1
|
Powers SK. Ventilator-induced diaphragm dysfunction: phenomenology and mechanism(s) of pathogenesis. J Physiol 2024. [PMID: 39216087 DOI: 10.1113/jp283860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 08/12/2024] [Indexed: 09/04/2024] Open
Abstract
Mechanical ventilation (MV) is used to support ventilation and pulmonary gas exchange in patients during critical illness and surgery. Although MV is a life-saving intervention for patients in respiratory failure, an unintended side-effect of MV is the rapid development of diaphragmatic atrophy and contractile dysfunction. This MV-induced diaphragmatic weakness is labelled as 'ventilator-induced diaphragm dysfunction' (VIDD). VIDD is an important clinical problem because diaphragmatic weakness is a risk factor for the failure to wean patients from MV. Indeed, the inability to remove patients from ventilator support results in prolonged hospitalization and increased morbidity and mortality. The pathogenesis of VIDD has been extensively investigated, revealing that increased mitochondrial production of reactive oxygen species within diaphragm muscle fibres promotes a cascade of redox-regulated signalling events leading to both accelerated proteolysis and depressed protein synthesis. Together, these events promote the rapid development of diaphragmatic atrophy and contractile dysfunction. This review highlights the MV-induced changes in the structure/function of diaphragm muscle and discusses the cell-signalling mechanisms responsible for the pathogenesis of VIDD. This report concludes with a discussion of potential therapeutic opportunities to prevent VIDD and suggestions for future research in this exciting field.
Collapse
Affiliation(s)
- Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL, USA
| |
Collapse
|
2
|
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.
Collapse
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.
| |
Collapse
|
3
|
Knebusch N, Mansour M, Vazquez S, Coss-Bu JA. Macronutrient and Micronutrient Intake in Children with Lung Disease. Nutrients 2023; 15:4142. [PMID: 37836425 PMCID: PMC10574027 DOI: 10.3390/nu15194142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/22/2023] [Accepted: 09/22/2023] [Indexed: 10/15/2023] Open
Abstract
This review article aims to summarize the literature findings regarding the role of micronutrients in children with lung disease. The nutritional and respiratory statuses of critically ill children are interrelated, and malnutrition is commonly associated with respiratory failure. The most recent nutrition support guidelines for critically ill children have recommended an adequate macronutrient intake in the first week of admission due to its association with good outcomes. In children with lung disease, it is important not to exceed the proportion of carbohydrates in the diet to avoid increased carbon dioxide production and increased work of breathing, which potentially could delay the weaning of the ventilator. Indirect calorimetry can guide the process of estimating adequate caloric intake and adjusting the proportion of carbohydrates in the diet based on the results of the respiratory quotient. Micronutrients, including vitamins, trace elements, and others, have been shown to play a role in the structure and function of the immune system, antioxidant properties, and the production of antimicrobial proteins supporting the defense mechanisms against infections. Sufficient levels of micronutrients and adequate supplementation have been associated with better outcomes in children with lung diseases, including pneumonia, cystic fibrosis, asthma, bronchiolitis, and acute respiratory failure.
Collapse
Affiliation(s)
- Nicole Knebusch
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (N.K.); (M.M.); (S.V.)
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Marwa Mansour
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (N.K.); (M.M.); (S.V.)
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Stephanie Vazquez
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (N.K.); (M.M.); (S.V.)
- Texas Children’s Hospital, Houston, TX 77030, USA
| | - Jorge A. Coss-Bu
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; (N.K.); (M.M.); (S.V.)
- Texas Children’s Hospital, Houston, TX 77030, USA
| |
Collapse
|
4
|
Duyndam A, Smit J, Heunks L, Molinger J, IJland M, van Rosmalen J, van Dijk M, Tibboel D, Ista E. Reference values of diaphragmatic dimensions in healthy children aged 0-8 years. Eur J Pediatr 2023:10.1007/s00431-023-04920-6. [PMID: 36939879 DOI: 10.1007/s00431-023-04920-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 02/28/2023] [Accepted: 03/02/2023] [Indexed: 03/21/2023]
Abstract
Diaphragmatic thickness (Tdi) and diaphragm thickening fraction (dTF) are widely used parameters in ultrasound studies of the diaphragm in mechanically ventilated children, but normal values for healthy children are scarce. We determined reference values of Tdi and dTF using ultrasound in healthy children aged 0-8 years old and assessed their reproducibility. In a prospective, observational cohort, Tdi and dTF were measured on ultrasound images across four age groups comprising at least 30 children per group: group 1 (0-6 months), group 2 (7 months-1 year), group 3 (2-4 years) and group 4 (5-8 years). Ultrasound images of 137 healthy children were included. Mean Tdi at inspiration was 2.07 (SD 0.40), 2.09 (SD 0.40), 1.69 (SD 0.30) and 1.72 (SD 0.30) mm for groups 1, 2, 3 and 4, respectively. Mean Tdi at expiration was 1.64 (SD 0.30), 1.67 (SD 0.30), 1.38 (SD 0.20) and 1.42 (SD 0.20) mm for groups 1, 2, 3 and 4, respectively. Mean Tdi at inspiration and mean Tdi at expiration for groups 1 and 2 were significantly greater than those for groups 3 and 4 (both p < 0.001). Mean dTF was 25.4% (SD 10.4), 25.2% (SD 8.3), 22.8% (SD 10.9) and 21.3% (SD 7.1) for group 1, 2, 3 and 4, respectively. The intraclass correlation coefficients (ICC) representing the level of inter-rater reliability between two examiners performing the ultrasounds was 0.996 (95% CI 0.982-0.999). ICC of the inter-rater reliability between the raters in 11 paired assessments was 0.989 (95% CI 0.973-0.995). Conclusion: Ultrasound measurements of Tdi and dTF were highly reproducible in healthy children aged 0-8 years. Trial registration: ClinicalTrials.gov identifier (NCT number): NCT04589910. What is Known: • Diaphragmatic thickness and diaphragm thickening fraction are widely used parameters in ultrasound studies of the diaphragm in mechanically ventilated children, but normal values for healthy children to compare these with are scarce. What is New: • We determined normal values of diaphragmatic thickness and diaphragm thickening fraction using ultrasound in 137 healthy children aged 0-8 years old. The diaphragmatic thickness of infants up to 1 year old was significantly greater than that of children from 2 to 8 years old. Diaphragmatic thickness decreased with an increase in body surface area. These normal values in healthy children can be used to assess changes in respiratory muscle thickness in mechanically ventilated children.
Collapse
Affiliation(s)
- Anita Duyndam
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands.
| | - Joke Smit
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
| | - Leo Heunks
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jeroen Molinger
- Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Division of Critical Care, Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Marloes IJland
- Department of Intensive Care Medicine, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Monique van Dijk
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
| | - Dick Tibboel
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands.,Department of Intensive Care, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Erwin Ista
- Department of Pediatric Surgery and Intensive Care, Erasmus , Sophia Children's Hospital, MC, Rotterdam, the Netherlands
| |
Collapse
|
5
|
Frizzelli A, Di Spigno F, Moderato L, Halasz G, Aiello M, Tzani P, Manari G, Calzetta L, Pisi R, Pelà G, Piepoli M, Chetta A. An Impairment in Resting and Exertional Breathing Pattern May Occur in Long-COVID Patients with Normal Spirometry and Unexplained Dyspnoea. J Clin Med 2022; 11:jcm11247388. [PMID: 36556003 PMCID: PMC9784722 DOI: 10.3390/jcm11247388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 12/03/2022] [Indexed: 12/15/2022] Open
Abstract
Background: Long-term sequelae, called Long-COVID (LC), may occur after SARS-CoV-2 infection, with unexplained dyspnoea as the most common symptom. The breathing pattern (BP) analysis, by means of the ratio of the inspiratory time (TI) during the tidal volume (VT) to the total breath duration (TI/TTOT) and by the VT/TI ratio, could further elucidate the underlying mechanisms of the unexplained dyspnoea in LC patients. Therefore, we analysed TI/TTOT and VT/TI at rest and during maximal exercise in LC patients with unexplained dyspnoea, compared to a control group. Methods: In this cross-sectional study, we enrolled LC patients with normal spirometry, who were required to perform a cardio-pulmonary exercise test (CPET) for unexplained dyspnoea, lasting at least 3 months after SARS-CoV-2 infection. As a control group, we recruited healthy age and sex-matched subjects (HS). All subjects performed spirometry and CPET, according to standardized procedures. Results: We found that 42 LC patients (23 females) had lower maximal exercise capacity, both in terms of maximal O2 uptake (VO2peak) and workload, compared to 40 HS (22 females) (p < 0.05). LC patients also showed significantly higher values of TI/TTOT at rest and at peak, and lower values in VT/TI at peak (p < 0.05). In LC patients, values of TI/TTOT at peak were significantly related to ∆PETCO2, i.e., the end-tidal pressure of CO2 at peak minus the one at rest (p < 0.05). When LC patients were categorized by the TI/TTOT 0.38 cut-off value, patients with TI/TTOT > 0.38 showed lower values in VO2peak and maximal workload, and greater values in the ventilation/CO2 linear relationship slope than patients with TI/TTOT ≤ 0.38 (p < 0.05). Conclusions: Our findings show that LC patients with unexplained dyspnoea have resting and exertional BP more prone to diaphragmatic fatigue, and less effective than controls. Pulmonary rehabilitation might be useful to revert this unpleasant condition.
Collapse
Affiliation(s)
- Annalisa Frizzelli
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Cardio-Thoracic and Vascular Department, University Hospital of Parma, 43126 Parma, Italy
| | | | - Luca Moderato
- Cardiac Unit, “G. da Saliceto” Hospital of Piacenza, 29121 Piacenza, Italy
| | - Geza Halasz
- Cardiac Unit, “G. da Saliceto” Hospital of Piacenza, 29121 Piacenza, Italy
| | - Marina Aiello
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Cardio-Thoracic and Vascular Department, University Hospital of Parma, 43126 Parma, Italy
| | - Panagiota Tzani
- Cardio-Thoracic and Vascular Department, University Hospital of Parma, 43126 Parma, Italy
| | - Gaia Manari
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Luigino Calzetta
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Correspondence:
| | - Roberta Pisi
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Giovanna Pelà
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Department of General and Specialistic Medicine, University Hospital of Parma, 43126 Parma, Italy
| | - Massimo Piepoli
- Clinical Cardiology Unit, Policlinico San Donato, University of Milan, 20122 Milan, Italy
- Department of Preventive Cardiology, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Alfredo Chetta
- Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
- Cardio-Thoracic and Vascular Department, University Hospital of Parma, 43126 Parma, Italy
| |
Collapse
|
6
|
Horn AG, Kunkel ON, Schulze KM, Baumfalk DR, Weber RE, Poole DC, Behnke BJ. Supplemental oxygen administration during mechanical ventilation reduces diaphragm blood flow and oxygen delivery. J Appl Physiol (1985) 2022; 132:1190-1200. [PMID: 35323060 PMCID: PMC9054262 DOI: 10.1152/japplphysiol.00021.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/04/2022] [Accepted: 03/18/2022] [Indexed: 11/22/2022] Open
Abstract
During mechanical ventilation (MV), supplemental oxygen (O2) is commonly administered to critically ill patients to combat hypoxemia. Previous studies demonstrate that hyperoxia exacerbates MV-induced diaphragm oxidative stress and contractile dysfunction. Whereas normoxic MV (i.e., 21% O2) diminishes diaphragm perfusion and O2 delivery in the quiescent diaphragm, the effect of MV with 100% O2 is unknown. We tested the hypothesis that MV supplemented with hyperoxic gas (100% O2) would increase diaphragm vascular resistance and reduce diaphragmatic blood flow and O2 delivery to a greater extent than MV alone. Female Sprague-Dawley rats (4-6 mo) were randomly divided into two groups: 1) MV + 100% O2 followed by MV + 21% O2 (n = 9) or 2) MV + 21% O2 followed by MV + 100% O2 (n = 10). Diaphragmatic blood flow (mL/min/100 g) and vascular resistance were determined, via fluorescent microspheres, during spontaneous breathing (SB), MV + 100% O2, and MV + 21% O2. Compared with SB, total diaphragm vascular resistance was increased, and blood flow was decreased with both MV + 100% O2 and MV + 21% O2 (all P < 0.05). Medial costal diaphragmatic blood flow was lower with MV + 100% O2 (26 ± 6 mL/min/100 g) versus MV + 21% O2 (51 ± 15 mL/min/100 g; P < 0.05). Second, the addition of 100% O2 during normoxic MV exacerbated the MV-induced reductions in medial costal diaphragm perfusion (23 ± 7 vs. 51 ± 15 mL/min/100 g; P < 0.05) and O2 delivery (3.4 ± 0.2 vs. 6.4 ± 0.3 mL O2/min/100 g; P < 0.05). These data demonstrate that administration of supplemental 100% O2 during MV increases diaphragm vascular resistance and diminishes perfusion and O2 delivery to a significantly greater degree than normoxic MV. This suggests that prolonged bouts of MV (i.e., 6 h) with hyperoxia may accelerate MV-induced vascular dysfunction in the quiescent diaphragm and potentially exacerbate downstream contractile dysfunction.NEW & NOTEWORTHY This is the first study, to our knowledge, demonstrating that supplemental oxygen (i.e., 100% O2) during mechanical ventilation (MV) augments the MV-induced reductions in diaphragmatic blood flow and O2 delivery. The accelerated reduction in diaphragmatic blood flow with hyperoxic MV would be expected to potentiate MV-induced diaphragm vascular dysfunction and consequently, downstream contractile dysfunction. The data presented herein provide a putative mechanism for the exacerbated oxidative stress and diaphragm dysfunction reported with prolonged hyperoxic MV.
Collapse
Affiliation(s)
- Andrew G Horn
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Olivia N Kunkel
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Kiana M Schulze
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Dryden R Baumfalk
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Ramona E Weber
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
- Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas
| | - Bradley J Behnke
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
- Johnson Cancer Research Center, Kansas State University, Manhattan, Kansas
| |
Collapse
|
7
|
Karageorgos V, Proklou A, Vaporidi K. Lung and diaphragm protective ventilation: a synthesis of recent data. Expert Rev Respir Med 2022; 16:375-390. [PMID: 35354361 DOI: 10.1080/17476348.2022.2060824] [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] [Indexed: 12/25/2022]
Abstract
INTRODUCTION : To adhere to the Hippocratic Oath, to "first, do no harm", we need to make every effort to minimize the adverse effects of mechanical ventilation. Our understanding of the mechanisms of ventilator-induced lung injury (VILI) and ventilator-induced diaphragm dysfunction (VIDD) has increased in recent years. Research focuses now on methods to monitor lung stress and inhomogeneity and targets we should aim for when setting the ventilator. In parallel, efforts to promote early assisted ventilation to prevent VIDD have revealed new challenges, such as titrating inspiratory effort and synchronizing the mechanical with the patients' spontaneous breaths, while at the same time adhering to lung-protective targets. AREAS COVERED This is a narrative review of the key mechanisms contributing to VILI and VIDD and the methods currently available to evaluate and mitigate the risk of lung and diaphragm injury. EXPERT OPINION Implementing lung and diaphragm protective ventilation requires individualizing the ventilator settings, and this can only be accomplished by exploiting in everyday clinical practice the tools available to monitor lung stress and inhomogeneity, inspiratory effort, and patient-ventilator interaction.
Collapse
Affiliation(s)
- Vlasios Karageorgos
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Athanasia Proklou
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| | - Katerina Vaporidi
- Department of Intensive Care, University Hospital of Heraklion and University of Crete Medical School, Greece
| |
Collapse
|
8
|
Rationale and design of a mechanistic clinical trial of JAK inhibition to prevent ventilator-induced diaphragm dysfunction. Respir Med 2021; 189:106620. [PMID: 34655959 DOI: 10.1016/j.rmed.2021.106620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 08/14/2021] [Accepted: 09/18/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Ventilator-induced diaphragm dysfunction (VIDD) is an important phenomenon that has been repeatedly demonstrated in experimental and clinical models of mechanical ventilation. Even a few hours of MV initiates signaling cascades that result in, first, reduced specific force, and later, atrophy of diaphragm muscle fibers. This severe, progressive weakness of the critical ventilatory muscle results in increased duration of MV and thus increased MV-associated complications/deaths. A drug that could prevent VIDD would likely have a major positive impact on intensive care unit outcomes. We identified the JAK/STAT pathway as important in VIDD and then demonstrated that JAK inhibition prevents VIDD in rats. We subsequently developed a clinical model of VIDD demonstrating reduced contractile force of isolated diaphragm fibers harvested after ∼7 vs ∼1 h of MV during a thoracic surgical procedure. MATERIALS AND METHODS The NIH-funded clinical trial that has been initiated is a prospective, placebo controlled trial: subjects undergoing esophagectomy are randomized to receive 6 preoperative doses of the FDA-approved JAK inhibitor Tofacitinib (commonly used for rheumatoid arthritis) vs. placebo. The primary outcome variable will be the difference in the reduction that occurs in force generation of diaphragm single muscle fibers (normalized to their cross-sectional area), in the Tofacitinib vs. placebo subjects, over 6 h of MV. DISCUSSION This trial represents a first-in-human, mechanistic clinical trial of a drug to prevent VIDD. It will provide proof-of-concept in human subjects whether JAK inhibition prevents clinical VIDD, and if successful, will support an ICU-based clinical trial that would determine whether JAK inhibition impacts clinical outcome variables such as duration of MV and mortality.
Collapse
|
9
|
Abstract
Neuromuscular diseases (NMD) are a heterogeneous group of motor unit disorders. Common to all is the main clinical symptom of muscle weakness. Depending on entity and phenotype, a broad range of disorders of neuronal, junctional or myocytic structures occurs. In addition to a weakness of the skeletal musculature, NMD can also affect throat musculature, respiratory and heart muscles. The possible consequences are immobility, deformities, tendency to aspiration as well as respiratory and cardiac insufficiency. In the context of surgery and anesthesia, complications that can result from the underlying disease and its interaction with anesthesia must be anticipated and averted. This article describes along the treatment pathway how preoperative evaluation, choice of the anesthetic procedure and postoperative care can be effectively and safely tailored to the needs of patients with NMD. Concise and practical recommendations for carrying out anesthesia for the most important NMDs are presented as well as relevant external sources of practice recommendations.
Collapse
|
10
|
Bronchodilator Response as a Possible Predictor of Lung Function Improvement After Pulmonary Rehabilitation in Post-COVID-19 Patients. Arch Bronconeumol 2021; 58:517-519. [PMID: 34219862 PMCID: PMC8233876 DOI: 10.1016/j.arbres.2021.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/03/2021] [Accepted: 06/07/2021] [Indexed: 11/21/2022]
|
11
|
Keough-Delgado E, López-Rodríguez L, de Olaiz B, Bertomeu-García A, Peñuelas Ó, Jiménez-Fernández M, Gato-Díaz P, Pérez-Domínguez H, Pérez-Vizcaíno F, Schultz MJ, Lorente JA. Case Studies in Physiology: Physiological and clinical effects of temporary diaphragm pacing in two patients with ventilator-induced diaphragm dysfunction. J Appl Physiol (1985) 2021; 130:1736-1742. [PMID: 33830811 DOI: 10.1152/japplphysiol.00543.2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Ventilator-induced diaphragm dysfunction (VIDD) is increasingly recognized as an important side-effect of invasive ventilation in critically ill patients and is associated with poor outcomes. Whether patients with VIDD benefit from temporary diaphragm pacing is uncertain. Intramuscular diaphragmatic electrodes were implanted for temporary stimulation with a pacing device (TransAeris System) in two patients with VIDD. The electrodes were implanted via laparoscopy (first patient) or via bilateral thoracoscopy (second patient). Stimulation parameters were titrated according to tolerance. Diaphragm thickening fraction by ultrasound, maximum inspiratory pressure (Pimax) and diaphragm electromyography (EMGdi) signal analysis were used to monitor the response to diaphragm pacing. Both patients tolerated diaphragm pacing. In the first patient, improvements in diaphragm excursions were noted once pacing was initiated and diaphragm thickening fraction did not further deteriorate over time. The diaphragm thickening fraction improved in the second patient, and Pimax as well as EMGdi analysis suggested improved muscle function. This patient could be fully weaned from the ventilator. These case reports present the first experience with temporary diaphragm pacing in critically ill patients with VIDD. Our results should be taken cautiously given the reduced sample size, but provide the proof of concept to put forward the hypothesis that a course of diaphragm pacing may be associated with improved diaphragmatic function. Our findings of the tolerance to the procedure and the beneficial physiological effects are not prove of safety and efficacy, but may set the ground to design and conduct larger studies.NEW & NOTEWORTHY Diaphragmatic electrode implantation and temporary diaphragm pacing have not been previously used in ICU patients with VIDD. Patients were monitored using a multimodal monitoring approach including ultrasound of the diaphragm, measurement of maximum inspiratory pressure and EMG signal analysis. Our results suggest that diaphragm pacing may improve diaphragmatic function, with the potential to prevent and treat VIDD in critically ill patients. Safety and efficacy of this intervention is yet to be proven in larger studies.
Collapse
Affiliation(s)
| | | | | | | | - Óscar Peñuelas
- Hospital Universitario de Getafe, Madrid, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | | | | | | | - Francisco Pérez-Vizcaíno
- Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Universidad Complutense de Madrid, Spain
| | - Marcus J Schultz
- Academic Medical Center, University of Amsterdam, Bijlmer, The Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - José A Lorente
- Hospital Universitario de Getafe, Madrid, Spain.,Centro de Investigación en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,Universidad Europea, Madrid, Spain
| |
Collapse
|
12
|
Wilkinson OM, Bates A, Cusack R. An observational feasibility study - does early limb ergometry affect oxygen delivery and uptake in intubated critically ill patients - a comparison of two assessment methods. BMC Anesthesiol 2021; 21:27. [PMID: 33494702 PMCID: PMC7829323 DOI: 10.1186/s12871-020-01227-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 12/25/2020] [Indexed: 11/17/2022] Open
Abstract
Background Early rehabilitation can reduce ventilation duration and improve functional outcomes in critically ill patients. Upper limb strength is associated with ventilator weaning. Passive muscle loading may preserve muscle fibre function, help recover peripheral muscle strength and improve longer term, post-hospital discharge function capacity. The physiological effects of initiating rehabilitation soon after physiological stabilisation of these patients can be concerning for clinicians. This study investigated the feasibility of measuring metabolic demand and the safety and feasibility of early upper limb passive ergometry. An additional comparison of results, achieved from simultaneous application of the methods, is reported. Methods This was an observational feasibility study undertaken in an acute teaching hospital’s General Intensive Care Unit in the United Kingdom. Twelve haemodynamically stable, mechanically ventilated patients underwent 30 minutes of arm ergometry. Cardiovascular and respiratory parameters were monitored. A Friedman test identified changes in physiological parameters. A metabolic cart was attached to the ventilator to measure oxygen uptake. Oxygen uptake was concurrently calculated by the reverse Fick method, utilising cardiac output from the LiDCO™ and paired mixed venous and arterial samples. A comparison of the two methods was made. Data collection began 10 minutes before ergometry and continued to recovery. Paired mixed venous and arterial samples were taken every 10 minutes. Results Twelve patients were studied; 9 male, median age 55 years, range (27–82), median APACHE score 18.5, range (7–31), median fraction inspired oxygen 42.5%, range (28–60). Eight patients were receiving noradrenaline. Mean dose was 0.07 mcg/kg/min, range (0.01–0.15). Early ergometry was well tolerated. There were no clinically significant changes in respiratory, haemodynamic or metabolic variables pre ergometry to end recovery. There was no significant difference between the two methods of calculating VO2 (p = 0.70). Conclusions We report the feasibility of using the reverse Fick method and indirect calorimetry to measure metabolic demand during early physical rehabilitation of critically ill patients. More research is needed to ascertain the most reliable method. Minimal change in metabolic demand supports the safety and feasibility of upper limb ergometry. These results will inform future study designs for further research into exercise response in critically ill patients. Trial Registration Clinicaltrials.gov No. NCT04383171. Registered on 06 May 2020 - Retrospectively registered. http://www.clinicaltrials.gov.
Collapse
Affiliation(s)
- Olive M Wilkinson
- Centre for Innovation and Leadership, Faculty of Health Sciences, University of Southampton, Building 45, Room 2035, Highfield Campus, S017 1BJ, Southampton, UK.
| | - Andrew Bates
- Critical Care Anaesthesia and Perioperative Research Unit and Integrative Physiology, Clinical Experimental Sciences and NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust and University Hospital Southampton, Southampton, UK
| | - Rebecca Cusack
- Centre for Innovation and Leadership, Faculty of Health Sciences, University of Southampton, Building 45, Room 2035, Highfield Campus, S017 1BJ, Southampton, UK. .,Critical Care Anaesthesia and Perioperative Research Unit and Integrative Physiology, Clinical Experimental Sciences and NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust and University Hospital Southampton, Southampton, UK.
| |
Collapse
|
13
|
Abdel-Hady H, Bahgat E, El-Halaby H, Abdelrahman A, Nasef N. Reply to the correspondence letter by Alonso-Ojembarrena, Almudena and Oulego-Erroz, Ignacio: How to improve precision and reliability of diaphragm ultrasonographic measurements in newborns. Eur J Pediatr 2021; 180:1325-1326. [PMID: 33185781 PMCID: PMC7661805 DOI: 10.1007/s00431-020-03874-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/05/2020] [Accepted: 11/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Hesham Abdel-Hady
- Neonatal Intensive Care Unit, Mansoura University Children's Hospital, Gomhoria Str., Mansoura, 35516, Egypt. .,Department of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt.
| | - Eslam Bahgat
- Neonatal Intensive Care Unit, Mansoura University Children’s Hospital, Gomhoria Str., Mansoura, 35516 Egypt
| | - Hanan El-Halaby
- Department of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt
| | - Ashraf Abdelrahman
- Department of Diagnostic Radiology, Mansoura University Children’s Hospital, Mansoura, Egypt
| | - Nehad Nasef
- Neonatal Intensive Care Unit, Mansoura University Children’s Hospital, Gomhoria Str., Mansoura, 35516 Egypt ,Department of Pediatrics, Faculty of Medicine, University of Mansoura, Mansoura, Egypt
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW Complications of mechanical ventilation, such as ventilator-induced lung injury (VILI) and ventilator-induced diaphragmatic dysfunction (VIDD), adversely affect the outcome of critically ill patients. Although mostly studied during control ventilation, it is increasingly appreciated that VILI and VIDD also occur during assisted ventilation. Hence, current research focuses on identifying ways to monitor and deliver protective ventilation in assisted modes. This review describes the operating principles of proportional modes of assist, their implications for lung and diaphragm protective ventilation, and the supporting clinical data. RECENT FINDINGS Proportional modes of assist, proportional assist ventilation, PAV, and neurally adjusted ventilatory assist, NAVA, deliver a pressure assist that is proportional to the patient's effort, enabling ventilation to be better controlled by the patient's brain. This control underlies the potential of proportional modes to avoid over-assist and under-assist, improve patient--ventilator interaction, and provide protective ventilation. Indeed, in clinical studies, proportional modes have been associated with reduced asynchronies, enhanced diaphragmatic recovery, and limitation of excessive tidal volume. Additionally, proportional modes facilitate better monitoring of the delivery of protective assisted ventilation. SUMMARY Physiological rationale and clinical data suggest a potential role for proportional modes of assist in providing and monitoring lung and diaphragm protective ventilation.
Collapse
|
15
|
Sharma A, Ramakrishna H. Assessing Diaphragmatic Dysfunction After Elective Cardiac Surgery: Expanding the Role of Critical Care Ultrasound. J Cardiothorac Vasc Anesth 2020; 34:3345-3347. [PMID: 32888798 DOI: 10.1053/j.jvca.2020.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Archit Sharma
- Divisions of Cardiothoracic Anesthesia, Solid Organ Transplant and Critical Care, Department of Anesthesia, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| |
Collapse
|
16
|
Horn AG, Baumfalk DR, Schulze KM, Kunkel ON, Colburn TD, Weber RE, Bruells CS, Musch TI, Poole DC, Behnke BJ. Effects of elevated positive end-expiratory pressure on diaphragmatic blood flow and vascular resistance during mechanical ventilation. J Appl Physiol (1985) 2020; 129:626-635. [PMID: 32730173 PMCID: PMC7517429 DOI: 10.1152/japplphysiol.00320.2020] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although mechanical ventilation (MV) is a life-saving intervention, prolonged MV can lead to deleterious effects on diaphragm function, including vascular incompetence and weaning failure. During MV, positive end-expiratory pressure (PEEP) is used to maintain small airway patency and mitigate alveolar damage. We tested the hypothesis that increased intrathoracic pressure with high levels of PEEP would increase diaphragm vascular resistance and decrease perfusion. Female Sprague-Dawley rats (~6 mo) were randomly divided into two groups receiving low PEEP (1 cmH2O; n = 10) or high PEEP (9 cmH2O; n = 9) during MV. Blood flow, via fluorescent microspheres, was determined during spontaneous breathing (SB), low-PEEP MV, high-PEEP MV, low-PEEP MV + surgical laparotomy (LAP), and high-PEEP MV + pneumothorax (PTX). Compared with SB, both low-PEEP MV and high-PEEP MV increased total diaphragm and medial costal vascular resistance (P ≤ 0.05) and reduced total and medial costal diaphragm blood flow (P ≤ 0.05). Also, during MV medial costal diaphragm vascular resistance was greater and blood flow lower with high-PEEP MV vs. low-PEEP MV (P ≤ 0.05). Diaphragm perfusion with high-PEEP MV+PTX and low-PEEP MV were not different (P > 0.05). The reduced total and medial costal diaphragmatic blood flow with low-PEEP MV appears to be independent of intrathoracic pressure changes and is attributed to increased vascular resistance and diaphragm quiescence. Mechanical compression of the diaphragm vasculature may play a role in the lower diaphragmatic blood flow at higher levels of PEEP. These reductions in blood flow to the quiescent diaphragm during MV could predispose critically ill patients to weaning complications. NEW & NOTEWORTHY This is the first study, to our knowledge, demonstrating that mechanical ventilation, with low and high positive-end expiratory pressure (PEEP), increases vascular resistance and reduces total and regional diaphragm perfusion. The rapid reduction in diaphragm perfusion and increased vascular resistance may initiate a cascade of events that predispose the diaphragm to vascular and thus contractile dysfunction with prolonged mechanical ventilation.
Collapse
Affiliation(s)
- Andrew G Horn
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Dryden R Baumfalk
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Kiana M Schulze
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Olivia N Kunkel
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Trenton D Colburn
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Ramona E Weber
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Christian S Bruells
- Department of Anesthesiology, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Timothy I Musch
- Department of Kinesiology, Kansas State University, Manhattan, Kansas.,Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas
| | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, Kansas.,Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas
| | - Bradley J Behnke
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| |
Collapse
|
17
|
Almario Alvarez JA, Okoye O, Tulla K, Spaggiari M, Di Cocco P, Benedetti E, Tzvetanov I. Tracheostomy Following Liver Transplantation. Transplant Proc 2020; 52:932-937. [PMID: 32139274 DOI: 10.1016/j.transproceed.2020.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 11/08/2019] [Accepted: 01/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND With increased demand for liver transplantation, sicker patients are being transplanted frequently. These patients are at a higher risk of significant postoperative morbidity, including respiratory failure. This study evaluated the phenotype that characterizes liver transplant candidates who may benefit from early tracheostomy. METHODS A single center retrospective review of all liver transplant candidates between January 2012 and December 2017. Patients who eventually required tracheostomies were identified and compared to their counterparts. RESULTS Of the 130 liver transplants performed during the study period, 11 patients required tracheostomy. Although patients in the tracheostomized population (TP) did not have significantly worse preoperative functional status (<4 metabolic equivalents; 64% vs 42%, P = .21), they had a higher native model for end-stage liver disease (MELD) score (37 vs 30, P < .05) at the time of transplantation. Patients who eventually succumbed to respiratory failure had lower arterial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2) ratios at the start of surgery and remained unchanged for the duration of surgery compared with the nontracheostomy group (P < .05). TP patients required more net fluid intraoperatively (7.3 vs 5.0 L, P < .05), increased length of time to attempted extubation (3.5 vs 1 day, P < .05), longer ventilation days (15 vs 1 day, P < .05), increased length of stay (37 vs 9 days, P < .05), and higher 1-year mortality (36% vs 8%, P < .05). CONCLUSIONS Based on our findings, patients with a high MELD score (>30), net postoperative fluid balance >6 L, and PaO2/FiO2 ratio ≤300 who fail to wean off mechanical ventilation after 72 hours may benefit from tracheostomy during the postoperative period.
Collapse
Affiliation(s)
| | - Obi Okoye
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Kiara Tulla
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Mario Spaggiari
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Pierpaolo Di Cocco
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Enrico Benedetti
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| | - Ivo Tzvetanov
- Department of General Surgery, University of Illinois at Chicago, Chicago, IL
| |
Collapse
|
18
|
Ding Y, Lyons SA, Scott GR, Gillis TE. Characterizing the influence of chronic hypobaric hypoxia on diaphragmatic myofilament contractile function and phosphorylation in high-altitude deer mice and low-altitude white-footed mice. J Comp Physiol B 2019; 189:489-499. [PMID: 31278612 DOI: 10.1007/s00360-019-01224-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 06/06/2019] [Accepted: 06/24/2019] [Indexed: 11/27/2022]
Abstract
Deer mice, Peromyscusmaniculatus, live at high altitudes where limited O2 represents a challenge to maintaining oxygen delivery to tissues. Previous work has demonstrated that hypoxia acclimation of deer mice and low altitude white-footed mice (P. leucopus) increases the force generating capacity of the diaphragm. The mechanism behind this improved contractile function is not known. Within myocytes, the myofilament plays a critical role in setting the rate and level of force production, and its ability to generate force can change in response to changes in physiological conditions. In the current study, we examined how chronic hypobaric hypoxia exposure of deer mice and white-footed mice influences the Ca2+ activation of force generation by skinned diaphragmatic myofilaments, and the phosphorylation of myofilament proteins. Results demonstrate that myofilament force production, and the Ca2+ sensitivity of force generation, were not impacted by acclimation to hypobaric hypoxia, and did not differ between preparations from the two species. The cooperativity of the force-pCa relationship, and the maximal rate of force generation were also the same in the preparations from both species, and not impacted by acclimation. Finally, the relative phosphorylation of TnT, and MLC was lower in deer mice than white-footed mice, but was not affected by acclimation. These results indicate that species differences in diaphragm function, and the increase in force production with hypoxia acclimation, are not due to differences, or changes, in myofilament function. However, it appears that diaphragmatic myofilament function in these species is not affected by chronic hypobaric hypoxia exposure.
Collapse
Affiliation(s)
- Y Ding
- Department of Integrative Biology, University of Guelph, Guelph, ON, N1G-2W1, Canada
| | - S A Lyons
- Department of Biology, McMaster University, Hamilton, ON, Canada
| | - G R Scott
- Department of Biology, McMaster University, Hamilton, ON, Canada
| | - Todd E Gillis
- Department of Integrative Biology, University of Guelph, Guelph, ON, N1G-2W1, Canada.
| |
Collapse
|
19
|
Horn AG, Davis RT, Baumfalk DR, Kunkel ON, Bruells CS, McCullough DJ, Opoku-Acheampong AB, Poole DC, Behnke BJ. Impaired diaphragm resistance vessel vasodilation with prolonged mechanical ventilation. J Appl Physiol (1985) 2019; 127:423-431. [PMID: 31161883 DOI: 10.1152/japplphysiol.00189.2019] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Mechanical ventilation (MV) is a life-saving intervention, yet with prolonged MV (i.e., ≥6 h) there are time-dependent reductions in diaphragm blood flow and an impaired hyperemic response of unknown origin. Female Sprague-Dawley rats (4-8 mo, n = 118) were randomized into two groups; spontaneous breathing (SB) and 6-h (prolonged) MV. After MV or SB, vasodilation (flow-induced, endothelium-dependent and -independent agonists) and constriction (myogenic and α-adrenergic) responses were measured in first-order (1A) diaphragm resistance arterioles in vitro, and endothelial nitric oxide synthase (eNOS) mRNA expression was quantified. Following prolonged MV, there was a significant reduction in diaphragm arteriolar flow-induced (SB, 34.7 ± 3.8% vs. MV, 22.6 ± 2.0%; P ≤ 0.05), endothelium-dependent (via acetylcholine; SB, 64.3 ± 2.1% vs. MV, 36.4 ± 2.3%; P ≤ 0.05) and -independent (via sodium nitroprusside; SB, 65.0 ± 3.1% vs. MV, 46.0 ± 4.6%; P ≤ 0.05) vasodilation. Compared with SB, there was reduced eNOS mRNA expression (P ≤ 0.05). Prolonged MV diminished phenylephrine-induced vasoconstriction (SB, 37.3 ± 6.7% vs. MV, 19.0 ± 1.9%; P ≤ 0.05) but did not alter myogenic or passive pressure responses. The severe reductions in diaphragmatic blood flow at rest and during contractions, with prolonged MV, are associated with diaphragm vascular dysfunction which occurs through both endothelium-dependent and endothelium-independent mechanisms.NEW & NOTEWORTHY Following prolonged mechanical ventilation, vascular alterations occur through both endothelium-dependent and -independent pathways. This is the first study, to our knowledge, demonstrating that diaphragm arteriolar dysfunction occurs consequent to prolonged mechanical ventilation and likely contributes to the severe reductions in diaphragmatic blood flow and weaning difficulties.
Collapse
Affiliation(s)
- Andrew G Horn
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Robert T Davis
- Department of Applied Physiology and Kinesiology, Center for Exercise Science, University of Florida, Gainesville, Florida
| | - Dryden R Baumfalk
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Olivia N Kunkel
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| | - Christian S Bruells
- Department of Anesthesiology, RWTH Aachen University, Faculty of Medicine, Aachen, Germany
| | - Danielle J McCullough
- Department of Anatomy and Physiology, Edward Via College of Osteopathic Medicine, Auburn Campus, Auburn, Alabama
| | | | - David C Poole
- Department of Kinesiology, Kansas State University, Manhattan, Kansas.,Department of Anatomy and Physiology, Kansas State University, Manhattan, Kansas
| | - Bradley J Behnke
- Department of Kinesiology, Kansas State University, Manhattan, Kansas
| |
Collapse
|
20
|
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.
Collapse
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
| |
Collapse
|
21
|
Bignami E, Guarnieri M, Saglietti F, Ramelli A, Vetrugno L. Diaphragmatic Dysfunction FollowingCardiac Surgery: Is There a Role forPulmonary Ultrasound? J Cardiothorac Vasc Anesth 2018; 32:e6-e7. [DOI: 10.1053/j.jvca.2018.04.054] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Indexed: 01/20/2023]
|
22
|
Abstract
OBJECTIVES Diaphragm atrophy is associated with delayed weaning from mechanical ventilation and increased mortality in critically ill adults. We sought to test for the presence of diaphragm atrophy in children with acute respiratory failure. DESIGN Prospective, observational study. SETTING Single-center tertiary noncardiac PICU in a children's hospital. PATIENTS Invasively ventilated children with acute respiratory failure. MEASUREMENTS AND MAIN RESULTS Diaphragm thickness at end-expiration and end-inspiration were serially measured by ultrasound in 56 patients (median age, 17 mo; interquartile range, 5.5-52), first within 36 hours of intubation and last preceding extubation. The median duration of mechanical ventilation was 140 hours (interquartile range, 83-201). At initial measurement, thickness at end-expiration was 2.0 mm (interquartile range, 1.8-2.5) and thickness at end-inspiration was 2.5 mm (interquartile range, 2-2.8). The change in thickness at end-expiration during mechanical ventilation between first and last measurement was -13.8% (interquartile range, -27.4% to 0%), with a -3.4% daily atrophy rate (interquartile range, -5.6 to 0%). Thickening fraction = ([thickness at end-inspiration - thickness at end-expiration]/thickness at end-inspiration) throughout the course of mechanical ventilation was linearly correlated with spontaneous breathing fraction (beta coefficient, 9.4; 95% CI, 4.2-14.7; p = 0.001). For children with a period of spontaneous breathing fraction less than 0.5 during mechanical ventilation, those with exposure to a continuous neuromuscular blockade infusion (n = 15) had a significantly larger decrease in thickness at end-expiration compared with children with low spontaneous breathing fraction who were not exposed to a neuromuscular blockade infusion (n = 18) (-16.4%, [interquartile range, -28.4% to -7.0%] vs -7.3%; [interquartile range, -10.9% to -0%]; p = 0.036). CONCLUSIONS Diaphragm atrophy is present in children on mechanical ventilation for acute respiratory failure. Diaphragm contractility, measured as thickening fraction, is strongly correlated with spontaneous breathing fraction. The combination of exposure to neuromuscular blockade infusion with low overall spontaneous breathing fraction is associated with a greater degree of atrophy.
Collapse
|
23
|
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
|
24
|
Smuder AJ, Gonzalez-Rothi EJ, Kwon OS, Morton AB, Sollanek KJ, Powers SK, Fuller DD. Cervical spinal cord injury exacerbates ventilator-induced diaphragm dysfunction. J Appl Physiol (1985) 2016; 120:166-77. [PMID: 26472866 PMCID: PMC4719055 DOI: 10.1152/japplphysiol.00488.2015] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 10/07/2015] [Indexed: 01/06/2023] Open
Abstract
Cervical spinal cord injury (SCI) can dramatically impair diaphragm muscle function and often necessitates mechanical ventilation (MV) to maintain adequate pulmonary gas exchange. MV is a life-saving intervention. However, prolonged MV results in atrophy and impaired function of the diaphragm. Since cervical SCI can also trigger diaphragm atrophy, it may create preconditions that exacerbate ventilator-induced diaphragm dysfunction (VIDD). Currently, no drug therapy or clinical standard of care exists to prevent or minimize diaphragm dysfunction following SCI. Therefore, we first tested the hypothesis that initiating MV acutely after cervical SCI will exacerbate VIDD and enhance proteolytic activation in the diaphragm to a greater extent than either condition alone. Rats underwent controlled MV for 12 h following acute (∼24 h) cervical spinal hemisection injury at C2 (SCI). Diaphragm tissue was then harvested for comprehensive functional and molecular analyses. Second, we determined if antioxidant therapy could mitigate MV-induced diaphragm dysfunction after cervical SCI. In these experiments, SCI rats received antioxidant (Trolox, a vitamin E analog) or saline treatment prior to initiating MV. Our results demonstrate that compared with either condition alone, the combination of SCI and MV resulted in increased diaphragm atrophy, contractile dysfunction, and expression of atrophy-related genes, including MuRF1. Importantly, administration of the antioxidant Trolox attenuated proteolytic activation, fiber atrophy, and contractile dysfunction in the diaphragms of SCI + MV animals. These findings provide evidence that cervical SCI greatly exacerbates VIDD, but antioxidant therapy with Trolox can preserve diaphragm contractile function following acute SCI.
Collapse
Affiliation(s)
- Ashley J Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida; and
| | | | - Oh Sung Kwon
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida; and
| | - Aaron B Morton
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida; and
| | - Kurt J Sollanek
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida; and
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida; and
| | - David D Fuller
- Department of Physical Therapy, University of Florida, Gainesville, Florida
| |
Collapse
|
25
|
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]
|
26
|
A Teaching Tool to Visually Illustrate How Manipulating the Physiology of the Ventilatory Muscle Pump Alters Functional Performance. Cardiopulm Phys Ther J 2015. [DOI: 10.1097/cpt.0000000000000004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
27
|
Almoosa KF, Gupta A, Pedroza C, Watts NB. Low Testosterone Levels are Frequent in Patients with Acute Respiratory Failure and are Associated with Poor Outcomes. Endocr Pract 2014; 20:1057-63. [PMID: 24936547 DOI: 10.4158/ep14003.or] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Low testosterone level is a common finding in critically ill patients with trauma, shock, and sepsis. However, its prevalence and outcomes in patients with primary acute respiratory failure is unknown; low testosterone could contribute to respiratory muscle weakness and further compromise ventilation in these patients. METHODS We aimed to determine the prevalence, severity, and effects of hypotestosteronemia in patients with acute respiratory failure in a 16-bed single academic center medical intensive care unit (ICU). We studied 30 men who required mechanical ventilation for ≥24 hours for a primary diagnosis of acute respiratory failure. Blood samples were drawn on ICU day 1 and day 3 to measure serum levels of total and free testosterone. RESULTS Hypotestosteronemia (level below the lower reference limit) was present on day 1 in 93.1% (total testosterone) and 76.7% (free testosterone) of patients and on day 3 in 94.4% (total testosterone) and 100% (free testosterone) of patients. Sex hormone-binding globulin, dehydroepiandrosterone sulfate, follicle-stimulating hormone, luteinizing hormone, and thyroid function levels were all within stated reference ranges. Total and free testosterone levels correlated inversely with ventilator days and ICU length of stay. CONCLUSION Hypotestosteronemia is common in mechanically ventilated patients with primary acute respiratory failure and may contribute to longer ICU stay. Further studies are needed to determine the effect of testosterone replacement on short- and long-term outcomes in these patients.
Collapse
|
28
|
Hooijman PE, Paul MA, Stienen GJM, Beishuizen A, Van Hees HWH, Singhal S, Bashir M, Budak MT, Morgen J, Barsotti RJ, Levine S, Ottenheijm CAC. Unaffected contractility of diaphragm muscle fibers in humans on mechanical ventilation. Am J Physiol Lung Cell Mol Physiol 2014; 307:L460-70. [PMID: 25038190 DOI: 10.1152/ajplung.00076.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Several studies have indicated that diaphragm dysfunction develops in patients on mechanical ventilation (MV). Here, we tested the hypothesis that the contractility of sarcomeres, i.e., the smallest contractile unit in muscle, is affected in humans on MV. To this end, we compared diaphragm muscle fibers of nine brain-dead organ donors (cases) that had been on MV for 26 ± 5 h with diaphragm muscle fibers from nine patients (controls) undergoing surgery for lung cancer that had been on MV for less than 2 h. In each diaphragm specimen we determined 1) muscle fiber cross-sectional area in cryosections by immunohistochemical methods and 2) the contractile performance of permeabilized single muscle fibers by means of maximum specific force, kinetics of cross-bridge cycling by rate of tension redevelopment, myosin heavy chain content and concentration, and calcium sensitivity of force of slow-twitch and fast-twitch muscle fibers. In case subjects, we noted no statistically significant decrease in outcomes compared with controls in slow-twitch or fast-twitch muscle fibers. These observations indicate that 26 h of MV of humans is not invariably associated with changes in the contractile performance of sarcomeres in the diaphragm.
Collapse
Affiliation(s)
| | | | - Ger J M Stienen
- Departments of Physiology, Faculty of Science, Department of Physics and Astronomy, Vrije Universiteit, Amsterdam, The Netherlands
| | - Albertus Beishuizen
- Intensive Care, Vrije Universiteit Medical Center, Amsterdam, The Netherlands
| | - Hieronymus W H Van Hees
- Department of Pulmonary Diseases, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Sunil Singhal
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Muhammad Bashir
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Murat T Budak
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Jacqueline Morgen
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Robert J Barsotti
- Department of Physiology, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Sanford Levine
- Department of Surgery, University of Pennsylvania and Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Gift of Life Donor Program, Philadelphia, Pennsylvania; and
| | - Coen A C Ottenheijm
- Departments of Physiology, Department of Cellular and Molecular Medicine, University of Arizona, Tucson, Arizona
| |
Collapse
|
29
|
Navalesi P, Frigerio P, Patzlaff A, Häußermann S, Henseke P, Kubitschek M. Prolonged weaning: from the intensive care unit to home. REVISTA PORTUGUESA DE PNEUMOLOGIA 2014; 20:264-72. [PMID: 24975297 DOI: 10.1016/j.rppneu.2014.04.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 04/28/2014] [Accepted: 04/29/2014] [Indexed: 11/18/2022] Open
Abstract
Weaning is the process of withdrawing mechanical ventilation which starts with the first spontaneous breathing trial (SBT). Based on the degree of difficulty and duration, weaning is classified as simple, difficult and prolonged. Prolonged weaning, which includes patients who fail 3 SBTs or are still on mechanical ventilation 7 days after the first SBT, affects a relatively small fraction of mechanically ventilated ICU patients but these, however, requires disproportionate resources. There are several potential causes which can lead to prolonged weaning. It is nonetheless important to understand the problem from the point of view of each individual patient in order to adopt appropriate treatment and define precise prognosis. An otherwise stable patient who remains on mechanical ventilation will be considered for transfer to a specialized weaning unit (SWU). Though there is not a precise definition, SWU can be considered as highly specialized and protected environments for patients requiring mechanical ventilation despite resolution of the acute disorder. Proper staffing, well defined short-term and long-term goals, attention to psychological and social problems represent key determinants of SWU success. Some patients cannot be weaned, either partly or entirely, and may require long-term home mechanical ventilation. In these cases the logistics relating to caregivers and the equipment must be carefully considered and addressed.
Collapse
Affiliation(s)
- P Navalesi
- Department of Translational Medicine, Eastern Piedmont University, Novara Anesthesia and Intensive Care, Sant'Andrea Hospital, Vercelli, CRRF Mons. L. Novarese, Moncrivello, VC, Italy
| | - P Frigerio
- Spinal Cord Unit, Niguarda-Ca' Granda Hospital, Milano, Italy
| | - A Patzlaff
- Inamed GmbH, Robert-Koch-Allee 29, 82131 Gauting, Germany
| | - S Häußermann
- Inamed GmbH, Robert-Koch-Allee 29, 82131 Gauting, Germany
| | - P Henseke
- GBU Healthcare, Linde Gas Headquarters, Seitnerstrasse 70, 82049 Pullach, Germany
| | - M Kubitschek
- GBU Healthcare, Linde Gas Headquarters, Seitnerstrasse 70, 82049 Pullach, Germany.
| |
Collapse
|
30
|
Díaz MC, Ospina-Tascón GA, Salazar C BC. Respiratory Muscle Dysfunction: A Multicausal Entity in the Critically Ill Patient Undergoing Mechanical Ventilation. ACTA ACUST UNITED AC 2014. [DOI: 10.1016/j.arbr.2014.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
31
|
Powers SK, Wiggs MP, Sollanek KJ, Smuder AJ. Ventilator-induced diaphragm dysfunction: cause and effect. Am J Physiol Regul Integr Comp Physiol 2013; 305:R464-77. [DOI: 10.1152/ajpregu.00231.2013] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Mechanical ventilation (MV) is used clinically to maintain gas exchange in patients that require assistance in maintaining adequate alveolar ventilation. Common indications for MV include respiratory failure, heart failure, drug overdose, and surgery. Although MV can be a life-saving intervention for patients suffering from respiratory failure, prolonged MV can promote diaphragmatic atrophy and contractile dysfunction, which is referred to as ventilator-induced diaphragm dysfunction (VIDD). This is significant because VIDD is thought to contribute to problems in weaning patients from the ventilator. Extended time on the ventilator increases health care costs and greatly increases patient morbidity and mortality. Research reveals that only 18–24 h of MV is sufficient to develop VIDD in both laboratory animals and humans. Studies using animal models reveal that MV-induced diaphragmatic atrophy occurs due to increased diaphragmatic protein breakdown and decreased protein synthesis. Recent investigations have identified calpain, caspase-3, autophagy, and the ubiquitin-proteasome system as key proteases that participate in MV-induced diaphragmatic proteolysis. The challenge for the future is to define the MV-induced signaling pathways that promote the loss of diaphragm protein and depress diaphragm contractility. Indeed, forthcoming studies that delineate the signaling mechanisms responsible for VIDD will provide the knowledge necessary for the development of a pharmacological approach that can prevent VIDD and reduce the incidence of weaning problems.
Collapse
Affiliation(s)
- Scott K. Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Michael P. Wiggs
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Kurt J. Sollanek
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| | - Ashley J. Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, Florida
| |
Collapse
|
32
|
Bruells CS, Maes K, Rossaint R, Thomas D, Cielen N, Bleilevens C, Bergs I, Loetscher U, Dreier A, Gayan-Ramirez G, Behnke BJ, Weis J. Prolonged mechanical ventilation alters the expression pattern of angio-neogenetic factors in a pre-clinical rat model. PLoS One 2013; 8:e70524. [PMID: 23950950 PMCID: PMC3738548 DOI: 10.1371/journal.pone.0070524] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2012] [Accepted: 06/19/2013] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Mechanical ventilation (MV) is a life saving intervention for patients with respiratory failure. Even after 6 hours of MV, diaphragm atrophy and dysfunction (collectively referred to as ventilator-induced diaphragmatic dysfunction, VIDD) occurs in concert with a blunted blood flow and oxygen delivery. The regulation of hypoxia sensitive factors (i.e. hypoxia inducible factor 1α, 2α (HIF-1α,-2α), vascular endothelial growth factor (VEGF)) and angio-neogenetic factors (angiopoietin 1-3, Ang) might contribute to reactive and compensatory alterations in diaphragm muscle. METHODS Male Wistar rats (n = 8) were ventilated for 24 hours or directly sacrificed (n = 8), diaphragm and mixed gastrocnemius muscle tissue was removed. Quantitative real time PCR and western blot analyses were performed to detect changes in angio-neogenetic factors and inflammatory markers. Tissues were stained using Isolectin (IB 4) to determine capillarity and calculate the capillary/fiber ratio. RESULTS MV resulted in up-regulation of Ang 2 and HIF-1α mRNA in both diaphragm and gastrocnemius, while VEGF mRNA was down-regulated in both tissues. HIF-2α mRNA was reduced in both tissues, while GLUT 4 mRNA was increased in gastrocnemius and reduced in diaphragm samples. Protein levels of VEGF, HIF-1α, -2α and 4 did not change significantly. Additionally, inflammatory cytokine mRNA (Interleukin (IL)-6, IL-1β and TNF α) were elevated in diaphragm tissue. CONCLUSION The results demonstrate that 24 hrs of MV and the associated limb disuse induce an up-regulation of angio-neogenetic factors that are connected to HIF-1α. Changes in HIF-1α expression may be due to several interactions occurring during MV.
Collapse
Affiliation(s)
- Christian S Bruells
- Department of Anesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Bom EA, de Souza CV, Thiesen RADS, Miranda ECM, de Souza CA. Evaluation of respiratory conditions in early phase of hematopoietic stem cell transplantation. Rev Bras Hematol Hemoter 2013; 34:188-92. [PMID: 23049417 PMCID: PMC3459632 DOI: 10.5581/1516-8484.20120047] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2011] [Accepted: 03/14/2012] [Indexed: 11/27/2022] Open
Abstract
Objectives To investigate the effectiveness of respiratory physiotherapy based on clinical evidence and analyze the improvement in respiratory parameters. Methods A prospective study was carried out in the Bone Marrow Transplant Unit of the Universidade Estadual de Campinas (UNICAMP). Two different previously established respiratory physiotherapy protocols were applied from days D-1 to D+7 that aimed to improve airway clearance, pulmonary re-expansion and the strengthening of respiratory muscles. Group A were subjected to diaphragmatic proprioceptive stimulation, breathing exercises, incentive spirometry with Respiron®, inspiratory muscle training with the Threshold® Inspiratory Muscle Training device, bronchial hygienization with Shaker® and cough stimulation. Group B performed a protocol that only used incentive spirometry. The parameters analyzed were: tidal volume, minute volume, maximal inspiratory pressure, maximal expiratory pressure, oxygen saturation, heart rate and respiratory frequency. Results Sixty-seven patients submitted to myeloablative hematopoietic stem cell transplantation were included in this study. Among these, thirty-nine were evaluated and randomized in the two groups. There were significant differences between the groups for tidal volume at D+2 (p-value = 0.007) and maximal inspiratory pressure (p-value = 0.03), maximal expiratory pressure (p-value = 0.03) and tidal volume (p-value = 0.004) at D+7. Conclusions On comparing Group A with Group B, the authors concluded that the protocol of respiratory physiotherapy applied in this study resulted in an improvement in ventilation and in respiratory muscle strength of patients submitted to hematopoietic stem cell transplantation.
Collapse
|
34
|
Tang H, Lee M, Khuong A, Wright E, Shrager JB. Diaphragm muscle atrophy in the mouse after long-term mechanical ventilation. Muscle Nerve 2013; 48:272-8. [DOI: 10.1002/mus.23748] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2012] [Indexed: 12/31/2022]
Affiliation(s)
- Huibin Tang
- Division of Thoracic Surgery; Department of Cardiothoracic Surgery; Stanford School of Medicine, VA Palo Alto Health Care System; 300 Pasteur Drive Stanford California 94305-5407 USA
| | - Myung Lee
- Division of Thoracic Surgery; Department of Cardiothoracic Surgery; Stanford School of Medicine, VA Palo Alto Health Care System; 300 Pasteur Drive Stanford California 94305-5407 USA
| | - Amanda Khuong
- Division of Thoracic Surgery; Department of Cardiothoracic Surgery; Stanford School of Medicine, VA Palo Alto Health Care System; 300 Pasteur Drive Stanford California 94305-5407 USA
| | - Erika Wright
- Division of Thoracic Surgery; Department of Cardiothoracic Surgery; Stanford School of Medicine, VA Palo Alto Health Care System; 300 Pasteur Drive Stanford California 94305-5407 USA
| | - Joseph B. Shrager
- Division of Thoracic Surgery; Department of Cardiothoracic Surgery; Stanford School of Medicine, VA Palo Alto Health Care System; 300 Pasteur Drive Stanford California 94305-5407 USA
| |
Collapse
|
35
|
Díaz MC, Ospina-Tascón GA, Salazar C BC. Respiratory muscle dysfunction: a multicausal entity in the critically ill patient undergoing mechanical ventilation. Arch Bronconeumol 2013; 50:73-7. [PMID: 23669061 DOI: 10.1016/j.arbres.2013.03.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 02/02/2013] [Accepted: 03/04/2013] [Indexed: 11/19/2022]
Abstract
Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation.
Collapse
Affiliation(s)
- Magda C Díaz
- Unidad de Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia; Departamento de Ciencias Fisiológicas, Facultad de Salud, Universidad del Valle, Cali, Colombia
| | - Gustavo A Ospina-Tascón
- Unidad de Cuidados Intensivos, Fundación Valle del Lili, Cali, Colombia; Grupo de Investigación Biomédica de la Universidad ICESI, Cali, Colombia
| | - Blanca C Salazar C
- Departamento de Ciencias Fisiológicas, Facultad de Salud, Universidad del Valle, Cali, Colombia.
| |
Collapse
|
36
|
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.
Collapse
|
37
|
Mechanical ventilation reduces rat diaphragm blood flow and impairs oxygen delivery and uptake. Crit Care Med 2012; 40:2858-66. [PMID: 22846782 DOI: 10.1097/ccm.0b013e31825b933a] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although mechanical ventilation is a life-saving intervention in patients suffering from respiratory failure, prolonged mechanical ventilation is often associated with numerous complications including problematic weaning. In contracting skeletal muscle, inadequate oxygen supply can limit oxidative phosphorylation resulting in muscular fatigue. However, whether prolonged mechanical ventilation results in decreased diaphragmatic blood flow and induces an oxygen supply-demand imbalance in the diaphragm remains unknown. DESIGN We tested the hypothesis that prolonged controlled mechanical ventilation results in a time-dependent reduction in rat diaphragmatic blood flow and microvascular PO2 and that prolonged mechanical ventilation would diminish the diaphragm's ability to increase blood flow in response to muscular contractions. MEASUREMENTS AND MAIN RESULTS Compared to 30 mins of mechanical ventilation, 6 hrs of mechanical ventilation resulted in a 75% reduction in diaphragm blood flow (via radiolabeled microspheres), which did not occur in the intercostal muscle or high-oxidative hindlimb muscle (e.g., soleus). There was also a time-dependent decline in diaphragm microvascular PO2 (via phosphorescence quenching). Further, contrary to 30 mins of mechanical ventilation, 6 hrs of mechanical ventilation significantly compromised the diaphragm's ability to increase blood flow during electrically-induced contractions, which resulted in a ~80% reduction in diaphragm oxygen uptake. In contrast, 6 hrs of spontaneous breathing in anesthetized animals did not alter diaphragm blood flow or the ability to augment flow during electrically-induced contractions. CONCLUSIONS These new and important findings reveal that prolonged mechanical ventilation results in a time-dependent decrease in the ability of the diaphragm to augment blood flow to match oxygen demand in response to contractile activity and could be a key contributing factor to difficult weaning. Although additional experiments are required to confirm, it is tempting to speculate that this ventilator-induced decline in diaphragmatic oxygenation could promote a hypoxia-induced generation of reactive oxygen species in diaphragm muscle fibers and contribute to ventilator-induced diaphragmatic atrophy and contractile dysfunction.
Collapse
|
38
|
Dermitzaki D, Tzortzaki E, Soulitzis N, Neofytou E, Prinianakis G, Matalliotakis I, Askitopoulou H, Siafakas NM. Molecular response of the human diaphragm on different modes of mechanical ventilation. ACTA ACUST UNITED AC 2012; 85:228-35. [PMID: 22869416 DOI: 10.1159/000338841] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 04/12/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND The mechanical stress that the human diaphragm is exposed to during mechanical ventilation affects a variety of processes, including signal transduction, gene expression, and angiogenesis. OBJECTIVES The study aim was to assess the change in the production of major angiogenic regulators [vascular endothelial growth factor (VEGF), fibroblast growth factor-2 (FGF2), and transforming growth factor beta 1 (TGFB1)] on the human diaphragm before and after contraction/relaxation cycles during mechanical ventilation. METHODS This observational study investigates the diaphragmatic mRNA expression of VEGF, FGF2, and TGFB1 in surgical patients receiving general anesthesia with controlled mechanical ventilation (CMV) with muscle relaxation (group A, n = 13), CMV without muscle relaxation (group B, n = 10), and pressure support of spontaneous breathing (group C, n = 9). Diaphragmatic samples were obtained from each patient at two time points: 30 min after the induction of anesthesia (t1) and 90 min after the first specimen collection (t2). RESULTS No significant changes in the mRNA expression of VEGF, FGF2, and TGFB1 were documented in groups A and C between time points t1 and t2. In contrast, in group B, the mRNA levels of the above angiogenic factors were increased in time point t2 compared to t1, a finding which was statistically significant (pVEGF = 0.003, pFGF2 = 0.028, pTGFB1 = 0.001). CONCLUSIONS These findings suggest that the molecular response of the human diaphragm before and after application of diverse modes of mechanical ventilation is different. Angiogenesis via the expression of VEGF, FGF2, and TGFB1 was only promoted in CMV without muscle relaxation, and this may have important clinical implications.
Collapse
Affiliation(s)
- Despina Dermitzaki
- Departments of Anaesthesia, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
| | | | | | | | | | | | | | | |
Collapse
|
39
|
Kalkan Y, Bostan H, Tumkaya L, Tomak Y, Bostan M, Yilmaz A, Turut H, Temiz A, Yalçin A, Turan A. The effect of rocuronium, sugammadex, and their combination on cardiac muscle and diaphragmatic skeletal muscle cells. J Anesth 2012; 26:870-7. [DOI: 10.1007/s00540-012-1440-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 06/13/2012] [Indexed: 12/17/2022]
|
40
|
Both high level pressure support ventilation and controlled mechanical ventilation induce diaphragm dysfunction and atrophy. Crit Care Med 2012; 40:1254-60. [PMID: 22425820 DOI: 10.1097/ccm.0b013e31823c8cc9] [Citation(s) in RCA: 114] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Previous workers have demonstrated that controlled mechanical ventilation results in diaphragm inactivity and elicits a rapid development of diaphragm weakness as a result of both contractile dysfunction and fiber atrophy. Limited data exist regarding the impact of pressure support ventilation, a commonly used mode of mechanical ventilation-that permits partial mechanical activity of the diaphragm-on diaphragm structure and function. We carried out the present study to test the hypothesis that high-level pressure support ventilation decreases the diaphragm pathology associated with CMV. METHODS Sprague-Dawley rats were randomly assigned to one of the following five groups:1) control (no mechanical ventilation); 2) 12 hrs of controlled mechanical ventilation (12CMV); 3) 18 hrs of controlled mechanical ventilation (18CMV); 4) 12 hrs of pressure support ventilation (12PSV); or 5) 18 hrs of pressure support ventilation (18PSV). MEASUREMENTS AND MAIN RESULTS We carried out the following measurements on diaphragm specimens: 4-hydroxynonenal-a marker of oxidative stress, active caspase-3 (casp-3), active calpain-1 (calp-1), fiber type cross-sectional area, and specific force (sp F). Compared with the control, both 12PSV and 18PSV promoted a significant decrement in diaphragmatic specific force production, but to a lesser degree than 12CMV and 18CMV. Furthermore, 12CMV, 18PSV, and 18CMV resulted in significant atrophy in all diaphragm fiber types as well as significant increases in a biomarker of oxidative stress (4-hydroxynonenal) and increased proteolytic activity (20S proteasome, calpain-1, and caspase-3). Furthermore, although no inspiratory effort occurs during controlled mechanical ventilation, it was observed that pressure support ventilation resulted in large decrement, approximately 96%, in inspiratory effort compared with spontaneously breathing animals. CONCLUSIONS High levels of prolonged pressure support ventilation promote diaphragmatic atrophy and contractile dysfunction. Furthermore, similar to controlled mechanical ventilation, pressure support ventilation-induced diaphragmatic atrophy and weakness are associated with both diaphragmatic oxidative stress and protease activation.
Collapse
|
41
|
Tang H, Lee M, Budak MT, Pietras N, Hittinger S, Vu M, Khuong A, Hoang CD, Hussain SNA, Levine S, Shrager JB. Intrinsic apoptosis in mechanically ventilated human diaphragm: linkage to a novel Fos/FoxO1/Stat3-Bim axis. FASEB J 2011; 25:2921-36. [PMID: 21597002 DOI: 10.1096/fj.11-183798] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Mechanical ventilation (MV) is a life-saving measure in many critically ill patients. However, prolonged MV results in diaphragm dysfunction that contributes to the frequent difficulty in weaning patients from the ventilator. The molecular mechanisms underlying ventilator-induced diaphragm dysfunction (VIDD) remain poorly understood. We report here that MV induces myonuclear DNA fragmentation (3-fold increase; P<0.01) and selective activation of caspase 9 (P<0.05) and Bcl2-interacting mediator of cell death (Bim; 2- to 7-fold increase; P<0.05) in human diaphragm. MV also statistically significantly down-regulates mitochondrial gene expression and induces oxidative stress. In cultured muscle cells, we show that oxidative stress activates each of the catabolic pathways thought to underlie VIDD: apoptotic (P<0.05), proteasomal (P<0.05), and autophagic (P<0.01). Further, silencing Bim expression blocks (P<0.05) oxidative stress-induced apoptosis. Overlapping the gene expression profiles of MV human diaphragm and H₂O₂-treated muscle cells, we identify Fos, FoxO1, and Stat3 as regulators of Bim expression as well as of expression of the catabolic markers atrogin and LC3. We thus identify a novel Fos/FoxO1/Stat3-Bim intrinsic apoptotic pathway and establish the centrality of oxidative stress in the development of VIDD. This information may help in the design of specific drugs to prevent this condition.
Collapse
Affiliation(s)
- Huibin Tang
- Division of Thoracic Surgery, Stanford University School of Medicine, Stanford, CA 94305, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
Falk DJ, Kavazis AN, Whidden MA, Smuder AJ, McClung JM, Hudson MB, Powers SK. Mechanical ventilation-induced oxidative stress in the diaphragm: role of heme oxygenase-1. Chest 2010; 139:816-824. [PMID: 21106654 DOI: 10.1378/chest.09-2787] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Prolonged mechanical ventilation (MV) results in a rapid onset of diaphragmatic atrophy that is primarily due to increased proteolysis. Although MV-induced protease activation can involve several factors, it is clear that oxidative stress is a required signal for protease activation in the diaphragm during prolonged MV. However, the oxidant-producing pathways in the diaphragm that contribute to MV-induced oxidative stress remain unknown. We have demonstrated that prolonged MV results in increased diaphragmatic expression of a key stress-sensitive enzyme, heme oxygenase (HO)-1. Paradoxically, HO-1 can function as either a pro-oxidant or an antioxidant, and the role that HO-1 plays in MV-induced diaphragmatic oxidative stress is unknown. We tested the hypothesis that HO-1 acts as a pro-oxidant in the diaphragm during prolonged MV. METHODS To determine whether HO-1 functions as a pro-oxidant or an antioxidant in the diaphragm during MV, we assigned rats into three experimental groups: (1) a control group, (2) a group that received 18 h of MV and saline solution, and (3) a group that received 18 h of MV and was treated with a selective HO-1 inhibitor. Indices of oxidative stress, protease activation, and fiber atrophy were measured in the diaphragm. RESULTS Inhibition of HO-1 activity did not prevent or exacerbate MV-induced diaphragmatic oxidative stress (as indicated by biomarkers of oxidative damage). Further, inhibition of HO-1 activity did not influence MV-induced protease activation or myofiber atrophy in the diaphragm. CONCLUSIONS Our results indicate that HO-1 is neither a pro-oxidant nor an antioxidant in the diaphragm during MV. Furthermore, our findings reveal that HO-1 does not play an important role in MV-induced protease activation and diaphragmatic atrophy.
Collapse
Affiliation(s)
- Darin J Falk
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL
| | - Andreas N Kavazis
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL
| | - Melissa A Whidden
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL
| | - Ashley J Smuder
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL
| | - Joseph M McClung
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL
| | - Matthew B Hudson
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL
| | - Scott K Powers
- Department of Applied Physiology and Kinesiology, University of Florida, Gainesville, FL.
| |
Collapse
|
43
|
Nowell MM, Choi H, Rourke BC. Muscle plasticity in hibernating ground squirrels (Spermophilus lateralis) is induced by seasonal, but not low-temperature, mechanisms. J Comp Physiol B 2010; 181:147-64. [DOI: 10.1007/s00360-010-0505-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Revised: 07/05/2010] [Accepted: 07/23/2010] [Indexed: 12/17/2022]
|
44
|
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.
Collapse
|
45
|
Kavazis AN, Talbert EE, Smuder AJ, Hudson MB, Nelson WB, Powers SK. Mechanical ventilation induces diaphragmatic mitochondrial dysfunction and increased oxidant production. Free Radic Biol Med 2009; 46:842-50. [PMID: 19185055 PMCID: PMC2906125 DOI: 10.1016/j.freeradbiomed.2009.01.002] [Citation(s) in RCA: 153] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2008] [Revised: 01/07/2009] [Accepted: 01/08/2009] [Indexed: 12/16/2022]
Abstract
Mechanical ventilation (MV) is a life-saving intervention used in patients with acute respiratory failure. Unfortunately, prolonged MV results in diaphragmatic weakness, which is an important contributor to the failure to wean patients from MV. Our laboratory has previously shown that reactive oxygen species (ROS) play a critical role in mediating diaphragmatic weakness after MV. However, the pathways responsible for MV-induced diaphragmatic ROS production remain unknown. These experiments tested the hypothesis that prolonged MV results in an increase in mitochondrial ROS release, mitochondrial oxidative damage, and mitochondrial dysfunction. To test this hypothesis, adult (3-4 months of age) female Sprague-Dawley rats were assigned to either a control or a 12-h MV group. After treatment, diaphragms were removed and mitochondria were isolated for subsequent respiratory and biochemical measurements. Compared to control, prolonged MV resulted in a lower respiratory control ratio in diaphragmatic mitochondria. Furthermore, diaphragmatic mitochondria from MV animals released higher rates of ROS in both State 3 and State 4 respiration. Prolonged MV was also associated with diaphragmatic mitochondrial oxidative damage as indicated by increased lipid peroxidation and protein oxidation. Finally, our data also reveal that the activities of the electron transport chain complexes II, III, and IV are depressed in mitochondria isolated from diaphragms of MV animals. In conclusion, these results are consistent with the concept that diaphragmatic inactivity promotes an increase in mitochondrial ROS emission, mitochondrial oxidative damage, and mitochondrial respiratory dysfunction.
Collapse
Affiliation(s)
- Andreas N Kavazis
- Applied Physiology and Kinesiology, University of Florida, Gainesville, FL 32611, USA.
| | | | | | | | | | | |
Collapse
|
46
|
Abstract
In septic patients increased central drive and increased metabolic demands combine to increase energy demands on the ventilatory muscles. This occurs at a time when energy supplies are limited and energy production hindered, and it leads to an energy supply-demand imbalance and often ventilatory failure. Problems related to contractile function of the ventilatory muscles also contribute, especially when the clinical course is prolonged. The increased ventilatory activity increases interactions between the ventilatory and cardiovascular systems, and when ventilatory muscles fail and mechanical ventilatory support is required a new set of problems emerges. In this review I discuss factors related to ventilatory muscle failure, giving emphasis to mechanical and supply demand aspects. I also review the implications of changes in ventilatory patterns for heart-lung interactions.
Collapse
Affiliation(s)
- Sheldon Magder
- Department of Medicine, Division of Critical Care, McGill University Health Centre, Montreal, Quebec, Canada.
| |
Collapse
|
47
|
Whidden MA, McClung JM, Falk DJ, Hudson MB, Smuder AJ, Nelson WB, Powers SK. Xanthine oxidase contributes to mechanical ventilation-induced diaphragmatic oxidative stress and contractile dysfunction. J Appl Physiol (1985) 2008; 106:385-94. [PMID: 18974366 DOI: 10.1152/japplphysiol.91106.2008] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Respiratory muscle weakness resulting from both diaphragmatic contractile dysfunction and atrophy has been hypothesized to contribute to the weaning difficulties associated with prolonged mechanical ventilation (MV). While it is clear that oxidative injury contributes to MV-induced diaphragmatic weakness, the source(s) of oxidants in the diaphragm during MV remain unknown. These experiments tested the hypothesis that xanthine oxidase (XO) contributes to MV-induced oxidant production in the rat diaphragm and that oxypurinol, a XO inhibitor, would attenuate MV-induced diaphragmatic oxidative stress, contractile dysfunction, and atrophy. Adult female Sprague-Dawley rats were randomly assigned to one of six experimental groups: 1) control, 2) control with oxypurinol, 3) 12 h of MV, 4) 12 h of MV with oxypurinol, 5) 18 h of MV, or 6) 18 h of MV with oxypurinol. XO activity was significantly elevated in the diaphragm after MV, and oxypurinol administration inhibited this activity and provided protection against MV-induced oxidative stress and contractile dysfunction. Specifically, oxypurinol treatment partially attenuated both protein oxidation and lipid peroxidation in the diaphragm during MV. Further, XO inhibition retarded MV-induced diaphragmatic contractile dysfunction at stimulation frequencies >60 Hz. Collectively, these results suggest that oxidant production by XO contributes to MV-induced oxidative injury and contractile dysfunction in the diaphragm. Nonetheless, the failure of XO inhibition to completely prevent MV-induced diaphragmatic oxidative damage suggests that other sources of oxidant production are active in the diaphragm during prolonged MV.
Collapse
Affiliation(s)
- Melissa A Whidden
- Dept. of Applied Physiology and Kinesiology, Univ. of Florida,Gainesville, FL 32611, USA
| | | | | | | | | | | | | |
Collapse
|
48
|
Unoki T, Serita A, Grap MJ. Automatic Tube Compensation During Weaning From Mechanical Ventilation. Crit Care Nurse 2008. [DOI: 10.4037/ccn2008.28.4.34] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Takeshi Unoki
- Takeshi Unoki is a senior assistant professor in the School of Nursing at St. Luke’s College of Nursing, Tokyo, Japan. He was a postdoctoral fellow in the School of Nursing at Virginia Commonwealth University in Richmond when this article was written
| | - Akimichi Serita
- Akimichi Serita is a staff nurse in an intensive care unit at Tokyo Dental College Ichikawa General Hospital, Ichikawa, Japan
| | - Mary Jo Grap
- Mary Jo Grap is a professor in the School of Nursing at Virginia Commonwealth University in Richmond
| |
Collapse
|
49
|
Dopamine alleviation of diaphragm contractile dysfunction and reduction of deoxyribonucleic acid damage in rats. Heart Lung 2008; 37:132-43. [DOI: 10.1016/j.hrtlng.2007.05.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2006] [Accepted: 05/07/2007] [Indexed: 12/27/2022]
|
50
|
Gosselink R, Bott J, Johnson M, Dean E, Nava S, Norrenberg M, Schönhofer B, Stiller K, van de Leur H, Vincent JL. Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med 2008; 34:1188-99. [PMID: 18283429 DOI: 10.1007/s00134-008-1026-7] [Citation(s) in RCA: 373] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2007] [Accepted: 01/03/2008] [Indexed: 11/30/2022]
Abstract
The Task Force reviewed and discussed the available literature on the effectiveness of physiotherapy for acute and chronic critically ill adult patients. Evidence from randomized controlled trials or meta-analyses was limited and most of the recommendations were level C (evidence from uncontrolled or nonrandomized trials, or from observational studies) and D (expert opinion). However, the following evidence-based targets for physiotherapy were identified: deconditioning, impaired airway clearance, atelectasis, intubation avoidance, and weaning failure. Discrepancies and lack of data on the efficacy of physiotherapy in clinical trials support the need to identify guidelines for physiotherapy assessments, in particular to identify patient characteristics that enable treatments to be prescribed and modified on an individual basis. There is a need to standardize pathways for clinical decision-making and education, to define the professional profile of physiotherapists, and increase the awareness of the benefits of prevention and treatment of immobility and deconditioning for critically ill adult patients.
Collapse
Affiliation(s)
- R Gosselink
- Respiratory Rehabilitation, Faculty of Kinesiology and Rehabilitation Sciences, Katholieke Universiteit Leuven, Tervuursevest 101, 3000, Leuven, Belgium.
| | | | | | | | | | | | | | | | | | | |
Collapse
|