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Wu H, Chasteen B. Rapid review of ventilator-induced diaphragm dysfunction. Respir Med 2024; 223:107541. [PMID: 38290603 DOI: 10.1016/j.rmed.2024.107541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/01/2024]
Abstract
Ventilator-induced diaphragm dysfunction is gaining increased recognition. Evidence of diaphragm weakness can manifest within 12 h to a few days after the initiation of mechanical ventilation. Various noninvasive and invasive methods have been developed to assess diaphragm function. The implementation of diaphragm-protective ventilation strategies is crucial for preventing diaphragm injuries. Furthermore, diaphragm neurostimulation emerges as a promising and novel treatment option. In this rapid review, our objective is to discuss the current understanding of ventilator-induced diaphragm dysfunction, diagnostic approaches, and updates on strategies for prevention and management.
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Affiliation(s)
- Huimin Wu
- Pulmonary, Critical Care and Sleep Medicine Section, Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, 73104, United States; Department of Adult Respiratory Care, University of Oklahoma Medical Center, Oklahoma City, OK, 73104, United States.
| | - Bobby Chasteen
- Department of Adult Respiratory Care, University of Oklahoma Medical Center, Oklahoma City, OK, 73104, United States.
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2
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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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3
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Villelabeitia-Jaureguizar K, Calvo-Lobo C, Rodríguez-Sanz D, Vicente-Campos D, Castro-Portal JA, López-Cañadas M, Becerro-de-Bengoa-Vallejo R, Chicharro JL. Low Intensity Respiratory Muscle Training in COVID-19 Patients after Invasive Mechanical Ventilation: A Retrospective Case-Series Study. Biomedicines 2022; 10:2807. [PMID: 36359327 PMCID: PMC9687222 DOI: 10.3390/biomedicines10112807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/06/2022] Open
Abstract
Worldwide, healthcare systems had to respond to an exponential increase in COVID-19 patients with a noteworthy increment in intensive care units (ICU) admissions and invasive mechanical ventilation (IMV). The aim was to determine low intensity respiratory muscle training (RMT) effects in COVID-19 patients upon medical discharge and after an ICU stay with IMV. A retrospective case-series study was performed. Forty COVID-19 patients were enrolled and divided into twenty participants who received IMV during ICU stay (IMV group) and 20 participants who did not receive IMV nor an ICU stay (non-IMV group). Maximal expiratory pressure (PEmax), maximal inspiratory pressure (PImax), COPD assessment test (CAT) and Medical Research Council (MRC) dyspnea scale were collected at baseline and after 12 weeks of low intensity RMT. A greater MRC dyspnea score and lower PImax were shown at baseline in the IMV group versus the non-IMV group (p < 0.01). RMT effects on the total sample improved all outcome measurements (p < 0.05; d = 0.38−0.98). Intragroup comparisons after RMT improved PImax, CAT and MRC scores in the IMV group (p = 0.001; d = 0.94−1.09), but not for PImax in the non-IMV group (p > 0.05). Between-groups comparison after RMT only showed MRC dyspnea improvements (p = 0.020; d = 0.74) in the IMV group versus non-IMV group. Furthermore, PImax decrease was only predicted by the IMV presence (R2 = 0.378). Low intensity RMT may improve respiratory muscle strength, health related quality of life and dyspnea in COVID-19 patients. Especially, low intensity RMT could improve dyspnea level and maybe PImax in COVID-19 patients who received IMV in ICU.
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Affiliation(s)
| | - César Calvo-Lobo
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - David Rodríguez-Sanz
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Davinia Vicente-Campos
- Faculty of Health Sciences, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 28223 Madrid, Spain
| | | | | | | | - José López Chicharro
- Faculty of Nursing, Physiotherapy and Podiatry, Universidad Complutense de Madrid, 28040 Madrid, Spain
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4
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Itagaki T. Diaphragm-protective mechanical ventilation in acute respiratory failure. THE JOURNAL OF MEDICAL INVESTIGATION 2022; 69:165-172. [DOI: 10.2152/jmi.69.165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
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Abstract
OBJECTIVES Mechanical ventilation is associated with primary diaphragmatic dysfunction, also termed ventilator-induced diaphragmatic dysfunction. Studies evaluating diaphragmatic function recovery after extubation are lacking. We evaluated early and late recoveries from ventilator-induced diaphragmatic dysfunction in a mouse model. DESIGN Experimental randomized study. SETTING Research laboratory. SUBJECTS C57/BL6 mice. INTERVENTIONS Six groups of C57/BL6 mice. Mice were ventilated for 6 hours and then euthanatized immediately (n = 18), or 1 (n = 18) or 10 days after extubation with (n = 5) and without S107 (n = 16) treatment. Mice euthanatized immediately after 6 hours of anesthesia (n = 15) or after 6 hours of anesthesia and 10 days of recovery (n = 5) served as controls. MEASUREMENTS AND MAIN RESULTS For each group, diaphragm force production, posttranslational modification of ryanodine receptor, oxidative stress, proteolysis, and cross-sectional areas were evaluated. After 6 hours of mechanical ventilation, diaphragm force production was decreased by 25-30%, restored to the control levels 1 day after extubation, and secondarily decreased by 20% 10 days after extubation compared with controls. Ryanodine receptor was protein kinase A-hyperphosphorylated, S-nitrosylated, oxidized, and depleted of its stabilizing subunit calstabin-1 6 hours after the onset of the mechanical ventilation, 1 and 10 days after extubation. Post extubation treatment with S107, a Rycal drug that stabilizes the ryanodine complex, did reverse the loss of diaphragmatic force associated with mechanical ventilation. Total protein oxidation was restored to the control levels 1 day after extubation. Markers of proteolysis including calpain 1 and calpain 2 remained activated 10 days after extubation without significant changes in cross-sectional areas. CONCLUSIONS We report that mechanical ventilation is associated with a late diaphragmatic dysfunction related to a structural alteration of the ryanodine complex that is reversed with the S107 treatment.
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Gonzalez A, Orozco-Aguilar J, Achiardi O, Simon F, Cabello-Verrugio C. SARS-CoV-2/Renin-Angiotensin System: Deciphering the Clues for a Couple with Potentially Harmful Effects on Skeletal Muscle. Int J Mol Sci 2020; 21:ijms21217904. [PMID: 33114359 PMCID: PMC7663203 DOI: 10.3390/ijms21217904] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 10/09/2020] [Accepted: 10/21/2020] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus (SARS-CoV-2) has produced significant health emergencies worldwide, resulting in the declaration by the World Health Organization of the coronavirus disease 2019 (COVID-19) pandemic. Acute respiratory syndrome seems to be the most common manifestation of COVID-19. A high proportion of patients require intensive care unit admission and mechanical ventilation (MV) to survive. It has been well established that angiotensin-converting enzyme type 2 (ACE2) is the primary cellular receptor for SARS-CoV-2. ACE2 belongs to the renin–angiotensin system (RAS), composed of several peptides, such as angiotensin II (Ang II) and angiotensin (1-7) (Ang-(1-7)). Both peptides regulate muscle mass and function. It has been described that SARS-CoV-2 infection, by direct and indirect mechanisms, affects a broad range of organ systems. In the skeletal muscle, through unbalanced RAS activity, SARS-CoV-2 could induce severe consequences such as loss of muscle mass, strength, and physical function, which will delay and interfere with the recovery process of patients with COVID-19. This article discusses the relationship between RAS, SARS-CoV-2, skeletal muscle, and the potentially harmful consequences for skeletal muscle in patients currently infected with and recovering from COVID-19.
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Affiliation(s)
- Andrea Gonzalez
- Laboratory of Muscle Pathology, Fragility and Aging, Department of Biological Sciences, Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370146, Chile; (A.G.); (J.O.-A.)
- Millennium Institute on Immunology and Immunotherapy, Santiago 8370146, Chile;
- Center for the Development of Nanoscience and Nanotechnology (CEDENNA), Universidad de Santiago de Chile, Santiago 8350709, Chile
| | - Josué Orozco-Aguilar
- Laboratory of Muscle Pathology, Fragility and Aging, Department of Biological Sciences, Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370146, Chile; (A.G.); (J.O.-A.)
- Millennium Institute on Immunology and Immunotherapy, Santiago 8370146, Chile;
- Center for the Development of Nanoscience and Nanotechnology (CEDENNA), Universidad de Santiago de Chile, Santiago 8350709, Chile
| | - Oscar Achiardi
- Escuela de Kinesiología, Facultad de Ciencias, Pontificia Universidad Católica de Valparaíso, Valparaíso 2340025, Chile;
| | - Felipe Simon
- Millennium Institute on Immunology and Immunotherapy, Santiago 8370146, Chile;
- Laboratory of Integrative Physiopathology, Department of Biological Sciences, Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370146, Chile
- Millennium Nucleus of Ion Channels-Associated Diseases (MiNICAD), Universidad de Chile, Santiago 8370146, Chile
| | - Claudio Cabello-Verrugio
- Laboratory of Muscle Pathology, Fragility and Aging, Department of Biological Sciences, Faculty of Life Sciences, Universidad Andres Bello, Santiago 8370146, Chile; (A.G.); (J.O.-A.)
- Millennium Institute on Immunology and Immunotherapy, Santiago 8370146, Chile;
- Center for the Development of Nanoscience and Nanotechnology (CEDENNA), Universidad de Santiago de Chile, Santiago 8350709, Chile
- Correspondence: ; Tel./Fax: +56-227-703-665
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7
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Lung- and Diaphragm-protective Ventilation in Acute Respiratory Distress Syndrome: Rationale and Challenges. Anesthesiology 2020; 130:620-633. [PMID: 30844950 DOI: 10.1097/aln.0000000000002605] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
A novel approach to ventilation aims to be both lung- and diaphragm-protective. This strategy integrates concerns over excessive lung stress during spontaneous breathing while avoiding both insufficient and excessive inspiratory effort.
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8
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Shimatani T, Shime N, Nakamura T, Ohshimo S, Hotz J, Khemani RG. Neurally adjusted ventilatory assist mitigates ventilator-induced diaphragm injury in rabbits. Respir Res 2019; 20:293. [PMID: 31870367 PMCID: PMC6929282 DOI: 10.1186/s12931-019-1265-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/18/2019] [Indexed: 12/18/2022] Open
Abstract
Background Ventilator-induced diaphragmatic dysfunction is a serious complication associated with higher ICU mortality, prolonged mechanical ventilation, and unsuccessful withdrawal from mechanical ventilation. Although neurally adjusted ventilatory assist (NAVA) could be associated with lower patient-ventilator asynchrony compared with conventional ventilation, its effects on diaphragmatic dysfunction have not yet been well elucidated. Methods Twenty Japanese white rabbits were randomly divided into four groups, (1) no ventilation, (2) controlled mechanical ventilation (CMV) with continuous neuromuscular blockade, (3) NAVA, and (4) pressure support ventilation (PSV). Ventilated rabbits had lung injury induced, and mechanical ventilation was continued for 12 h. Respiratory waveforms were continuously recorded, and the asynchronous events measured. Subsequently, the animals were euthanized, and diaphragm and lung tissue were removed, and stained with Hematoxylin-Eosin to evaluate the extent of lung injury. The myofiber cross-sectional area of the diaphragm was evaluated under the adenosine triphosphatase staining, sarcomere disruptions by electron microscopy, apoptotic cell numbers by the TUNEL method, and quantitative analysis of Caspase-3 mRNA expression by real-time polymerase chain reaction. Results Physiological index, respiratory parameters, and histologic lung injury were not significantly different among the CMV, NAVA, and PSV. NAVA had lower asynchronous events than PSV (median [interquartile range], NAVA, 1.1 [0–2.2], PSV, 6.8 [3.8–10.0], p = 0.023). No differences were seen in the cross-sectional areas of myofibers between NAVA and PSV, but those of Type 1, 2A, and 2B fibers were lower in CMV compared with NAVA. The area fraction of sarcomere disruptions was lower in NAVA than PSV (NAVA vs PSV; 1.6 [1.5–2.8] vs 3.6 [2.7–4.3], p < 0.001). The proportion of apoptotic cells was lower in NAVA group than in PSV (NAVA vs PSV; 3.5 [2.5–6.4] vs 12.1 [8.9–18.1], p < 0.001). There was a tendency in the decreased expression levels of Caspase-3 mRNA in NAVA groups. Asynchrony Index was a mediator in the relationship between NAVA and sarcomere disruptions. Conclusions Preservation of spontaneous breathing using either PSV or NAVA can preserve the cross sectional area of the diaphragm to prevent atrophy. However, NAVA may be superior to PSV in preventing sarcomere injury and apoptosis of myofibrotic cells of the diaphragm, and this effect may be mediated by patient-ventilator asynchrony.
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Affiliation(s)
- Tatsutoshi Shimatani
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan.
| | - Tomohiko Nakamura
- Division of Neonatology, Nagano Children's Hospital, 3100 Toyoshina, Azumino City, Nagano, 399-8288, Japan
| | - Shinichiro Ohshimo
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551, Japan
| | - Justin Hotz
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, United States
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Los Angeles, 4650 Sunset Boulevard, Los Angeles, CA, 90027, United States.,Department of Pediatrics, University of Southern California, Keck School of Medicine, 1975 Zonal Ave, Los Angeles, CA, 90033, United States
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9
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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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10
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van der Pijl RJ, Granzier HL, Ottenheijm CAC. Diaphragm contractile weakness due to reduced mechanical loading: role of titin. Am J Physiol Cell Physiol 2019; 317:C167-C176. [PMID: 31042425 DOI: 10.1152/ajpcell.00509.2018] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The diaphragm, the main muscle of inspiration, is constantly subjected to mechanical loading. Only during controlled mechanical ventilation, as occurs during thoracic surgery and in the intensive care unit, is mechanical loading of the diaphragm arrested. Animal studies indicate that the diaphragm is highly sensitive to unloading, causing rapid muscle fiber atrophy and contractile weakness; unloading-induced diaphragm atrophy and contractile weakness have been suggested to contribute to the difficulties in weaning patients from ventilator support. The molecular triggers that initiate the rapid unloading atrophy of the diaphragm are not well understood, although proteolytic pathways and oxidative signaling have been shown to be involved. Mechanical stress is known to play an important role in the maintenance of muscle mass. Within the muscle's sarcomere, titin is considered to play an important role in the stress-response machinery. Titin is a giant protein that acts as a mechanosensor regulating muscle protein expression in a sarcomere strain-dependent fashion. Thus titin is an attractive candidate for sensing the sudden mechanical arrest of the diaphragm when patients are mechanically ventilated, leading to changes in muscle protein expression. Here, we provide a novel perspective on how titin and its biomechanical sensing and signaling might be involved in the development of mechanical unloading-induced diaphragm weakness.
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Affiliation(s)
- Robbert J van der Pijl
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Henk L Granzier
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona
| | - Coen A C Ottenheijm
- Department of Cellular and Molecular Medicine, University of Arizona , Tucson, Arizona.,Department of Physiology, Amsterdam University Medical Center, Amsterdam, The Netherlands
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11
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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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12
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Schreiber A, Bertoni M, Goligher EC. Avoiding Respiratory and Peripheral Muscle Injury During Mechanical Ventilation: Diaphragm-Protective Ventilation and Early Mobilization. Crit Care Clin 2018; 34:357-381. [PMID: 29907270 DOI: 10.1016/j.ccc.2018.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Both limb muscle weakness and respiratory muscle weakness are exceedingly common in critically ill patients. Respiratory muscle weakness prolongs ventilator dependence, predisposing to nosocomial complications and death. Limb muscle weakness persists for months after discharge from intensive care and results in poor long-term functional status and quality of life. Major mechanisms of muscle injury include critical illness polymyoneuropathy, sepsis, pharmacologic exposures, metabolic derangements, and excessive muscle loading and unloading. The diaphragm may become weak because of excessive unloading (leading to atrophy) or because of excessive loading (either concentric or eccentric) owing to insufficient ventilator assistance.
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Affiliation(s)
- Annia Schreiber
- Respiratory Intensive Care Unit and Pulmonary Rehabilitation Unit, Istituti Clinici Scientifici Maugeri, Scientific Institute of Pavia, Via Salvatore Maugeri 10, Pavia 27100, Italy
| | - Michele Bertoni
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Piazzale Spedali Civili 1, Brescia 25123, Italy
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Division of Respirology, Department of Medicine, University Health Network, Toronto General Hospital, 585 University Avenue, Peter Munk Building, 11th Floor Room 192, Toronto, ON M5G 2N2, Canada.
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13
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Petrof BJ, Sassoon CS. Diaphragm Remodeling during Application of Positive End-Expiratory Pressure. A Case of Normal Physiologic Adaptation Gone Awry? Am J Respir Crit Care Med 2018; 198:416-418. [DOI: 10.1164/rccm.201803-0518ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Basil J. Petrof
- Meakins-Christie LaboratoriesMcGill UniversityMontreal, Quebec, Canada
- Translational Research in Respiratory Diseases ProgramMcGill University Health CentreMontreal, Quebec, Canada
| | - Catherine S. Sassoon
- Department of MedicineUniversity of California, IrvineIrvine, Californiaand
- VA Long Beach Healthcare SystemLong Beach, California
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14
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Lindqvist J, van den Berg M, van der Pijl R, Hooijman PE, Beishuizen A, Elshof J, de Waard M, Girbes A, Spoelstra-de Man A, Shi ZH, van den Brom C, Bogaards S, Shen S, Strom J, Granzier H, Kole J, Musters RJP, Paul MA, Heunks LMA, Ottenheijm CAC. Positive End-Expiratory Pressure Ventilation Induces Longitudinal Atrophy in Diaphragm Fibers. Am J Respir Crit Care Med 2018; 198:472-485. [PMID: 29578749 PMCID: PMC6118031 DOI: 10.1164/rccm.201709-1917oc] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 03/26/2018] [Indexed: 01/11/2023] Open
Abstract
RATIONALE Diaphragm weakness in critically ill patients prolongs ventilator dependency and duration of hospital stay and increases mortality and healthcare costs. The mechanisms underlying diaphragm weakness include cross-sectional fiber atrophy and contractile protein dysfunction, but whether additional mechanisms are at play is unknown. OBJECTIVES To test the hypothesis that mechanical ventilation with positive end-expiratory pressure (PEEP) induces longitudinal atrophy by displacing the diaphragm in the caudal direction and reducing the length of fibers. METHODS We studied structure and function of diaphragm fibers of mechanically ventilated critically ill patients and mechanically ventilated rats with normal and increased titin compliance. MEASUREMENTS AND MAIN RESULTS PEEP causes a caudal movement of the diaphragm, both in critically ill patients and in rats, and this caudal movement reduces fiber length. Diaphragm fibers of 18-hour mechanically ventilated rats (PEEP of 2.5 cm H2O) adapt to the reduced length by absorbing serially linked sarcomeres, the smallest contractile units in muscle (i.e., longitudinal atrophy). Increasing the compliance of titin molecules reduces longitudinal atrophy. CONCLUSIONS Mechanical ventilation with PEEP results in longitudinal atrophy of diaphragm fibers, a response that is modulated by the elasticity of the giant sarcomeric protein titin. We postulate that longitudinal atrophy, in concert with the aforementioned cross-sectional atrophy, hampers spontaneous breathing trials in critically ill patients: during these efforts, end-expiratory lung volume is reduced, and the shortened diaphragm fibers are stretched to excessive sarcomere lengths. At these lengths, muscle fibers generate less force, and diaphragm weakness ensues.
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Affiliation(s)
- Johan Lindqvist
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | | | - Robbert van der Pijl
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
- Department of Physiology
| | | | - Albertus Beishuizen
- Department of Intensive Care, Medisch Spectrum Twente, Enschede, the Netherlands; and
| | | | | | | | | | - Zhong-Hua Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | | | | | - Shengyi Shen
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | - Joshua Strom
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | - Henk Granzier
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| | | | | | - Marinus A. Paul
- Department of Cardiothoracic Surgery, Vrije Universiteit Medical Center, Amsterdam, the Netherlands
| | | | - Coen A. C. Ottenheijm
- Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
- Department of Physiology
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15
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Song Y, Dahl M, Leavitt W, Alvord J, Bradford CY, Albertine KH, Pillow JJ. Vitamin A Protects the Preterm Lamb Diaphragm Against Adverse Effects of Mechanical Ventilation. Front Physiol 2018; 9:1119. [PMID: 30150942 PMCID: PMC6099107 DOI: 10.3389/fphys.2018.01119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 07/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Preterm infants are deficient in vitamin A, which is essential for growth and development of the diaphragm. Preterm infants often require mechanical ventilation (MV) for respiratory distress. In adults, MV is associated with the development of ventilation-induced diaphragm dysfunction and difficulty weaning from the ventilator. We assessed the impact of MV on the preterm diaphragm and the protective effect of vitamin A during MV. Methods: Preterm lambs delivered operatively at ∼131 days gestation (full gestation: 150 days) received respiratory support by synchronized intermittent mandatory ventilation for 3 days. Lambs in the treated group received daily (24 h) enteral doses of 2500 IU/kg/day vitamin A combined with 250 IU/kg/day retinoic acid (VARA) during MV, while MV control lambs received saline. Unventilated fetal reference lambs were euthanized at birth, without being allowed to breathe. The fetal diaphragm was collected to quantify mRNA levels of myosin heavy chain (MHC) isoforms, atrophy genes, antioxidant genes, and pro-inflammatory genes; to determine ubiquitin proteasome pathway activity; to measure the abundance of protein carbonyl, and to investigate metabolic signaling. Results: Postnatal MV significantly decreased expression level of the neonatal MHC gene but increased expression level of MHC IIx mRNA level (p < 0.05). Proteasome activity increased after 3 days MV, accompanied by increased MuRF1 mRNA level and accumulated protein carbonyl abundance. VARA supplementation decreased proteasome activity and FOXO1 signaling, down-regulated MuRF1 expression, and reduced reactive oxidant production. Conclusion: These findings suggest that 3 days of MV results in abnormal myofibrillar composition, activation of the proteolytic pathway, and oxidative injury of diaphragms in mechanically ventilated preterm lambs. Daily enteral VARA protects the preterm diaphragm from these adverse effects.
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Affiliation(s)
- Yong Song
- School of Human Sciences, The University of Western Australia, Crawley, WA, Australia.,Centre for Neonatal Research and Education, Division of Paediatrics and Child Health, Medical School, The University of Western Australia, Crawley, WA, Australia.,School of Public Health, Curtin University, Bentley, WA, Australia.,Centre for Genetic Origins of Health and Disease, The University of Western Australia, Curtin University, Crawley, WA, Australia
| | - MarJanna Dahl
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Wendy Leavitt
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Jeremy Alvord
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Calan Y Bradford
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - Kurt H Albertine
- Department of Pediatrics, University of Utah, Salt Lake City, UT, United States
| | - J Jane Pillow
- School of Human Sciences, The University of Western Australia, Crawley, WA, Australia.,Centre for Neonatal Research and Education, Division of Paediatrics and Child Health, Medical School, The University of Western Australia, Crawley, WA, Australia
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16
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Vassilakopoulos T, Petrof BJ. A Stimulating Approach to Ventilator-induced Diaphragmatic Dysfunction. Am J Respir Crit Care Med 2017; 169:336-41. [PMID: 14739134 DOI: 10.1164/rccm.200304-489cp] [Citation(s) in RCA: 288] [Impact Index Per Article: 41.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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17
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Wilcox SR. Corticosteroids and neuromuscular blockers in development of critical illness neuromuscular abnormalities: A historical review. J Crit Care 2016; 37:149-155. [PMID: 27736708 DOI: 10.1016/j.jcrc.2016.09.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 08/31/2016] [Accepted: 09/20/2016] [Indexed: 01/28/2023]
Abstract
Weakness is common in critically ill patients, associated with prolonged mechanical ventilation and increased mortality. Corticosteroids and neuromuscular blockade (NMB) administration have been implicated as etiologies of acquired weakness in the intensive care unit. Medical literature since the 1970s is replete with case reports and small case series of patients with weakness after receiving high-dose corticosteroids, prolonged NMB, or both. Several risk factors for weakness appear in the early literature, including large doses of steroids, the dose and duration of NMB, hyperglycemia, and the duration of mechanical ventilation. With improved quality of data, however, the association between weakness and steroids or NMB wanes. This may reflect changes in clinical practice, such as a reduction in steroid dosing, use of cisatracurium besylate instead of aminosteroid NMBs, improved glycemic control, or trends in minimizing mechanical ventilatory support. Thus, based on the most recent and high-quality literature, neither corticosteroids in commonly used doses nor NMB is associated with increased duration of mechanical ventilation, the greatest morbidity of weakness. Minimizing ventilator support as soon as the patient's condition allows may be associated with a reduction in weakness-related morbidity.
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Affiliation(s)
- Susan R Wilcox
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine and Division of Emergency Medicine, Department of Medicine, Medical University of South Carolina, Charleston, SC.
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18
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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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19
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Sigurta' A, Zambelli V, Bellani G. Renin-angiotensin system in ventilator-induced diaphragmatic dysfunction: Potential protective role of Angiotensin (1-7). Med Hypotheses 2016; 94:132-7. [PMID: 27515219 DOI: 10.1016/j.mehy.2016.07.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 07/12/2016] [Accepted: 07/18/2016] [Indexed: 12/14/2022]
Abstract
Ventilator-induced diaphragmatic dysfunction is a feared complication of mechanical ventilation that adversely affects the outcome of intensive care patients. Human and animal studies demonstrate atrophy and ultrastructural alteration of diaphragmatic muscular fibers attributable to increased oxidative stress, depression of the anabolic pathway regulated by Insulin-like growing factor 1 and increased proteolysis. The renin-angiotensin system, through its main peptide Angiotensin II, plays a major role in skeletal muscle diseases, mainly increasing oxidative stress and inducing insulin resistance, atrophy and fibrosis. Conversely, its counter-regulatory peptide Angiotensin (1-7) has a protective role in these processes. Recent data on rodent models show that renin-angiotensin system is activated after mechanical ventilation and that infusion of Angiotensin II induces diaphragmatic skeletal muscle atrophy. Given: (A) common pathways shared by ventilator-induced diaphragmatic dysfunction and skeletal muscle pathology induced by renin-angiotensin system, (B) evidences of an involvement of renin-angiotensin system in diaphragm atrophy and dysfunction, we hypothesize that renin-angiotensin system plays an important role in ventilator-induced diaphragmatic dysfunction, while Angiotensin (1-7) can have a protective effect on this pathological process. The activation of renin-angiotensin system in ventilator-induced diaphragmatic dysfunction can be demonstrated by quantification of its main components in the diaphragm of ventilated humans or animals. The infusion of Angiotensin (1-7) in an established rodent model of ventilator-induced diaphragmatic dysfunction can be used to test its potential protective role, that can be further confirmed with the infusion of Angiotensin (1-7) antagonists like A-779. Verifying this hypothesis can help in understanding the processes involved in ventilator-induced diaphragmatic dysfunction pathophysiology and open new possibilities for its prevention and treatment.
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Affiliation(s)
- Anna Sigurta'
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.
| | - Vanessa Zambelli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency, San Gerardo Hospital, Monza, Italy
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20
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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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21
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Jung B, Gleeton D, Daurat A, Conseil M, Mahul M, Rao G, Matecki S, Lacampagne A, Jaber S. Conséquences de la ventilation mécanique sur le diaphragme. Rev Mal Respir 2015; 32:370-80. [DOI: 10.1016/j.rmr.2014.08.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 08/25/2014] [Indexed: 01/23/2023]
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22
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Corpeno R, Dworkin B, Cacciani N, Salah H, Bergman HM, Ravara B, Vitadello M, Gorza L, Gustafson AM, Hedström Y, Petersson J, Feng HZ, Jin JP, Iwamoto H, Yagi N, Artemenko K, Bergquist J, Larsson L. Time course analysis of mechanical ventilation-induced diaphragm contractile muscle dysfunction in the rat. J Physiol 2014; 592:3859-80. [PMID: 25015920 DOI: 10.1113/jphysiol.2014.277962] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Controlled mechanical ventilation (CMV) plays a key role in triggering the impaired diaphragm muscle function and the concomitant delayed weaning from the respirator in critically ill intensive care unit (ICU) patients. To date, experimental and clinical studies have primarily focused on early effects on the diaphragm by CMV, or at specific time points. To improve our understanding of the mechanisms underlying the impaired diaphragm muscle function in response to mechanical ventilation, we have performed time-resolved analyses between 6 h and 14 days using an experimental rat ICU model allowing detailed studies of the diaphragm in response to long-term CMV. A rapid and early decline in maximum muscle fibre force and preceding muscle fibre atrophy was observed in the diaphragm in response to CMV, resulting in an 85% reduction in residual diaphragm fibre function after 9-14 days of CMV. A modest loss of contractile proteins was observed and linked to an early activation of the ubiquitin proteasome pathway, myosin:actin ratios were not affected and the transcriptional regulation of myosin isoforms did not show any dramatic changes during the observation period. Furthermore, small angle X-ray diffraction analyses demonstrate that myosin can bind to actin in an ATP-dependent manner even after 9-14 days of exposure to CMV. Thus, quantitative changes in muscle fibre size and contractile proteins are not the dominating factors underlying the dramatic decline in diaphragm muscle function in response to CMV, in contrast to earlier observations in limb muscles. The observed early loss of subsarcolemmal neuronal nitric oxide synthase activity, onset of oxidative stress, intracellular lipid accumulation and post-translational protein modifications strongly argue for significant qualitative changes in contractile proteins causing the severely impaired residual function in diaphragm fibres after long-term mechanical ventilation. For the first time, the present study demonstrates novel changes in the diaphragm structure/function and underlying mechanisms at the gene, protein and cellular levels in response to CMV at a high temporal resolution ranging from 6 h to 14 days.
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Affiliation(s)
- R Corpeno
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - B Dworkin
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - N Cacciani
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - H Salah
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - H-M Bergman
- Department of Chemistry-Biomedical Center, Analytical Chemistry and SciLifeLab, Uppsala University, Sweden
| | - B Ravara
- Department of Biomedical Sciences, University of Padova, Italy
| | - M Vitadello
- Department of Biomedical Sciences, University of Padova, Italy CNR-Institute of Neuroscience, Padova section, Italy
| | - L Gorza
- Department of Biomedical Sciences, University of Padova, Italy
| | - A-M Gustafson
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden
| | - Y Hedström
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - J Petersson
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden
| | - H-Z Feng
- Department of Physiology, Wayne State University, Detroit, MI, USA
| | - J-P Jin
- Department of Physiology, Wayne State University, Detroit, MI, USA
| | - H Iwamoto
- Japan Synchrotron Radiation Research Institute, Sayo-cho, Sayo-gun, Hyogo, Japan
| | - N Yagi
- Japan Synchrotron Radiation Research Institute, Sayo-cho, Sayo-gun, Hyogo, Japan
| | - K Artemenko
- Department of Chemistry-Biomedical Center, Analytical Chemistry and SciLifeLab, Uppsala University, Sweden
| | - J Bergquist
- Department of Chemistry-Biomedical Center, Analytical Chemistry and SciLifeLab, Uppsala University, Sweden
| | - L Larsson
- Department of Neuroscience, Clinical Neurophysiology, Uppsala University, Sweden Department of Physiology and Pharmacology, Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
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Tobin MJ, Laghi F, Jubran A. Ventilatory failure, ventilator support, and ventilator weaning. Compr Physiol 2013; 2:2871-921. [PMID: 23720268 DOI: 10.1002/cphy.c110030] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The development of acute ventilatory failure represents an inability of the respiratory control system to maintain a level of respiratory motor output to cope with the metabolic demands of the body. The level of respiratory motor output is also the main determinant of the degree of respiratory distress experienced by such patients. As ventilatory failure progresses and patient distress increases, mechanical ventilation is instituted to help the respiratory muscles cope with the heightened workload. While a patient is connected to a ventilator, a physician's ability to align the rhythm of the machine with the rhythm of the patient's respiratory centers becomes the primary determinant of the level of rest accorded to the respiratory muscles. Problems of alignment are manifested as failure to trigger, double triggering, an inflationary gas-flow that fails to match inspiratory demands, and an inflation phase that persists after a patient's respiratory centers have switched to expiration. With recovery from disorders that precipitated the initial bout of acute ventilatory failure, attempts are made to discontinue the ventilator (weaning). About 20% of weaning attempts fail, ultimately, because the respiratory controller is unable to sustain ventilation and this failure is signaled by development of rapid shallow breathing. Substantial advances in the medical management of acute ventilatory failure that requires ventilator assistance are most likely to result from research yielding novel insights into the operation of the respiratory control system.
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Affiliation(s)
- Martin J Tobin
- Division of Pulmonary and Critical Care Medicine, Edward Hines Jr. Veterans Affairs Hospital and Loyola University of Chicago Stritch School of Medicine, Hines, Illinois, USA.
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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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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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Lollo P, Silva L, Batista T, Morato P, Moura C, Cruz A, Faria J, Carneiro E, Amaya-Farfan J. Effects of whey protein and casein plus leucine on diaphragm the mTOR pathway of sedentary, trained rats. Food Res Int 2012. [DOI: 10.1016/j.foodres.2012.07.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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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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Abstract
PURPOSE OF REVIEW It has become clear from experimental data that prolonged mechanical ventilation can induce diaphragm dysfunction, also known as ventilator-induced diaphragm dysfunction. In this article we will discuss most recent understanding on ventilator-induced diaphragm dysfunction and data on diaphragm dysfunction in patients. RECENT FINDINGS Over the last year several studies confirmed the existence of diaphragm dysfunction in patients. Known atrophy pathways are activated in patients undergoing prolonged conventional ventilation resulting in muscle proteolysis and a decrease in myofiber content. The loss of diaphragm force is time-dependent, but current data do not distinguish between the role played by other factors involved in diaphragm dysfunction. SUMMARY Diaphragm dysfunction occurs in patients, especially when ventilated with controlled modes of ventilation that minimize diaphragm activity. Time on the ventilator seems to be one of the biggest risk factors resulting in difficulties in weaning patients and prolonging time on the ventilator. Future trials should investigate whether improved patient-ventilator synchrony can reduce ventilator-induced diaphragm dysfunction and decrease weaning failure.
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Ochala J, Renaud G, Llano Diez M, Banduseela VC, Aare S, Ahlbeck K, Radell PJ, Eriksson LI, Larsson L. Diaphragm muscle weakness in an experimental porcine intensive care unit model. PLoS One 2011; 6:e20558. [PMID: 21698290 PMCID: PMC3115952 DOI: 10.1371/journal.pone.0020558] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2011] [Accepted: 05/05/2011] [Indexed: 01/10/2023] Open
Abstract
In critically ill patients, mechanisms underlying diaphragm muscle remodeling and resultant dysfunction contributing to weaning failure remain unclear. Ventilator-induced modifications as well as sepsis and administration of pharmacological agents such as corticosteroids and neuromuscular blocking agents may be involved. Thus, the objective of the present study was to examine how sepsis, systemic corticosteroid treatment (CS) and neuromuscular blocking agent administration (NMBA) aggravate ventilator-related diaphragm cell and molecular dysfunction in the intensive care unit. Piglets were exposed to different combinations of mechanical ventilation and sedation, endotoxin-induced sepsis, CS and NMBA for five days and compared with sham-operated control animals. On day 5, diaphragm muscle fibre structure (myosin heavy chain isoform proportion, cross-sectional area and contractile protein content) did not differ from controls in any of the mechanically ventilated animals. However, a decrease in single fibre maximal force normalized to cross-sectional area (specific force) was observed in all experimental piglets. Therefore, exposure to mechanical ventilation and sedation for five days has a key negative impact on diaphragm contractile function despite a preservation of muscle structure. Post-translational modifications of contractile proteins are forwarded as one probable underlying mechanism. Unexpectedly, sepsis, CS or NMBA have no significant additive effects, suggesting that mechanical ventilation and sedation are the triggering factors leading to diaphragm weakness in the intensive care unit.
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Affiliation(s)
- Julien Ochala
- Department of Neuroscience, Uppsala University, Uppsala, Sweden.
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Agten A, Maes K, Smuder A, Powers SK, Decramer M, Gayan-Ramirez G. N-Acetylcysteine protects the rat diaphragm from the decreased contractility associated with controlled mechanical ventilation*. Crit Care Med 2011; 39:777-82. [DOI: 10.1097/ccm.0b013e318206cca9] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Jaber S, Jung B, Matecki S, Petrof BJ. Clinical review: ventilator-induced diaphragmatic dysfunction--human studies confirm animal model findings! Crit Care 2011; 15:206. [PMID: 21457528 PMCID: PMC3219309 DOI: 10.1186/cc10023] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Diaphragmatic function is a major determinant of the ability to successfully wean patients from mechanical ventilation. However, the use of controlled mechanical ventilation in animal models results in a major reduction of diaphragmatic force-generating capacity together with structural injury and atrophy of diaphragm muscle fibers, a condition termed ventilator-induced diaphragmatic dysfunction (VIDD). Increased oxidative stress and exaggerated proteolysis in the diaphragm have been linked to the development of VIDD in animal models, but much less is known about the extent to which these phenomena occur in humans undergoing mechanical ventilation in the ICU. In the present review, we first briefly summarize the large body of evidence demonstrating the existence of VIDD in animal models, and outline the major cellular mechanisms that have been implicated in this process. We then relate these findings to very recently published data in critically ill patients, which have thus far been found to exhibit a remarkable degree of similarity with the animal model data. Hence, the human studies to date have indicated that mechanical ventilation is associated with increased oxidative stress, atrophy, and injury of diaphragmatic muscle fibers along with a rapid loss of diaphragmatic force production. These changes are, to a large extent, directly proportional to the duration of mechanical ventilation. In the context of these human data, we also review the methods that can be used in the clinical setting to diagnose and/or monitor the development of VIDD in critically ill patients. Finally, we discuss the potential for using different mechanical ventilation strategies and pharmacological approaches to prevent and/or to treat VIDD and suggest promising avenues for future research in this area.
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Affiliation(s)
- Samir Jaber
- Department of Critical Care and Anesthesiology (DAR B), CHU Montpellier, Hôpital Saint Eloi, 80 avenue Augustin Fliche, 34295 Montpellier Cedex 5, France
- Intensive Care Unit, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Equipe soutenue par la Région et l'Institut National de la Santé et de la Recherche Médicale 25, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier 34000, France
- Clinical Physiology Center, Arnaud de Villeneuve Teaching Hospital, Equipe soutenue par la Région et l'Institut National de la Santé et de la Recherche Médicale 25, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier 34000, France
| | - Boris Jung
- Intensive Care Unit, Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Equipe soutenue par la Région et l'Institut National de la Santé et de la Recherche Médicale 25, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier 34000, France
- Clinical Physiology Center, Arnaud de Villeneuve Teaching Hospital, Equipe soutenue par la Région et l'Institut National de la Santé et de la Recherche Médicale 25, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier 34000, France
- Meakins-Christie Laboratories and Respiratory Division, McGill University Health Center and Research Institute, Montreal, Quebec H2X 2P2, Canada
| | - Stefan Matecki
- Clinical Physiology Center, Arnaud de Villeneuve Teaching Hospital, Equipe soutenue par la Région et l'Institut National de la Santé et de la Recherche Médicale 25, Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier 34000, France
| | - Basil J Petrof
- Meakins-Christie Laboratories and Respiratory Division, McGill University Health Center and Research Institute, Montreal, Quebec H2X 2P2, Canada
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Jaber S, Petrof BJ, Jung B, Chanques G, Berthet JP, Rabuel C, Bouyabrine H, Courouble P, Koechlin-Ramonatxo C, Sebbane M, Similowski T, Scheuermann V, Mebazaa A, Capdevila X, Mornet D, Mercier J, Lacampagne A, Philips A, Matecki S. Rapidly Progressive Diaphragmatic Weakness and Injury during Mechanical Ventilation in Humans. Am J Respir Crit Care Med 2011; 183:364-71. [DOI: 10.1164/rccm.201004-0670oc] [Citation(s) in RCA: 439] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hussain SNA, Mofarrahi M, Sigala I, Kim HC, Vassilakopoulos T, Maltais F, Bellenis I, Chaturvedi R, Gottfried SB, Metrakos P, Danialou G, Matecki S, Jaber S, Petrof BJ, Goldberg P. Mechanical ventilation-induced diaphragm disuse in humans triggers autophagy. Am J Respir Crit Care Med 2010; 182:1377-86. [PMID: 20639440 DOI: 10.1164/rccm.201002-0234oc] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Controlled mechanical ventilation (CMV) results in atrophy of the human diaphragm. The autophagy-lysosome pathway (ALP) contributes to skeletal muscle proteolysis, but its contribution to diaphragmatic protein degradation in mechanically ventilated patients is unknown. OBJECTIVES To evaluate the autophagy pathway responses to CMV in the diaphragm and limb muscles of humans and to identify the roles of FOXO transcription factors in these responses. METHODS Muscle biopsies were obtained from nine control subjects and nine brain-dead organ donors. Subjects were mechanically ventilated for 2 to 4 hours and 15 to 276 hours, respectively. Activation of the ubiquitin-proteasome system was detected by measuring mRNA expressions of Atrogin-1, MURF1, and protein expressions of UBC2, UBC4, and the α subunits of the 20S proteasome (MCP231). Activation of the ALP was detected by electron microscopy and by measuring the expressions of several autophagy-related genes. Total carbonyl content and HNE-protein adduct formation were measured to assess oxidative stress. Total AKT, phosphorylated and total FOXO1, and FOXO3A protein levels were also measured. MEASUREMENTS AND MAIN RESULTS Prolonged CMV triggered activation of the ALP as measured by the appearance of autophagosomes in the diaphragm and increased expressions of autophagy-related genes, as compared with controls. Induction of autophagy was associated with increased protein oxidation and enhanced expression of the FOXO1 gene, but not the FOXO3A gene. CMV also triggered the inhibition of both AKT expression and FOXO1 phosphorylation. CONCLUSIONS We propose that prolonged CMV causes diaphragm disuse, which, in turn, leads to activation of the ALP through oxidative stress and the induction of the FOXO1 transcription factor.
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Hermans G, Agten A, Testelmans D, Decramer M, Gayan-Ramirez G. Increased duration of mechanical ventilation is associated with decreased diaphragmatic force: a prospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R127. [PMID: 20594319 PMCID: PMC2945090 DOI: 10.1186/cc9094] [Citation(s) in RCA: 179] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2010] [Revised: 05/06/2010] [Accepted: 07/01/2010] [Indexed: 11/10/2022]
Abstract
Introduction Respiratory muscle weakness is an important risk factor for delayed weaning. Animal data show that mechanical ventilation itself can cause atrophy and weakness of the diaphragm, called ventilator-induced diaphragmatic dysfunction (VIDD). Transdiaphragmatic pressure after magnetic stimulation (TwPdi BAMPS) allows evaluation of diaphragm strength. We aimed to evaluate the repeatability of TwPdi BAMPS in critically ill, mechanically ventilated patients and to describe the relation between TwPdi and the duration of mechanical ventilation. Methods This was a prospective observational study in critically ill and mechanically ventilated patients, admitted to the medical intensive care unit of a university hospital. Nineteen measurements were made in a total of 10 patients at various intervals after starting mechanical ventilation. In seven patients, measurements were made on two or more occasions, with a minimum interval of 24 hours. Results The TwPdi was 11.5 ± 3.9 cm H2O (mean ± SD), indicating severe respiratory muscle weakness. The between-occasion coefficient of variation of TwPdi was 9.7%, comparable with data from healthy volunteers. Increasing duration of mechanical ventilation was associated with a logarithmic decline in TwPdi (R = 0.69; P = 0.038). This association was also found for cumulative time on pressure control (R = 0.71; P = 0.03) and pressure-support ventilation (P = 0.05; R = 0.66) separately, as well as for cumulative dose of propofol (R = 0.66; P = 0.05) and piritramide (R = 0.79; P = 0.01). Conclusions Duration of mechanical ventilation is associated with a logarithmic decline in diaphragmatic force, which is compatible with the concept of VIDD. The observed decline may also be due to other potentially contributing factors such as sedatives/analgesics, sepsis, or others.
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Affiliation(s)
- Greet Hermans
- Medical Intensive Care Unit, General Internal Medicine, University Hospitals Leuven, Herestraat 49, B3000 Leuven, Belgium.
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Abstract
OBJECTIVE To review current knowledge about the impact of prolonged mechanical ventilation on diaphragmatic function and biology. MEASUREMENTS Systematic literature review. CONCLUSIONS Prolonged mechanical ventilation can promote diaphragmatic atrophy and contractile dysfunction. As few as 18 hrs of mechanical ventilation results in diaphragmatic atrophy in both laboratory animals and humans. Prolonged mechanical ventilation is also associated with diaphragmatic contractile dysfunction. Studies using animal models revealed that mechanical ventilation-induced diaphragmatic atrophy is due to increased diaphragmatic protein breakdown and decreased protein synthesis. Recent investigations have identified calpain, caspase-3, and the ubiquitin-proteasome system as key proteases that contribute to mechanical ventilation-induced diaphragmatic proteolysis. The scientific challenge for the future is to delineate the mechanical ventilation-induced signaling pathways that activate these proteases and depress protein synthesis in the diaphragm. Future investigations that define the signaling mechanisms responsible for mechanical ventilation-induced diaphragmatic weakness will provide the knowledge required for the development of new medicines that can maintain diaphragmatic mass and function during prolonged mechanical ventilation.
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Maes K, Testelmans D, Cadot P, Deruisseau K, Powers SK, Decramer M, Gayan-Ramirez G. Effects of acute administration of corticosteroids during mechanical ventilation on rat diaphragm. Am J Respir Crit Care Med 2008; 178:1219-26. [PMID: 18849500 DOI: 10.1164/rccm.200702-296oc] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Mechanical ventilation is known to induce ventilator-induced diaphragm dysfunction. Patients submitted to mechanical ventilation often receive massive doses of corticosteroids that may cause further deterioration of diaphragm function. OBJECTIVES To examine whether the combination of 24 hours of controlled mechanical ventilation with corticosteroid administration would exacerbate ventilator-induced diaphragm dysfunction. METHODS Rats were randomly assigned to a group submitted to 24 hours of controlled mechanical ventilation receiving an intramuscular injection of saline or 80 mg/kg methylprednisolone, a group submitted to 24 hours of spontaneous breathing receiving saline, or methylprednisolone and a control group. MEASUREMENTS AND MAIN RESULTS The diaphragm force-frequency curve was shifted downward in the mechanical ventilation group, but this deleterious effect was prevented when corticosteroids were administered. Diaphragm cross-sectional area of type I fibers was similarly decreased in both mechanical ventilation groups while atrophy of type IIx/b fibers was attenuated after corticosteroid administration. The mechanical ventilation-induced reduction in diaphragm MyoD and myogenin protein expression was attenuated after corticosteroids. Plasma cytokine levels were unchanged while diaphragm lipid hydroperoxides were similarly increased in both mechanical ventilation groups. Diaphragmatic calpain activity was significantly increased in the mechanical ventilation group, but calpain activation was abated with corticosteroid administration. Inverse correlations were found between calpain activity and diaphragm force. CONCLUSIONS A single high dose of methylprednisolone combined with controlled mechanical ventilation protected diaphragm function from the deleterious effects of controlled mechanical ventilation. Inhibition of the calpain system is most likely the mechanism by which corticosteroids induce this protective effect.
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Affiliation(s)
- Karen Maes
- Respiratory Muscle Research Unit, Laboratory of Pneumology and Respiratory Division, Katholieke Universiteit Leuven, Leuven, Belgium
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Futier E, Constantin JM, Combaret L, Mosoni L, Roszyk L, Sapin V, Attaix D, Jung B, Jaber S, Bazin JE. Pressure support ventilation attenuates ventilator-induced protein modifications in the diaphragm. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R116. [PMID: 18786263 PMCID: PMC2592744 DOI: 10.1186/cc7010] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2008] [Revised: 07/31/2008] [Accepted: 09/11/2008] [Indexed: 11/10/2022]
Abstract
Introduction Controlled mechanical ventilation (CMV) induces profound modifications of diaphragm protein metabolism, including muscle atrophy and severe ventilator-induced diaphragmatic dysfunction. Diaphragmatic modifications could be decreased by spontaneous breathing. We hypothesized that mechanical ventilation in pressure support ventilation (PSV), which preserves diaphragm muscle activity, would limit diaphragmatic protein catabolism. Methods Forty-two adult Sprague-Dawley rats were included in this prospective randomized animal study. After intraperitoneal anesthesia, animals were randomly assigned to the control group or to receive 6 or 18 hours of CMV or PSV. After sacrifice and incubation with 14C-phenylalanine, in vitro proteolysis and protein synthesis were measured on the costal region of the diaphragm. We also measured myofibrillar protein carbonyl levels and the activity of 20S proteasome and tripeptidylpeptidase II. Results Compared with control animals, diaphragmatic protein catabolism was significantly increased after 18 hours of CMV (33%, P = 0.0001) but not after 6 hours. CMV also decreased protein synthesis by 50% (P = 0.0012) after 6 hours and by 65% (P < 0.0001) after 18 hours of mechanical ventilation. Both 20S proteasome activity levels were increased by CMV. Compared with CMV, 6 and 18 hours of PSV showed no significant increase in proteolysis. PSV did not significantly increase protein synthesis versus controls. Both CMV and PSV increased protein carbonyl levels after 18 hours of mechanical ventilation from +63% (P < 0.001) and +82% (P < 0.0005), respectively. Conclusions PSV is efficient at reducing mechanical ventilation-induced proteolysis and inhibition of protein synthesis without modifications in the level of oxidative injury compared with continuous mechanical ventilation. PSV could be an interesting alternative to limit ventilator-induced diaphragmatic dysfunction.
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Affiliation(s)
- Emmanuel Futier
- General Intensive Care Unit, Hotel-Dieu Hospital, University Hospital of Clermont-Ferrand, Boulevard L. Malfreyt, Clermond-Ferrand, 63058, France
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Hypoventilation and Respiratory Muscle Dysfunction. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50043-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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41
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Vassilakopoulos T. Ventilator-induced diaphragm dysfunction: the clinical relevance of animal models. Intensive Care Med 2007; 34:7-16. [DOI: 10.1007/s00134-007-0866-x] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 08/28/2007] [Indexed: 11/25/2022]
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De Jonghe B, Bastuji-Garin S, Durand MC, Malissin I, Rodrigues P, Cerf C, Outin H, Sharshar T. Respiratory weakness is associated with limb weakness and delayed weaning in critical illness. Crit Care Med 2007; 35:2007-15. [PMID: 17855814 DOI: 10.1097/01.ccm.0000281450.01881.d8] [Citation(s) in RCA: 314] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Although critical illness neuromyopathy might interfere with weaning from mechanical ventilation, its respiratory component has not been investigated. We designed a study to assess the level of respiratory muscle weakness emerging during the intensive care unit stay in mechanically ventilated patients and to examine the correlation between respiratory and limb muscle strength and the specific contribution of respiratory weakness to delayed weaning. DESIGN Prospective observational study. SETTING Two medical, one surgical, and one medicosurgical intensive care units in two university hospitals and one university- affiliated hospital. PATIENTS A total of 116 consecutive patients were enrolled after >or=7 days of mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Maximal inspiratory and expiratory pressures and vital capacity were measured via the tracheal tube on the first day of return to normal consciousness. Muscle strength was measured using the Medical Research Council score. After standardized weaning, successful extubation was defined as the day from which mechanical ventilatory support was no longer required within the next 15 days. The median value (interquartile range) of maximal inspiratory pressure was 30 (20-40) cm H2O, maximal expiratory pressure was 30 (20-50) cm H2O, and vital capacity was 11.1 (6.3-19.8) mL/kg. Maximal inspiratory pressure, maximal expiratory pressure, and vital capacity were significantly correlated with the Medical Research Council score. The median time (interquartile range) from awakening to successful extubation was 6 (1-17) days. Low maximal inspiratory pressure (hazard ratio, 1.86; 95% confidence interval, 1.07-3.23), maximal expiratory pressure (hazard ratio, 2.18; 95% confidence interval, 1.44-3.84), and Medical Research Council score (hazard ratio, 1.96; 95% confidence interval, 1.27-3.02) were independent predictors of delayed extubation. Septic shock before awakening was significantly associated with respiratory weakness (odds ratio, 3.17; 95% confidence interval, 1.17-8.58). CONCLUSIONS Respiratory and limb muscle strength are both altered after 1 wk of mechanical ventilation. Respiratory muscle weakness is associated with delayed extubation and prolonged ventilation. In our study, septic shock is a contributor to respiratory weakness.
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Affiliation(s)
- Bernard De Jonghe
- Réanimation Médico-chirurgicale, Centre Hospitalier de Poissy-Saint-Germain en Laye, Poissy, France.
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Norman H, Nordquist J, Andersson P, Ansved T, Tang X, Dworkin B, Larsson L. Impact of post-synaptic block of neuromuscular transmission, muscle unloading and mechanical ventilation on skeletal muscle protein and mRNA expression. Pflugers Arch 2006; 453:53-66. [PMID: 16868767 DOI: 10.1007/s00424-006-0110-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Revised: 05/11/2006] [Accepted: 05/30/2006] [Indexed: 11/26/2022]
Abstract
To analyse mechanisms of muscle wasting in intensive care unit patients, we developed an experimental model where rats were pharmacologically paralysed by post-synaptic block of neuromuscular transmission (NMB) and mechanically ventilated for 9+/-2 days. Specific interest was focused on the effects on protein and mRNA expression of sarcomeric proteins, i.e., myosin heavy chain (MyHC), actin, myosin-binding protein C (MyBP-C) and myosin-binding protein H (MyBP-H) in fast- and slow-twitch limb, respiratory and masticatory muscles. Muscle-specific differences were observed in response to NMB at both the protein and mRNA levels. At the protein level, a decreased MyHC-to-actin ratio was observed in all muscles excluding the diaphragm, whereas at the mRNA level a decreased expression of the dominating MyHC isoform(s) was observed in the hind limb and intercostal muscles, but not in the diaphragm and masseter muscles. MyBP-C mRNA expression was decreased in the limb muscles, but it otherwise remained unaffected. MyBP-H conversely increased in all muscles. Furthermore, we found myofibrillar protein and mRNA expression to be affected differently when comparing NMB animals with peripherally denervated (DEN) ambulatory rats. We report that NMB has both a larger and different impact on muscle, at the protein and mRNA levels, than DEN has.
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Affiliation(s)
- H Norman
- Department of Neuroscience/Clinical Neurophysiology, Uppsala University, SE-751 85, Uppsala, Sweden
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Vassilakopoulos T, Zakynthinos S, Roussos C. Bench-to-bedside review: weaning failure--should we rest the respiratory muscles with controlled mechanical ventilation? Crit Care 2006; 10:204. [PMID: 16356210 PMCID: PMC1550863 DOI: 10.1186/cc3917] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The use of controlled mechanical ventilation (CMV) in patients who experience weaning failure after a spontaneous breathing trial or after extubation is a strategy based on the premise that respiratory muscle fatigue (requiring rest to recover) is the cause of weaning failure. Recent evidence, however, does not support the existence of low frequency fatigue (the type of fatigue that is long-lasting) in patients who fail to wean despite the excessive respiratory muscle load. This is because physicians have adopted criteria for the definition of spontaneous breathing trial failure and thus termination of unassisted breathing, which lead them to put patients back on the ventilator before the development of low frequency respiratory muscle fatigue. Thus, no reason exists to completely unload the respiratory muscles with CMV for low frequency fatigue reversal if weaning is terminated based on widely accepted predefined criteria. This is important, since experimental evidence suggests that CMV can induce dysfunction of the diaphragm, resulting in decreased diaphragmatic force generating capacity, which has been called ventilator-induced diaphragmatic dysfunction (VIDD). The mechanisms of VIDD are not fully elucidated, but include muscle atrophy, oxidative stress and structural injury. Partial modes of ventilatory support should be used whenever possible, since these modes attenuate the deleterious effects of mechanical ventilation on respiratory muscles. When CMV is used, concurrent administration of antioxidants (which decrease oxidative stress and thus attenuate VIDD) seems justified, since antioxidants may be beneficial (and are certainly not harmful) in critical care patients.
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Affiliation(s)
- Theodoros Vassilakopoulos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Spyros Zakynthinos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
| | - Charis Roussos
- Department of Critical Care and Pulmonary Services, University of Athens Medical School, Evangelismos Hospital, Athens, Greece
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DeRuisseau KC, Shanely RA, Akunuri N, Hamilton MT, Van Gammeren D, Zergeroglu AM, McKenzie M, Powers SK. Diaphragm unloading via controlled mechanical ventilation alters the gene expression profile. Am J Respir Crit Care Med 2005; 172:1267-75. [PMID: 16126937 PMCID: PMC2718415 DOI: 10.1164/rccm.200503-403oc] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Prolonged controlled mechanical ventilation results in diaphragmatic inactivity and promotes oxidative injury, atrophy, and contractile dysfunction in this important inspiratory muscle. However, the impact of controlled mechanical ventilation on global mRNA alterations in the diaphragm remains unknown. OBJECTIVES In these experiments, we used an Affymetrix oligonucleotide array to identify the temporal changes in diaphragmatic gene expression during controlled mechanical ventilation in the rat. METHODS Adult Sprague-Dawley rats were assigned to either control or mechanical ventilation groups (n = 5/group). Mechanically ventilated animals were anesthetized, tracheostomized, and ventilated with room air for 6 or 18 h. Animals in the control group were acutely anesthetized but not exposed to mechanical ventilation. MEASUREMENTS AND MAIN RESULTS Compared with control diaphragms, microarray analysis identified 354 differentially expressed, unique gene products after 6 and 18 h of mechanical ventilation. In general, genes in the cell growth/cell maintenance, stress response, and nucleic acid metabolism categories showed predominant upregulation, whereas genes in the structural protein and energy metabolism categories were predominantly downregulated. CONCLUSIONS We conclude that mechanical ventilation results in rapid changes in diaphragmatic gene expression, and subsequently, many of these changes may contribute to atrophy and muscle fiber remodeling associated with unloading this primary inspiratory muscle. Importantly, this study also provides new insights into why the diaphragm, after the onset of contractile inactivity, atrophies more rapidly than locomotor skeletal muscles and also highlights unique differences that exist between these muscles in the mRNA response to inactivity.
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Affiliation(s)
- Keith C DeRuisseau
- Department of Applied Physiology and Kinesiology, University of Florida, Room 25, Florida Gym, Gainesville, Florida 32611, USA.
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Reduced Inspiratory Muscle Endurance Following Successful Weaning From Prolonged Mechanical Ventilation. Chest 2005. [DOI: 10.1016/s0012-3692(15)50395-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Zhu E, Sassoon CSH, Nelson R, Pham HT, Zhu L, Baker MJ, Caiozzo VJ. Early effects of mechanical ventilation on isotonic contractile properties and MAF-box gene expression in the diaphragm. J Appl Physiol (1985) 2005; 99:747-56. [PMID: 15831803 DOI: 10.1152/japplphysiol.00126.2005] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
This study aimed to determine the time-dependent effects of diaphragmatic inactivity on its maximum shortening velocity ( Vmax) and the muscle atrophy F-box (MAF-box, atrogin-1) gene expression during controlled mechanical ventilation (CMV). Twenty-four New Zealand White rabbits were grouped into 1 day, 2 days, and 3 days of CMV and controls in equal numbers. The in vitro isotonic contractile properties of the diaphragm were determined. In addition, myosin heavy chain protein and mRNA, myosin light chain, MAF-box mRNA, and volume density of abnormal myofibrils were measured. Tetanic force decreased, and Vmaxincreased from control of 6.4 to 6.6, 7.7, and 8.1 muscle lengths per second after 1, 2, and 3 days of CMV, respectively ( P < 0.02). The increased Vmaxcompensated for the decreased tetanic force; consequently, compared with the controls, maximum power output was unchanged after 3 days of CMV. Vmaxcorrelated with the volume density of abnormal myofibrils [ y = 0.1 x + 5.7 ( r = 0.87, P < 0.01)]. In the diaphragm, MAF-box was overexpressed (355% of control) after 1 day of CMV, before the evidence of structural myofibril disarray. In conclusion, CMV produced a time-dependent increase in Vmaxthat was associated with the degree of myofibrillar disarray and independent of changes in myosin isoform expression. Furthermore, CMV produced an increase in MAF-box mRNA levels that may be partially or completely responsible for the degree of myofibrillar disarray resulting from CMV.
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Affiliation(s)
- Ercheng Zhu
- Pulmonary and Critical Care Section, VA Long Beach Healthcare System (11/111P), 5901 East 7th Street, Long Beach, CA 90822, USA
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Jaber S, Sebbane M, Koechlin C, Hayot M, Capdevila X, Eledjam JJ, Prefaut C, Ramonatxo M, Matecki S. Effects of short vs. prolonged mechanical ventilation on antioxidant systems in piglet diaphragm. Intensive Care Med 2005; 31:1427-33. [PMID: 16041522 DOI: 10.1007/s00134-005-2694-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2004] [Accepted: 05/30/2005] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Prolonged controlled mechanical ventilation (MV) is known to induce diaphragmatic oxidative stress that seems to be an important factor reducing force-generating capacity. To better understand the cellular mechanisms involved, this work examined the effect of short vs. prolonged MV on antioxidant defense in the diaphragm. DESIGN AND SETTING Prospective, randomized, controlled animal study in a university laboratory. METHODS Eleven piglets (15-20 kg) were assigned to one of two groups: a long-MV group (n=6) ventilated for 3 days or a short-MV group (n=5) ventilated for 3 h. Force frequency curves of the transdiaphragmatic pressure (Pdi) were obtained in vivo by phrenic nerve pacing. Oxidative stress was evaluated by thiobarbituric reactive substance (TBARs) content and the enzymatic antioxidant activity of both superoxide dismutase (SOD) and glutathione peroxidase (GPx) in samples of diaphragm. RESULTS Pdi decreased in the long-MV group by 30-35% over the 3 days at all frequencies compared to the short-MV group. Diaphragm TBARs content was significantly higher and SOD activity lower in long-MV animals than in short-MV animals after 72 h. GPx activity tended to be lower in diaphragms from long-MV animals, but this difference was not significant. CONCLUSIONS This study shows that 3 days of MV in piglets is associated with a decrease in antioxidant activity which could emphasize oxidative stress and both contribute to the diaphragm dysfunction caused by MV.
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Affiliation(s)
- Samir Jaber
- Intensive Care Unit, Department of Anesthesiology: DAR B, CHU de Montpellier, Hôpital Saint Eloi, 80 avenue Augustin Fliche, 34295 Montpellier, France.
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Gayan-Ramirez GN, Decramer ML. Diaphragm antioxidant system in controlled mechanical ventilation in piglets: short term vs. prolonged mechanical ventilation response. Intensive Care Med 2005; 31:1303-5. [PMID: 16041523 DOI: 10.1007/s00134-005-2693-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2005] [Accepted: 06/27/2005] [Indexed: 11/29/2022]
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Van Gammeren D, Falk DJ, DeRuisseau KC, Sellman JE, Decramer M, Powers SK. Reloading the Diaphragm Following Mechanical Ventilation Does Not Promote Injury. Chest 2005; 127:2204-10. [PMID: 15947338 DOI: 10.1378/chest.127.6.2204] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVE Mechanical ventilation (MV) is used clinically to treat patients who are incapable of maintaining adequate alveolar ventilation. Prolonged MV is associated with diaphragmatic atrophy and a decrement in maximal specific force production (P(O)). Collectively, these alterations may predispose the diaphragm to injury on the return to spontaneous breathing (ie, reloading). Therefore, these experiments tested the hypothesis that reloading the diaphragm following MV exacerbates MV-induced diaphragmatic contractile dysfunction, while causing muscle fiber membrane damage and inflammation. METHODS To test this postulate, Sprague-Dawley rats were randomly assigned to the following groups: (1) control; (2) 24 h of controlled MV; and (3) 24 h of controlled MV followed by 2 h of anesthetized spontaneous breathing. Controls were anesthetized in the short term but were not exposed to MV, whereas MV animals were anesthetized, tracheostomized, and ventilated. Reloaded animals remained under anesthesia, but were removed from MV and returned to spontaneous breathing for 2 h. RESULTS Compared to the situation with control animals, MV resulted in a 26% decrement in diaphragmatic specific P(O) without muscle fiber membrane damage, as measured by an increase in membrane permeability (using the procion orange technique). Further, there were no increases in neutrophil or macrophage influx. Two hours of reloading did not exacerbate MV-induced diaphragmatic contractile dysfunction or cause fiber membrane damage, but increased neutrophil infiltration, myeloperoxidase activity, and muscle edema. CONCLUSION We conclude that the return to spontaneous breathing following 24 h of controlled MV does not exacerbate MV-induced diaphragm contractile dysfunction or result in fiber membrane damage, but increases neutrophil infiltration.
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Affiliation(s)
- Darin Van Gammeren
- Department of Applied Psychology, Center for Exercise Science, University of Florida, Room 25 FLG, Gainesville, FL 32611, USA
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