signaling events and protein synthesis in the diaphragm muscle. MV-induced activation of calpain in diaphragm muscle fibers was prevented by transgene overexpression of calpastatin, an endogenous inhibitor of calpain. Our findings indicate that overexpression of calpastatin averts MV-induced activation of calpain in diaphragm fibers and rescues the MV-induced depression of protein synthesis in the diaphragm muscle. Surprisingly, deterrence of calpain activation did not impede the MV-induced inhibition of key anabolic signaling events including mTOR activation. However, blockade of calpain activation prevented the calpain-induced cleavage of glutaminyl-tRNA synthetase in diaphragm fibers; this finding is potentially important because aminoacyl-tRNA synthetases play a central role in protein synthesis. Regardless of the mechanism(s) responsible for calpain’s depression of protein synthesis, these results provide the first evidence that active calpain plays an important role in promoting the MV-induced depression of protein synthesis within diaphragm fibers.
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Affiliation(s)
- Hayden W. Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA; (H.W.H.); (M.O.); (M.P.B.)
- Department of Physiology, The Johns Hopkins University School of Medicine, Baltimore, MD 21201, USA
| | - Mustafa Ozdemir
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA; (H.W.H.); (M.O.); (M.P.B.)
| | - Matthew P. Bomkamp
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA; (H.W.H.); (M.O.); (M.P.B.)
| | - Scott K. Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA; (H.W.H.); (M.O.); (M.P.B.)
- Department of Health Sciences, Stetson University, Deland, FL 32720, USA
- Correspondence: author:
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Yoshihara T, Deminice R, Hyatt HW, Ozdemir M, Nguyen BL, Powers SK. Angiotensin 1-7 protects against ventilator-induced diaphragm dysfunction. Clin Transl Sci 2021; 14:1512-1523. [PMID: 33742769 PMCID: PMC8301547 DOI: 10.1111/cts.13015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/29/2021] [Accepted: 02/20/2021] [Indexed: 12/24/2022] Open
Abstract
Mechanical ventilation (MV) is a life‐saving instrument used to provide ventilatory support for critically ill patients and patients undergoing surgery. Unfortunately, an unintended consequence of prolonged MV is the development of inspiratory weakness due to both diaphragmatic atrophy and contractile dysfunction; this syndrome is labeled ventilator‐induced diaphragm dysfunction (VIDD). VIDD is clinically important because diaphragmatic weakness is an important contributor to problems in weaning patients from MV. Investigations into the pathogenesis of VIDD reveal that oxidative stress is essential for the rapid development of VIDD as redox disturbances in diaphragm fibers promote accelerated proteolysis. Currently, no standard treatment exists to prevent VIDD and, therefore, developing a strategy to avert VIDD is vital. Guided by evidence indicating that activation of the classical axis of the renin‐angiotensin system (RAS) in diaphragm fibers promotes oxidative stress and VIDD, we hypothesized that activation of the nonclassical RAS signaling pathway via angiotensin 1‐7 (Ang1‐7) will protect against VIDD. Using an established animal model of prolonged MV, our results disclose that infusion of Ang1‐7 protects the diaphragm against MV‐induced contractile dysfunction and fiber atrophy in both fast and slow muscle fibers. Further, Ang1‐7 shielded diaphragm fibers against MV‐induced mitochondrial damage, oxidative stress, and protease activation. Collectively, these results reveal that treatment with Ang1‐7 protects against VIDD, in part, due to diminishing oxidative stress and protease activation. These important findings provide robust evidence that Ang1‐7 has the therapeutic potential to protect against VIDD by preventing MV‐induced contractile dysfunction and atrophy of both slow and fast muscle fibers.
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Affiliation(s)
- Toshinori Yoshihara
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA.,Graduate School of Health and Sports Science, Juntendo University, Inzai, Japan
| | - Rafael Deminice
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA.,Department of Physical Education, State University of Londrina, Londrina, Brazil
| | - Hayden W Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Mustafa Ozdemir
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Branden L Nguyen
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
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Hyatt HW, Powers SK. Disturbances in Calcium Homeostasis Promotes Skeletal Muscle Atrophy: Lessons From Ventilator-Induced Diaphragm Wasting. Front Physiol 2020; 11:615351. [PMID: 33391032 PMCID: PMC7773636 DOI: 10.3389/fphys.2020.615351] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/19/2020] [Indexed: 12/23/2022] Open
Abstract
Mechanical ventilation (MV) is often a life-saving intervention for patients in respiratory failure. Unfortunately, a common and undesired consequence of prolonged MV is the development of diaphragmatic atrophy and contractile dysfunction. This MV-induced diaphragmatic weakness is commonly labeled “ventilator-induced diaphragm dysfunction” (VIDD). VIDD is an important clinical problem because diaphragmatic weakness is a major risk factor for the failure to wean patients from MV; this inability to remove patients from ventilator support results in prolonged hospitalization and increased morbidity and mortality. Although several processes contribute to the development of VIDD, it is clear that oxidative stress leading to the rapid activation of proteases is a primary contributor. While all major proteolytic systems likely contribute to VIDD, emerging evidence reveals that activation of the calcium-activated protease calpain plays a required role. This review highlights the signaling pathways leading to VIDD with a focus on the cellular events that promote increased cytosolic calcium levels and the subsequent activation of calpain within diaphragm muscle fibers. In particular, we discuss the emerging evidence that increased mitochondrial production of reactive oxygen species promotes oxidation of the ryanodine receptor/calcium release channel, resulting in calcium release from the sarcoplasmic reticulum, accelerated proteolysis, and VIDD. We conclude with a discussion of important and unanswered questions associated with disturbances in calcium homeostasis in diaphragm muscle fibers during prolonged MV.
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Affiliation(s)
- Hayden W Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, United States
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, United States
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Hyatt HW, Ozdemir M, Yoshihara T, Nguyen BL, Deminice R, Powers SK. Calpains play an essential role in mechanical ventilation-induced diaphragmatic weakness and mitochondrial dysfunction. Redox Biol 2020; 38:101802. [PMID: 33279868 PMCID: PMC7724197 DOI: 10.1016/j.redox.2020.101802] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/13/2020] [Indexed: 02/07/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving intervention for many critically ill patients. Unfortunately, an unintended consequence of prolonged MV is the rapid development of diaphragmatic atrophy and contractile dysfunction, known as ventilator-induced diaphragm dysfunction (VIDD). Although the mechanism(s) responsible for VIDD are not fully understood, abundant evidence reveals that oxidative stress leading to the activation of the major proteolytic systems (i.e., autophagy, ubiquitin-proteasome, caspase, and calpain) plays a dominant role. Of the proteolytic systems involved in VIDD, calpain has received limited experimental attention due to the longstanding dogma that calpain plays a minor role in inactivity-induced muscle atrophy. Guided by preliminary experiments, we tested the hypothesis that activation of calpains play an essential role in MV-induced oxidative stress and the development of VIDD. This premise was rigorously tested by transgene overexpression of calpastatin, an endogenous inhibitor of calpains. Animals with/without transfection of the calpastatin gene in diaphragm muscle fibers were exposed to 12 h of MV. Results confirmed that overexpression of calpastatin barred MV-induced activation of calpain in diaphragm fibers. Importantly, deterrence of calpain activation protected the diaphragm against MV-induced oxidative stress, fiber atrophy, and contractile dysfunction. Moreover, prevention of calpain activation in the diaphragm forstalled MV-induced mitochondrial dysfunction and prevented MV-induced activation of caspase-3 along with the transcription of muscle specific E3 ligases. Collectively, these results support the hypothesis that calpain activation plays an essential role in the early development of VIDD. Further, these findings provide the first direct evidence that calpain plays an important function in inactivity-induced mitochondrial dysfunction and oxidative stress in skeletal muscle fibers. Inhibiting calpains during mechanical ventilation protects the diaphragm. Calpains play an important role in muscle atrophy and contractile dysfunction. Calpain inhibition during mechanical ventilation prevents mitochondrial dysfunction. Calpain-cleaved molecules may play important signaling roles. Calpain activation cross-talks with other proteolytic systems.
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Affiliation(s)
- Hayden W Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA.
| | - Mustafa Ozdemir
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Exercise and Sport Sciences, Hacettepe University, Ankara, Turkey
| | - Toshinori Yoshihara
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Exercise Physiology, Juntendo University, Tokyo, Japan
| | - Branden L Nguyen
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| | - Rafael Deminice
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA; Department of Physical Education, State University of Londrina, Londrina, Brazil
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
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Hall SE, Ahn B, Smuder AJ, Morton AB, Hinkley JM, Wiggs MP, Sollanek KJ, Hyatt H, Powers SK. Comparative Efficacy of Angiotensin II Type 1 Receptor Blockers Against Ventilator-Induced Diaphragm Dysfunction in Rats. Clin Transl Sci 2020; 14:481-486. [PMID: 33222389 PMCID: PMC7993256 DOI: 10.1111/cts.12916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/29/2020] [Indexed: 12/16/2022] Open
Abstract
Mechanical ventilation (MV) is a life‐saving intervention for many critically ill patients. Unfortunately, prolonged MV results in the rapid development of inspiratory muscle weakness due to diaphragmatic atrophy and contractile dysfunction (termed ventilator‐induced diaphragm dysfunction (VIDD)). Although VIDD is a major risk factor for problems in weaning patients from MV, a standard therapy to prevent VIDD does not exist. However, emerging evidence suggests that pharmacological blockade of angiotensin II type 1 receptors (AT1Rs) protects against VIDD. Nonetheless, the essential characteristics of AT1R blockers (ARBs) required to protect against VIDD remain unclear. To determine the traits of ARBs that are vital for protection against VIDD, we compared the efficacy of two clinically relevant ARBs, irbesartan and olmesartan; these ARBs differ in molecular structure and effects on AT1Rs. Specifically, olmesartan blocks both angiotensin II (AngII) binding and mechanical activation of AT1Rs, whereas irbesartan prevents only AngII binding to AT1Rs. Using a well‐established preclinical model of prolonged MV, we tested the hypothesis that compared with irbesartan, olmesartan provides greater protection against VIDD. Our results reveal that irbesartan does not protect against VIDD whereas olmesartan defends against both MV‐induced diaphragmatic atrophy and contractile dysfunction. These findings support the hypothesis that olmesartan is superior to irbesartan in protecting against VIDD and are consistent with the concept that blockade of mechanical activation of AT1Rs is a required property of ARBs to shield against VIDD. These important findings provide a foundation for future clinical trials to evaluate ARBs as a therapy to protect against VIDD.
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Affiliation(s)
- Stephanie E Hall
- Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas, USA
| | - Bumsoo Ahn
- Aging and Metabolism Research Program, Oklahoma Medical Research Foundation, Oklahoma City, Oklahoma, USA
| | - Ashley J Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | | | - J Matthew Hinkley
- Advent Health Translational Research Institute, Orlando, Florida, USA
| | | | | | - Hayden Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
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Powers SK, Ozdemir M, Hyatt H. Redox Control of Proteolysis During Inactivity-Induced Skeletal Muscle Atrophy. Antioxid Redox Signal 2020; 33:559-569. [PMID: 31941357 PMCID: PMC7454189 DOI: 10.1089/ars.2019.8000] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Significance: Skeletal muscles play essential roles in key body functions including breathing, locomotion, and glucose homeostasis; therefore, maintaining healthy skeletal muscles is important. Prolonged periods of muscle inactivity (e.g., bed rest, mechanical ventilation, or limb immobilization) result in skeletal muscle atrophy and weakness. Recent Advances: Disuse skeletal muscle atrophy occurs due to both accelerated proteolysis and decreased protein synthesis with proteolysis playing a leading role in some types of inactivity-induced atrophy. Although all major proteolytic systems are involved in inactivity-induced proteolysis in skeletal muscles, growing evidence indicates that both calpain and autophagy play an important role. Regulation of proteolysis in skeletal muscle is under complex control, but it is established that activation of both calpain and autophagy is directly linked to oxidative stress. Critical Issues: In this review, we highlight the experimental evidence that supports a cause and effect link between reactive oxygen species (ROS) and activation of both calpain and autophagy in skeletal muscle fibers during prolonged inactivity. We also review the sources of oxidant production in muscle fibers during inactivity-induced atrophy, and provide a detailed discussion on how ROS activates both calpain and autophagy during disuse muscle wasting. Future Directions: Future studies are required to delineate the specific mechanisms by which ROS activates both calpain and autophagy in skeletal muscles during prolonged periods of contractile inactivity. This knowledge is essential to develop the most effective strategies to protect against disuse muscle atrophy. Antioxid. Redox Signal. 33, 559-569.
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Affiliation(s)
- Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Mustafa Ozdemir
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Hayden Hyatt
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
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Yu T, Wu R, Yao L, Wang K, Wang G, Fan Z, Wu N, Fang X. Neurally adjusted ventilatory assist after surgical treatment of intracerebral hemorrhage: a randomized crossover study. J Int Med Res 2020; 48:300060520939837. [PMID: 32720550 PMCID: PMC7388128 DOI: 10.1177/0300060520939837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE We assessed the neuromechanical efficiency (NME), neuroventilatory efficiency (NVE), and diaphragmatic function effects between pressure support ventilation (PSV) and neutrally adjusted ventilatory assist (NAVA). METHODS Fifteen patients who had undergone surgical treatment of intracerebral hemorrhage were enrolled in this randomized crossover study. The patients were assigned to PSV for the first 24 hours and then to NAVA for the following 24 hours or vice versa. The monitored ventilatory parameters under the two ventilation models were compared. NME, NVE, and diaphragmatic function were compared between the two ventilation models. RESULTS One patient's illness worsened during the study. The study was stopped for this patient, and intact data were obtained from the other 14 patients and analyzed. The monitored tidal volume was significantly higher with PSV than NAVA (487 [443-615] vs. 440 [400-480] mL, respectively). NME, NVE, diaphragmatic function, and the partial pressures of arterial carbon dioxide and oxygen were not significantly different between the two ventilation models. CONCLUSION The tidal volume was lower with NAVA than PSV; however, the patients' selected respiratory pattern during NAVA did not change the NME, NVE, or diaphragmatic function.Clinical trial registration no. ChiCTR1900022861.
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Affiliation(s)
- Tao Yu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Rongrong Wu
- Department of Education, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Lin Yao
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Kui Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Guiliang Wang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Zhen Fan
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Nianlong Wu
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
| | - Xinggen Fang
- Department of Neurosurgery, Research Center for Functional Maintenance and Reconstruction of Viscera, The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital), Wuhu, China
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12
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Luo Z, Han S, Sun W, Wang Y, Liu S, Yang L, Pang B, Jin J, Chen H, Cao Z, Ma Y. Maintenance of spontaneous breathing at an intensity of 60%-80% may effectively prevent mechanical ventilation-induced diaphragmatic dysfunction. PLoS One 2020; 15:e0229944. [PMID: 32131083 PMCID: PMC7056322 DOI: 10.1371/journal.pone.0229944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 02/18/2020] [Indexed: 11/18/2022] Open
Abstract
Controlled mechanical ventilation (CMV) can cause diaphragmatic motionlessness to induce diaphragmatic dysfunction. Partial maintenance of spontaneous breathing (SB) can reduce ventilation-induced diaphragmatic dysfunction (VIDD). However, to what extent SB is maintained in CMV can attenuate or even prevent VIDD has been rarely reported. The current study aimed to investigate the relationship between SB intensity and VIDD and to identify what intensity of SB maintained in CMV can effectively avoid VIDD. Adult rats were randomly divided according to different SB intensities: SB (0% pressure controlled ventilation (PCV)), high-intensity SB (20% PCV), medium-intensity SB (40% PCV), medium-low intensity SB (60% PCV), low-intensity SB (80% PCV), and PCV (100% PCV). The animals underwent 24-h controlled mechanical ventilation (CMV). The transdiaphragmatic pressure (Pdi), the maximal Pdi (Pdi max) when phrenic nerves were stimulated, Pdi/Pdi max, and the diaphragmatic tonus under different frequencies of electric stimulations were determined. Calpain and caspase-3 were detected using ELISA and the cross-section areas (CSAs) of different types of muscle fibers were measured. The Pdi showed a significant decrease from 20% PCV and the Pdi max showed a significant decrease from 40% PCV (P<0.05). In vivo and vitro diaphragmatic tonus exhibited a significant decrease from 40% PCV and 20% PCV, respectively (P<0.05). From 20% PCV, the CSAs of types I, IIa, and IIb/x muscle fibers showed significant differences, which reached the lowest levels at 100% PCV. SB intensity is negatively associated with the development of VIDD. Maintenance of SB at an intensity of 60%-80% may effectively prevent the occurrence of VIDD.
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Affiliation(s)
- Zujin Luo
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Silu Han
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Wei Sun
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Sijie Liu
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Liu Yang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Baosen Pang
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Jiawei Jin
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Hong Chen
- Department of Pathology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhixin Cao
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- * E-mail: (ZC); (YM)
| | - Yingmin Ma
- Department of Respiratory and Critical Care Medicine, Beijing Engineering Research Center of Respiratory and Critical Care Medicine, Beijing Institute of Respiratory Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
- * E-mail: (ZC); (YM)
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13
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Zhou XL, Wei XJ, Li SP, Ma HL, Zhao Y. Lung-protective ventilation worsens ventilator-induced diaphragm atrophy and weakness. Respir Res 2020; 21:16. [PMID: 31924204 PMCID: PMC6954632 DOI: 10.1186/s12931-020-1276-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023] Open
Abstract
Background Lung–protective ventilation (LPV) has been found to minimize the risk of ventilator–induced lung injury (VILI). However, whether LPV is able to diminish ventilator–induced diaphragm dysfunction (VIDD) remains unknown. This study was designed to test the hypothesis that LPV protects the diaphragm against VIDD. Methods Adult male Wistar rats received either conventional mechanical (tidal volume [VT]: 10 ml/kg, positive end–expiratory pressure [PEEP]: 2 cm H2O; CV group) or lung-protective (VT: 5 ml/kg, PEEP: 10 cm H2O; LPV group) ventilation for 12 h. Then, diaphragms and lungs were collected for biochemical and histological analyses. Transcriptome sequencing (RNA–seq) was performed to determine the differentially expressed genes in the diaphragms between groups. Results Our results suggested that LPV was associated with diminished pulmonary injuries and reduced oxidative stress compared with the effects of the CV strategy in rats. However, animals that received LPV showed increased protein degradation, decreased cross–sectional areas (CSAs) of myofibers, and reduced forces of the diaphragm compared with the same parameters in animals receiving CV (p < 0.05). In addition, the LPV group showed a higher level of oxidative stress in the diaphragm than the CV group (p < 0.05). Moreover, RNA–seq and western blots revealed that the peroxisome proliferator–activated receptor γ coactivator–1alpha (PGC–1α), a powerful reactive oxygen species (ROS) inhibitor, was significantly downregulated in the LPV group compared with its expression in the CV group (p < 0.05). Conclusions Compared with the CV strategy, the LPV strategy did not protect the diaphragm against VIDD in rats. In contrast, the LPV strategy worsened VIDD by inducing oxidative stress together with the downregulation of PGC–1α in the diaphragm. However, further studies are required to determine the roles of PGC–1α in ventilator-induced diaphragmatic oxidative stress.
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Affiliation(s)
- Xian-Long Zhou
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Xiao-Jun Wei
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Shao-Ping Li
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Hao-Li Ma
- Department of Biological Repositories, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China
| | - Yan Zhao
- Emergency Center, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan, 430071, Hubei, China.
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14
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Peñuelas O, Keough E, López-Rodríguez L, Carriedo D, Gonçalves G, Barreiro E, Lorente JÁ. Ventilator-induced diaphragm dysfunction: translational mechanisms lead to therapeutical alternatives in the critically ill. Intensive Care Med Exp 2019; 7:48. [PMID: 31346802 PMCID: PMC6658639 DOI: 10.1186/s40635-019-0259-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/23/2019] [Indexed: 02/08/2023] Open
Abstract
Mechanical ventilation [MV] is a life-saving technique delivered to critically ill patients incapable of adequately ventilating and/or oxygenating due to respiratory or other disease processes. This necessarily invasive support however could potentially result in important iatrogenic complications. Even brief periods of MV may result in diaphragm weakness [i.e., ventilator-induced diaphragm dysfunction [VIDD]], which may be associated with difficulty weaning from the ventilator as well as mortality. This suggests that VIDD could potentially have a major impact on clinical practice through worse clinical outcomes and healthcare resource use. Recent translational investigations have identified that VIDD is mainly characterized by alterations resulting in a major decline of diaphragmatic contractile force together with atrophy of diaphragm muscle fibers. However, the signaling mechanisms responsible for VIDD have not been fully established. In this paper, we summarize the current understanding of the pathophysiological pathways underlying VIDD and highlight the diagnostic approach, as well as novel and experimental therapeutic options.
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Affiliation(s)
- Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain. .,Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.
| | - Elena Keough
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Lucía López-Rodríguez
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Demetrio Carriedo
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Gesly Gonçalves
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain
| | - Esther Barreiro
- Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.,Pulmonology Department-Muscle Wasting and Cachexia in Chronic Respiratory Diseases and Lung Cancer Research Group, IMIM-Hospital del Mar, Parc de Salut Mar, Health and Experimental Sciences Department [CEXS], Barcelona, Spain.,Universitat Pompeu Fabra [UPF], Barcelona Biomedical Research Park [PRBB], Barcelona, Spain
| | - José Ángel Lorente
- Intensive Care Unit, Hospital Universitario de Getafe, Carretera de Toledo, km 12.5, 28905, Getafe, Madrid, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias [CIBERES], Instituto de Salud Carlos III [ISCIII], Madrid, Spain.,Universidad Europea, Madrid, Spain
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15
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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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16
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Saddala MS, Adi PJ. Discovery of small molecules through pharmacophore modeling, docking and molecular dynamics simulation against Plasmodium vivax Vivapain-3 (VP-3). Heliyon 2018; 4:e00612. [PMID: 29756074 PMCID: PMC5944417 DOI: 10.1016/j.heliyon.2018.e00612] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 03/29/2018] [Accepted: 04/18/2018] [Indexed: 11/24/2022] Open
Abstract
Vivapain-3(VP-3) protein is a family of cysteine rich proteases of malaria parasite is extensively reported to participate in a range of wide cellular processes including survival. VP-3 of plasmodium recognized as an attractive drug target in vector-borne diseases like malaria. In the present study we robust a homology model of VP-3 protein and generated the pharmacophore based models adapted to screen the best drug like compounds from PubChem database. Our results finds the fourteen best lead molecules were mapped with core pharmacophore features of VP-3 and top hits were further evaluated by molecular dynamics simulation and docking studies. Based on the molecular dynamics simulation and docking results and binding vicinity of ligand molecules, top five i.e., CID 74427945, CID 74427946, CID 360883, CID193721 and CID 51416859 showed the best docking scores with good molecular interactions against VP-3. Furthermore in silico ADMET and in vitro assays clearly exhibited that out of five three CID74427946, CID74427945 and CID360883 ligand molecules showed the best promising inhibition against VP-3. The present study believed to provide significant information of potential ligand inhibitors against VP-3 to design and develop the next generation malaria therapeutics through computational approach.
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Affiliation(s)
- Madhu Sudhana Saddala
- Centre for Agricultural Bioinformatics, ICAR-IASRI, New Delhi, India
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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17
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Shen L, Meng X, Zhang Z, Wang T. Physical Exercise for Muscle Atrophy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1088:529-545. [PMID: 30390268 DOI: 10.1007/978-981-13-1435-3_24] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The most direct characteristic of muscle atrophy is reduction in muscle mass, which is due to increased protein degradation or reduced protein synthesis in skeletal muscle. The loss of muscle mass can directly affect the quality of daily life, prolong the recovery period, and become the main risk factor for chronic diseases. However, there is currently no effective way to prevent and treat this disease, and therefore it is imperative to explore effective therapeutic approaches for muscle atrophy. It is well known that physical exercise is important for maintaining good health and long-term adherence to exercise can reduce the risk of cardiovascular diseases, obesity, and diabetes. It is also well established that exercise training can promote the synthesis of muscle protein and activate signaling pathways that regulate the metabolism and function of muscle fibers. Therefore, exercise can be used as a method to treat muscle atrophy in many of these conditions. Mitochondria play an important role in skeletal muscle homeostasis and bioenergy metabolism. Mitochondria are sensitive to contractile signals, and hence exercise can improve mitochondrial function and promote biosynthesis, which ultimately maintains the healthy state of cells and the whole body. On the other hand, frequent unaccustomed exercise will change the structure and function of skeletal muscle fibers, which is called exercise-induced muscle damage. When the exercise-induced muscle damage happens, it can cause temporary muscle damage and soreness, giving a negative effect on the muscle function.
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Affiliation(s)
- Liang Shen
- Physical Education College of Shanghai University, Shanghai, China
| | - Xiangmin Meng
- Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Science, Shanghai University, Shanghai, China
| | - Zhongrong Zhang
- Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Science, Shanghai University, Shanghai, China
| | - Tianhui Wang
- Cardiac Regeneration and Ageing Lab, Institute of Cardiovascular Sciences, School of Life Science, Shanghai University, Shanghai, China.
- Shanghai Key Laboratory of Bio-Energy Crops, School of Life Sciences, Shanghai University, Shanghai, China.
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18
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Liang F, Li T, Azuelos I, Giordano C, Liang H, Hussain SN, Matecki S, Petrof BJ. Ventilator-induced diaphragmatic dysfunction in MDX
mice. Muscle Nerve 2017; 57:442-448. [DOI: 10.1002/mus.25760] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 07/26/2017] [Accepted: 08/05/2017] [Indexed: 01/17/2023]
Affiliation(s)
- Feng Liang
- Meakins-Christie Laboratories, and Translational Research in Respiratory Diseases Program; McGill University Health Centre and Research Institute; 1001 Decarie Boulevard, Montreal Quebec H4A 3J1 Canada
| | - Tong Li
- Meakins-Christie Laboratories, and Translational Research in Respiratory Diseases Program; McGill University Health Centre and Research Institute; 1001 Decarie Boulevard, Montreal Quebec H4A 3J1 Canada
| | - Ilan Azuelos
- Meakins-Christie Laboratories, and Translational Research in Respiratory Diseases Program; McGill University Health Centre and Research Institute; 1001 Decarie Boulevard, Montreal Quebec H4A 3J1 Canada
| | - Christian Giordano
- Meakins-Christie Laboratories, and Translational Research in Respiratory Diseases Program; McGill University Health Centre and Research Institute; 1001 Decarie Boulevard, Montreal Quebec H4A 3J1 Canada
| | - Han Liang
- Department of Bioinformatics and Computational Biology; University of Texas MD Anderson Cancer Center; Houston Texas USA
- Department of Systems Biology; University of Texas MD Anderson Cancer Center; Houston Texas USA
| | - Sabah N. Hussain
- Meakins-Christie Laboratories, and Translational Research in Respiratory Diseases Program; McGill University Health Centre and Research Institute; 1001 Decarie Boulevard, Montreal Quebec H4A 3J1 Canada
- Department of Critical Care; McGill University Health Centre; Montreal Quebec Canada
| | - Stefan Matecki
- Pediatric Functional Exploration Unit; University Hospital of Montpellier, UMR CNRS 9214-INSERM U1046, Université Montpellier; Montpellier France
| | - Basil J. Petrof
- Meakins-Christie Laboratories, and Translational Research in Respiratory Diseases Program; McGill University Health Centre and Research Institute; 1001 Decarie Boulevard, Montreal Quebec H4A 3J1 Canada
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19
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Powers SK, Lynch GS, Murphy KT, Reid MB, Zijdewind I. Disease-Induced Skeletal Muscle Atrophy and Fatigue. Med Sci Sports Exerc 2017; 48:2307-2319. [PMID: 27128663 DOI: 10.1249/mss.0000000000000975] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Numerous health problems, including acute critical illness, cancer, diseases associated with chronic inflammation, and neurological disorders, often result in skeletal muscle weakness and fatigue. Disease-related muscle atrophy and fatigue is an important clinical problem because acquired skeletal muscle weakness can increase the duration of hospitalization, result in exercise limitation, and contribute to a poor quality of life. Importantly, skeletal muscle atrophy is also associated with increased morbidity and mortality of patients. Therefore, improving our understanding of the mechanism(s) responsible for skeletal muscle weakness and fatigue in patients is a required first step to develop clinical protocols to prevent these skeletal muscle problems. This review will highlight the consequences and potential mechanisms responsible for skeletal muscle atrophy and fatigue in patients experiencing acute critical illness, cancer, chronic inflammatory diseases, and neurological disorders.
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Affiliation(s)
- Scott K Powers
- 1Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL; 2Basic and Clinical Myology Laboratory, Department of Physiology, University of Melbourne, Victoria, AUSTRALIA; and 3Medical Physiology, Department of Neuroscience, University Medical Center Groningen, Groningen, THE NETHERLANDS
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20
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Respiratory muscle contractile inactivity induced by mechanical ventilation in piglets leads to leaky ryanodine receptors and diaphragm weakness. J Muscle Res Cell Motil 2017; 38:17-24. [PMID: 28260211 DOI: 10.1007/s10974-017-9464-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 01/04/2017] [Indexed: 10/20/2022]
Abstract
Respiratory muscle contractile inactivity during mechanical ventilation (MV) induces diaphragm muscle weakness, a condition referred to as ventilator-induced diaphragmatic dysfunction (VIDD). Although VIDD pathophysiological mechanisms are still not fully understood, it has been recently suggested that remodeling of the sarcoplasmic reticulum (SR) calcium release channel/ryanodine receptors (RyR1) in the diaphragm is a proximal mechanism of VIDD. Here, we used piglets, a large animal model of VIDD that is more relevant to human pathophysiology, to determine whether RyR1 alterations are observed in the presence of diaphragm weakness. In piglets, diaphragm weakness induced by 72 h of respiratory muscle unloading was associated with SR RyR1 remodeling and abnormal resting SR Ca2+ leak in the diaphragm. Specifically, following controlled mechanical ventilation, diaphragm contractile function was reduced. Moreover, RyR1 macromolecular complexes were more oxidized, S-nitrosylated and phosphorylated at Ser-2844 and depleted of the stabilizing subunit calstabin1 compared with controls on adaptive support ventilation that maintains diaphragmatic contractile activity. Our study strongly supports the hypothesis that RyR1 is a potential therapeutic target in VIDD and the interest of using small molecule drugs to prevent RyR1-mediated SR Ca2+ leak induced by respiratory muscle unloading in patients who require controlled mechanical ventilation.
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21
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Bruells CS, Marx G. [Diaphragm dysfunction : Facts for clinicians]. Med Klin Intensivmed Notfmed 2016; 113:526-532. [PMID: 27766377 DOI: 10.1007/s00063-016-0226-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Revised: 08/04/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2023]
Abstract
Diaphragm function is crucial for patient outcome in the ICU setting and during the treatment period. The occurrence of an insufficiency of the respiratory pump, which is predominantly formed by the diaphragm, may result in intubation after failure of noninvasive ventilation. Especially patients suffering from chronic obstructive pulmonary disease are in danger of hypercapnic respiratory failure. Changes in biomechanical properties and fiber texture of the diaphragm are further cofactors directly leading to a need for intubation and mechanical ventilation. After intubation and the following inactivity the diaphragm is subject to profound pathophysiologic changes resulting in atrophy and dysfunction. Besides this inactivity-triggered mechanism (termed as ventilator-induced diaphragmatic dysfunction) multiple factors, comorbidities, pharmaceutical agents and additional hits during the ICU treatment, especially the occurrence of sepsis, influence diaphragm homeostasis and can lead to weaning failure. During the weaning process monitoring of diaphragm function can be done with invasive methods - ultrasound is increasingly established to monitor diaphragm contraction, but further and better powered studies are in need to prove its value as a diagnostic tool.
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Affiliation(s)
- C S Bruells
- Klinik für Operative Intensivmedizin und Intermediate Care, Universitätsklinik der RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
| | - G Marx
- Klinik für Operative Intensivmedizin und Intermediate Care, Universitätsklinik der RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland
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22
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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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23
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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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24
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Matecki S, Dridi H, Jung B, Saint N, Reiken SR, Scheuermann V, Mrozek S, Santulli G, Umanskaya A, Petrof BJ, Jaber S, Marks AR, Lacampagne A. Leaky ryanodine receptors contribute to diaphragmatic weakness during mechanical ventilation. Proc Natl Acad Sci U S A 2016; 113:9069-74. [PMID: 27457930 PMCID: PMC4987795 DOI: 10.1073/pnas.1609707113] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Ventilator-induced diaphragmatic dysfunction (VIDD) refers to the diaphragm muscle weakness that occurs following prolonged controlled mechanical ventilation (MV). The presence of VIDD impedes recovery from respiratory failure. However, the pathophysiological mechanisms accounting for VIDD are still not fully understood. Here, we show in human subjects and a mouse model of VIDD that MV is associated with rapid remodeling of the sarcoplasmic reticulum (SR) Ca(2+) release channel/ryanodine receptor (RyR1) in the diaphragm. The RyR1 macromolecular complex was oxidized, S-nitrosylated, Ser-2844 phosphorylated, and depleted of the stabilizing subunit calstabin1, following MV. These posttranslational modifications of RyR1 were mediated by both oxidative stress mediated by MV and stimulation of adrenergic signaling resulting from the anesthesia. We demonstrate in the murine model that such abnormal resting SR Ca(2+) leak resulted in reduced contractile function and muscle fiber atrophy for longer duration of MV. Treatment with β-adrenergic antagonists or with S107, a small molecule drug that stabilizes the RyR1-calstabin1 interaction, prevented VIDD. Diaphragmatic dysfunction is common in MV patients and is a major cause of failure to wean patients from ventilator support. This study provides the first evidence to our knowledge of RyR1 alterations as a proximal mechanism underlying VIDD (i.e., loss of function, muscle atrophy) and identifies RyR1 as a potential target for therapeutic intervention.
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Affiliation(s)
- Stefan Matecki
- Inserm U1046, CNRS UMR 91214, Université de Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, 34295 Montpellier, France
| | - Haikel Dridi
- Inserm U1046, CNRS UMR 91214, Université de Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, 34295 Montpellier, France
| | - Boris Jung
- Inserm U1046, CNRS UMR 91214, Université de Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, 34295 Montpellier, France; Department of Anesthesiology and Critical Care Medicine, St. Eloi Teaching Hospital, 34295 Montpellier, France
| | - Nathalie Saint
- Inserm U1046, CNRS UMR 91214, Université de Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, 34295 Montpellier, France
| | - Steven R Reiken
- Department of Physiology and Cellular Biophysics, College of Physicians and Surgeons, Columbia University, New York, NY 10032; The Clyde and Helen Wu Center for Molecular Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032; Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032
| | - Valérie Scheuermann
- Inserm U1046, CNRS UMR 91214, Université de Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, 34295 Montpellier, France
| | - Ségolène Mrozek
- Inserm U1046, CNRS UMR 91214, Université de Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, 34295 Montpellier, France
| | - Gaetano Santulli
- Department of Physiology and Cellular Biophysics, College of Physicians and Surgeons, Columbia University, New York, NY 10032; The Clyde and Helen Wu Center for Molecular Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032; Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032
| | - Alisa Umanskaya
- Department of Physiology and Cellular Biophysics, College of Physicians and Surgeons, Columbia University, New York, NY 10032; The Clyde and Helen Wu Center for Molecular Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032; Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032
| | - Basil J Petrof
- Meakins-Christie Laboratories, McGill University and McGill University Hospital Research Institute, Montreal, QC H2X 2P2, Canada
| | - Samir Jaber
- Inserm U1046, CNRS UMR 91214, Université de Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, 34295 Montpellier, France; Department of Anesthesiology and Critical Care Medicine, St. Eloi Teaching Hospital, 34295 Montpellier, France
| | - Andrew R Marks
- Department of Physiology and Cellular Biophysics, College of Physicians and Surgeons, Columbia University, New York, NY 10032; The Clyde and Helen Wu Center for Molecular Cardiology, College of Physicians and Surgeons, Columbia University, New York, NY 10032; Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY 10032;
| | - Alain Lacampagne
- Inserm U1046, CNRS UMR 91214, Université de Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, 34295 Montpellier, France;
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25
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Microbial inhibitors of cysteine proteases. Med Microbiol Immunol 2016; 205:275-96. [DOI: 10.1007/s00430-016-0454-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 03/24/2016] [Indexed: 01/06/2023]
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26
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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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27
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Partial Support Ventilation and Mitochondrial-Targeted Antioxidants Protect against Ventilator-Induced Decreases in Diaphragm Muscle Protein Synthesis. PLoS One 2015; 10:e0137693. [PMID: 26361212 PMCID: PMC4567376 DOI: 10.1371/journal.pone.0137693] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/19/2015] [Indexed: 01/08/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving intervention in patients in respiratory failure. Unfortunately, prolonged MV results in the rapid development of diaphragm atrophy and weakness. MV-induced diaphragmatic weakness is significant because inspiratory muscle dysfunction is a risk factor for problematic weaning from MV. Therefore, developing a clinical intervention to prevent MV-induced diaphragm atrophy is important. In this regard, MV-induced diaphragmatic atrophy occurs due to both increased proteolysis and decreased protein synthesis. While efforts to impede MV-induced increased proteolysis in the diaphragm are well-documented, only one study has investigated methods of preserving diaphragmatic protein synthesis during prolonged MV. Therefore, we evaluated the efficacy of two therapeutic interventions that, conceptually, have the potential to sustain protein synthesis in the rat diaphragm during prolonged MV. Specifically, these experiments were designed to: 1) determine if partial-support MV will protect against the decrease in diaphragmatic protein synthesis that occurs during prolonged full-support MV; and 2) establish if treatment with a mitochondrial-targeted antioxidant will maintain diaphragm protein synthesis during full-support MV. Compared to spontaneously breathing animals, full support MV resulted in a significant decline in diaphragmatic protein synthesis during 12 hours of MV. In contrast, diaphragm protein synthesis rates were maintained during partial support MV at levels comparable to spontaneous breathing animals. Further, treatment of animals with a mitochondrial-targeted antioxidant prevented oxidative stress during full support MV and maintained diaphragm protein synthesis at the level of spontaneous breathing animals. We conclude that treatment with mitochondrial-targeted antioxidants or the use of partial-support MV are potential strategies to preserve diaphragm protein synthesis during prolonged MV.
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28
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Kwon OS, Smuder AJ, Wiggs MP, Hall SE, Sollanek KJ, Morton AB, Talbert EE, Toklu HZ, Tumer N, Powers SK. AT1 receptor blocker losartan protects against mechanical ventilation-induced diaphragmatic dysfunction. J Appl Physiol (1985) 2015; 119:1033-41. [PMID: 26359481 DOI: 10.1152/japplphysiol.00237.2015] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 09/04/2015] [Indexed: 11/22/2022] Open
Abstract
Mechanical ventilation is a life-saving intervention for patients in respiratory failure. Unfortunately, prolonged ventilator support results in diaphragmatic atrophy and contractile dysfunction leading to diaphragm weakness, which is predicted to contribute to problems in weaning patients from the ventilator. While it is established that ventilator-induced oxidative stress is required for the development of ventilator-induced diaphragm weakness, the signaling pathway(s) that trigger oxidant production remain unknown. However, recent evidence reveals that increased plasma levels of angiotensin II (ANG II) result in oxidative stress and atrophy in limb skeletal muscles. Using a well-established animal model of mechanical ventilation, we tested the hypothesis that increased circulating levels of ANG II are required for both ventilator-induced diaphragmatic oxidative stress and diaphragm weakness. Cause and effect was determined by administering an angiotensin-converting enzyme inhibitor (enalapril) to prevent ventilator-induced increases in plasma ANG II levels, and the ANG II type 1 receptor antagonist (losartan) was provided to prevent the activation of ANG II type 1 receptors. Enalapril prevented the increase in plasma ANG II levels but did not protect against ventilator-induced diaphragmatic oxidative stress or diaphragm weakness. In contrast, losartan attenuated both ventilator-induced oxidative stress and diaphragm weakness. These findings indicate that circulating ANG II is not essential for the development of ventilator-induced diaphragm weakness but that activation of ANG II type 1 receptors appears to be a requirement for ventilator-induced diaphragm weakness. Importantly, these experiments provide the first evidence that the Food and Drug Administration-approved drug losartan may have clinical benefits to protect against ventilator-induced diaphragm weakness in humans.
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Affiliation(s)
- Oh Sung Kwon
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Ashley J Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Michael P Wiggs
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Stephanie E Hall
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Kurt J Sollanek
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Aaron B Morton
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Erin E Talbert
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Hale Z Toklu
- Department of Pharmacology and Therapeutics, University of Florida, Gainesville, Florida; and Geriatric Research, Education, and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Nihal Tumer
- Department of Pharmacology and Therapeutics, University of Florida, Gainesville, Florida; and Geriatric Research, Education, and Clinical Center, North Florida/South Georgia Veterans Health System, Gainesville, Florida
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida;
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29
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Schellekens WJM, van Hees HWH, Heunks LMA. Letter to the Editor. J Physiol 2015; 593:3389. [PMID: 26228555 DOI: 10.1113/jp270385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
| | | | - Leo M A Heunks
- Radboud UMC, Postbox 9101 R715, Nijmegen, 6500, HB, The Netherlands.
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30
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Abstract
Long periods of skeletal muscle inactivity (e.g. prolonged bed rest or limb immobilization) results in a loss of muscle protein and fibre atrophy. This disuse-induced muscle atrophy is due to both a decrease in protein synthesis and increased protein breakdown. Although numerous factors contribute to the regulation of the rates of protein breakdown and synthesis in skeletal muscle, it has been established that prolonged muscle inactivity results in increased radical production in the inactive muscle fibres. Further, this increase in radical production plays an important role in the regulation of redox-sensitive signalling pathways that regulate both protein synthesis and proteolysis in skeletal muscle. Indeed, it was suggested over 20 years ago that antioxidant supplementation has the potential to protect skeletal muscles against inactivity-induced fibre atrophy. Since this original proposal, experimental evidence has implied that a few compounds with antioxidant properties are capable of delaying inactivity-induced muscle atrophy. The objective of this review is to discuss the role that radicals play in the regulation of inactivity-induced skeletal muscle atrophy and to provide an analysis of the recent literature indicating that specific antioxidants have the potential to defer disuse muscle atrophy.
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31
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Wiggs MP. Can endurance exercise preconditioning prevention disuse muscle atrophy? Front Physiol 2015; 6:63. [PMID: 25814955 PMCID: PMC4356230 DOI: 10.3389/fphys.2015.00063] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 02/17/2015] [Indexed: 12/18/2022] Open
Abstract
Emerging evidence suggests that exercise training can provide a level of protection against disuse muscle atrophy. Endurance exercise training imposes oxidative, metabolic, and heat stress on skeletal muscle which activates a variety of cellular signaling pathways that ultimately leads to the increased expression of proteins that have been demonstrated to protect muscle from inactivity -induced atrophy. This review will highlight the effect of exercise-induced oxidative stress on endogenous enzymatic antioxidant capacity (i.e., superoxide dismutase, glutathione peroxidase, and catalase), the role of oxidative and metabolic stress on PGC1-α, and finally highlight the effect heat stress and HSP70 induction. Finally, this review will discuss the supporting scientific evidence that these proteins can attenuate muscle atrophy through exercise preconditioning.
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Affiliation(s)
- Michael P Wiggs
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida Gainesville, FL, USA
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32
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Tang H, Smith IJ, Hussain SNA, Goldberg P, Lee M, Sugiarto S, Godinez GL, Singh BK, Payan DG, Rando TA, Kinsella TM, Shrager JB. The JAK-STAT pathway is critical in ventilator-induced diaphragm dysfunction. Mol Med 2015; 20:579-89. [PMID: 25286450 DOI: 10.2119/molmed.2014.00049] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 09/30/2014] [Indexed: 12/11/2022] Open
Abstract
Mechanical ventilation (MV) is one of the lynchpins of modern intensive-care medicine and is life saving in many critically ill patients. Continuous ventilator support, however, results in ventilation-induced diaphragm dysfunction (VIDD) that likely prolongs patients' need for MV and thereby leads to major associated complications and avoidable intensive care unit (ICU) deaths. Oxidative stress is a key pathogenic event in the development of VIDD, but its regulation remains largely undefined. We report here that the JAK-STAT pathway is activated in MV in the human diaphragm, as evidenced by significantly increased phosphorylation of JAK and STAT. Blockage of the JAK-STAT pathway by a JAK inhibitor in a rat MV model prevents diaphragm muscle contractile dysfunction (by ~85%, p < 0.01). We further demonstrate that activated STAT3 compromises mitochondrial function and induces oxidative stress in vivo, and, interestingly, that oxidative stress also activates JAK-STAT. Inhibition of JAK-STAT prevents oxidative stress-induced protein oxidation and polyubiquitination and recovers mitochondrial function in cultured muscle cells. Therefore, in ventilated diaphragm muscle, activation of JAK-STAT is critical in regulating oxidative stress and is thereby central to the downstream pathogenesis of clinical VIDD. These findings establish the molecular basis for the therapeutic promise of JAK-STAT inhibitors in ventilated ICU patients.
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Affiliation(s)
- Huibin Tang
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, United States of America.,Veterans Administration Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Ira J Smith
- Rigel Pharmaceuticals, South San Francisco, California, United States of America
| | - Sabah N A Hussain
- Critical Care Division, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Peter Goldberg
- Critical Care Division, Royal Victoria Hospital, Montreal, Quebec, Canada
| | - Myung Lee
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, United States of America.,Veterans Administration Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Sista Sugiarto
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, United States of America.,Veterans Administration Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Guillermo L Godinez
- Rigel Pharmaceuticals, South San Francisco, California, United States of America
| | - Baljit K Singh
- Rigel Pharmaceuticals, South San Francisco, California, United States of America
| | - Donald G Payan
- Rigel Pharmaceuticals, South San Francisco, California, United States of America
| | - Thomas A Rando
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California, United States of America.,Neurology Service, Veterans Administration Palo Alto Healthcare System, Palo Alto, California, United States of America
| | - Todd M Kinsella
- Rigel Pharmaceuticals, South San Francisco, California, United States of America
| | - Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California, United States of America.,Veterans Administration Palo Alto Healthcare System, Palo Alto, California, United States of America
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33
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Reilly BD, Cramp RL, Franklin CE. Activity, abundance and expression of Ca2+-activated proteases in skeletal muscle of the aestivating frog, Cyclorana alboguttata. J Comp Physiol B 2014; 185:243-55. [DOI: 10.1007/s00360-014-0880-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Revised: 11/18/2014] [Accepted: 11/27/2014] [Indexed: 10/24/2022]
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34
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Smuder AJ, Nelson WB, Hudson MB, Kavazis AN, Powers SK. Inhibition of the ubiquitin-proteasome pathway does not protect against ventilator-induced accelerated proteolysis or atrophy in the diaphragm. Anesthesiology 2014; 121:115-26. [PMID: 24681580 DOI: 10.1097/aln.0000000000000245] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Mechanical ventilation (MV) is a life-saving intervention in patients with acute respiratory failure. However, prolonged MV results in ventilator-induced diaphragm dysfunction (VIDD), a condition characterized by both diaphragm fiber atrophy and contractile dysfunction. Previous work has shown that calpain, caspase-3, and the ubiquitin-proteasome pathway (UPP) are all activated in the diaphragm during prolonged MV. However, although it is established that both calpain and caspase-3 are important contributors to VIDD, the role that the UPP plays in the development of VIDD remains unknown. These experiments tested the hypothesis that inhibition of the UPP will protect the diaphragm against VIDD. METHODS The authors tested this prediction in an established animal model of MV using a highly specific UPP inhibitor, epoxomicin, to prevent MV-induced activation of the proteasome in the diaphragm (n = 8 per group). RESULTS The results of this study reveal that inhibition of the UPP did not prevent ventilator-induced diaphragm muscle fiber atrophy and contractile dysfunction during 12 h of MV. Also, inhibition of the UPP does not affect MV-induced increases in calpain and caspase-3 activity in the diaphragm. Finally, administration of the proteasome inhibitor did not protect against the MV-induced increases in the expression of the E3 ligases, muscle ring finger-1 (MuRF1), and atrogin-1/MaFbx. CONCLUSION Collectively, these results indicate that proteasome activation does not play a required role in VIDD development during the first 12 h of MV.
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Affiliation(s)
- Ashley J Smuder
- From the Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, Florida (A.J.S., S.K.P.); Division of Mathematics, Computer, and Natural Sciences, Department of Natural Sciences, Ohio Dominican University, Columbus, Ohio (W.B.N.); Department of Medicine, Emory University, Atlanta, Georgia (M.B.H.); and School of Kinesiology, Auburn University, Auburn, Alabama (A.N.K.)
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35
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Smith IJ, Godinez GL, Singh BK, McCaughey KM, Alcantara RR, Gururaja T, Ho MS, Nguyen HN, Friera AM, White KA, McLaughlin JR, Hansen D, Romero JM, Baltgalvis KA, Claypool MD, Li W, Lang W, Yam GC, Gelman MS, Ding R, Yung SL, Creger DP, Chen Y, Singh R, Smuder AJ, Wiggs MP, Kwon OS, Sollanek KJ, Powers SK, Masuda ES, Taylor VC, Payan DG, Kinoshita T, Kinsella TM. Inhibition of Janus kinase signaling during controlled mechanical ventilation prevents ventilation-induced diaphragm dysfunction. FASEB J 2014; 28:2790-803. [PMID: 24671708 PMCID: PMC4062832 DOI: 10.1096/fj.13-244210] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Controlled mechanical ventilation (CMV) is associated with the development of diaphragm atrophy and contractile dysfunction, and respiratory muscle weakness is thought to contribute significantly to delayed weaning of patients. Therefore, therapeutic strategies for preventing these processes may have clinical benefit. The aim of the current study was to investigate the role of the Janus kinase (JAK)/signal transducer and activator of transcription 3 (STAT3) signaling pathway in CMV-mediated diaphragm wasting and weakness in rats. CMV-induced diaphragm atrophy and contractile dysfunction coincided with marked increases in STAT3 phosphorylation on both tyrosine 705 (Tyr705) and serine 727 (Ser727). STAT3 activation was accompanied by its translocation into mitochondria within diaphragm muscle and mitochondrial dysfunction. Inhibition of JAK signaling during CMV prevented phosphorylation of both target sites on STAT3, eliminated the accumulation of phosphorylated STAT3 within the mitochondria, and reversed the pathologic alterations in mitochondrial function, reduced oxidative stress in the diaphragm, and maintained normal diaphragm contractility. In addition, JAK inhibition during CMV blunted the activation of key proteolytic pathways in the diaphragm, as well as diaphragm atrophy. These findings implicate JAK/STAT3 signaling in the development of diaphragm muscle atrophy and dysfunction during CMV and suggest that the delayed extubation times associated with CMV can be prevented by inhibition of Janus kinase signaling.-Smith, I. J., Godinez, G. L., Singh, B. K., McCaughey, K. M., Alcantara, R. R., Gururaja, T., Ho, M. S., Nguyen, H. N., Friera, A. M., White, K. A., McLaughlin, J. R., Hansen, D., Romero, J. M., Baltgalvis, K. A., Claypool, M. D., Li, W., Lang, W., Yam, G. C., Gelman, M. S., Ding, R., Yung, S. L., Creger, D. P., Chen, Y., Singh, R., Smuder, A. J., Wiggs, M. P., Kwon, O.-S., Sollanek, K. J., Powers, S. K., Masuda, E. S., Taylor, V. C., Payan, D. G., Kinoshita, T., Kinsella, T. M. Inhibition of Janus kinase signaling during controlled mechanical ventilation prevents ventilation-induced diaphragm dysfunction.
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Affiliation(s)
- Ira J Smith
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | | | - Baljit K Singh
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | | | | | | | - Melissa S Ho
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Henry N Nguyen
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | | | - Kathy A White
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | | | - Derek Hansen
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Jason M Romero
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | | | - Mark D Claypool
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Wei Li
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Wayne Lang
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - George C Yam
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Marina S Gelman
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Rongxian Ding
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Stephanie L Yung
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Daniel P Creger
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Yan Chen
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Rajinder Singh
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Ashley J Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Michael P Wiggs
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Oh-Sung Kwon
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Kurt J Sollanek
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida, USA
| | - Esteban S Masuda
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Vanessa C Taylor
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Donald G Payan
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Taisei Kinoshita
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
| | - Todd M Kinsella
- Rigel Pharmaceuticals, South San Francisco, California, USA; and
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Schellekens WJM, van Hees HWH, Kox M, Linkels M, Acuña GLA, Dekhuijzen PNR, Scheffer GJ, van der Hoeven JG, Heunks LMA. Hypercapnia attenuates ventilator-induced diaphragm atrophy and modulates dysfunction. Crit Care 2014; 18:R28. [PMID: 24506836 PMCID: PMC4056638 DOI: 10.1186/cc13719] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 01/22/2014] [Indexed: 11/26/2022] Open
Abstract
Introduction Diaphragm weakness induced by prolonged mechanical ventilation may contribute to difficult weaning from the ventilator. Hypercapnia is an accepted side effect of low tidal volume mechanical ventilation, but the effects of hypercapnia on respiratory muscle function are largely unknown. The present study investigated the effect of hypercapnia on ventilator-induced diaphragm inflammation, atrophy and function. Methods Male Wistar rats (n = 10 per group) were unventilated (CON), mechanically ventilated for 18 hours without (MV) or with hypercapnia (MV + H, Fico2 = 0.05). Diaphragm muscle was excised for structural, biochemical and functional analyses. Results Myosin concentration in the diaphragm was decreased in MV versus CON, but not in MV + H versus CON. MV reduced diaphragm force by approximately 22% compared with CON. The force-generating capacity of diaphragm fibers from MV + H rats was approximately 14% lower compared with CON. Inflammatory cytokines were elevated in the diaphragm of MV rats, but not in the MV + H group. Diaphragm proteasome activity did not significantly differ between MV and CON. However, proteasome activity in the diaphragm of MV + H was significantly lower compared with CON. LC3B-II a marker of lysosomal autophagy was increased in both MV and MV + H. Incubation of MV + H diaphragm muscle fibers with the antioxidant dithiothreitol restored force generation of diaphragm fibers. Conclusions Hypercapnia partly protects the diaphragm against adverse effects of mechanical ventilation.
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Bruells C, Goetzenich A, Rossaint R. Ventilatorinduzierte diaphragmale Dysfunktion in der Kardiochirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2013. [DOI: 10.1007/s00398-013-1028-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Powers SK, Wiggs MP, Sollanek KJ, Smuder AJ. Ventilator-induced diaphragm dysfunction: cause and effect. Am J Physiol Regul Integr Comp Physiol 2013; 305:R464-77. [DOI: 10.1152/ajpregu.00231.2013] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Mechanical ventilation (MV) is used clinically to maintain gas exchange in patients that require assistance in maintaining adequate alveolar ventilation. Common indications for MV include respiratory failure, heart failure, drug overdose, and surgery. Although MV can be a life-saving intervention for patients suffering from respiratory failure, prolonged MV can promote diaphragmatic atrophy and contractile dysfunction, which is referred to as ventilator-induced diaphragm dysfunction (VIDD). This is significant because VIDD is thought to contribute to problems in weaning patients from the ventilator. Extended time on the ventilator increases health care costs and greatly increases patient morbidity and mortality. Research reveals that only 18–24 h of MV is sufficient to develop VIDD in both laboratory animals and humans. Studies using animal models reveal that MV-induced diaphragmatic atrophy occurs due to increased diaphragmatic protein breakdown and decreased protein synthesis. Recent investigations have identified calpain, caspase-3, autophagy, and the ubiquitin-proteasome system as key proteases that participate in MV-induced diaphragmatic proteolysis. The challenge for the future is to define the MV-induced signaling pathways that promote the loss of diaphragm protein and depress diaphragm contractility. Indeed, forthcoming studies that delineate the signaling mechanisms responsible for VIDD will provide the knowledge necessary for the development of a pharmacological approach that can prevent VIDD and reduce the incidence of weaning problems.
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Affiliation(s)
- Scott K. Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Michael P. Wiggs
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Kurt J. Sollanek
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Ashley J. Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
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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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Thomas D, Maes K, Agten A, Heunks L, Dekhuijzen R, Decramer M, Van Hees H, Gayan-Ramirez G. Time course of diaphragm function recovery after controlled mechanical ventilation in rats. J Appl Physiol (1985) 2013; 115:775-84. [PMID: 23845980 DOI: 10.1152/japplphysiol.00302.2012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Controlled mechanical ventilation (CMV) is known to result in rapid and severe diaphragmatic dysfunction, but the recovery response of the diaphragm to normal function after CMV is unknown. Therefore, we examined the time course of diaphragm function recovery in an animal model of CMV. Healthy rats were submitted to CMV for 24-27 h (n = 16), or to 24-h CMV followed by either 1 h (CMV + 1 h SB, n = 9), 2 h (CMV + 2 h SB, n = 9), 3 h (CMV + 3 h SB, n = 9), or 4-7 h (CMV + 4-7 h SB, n = 9) of spontaneous breathing (SB). At the end of the experiment, the diaphragm muscle was excised for functional and biochemical analysis. The in vitro diaphragm force was significantly improved in the CMV + 3 h SB and CMV + 4-7 h SB groups compared with CMV (maximal tetanic force: +27%, P < 0.05, and +59%, P < 0.001, respectively). This was associated with an increase in the type IIx/b fiber dimensions (P < 0.05). Neutrophil influx was increased in the CMV + 4-7 h SB group (P < 0.05), while macrophage numbers remained unchanged. Markers of protein synthesis (phosphorylated Akt and eukaryotic initiation factor 4E binding protein 1) were significantly increased (±40%, P < 0.001, and ±52%, P < 0.01, respectively) in the CMV + 3 h SB and CMV + 4-7 h SB groups and were positively correlated with diaphragm force (P < 0.05). Finally, also the maximal specific force generation of skinned single diaphragm fibers was increased in the CMV + 4-7 h SB group compared with CMV (+45%, P < 0.05). In rats, reloading the diaphragm for 3 h after CMV is sufficient to improve diaphragm function, while complete recovery occurs after longer periods of reloading. Enhanced muscle fiber dimensions, increased protein synthesis, and improved intrinsic contractile properties of diaphragm muscle fibers may have contributed to diaphragm function recovery.
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Affiliation(s)
- Debby Thomas
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, Leuven, Belgium
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Supinski GS, Callahan LA. Diaphragm weakness in mechanically ventilated critically ill patients. Crit Care 2013; 17:R120. [PMID: 23786764 PMCID: PMC3840677 DOI: 10.1186/cc12792] [Citation(s) in RCA: 159] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 06/20/2013] [Indexed: 12/02/2022] Open
Abstract
Introduction Studies indicate that mechanically ventilated patients develop significant diaphragm muscle weakness, but the etiology of weakness and its clinical impact remain incompletely understood. We assessed diaphragm strength in mechanically ventilated medical ICU patients, correlated the development of diaphragm weakness with multiple clinical parameters, and examined the relationship between the level of diaphragm weakness and patient outcomes. Methods Transdiaphragmatic twitch pressure (PdiTw) in response to bilateral magnetic stimulation of the phrenic nerves was measured. Diaphragm weakness was correlated with the presence of infection, blood urea nitrogen, albumin, and glucose levels. The relationship of diaphragm strength to patient outcomes, including mortality and the duration of mechanical ventilation for successfully weaned patients, was also assessed. Results We found that infection is a major risk factor for diaphragm weakness in mechanically ventilated medical ICU patients. Outcomes for patients with severe diaphragm weakness (PdiTw <10 cmH2O) were poor, with a markedly increased mortality (49%) compared to patients with PdiTw ≥10 cmH2O (7% mortality, P = 0.022). In addition, survivors with PdiTw <10 cmH2O required a significantly longer duration of mechanical ventilation (12.3 ± 1.7 days) than those with PdiTw ≥10 cmH2O (5.5 ± 2.0 days, P = 0.016). Conclusions Infection is a major cause of severe diaphragm weakness in mechanically ventilated patients. Moreover, diaphragm weakness is an important determinant of poor outcomes in this patient population.
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Talbert EE, Smuder AJ, Min K, Kwon OS, Powers SK. Calpain and caspase-3 play required roles in immobilization-induced limb muscle atrophy. J Appl Physiol (1985) 2013; 114:1482-9. [DOI: 10.1152/japplphysiol.00925.2012] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Prolonged skeletal muscle inactivity results in a rapid decrease in fiber size, primarily due to accelerated proteolysis. Although several proteases are known to contribute to disuse muscle atrophy, the ubiquitin proteasome system is often considered the most important proteolytic system during many conditions that promote muscle wasting. Emerging evidence suggests that calpain and caspase-3 may also play key roles in inactivity-induced atrophy of respiratory muscles, but it remains unknown if these proteases are essential for disuse atrophy in limb skeletal muscles. Therefore, we tested the hypothesis that activation of both calpain and caspase-3 is required for locomotor muscle atrophy induced by hindlimb immobilization. Seven days of immobilization (i.e., limb casting) promoted significant atrophy in type I muscle fibers of the rat soleus muscle. Independent pharmacological inhibition of calpain or caspase-3 prevented this casting-induced atrophy. Interestingly, inhibition of calpain activity also prevented caspase-3 activation, and, conversely, inhibition of caspase-3 prevented calpain activation. These findings indicate that a regulatory cross talk exists between these proteases and provide the first evidence that the activation of calpain and caspase-3 is required for inactivity-induced limb muscle atrophy.
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Affiliation(s)
- Erin E. Talbert
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Ashley J. Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Kisuk Min
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Oh Sung Kwon
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Scott K. Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
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Moderate and prolonged hypercapnic acidosis may protect against ventilator-induced diaphragmatic dysfunction in healthy piglet: an in vivo study. Crit Care 2013; 17:R15. [PMID: 23347872 PMCID: PMC4056755 DOI: 10.1186/cc12486] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Accepted: 01/07/2013] [Indexed: 11/10/2022] Open
Abstract
Introduction Protective ventilation by using limited airway pressures and ventilation may result in moderate and prolonged hypercapnic acidosis, as often observed in critically ill patients. Because allowing moderate and prolonged hypercapnia may be considered protective measure for the lungs, we hypothesized that moderate and prolonged hypercapnic acidosis may protect the diaphragm against ventilator-induced diaphragmatic dysfunction (VIDD). The aim of our study was to evaluate the effects of moderate and prolonged (72 hours of mechanical ventilation) hypercapnic acidosis on in vivo diaphragmatic function. Methods Two groups of anesthetized piglets were ventilated during a 72-hour period. Piglets were assigned to the Normocapnia group (n = 6), ventilated in normocapnia, or to the Hypercapnia group (n = 6), ventilated with moderate hypercapnic acidosis (PaCO2 from 55 to 70 mm Hg) during the 72-hour period of the study. Every 12 hours, we measured transdiaphragmatic pressure (Pdi) after bilateral, supramaximal transjugular stimulation of the two phrenic nerves to assess in vivo diaphragmatic contractile force. Pressure/frequency curves were drawn after stimulation from 20 to 120 Hz of the phrenic nerves. The protocol was approved by our institutional animal-care committee. Results Moderate and prolonged hypercapnic acidosis was well tolerated during the study period. The baseline pressure/frequency curves of the two groups were not significantly different (Pdi at 20 Hz, 32.7 ± 8.7 cm H2O, versus 34.4 ± 8.4 cm H2O; and at 120 Hz, 56.8 ± 8.7 cm H2O versus 60.8 ± 5.7 cm H2O, for Normocapnia and Hypercapnia groups, respectively). After 72 hours of ventilation, Pdi decreased by 25% of its baseline value in the Normocapnia group, whereas Pdi did not decrease in the Hypercapnia group. Conclusions Moderate and prolonged hypercapnic acidosis limited the occurrence of VIDD during controlled mechanical ventilation in a healthy piglet model. Consequences of moderate and prolonged hypercapnic acidosis should be better explored with further studies before being tested on patients.
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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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Proteasome inhibition and ventilator-induced diaphragmatic dysfunction: is the glass half full or half empty? Crit Care Med 2012; 40:2525-6. [PMID: 22809936 DOI: 10.1097/ccm.0b013e318258ebc5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Bortezomib partially protects the rat diaphragm from ventilator-induced diaphragm dysfunction. Crit Care Med 2012; 40:2449-55. [PMID: 22809912 DOI: 10.1097/ccm.0b013e3182553a88] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVE Controlled mechanical ventilation leads to diaphragmatic contractile dysfunction and atrophy. Since proteolysis is enhanced in the diaphragm during controlled mechanical ventilation, we examined whether the administration of a proteasome inhibitor, bortezomib, would have a protective effect against ventilator-induced diaphragm dysfunction. DESIGN Randomized, controlled experiment. SETTINGS Basic science animal laboratory. INTERVENTIONS Anesthetized rats were submitted for 24 hrs to controlled mechanical ventilation while receiving 0.05 mg/kg bortezomib or saline. Control rats were acutely anesthetized. MEASUREMENTS AND MAIN RESULTS After 24 hrs, diaphragm force production was significantly lower in mechanically ventilated animals receiving an injection of saline compared to control animals (-36%, p<.001). Importantly, administration of bortezomib improved the diaphragmatic force compared to mechanically ventilated animals receiving an injection of saline (+15%, p<.01), but force did not return to control levels. Compared to control animals, diaphragm cross-sectional area of the type IIx/b fibers was significantly decreased by 28% in mechanically ventilated animals receiving an injection of saline (p<.01) and by 16% in mechanically ventilated animals receiving an injection of bortezomib (p<.05). Diaphragmatic calpain activity was significantly increased in mechanically ventilated animals receiving an injection of saline (+52%, p<.05) and in mechanically ventilated animals receiving an injection of bortezomib (+36%, p<.05). Caspase-3 activity was increased after controlled mechanical ventilation with saline by 55% (p<.05), while it remained similar to control animals in mechanically ventilated animals receiving an injection of bortezomib. Diaphragm 20S proteasome activity was slightly increased in both ventilated groups, and the amount of ubiquitinated proteins was significantly and similarly enhanced in mechanically ventilated animals receiving an injection of saline and mechanically ventilated animals receiving an injection of bortezomib. CONCLUSIONS These data show that the administration of bortezomib partially protects the diaphragm from controlled mechanical ventilation-induced diaphragm contractile dysfunction without preventing atrophy. The fact that calpain activity was still increased after bortezomib treatment may explain the persistence of atrophy. Part of bortezomib effects might have been due to its ability to inhibit caspase-3 in this model.
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Cross-talk between the calpain and caspase-3 proteolytic systems in the diaphragm during prolonged mechanical ventilation. Crit Care Med 2012; 40:1857-63. [PMID: 22487998 DOI: 10.1097/ccm.0b013e318246bb5d] [Citation(s) in RCA: 89] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Diaphragmatic weakness, due to both atrophy and contractile dysfunction, is a well-documented response following prolonged mechanical ventilation. Evidence indicates that activation of the proteases calpain and caspase-3 is essential for mechanical ventilation-induced diaphragmatic weakness to occur. We tested the hypothesis that a regulatory cross-talk exists between calpain and caspase-3 in the diaphragm during prolonged mechanical ventilation. To test this prediction, we determined whether selective pharmacological inhibition of calpain would prevent activation of caspase-3 and conversely whether selective inhibition of caspase-3 would abate calpain activation. DESIGN Animal study. SETTING University Research Laboratory. SUBJECTS Female Sprague-Dawley rats. INTERVENTIONS Animals were randomly divided into control or one of three 12-hr mechanical ventilation groups that were treated with/without a selective pharmacological protease inhibitor: 1) control, 2) mechanical ventilation, 3) mechanical ventilation with a selective caspase-3 inhibitor, and 4) mechanical ventilation with a selective calpain inhibitor. MEASUREMENTS AND MAIN RESULTS Compared to control, mechanical ventilation resulted in calpain and caspase-3 activation in the diaphragm accompanied by atrophy of type I, type IIa, and type IIx/IIb fibers. Independent inhibition of either calpain or caspase-3 prevented this mechanical ventilation-induced atrophy. Pharmacological inhibition of calpain prevented mechanical ventilation-induced activation of diaphragmatic caspase-3 and inhibition of caspase-3 prevented activation of diaphragmatic calpain. Furthermore, calpain inhibition also prevented the activation of caspase-9 and caspase-12, along with the cleavage of Bid to tBid, all upstream signals for caspase-3 activation. Lastly, caspase-3 inhibition prevented the mechanical ventilation-induced degradation of the endogenous calpain inhibitor, calpastatin. CONCLUSIONS Collectively, these results indicate that mechanical ventilation-induced diaphragmatic atrophy is dependent on the activation of both calpain and caspase-3. Importantly, these findings provide the first experimental evidence in diaphragm muscle that calpain inhibition prevents the activation of caspase-3 and vice versa and caspase-3 inhibition prevents the activation of calpain. These findings support our hypothesis that a regulatory calpain/caspase-3 cross-talk exists whereby calpain can promote caspase-3 activation and active caspase-3 can enhance calpain activity in diaphragm muscle during prolonged mechanical ventilation.
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Powers SK, Wiggs MP, Duarte JA, Zergeroglu AM, Demirel HA. Mitochondrial signaling contributes to disuse muscle atrophy. Am J Physiol Endocrinol Metab 2012; 303:E31-9. [PMID: 22395111 PMCID: PMC3404565 DOI: 10.1152/ajpendo.00609.2011] [Citation(s) in RCA: 164] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
It is well established that long durations of bed rest, limb immobilization, or reduced activity in respiratory muscles during mechanical ventilation results in skeletal muscle atrophy in humans and other animals. The idea that mitochondrial damage/dysfunction contributes to disuse muscle atrophy originated over 40 years ago. These early studies were largely descriptive and did not provide unequivocal evidence that mitochondria play a primary role in disuse muscle atrophy. However, recent experiments have provided direct evidence connecting mitochondrial dysfunction to muscle atrophy. Numerous studies have described changes in mitochondria shape, number, and function in skeletal muscles exposed to prolonged periods of inactivity. Furthermore, recent evidence indicates that increased mitochondrial ROS production plays a key signaling role in both immobilization-induced limb muscle atrophy and diaphragmatic atrophy occurring during prolonged mechanical ventilation. Moreover, new evidence reveals that, during denervation-induced muscle atrophy, increased mitochondrial fragmentation due to fission is a required signaling event that activates the AMPK-FoxO3 signaling axis, which induces the expression of atrophy genes, protein breakdown, and ultimately muscle atrophy. Collectively, these findings highlight the importance of future research to better understand the mitochondrial signaling mechanisms that contribute to disuse muscle atrophy and to develop novel therapeutic interventions for prevention of inactivity-induced skeletal muscle atrophy.
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Affiliation(s)
- Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA.
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Both high level pressure support ventilation and controlled mechanical ventilation induce diaphragm dysfunction and atrophy. Crit Care Med 2012; 40:1254-60. [PMID: 22425820 DOI: 10.1097/ccm.0b013e31823c8cc9] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Previous workers have demonstrated that controlled mechanical ventilation results in diaphragm inactivity and elicits a rapid development of diaphragm weakness as a result of both contractile dysfunction and fiber atrophy. Limited data exist regarding the impact of pressure support ventilation, a commonly used mode of mechanical ventilation-that permits partial mechanical activity of the diaphragm-on diaphragm structure and function. We carried out the present study to test the hypothesis that high-level pressure support ventilation decreases the diaphragm pathology associated with CMV. METHODS Sprague-Dawley rats were randomly assigned to one of the following five groups:1) control (no mechanical ventilation); 2) 12 hrs of controlled mechanical ventilation (12CMV); 3) 18 hrs of controlled mechanical ventilation (18CMV); 4) 12 hrs of pressure support ventilation (12PSV); or 5) 18 hrs of pressure support ventilation (18PSV). MEASUREMENTS AND MAIN RESULTS We carried out the following measurements on diaphragm specimens: 4-hydroxynonenal-a marker of oxidative stress, active caspase-3 (casp-3), active calpain-1 (calp-1), fiber type cross-sectional area, and specific force (sp F). Compared with the control, both 12PSV and 18PSV promoted a significant decrement in diaphragmatic specific force production, but to a lesser degree than 12CMV and 18CMV. Furthermore, 12CMV, 18PSV, and 18CMV resulted in significant atrophy in all diaphragm fiber types as well as significant increases in a biomarker of oxidative stress (4-hydroxynonenal) and increased proteolytic activity (20S proteasome, calpain-1, and caspase-3). Furthermore, although no inspiratory effort occurs during controlled mechanical ventilation, it was observed that pressure support ventilation resulted in large decrement, approximately 96%, in inspiratory effort compared with spontaneously breathing animals. CONCLUSIONS High levels of prolonged pressure support ventilation promote diaphragmatic atrophy and contractile dysfunction. Furthermore, similar to controlled mechanical ventilation, pressure support ventilation-induced diaphragmatic atrophy and weakness are associated with both diaphragmatic oxidative stress and protease activation.
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