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Jiang W, Liu J, Cui J, Su J, Xu W, Zhang F, Ding Y. Ferroptosis plays a crucial role in lung cell damage caused by ventilation stretch. Free Radic Biol Med 2023; 209:84-95. [PMID: 37827457 DOI: 10.1016/j.freeradbiomed.2023.10.381] [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: 08/04/2023] [Revised: 10/07/2023] [Accepted: 10/09/2023] [Indexed: 10/14/2023]
Abstract
Mechanical ventilation is an essential respiratory support in acute respiratory distress syndrome and intensive care cases. However, it is possible to cause ventilator-induced lung damage (VILI). In this work, we used a microfluidic device to provide a mechanical ventilation with cyclic stretch (30% total area change rate and 15 cycles per min) and oxygen (air) flux applied by a controlled pressured airflow. Compared to static control, the ventilation stretch resulted in significant death of A549 cells accompanied by increased lipid peroxidation, mitochondrial reactive oxygen species (ROS) production, and ferrous ion accumulation, while by decreased protein expression of solute carrier family 7 member 11 (SLC7A11) and glutathione peroxidase 4 (GPX4) proteins, as well as ratio of reduced-to-oxidized glutathione. The resulted A549 cell death could be alleviated by two ferroptosis inhibitors, deferoxamine and ferrostatin-1. These similar phenomena also occurred in other three types of human lung cells, such as primary alveolar type II epithelial cells, primary alveolar microvascular endothelial cells, and bronchial epithelial cell line. From the A549 RNA sequence analysis, the gene ontology (GO) based on 85 ferroptosis-related genes (FRGs) indicated that several iron homeostasis-related biological processes and molecular functions were involved in the ventilation-stretch-induced cell death, while the gene set enrichment analysis (GSEA) based on 2901 differentially expressed genes (DEGs) showed that glutathione metabolism was significantly suppressed. Finally, solute carrier family 39 member 14 (SLC39A14), a transporter of uptake extracellular divalent metal ion, was selected to be knocked down to verify its role in the ventilation-stretch-induced death of A549. Our results suggest that ferroptosis may be an alternative pathway for VILI, but it needs to be confirmed by further animal experiments and clinical data.
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Affiliation(s)
- Wei Jiang
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Jing Liu
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Jingang Cui
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Jilei Su
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Wei Xu
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Fang Zhang
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Yongsheng Ding
- College of Life Sciences, University of Chinese Academy of Sciences, Beijing, 100049, China.
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Valentine MS, Weigel C, Kamga Gninzeko F, Tho C, Gräler MH, Reynolds AM, Spiegel S, Heise RL. S1P lyase inhibition prevents lung injury following high pressure-controlled mechanical ventilation in aging mice. Exp Gerontol 2023; 173:112074. [PMID: 36566871 PMCID: PMC9975034 DOI: 10.1016/j.exger.2022.112074] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 12/24/2022]
Abstract
Ventilator-induced Lung Injury (VILI) is characterized by hypoxia, inflammatory cytokine influx, loss of alveolar barrier integrity, and decreased lung compliance. Aging influences lung structure and function and is a predictive factor in the severity of VILI; however, the mechanisms of aging that influence the progression or increased susceptibility remain unknown. Aging impacts immune system function and may increase inflammation in healthy individuals. Recent studies suggest that the bioactive sphingolipid mediator sphingosine-1-phosphate (S1P) and the enzyme that degrades it S1P lyase (SPL) may be involved in lung pathologies including acute lung injury. It is unknown whether aging influences S1P and SPL expression that have been implicated in lung inflammation, injury, and cell apoptosis. We hypothesized that aging and injurious mechanical ventilation synergistically impair S1P levels and enhance S1P lyase (SPL) expression that amplifies alveolar barrier damage and diminishes pulmonary function. Young (2-3 mo) and old (20-25 mo) C57BL/6 mice were mechanically ventilated for 2 h using pressure-controlled mechanical ventilation (PCMV) at 45 cmH2O and 35 cmH2O, respectively. We assessed the impact of aging and PCMV on several indications of acute lung injury, immune cell recruitment, S1P levels and SPL activity. Furthermore, we evaluated the protective effects of inhibiting SPL by tetrahydroxybutylimidazol (THI) administration on the negative outcomes associated with aging and mechanical injury. PCMV exacerbated lung injury in old mice and increased neutrophil influx that was further exacerbated due to aging. SPL expression increased in the young and old ventilated mice and the old nonventilated group. THI treatment reduced several of the indicators of lung injury and resulted in elevated S1P levels in lung tissue and plasma from mice that were injured from mechanical ventilation. CD80 and CD206 activation markers of alveolar and interstitial macrophages were also influenced by THI. SPL inhibition may be a viable therapeutic approach for patients requiring mechanical ventilation by preventing or regulating the exaggerated inflammatory response and reducing lung injury.
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Affiliation(s)
- M S Valentine
- Department of Biomedical Engineering, Virginia Commonwealth University, United States of America
| | - C Weigel
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, United States of America
| | - F Kamga Gninzeko
- Department of Biomedical Engineering, Virginia Commonwealth University, United States of America
| | - C Tho
- Department of Biomedical Engineering, Virginia Commonwealth University, United States of America
| | - M H Gräler
- Department of Anesthesiology and Intensive Care Medicine, Center for Molecular Biomedicine (CMB) and Center for Sepsis Control and Care (CSCC), Jena University Hospital, Jena, Germany
| | - A M Reynolds
- Department of Mathematics and Applied Mathematics, Virginia Commonwealth University, United States of America
| | - S Spiegel
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University, United States of America
| | - R L Heise
- Department of Biomedical Engineering, Virginia Commonwealth University, United States of America.
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Zhou L, Yang R, Xue C, Chen Z, Jiang W, He S, Zhang X. Biphasic positive airway pressure spontaneous breathing attenuates lung injury in an animal model of severe acute respiratory distress syndrome. BMC Anesthesiol 2022; 22:228. [PMID: 35842600 PMCID: PMC9287822 DOI: 10.1186/s12871-022-01763-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 07/05/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To compare the effects of unassisted spontaneous breathing (SB) and complete muscle paralysis (PC) on early severe acute respiratory distress syndrome (ARDS) in an animal model, and to explore the possibility of biphasic positive airway pressure (BIPAP) as lung protective ventilation support for patients in the early stage of severe ARDS. METHODS Twelve healthy beagle dogs between the ages of 10 and 15 months were randomly divided into two groups: the SB group (BIPAPSB) and the PC group (BIPAPPC). Arterial blood samples were drawn before modelling. Arterial blood gas analysis and mechanical tests were conducted. The animal model of severe ARDS was established using a deep intravenous injection of oleic acid, and BIPAP ventilation was performed for 8 hours. Lung tissue and blood were taken to detect lung function, inflammatory reactions and degree of pathological damage. RESULTS At the beginning of the experiment, there was no significant difference in the arterial blood gas analysis between the two groups (p > 0.05). After successful modelling, the oxygenation index and the end-expiratory lung volume in the SB group were significantly higher than those in the PC group 8 hours after MV. Pathologically, the wet-dry ratio and pathological score of the PC group were higher than those of the SB group; the lung injury in the gravity-dependent area in the SB group was less than that in the PC group (p< 0.05). CONCLUSIONS In the early stage of severe ARDS induced by oleic acid, compared with PC, retention of the BIPAP mode of SB can reduce the risk of lung injury and improve respiratory function.
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Affiliation(s)
- Leilei Zhou
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Rui Yang
- Department of Internal Medicine, Guiyang First People's Hospital, Guiyang, China
| | - Chunju Xue
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Zongyu Chen
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Wenqing Jiang
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Shuang He
- School of Clinical Medicine, Guizhou Medical University, Guiyang, 550004, China
| | - Xianming Zhang
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, 550004, China.
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Makhnevich A, Gandomi A, Wu Y, Qiu M, Jafari D, Rolston D, Tsegaye A, Hajizadeh N. A Novel Method to Improve the Identification of Time of Intubation for Retrospective EHR Data Analysis During a Time of Resource Strain, the COVID-19 Pandemic. Am J Med Qual 2022; 37:327-334. [PMID: 35285459 PMCID: PMC9241560 DOI: 10.1097/jmq.0000000000000048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Accurate determinations of the time of intubation (TOI) are critical for retrospective electronic health record (EHR) data analyses. In a retrospective study, the authors developed and validated an improved query (Ti) to identify TOI across numerous settings in a large health system, using EHR data, during the COVID-19 pandemic. Further, they evaluated the affect of Ti on peri-intubation patient parameters compared to a previous method-ventilator parameters (Tv). Ti identified an earlier TOI for 84.8% (n = 1666) of cases with a mean (SD) of 3.5 hours (15.5), resulting in alternate values for: partial pressure of arterial oxygen (PaO 2 ) in 18.4% of patients (mean 43.95 mmHg [54.24]); PaO 2 /fractional inspired oxygen (FiO 2 ) in 17.8% of patients (mean 48.29 [69.81]), and oxygen saturation/FiO 2 in 62.7% (mean 16.75 [34.14]), using the absolute difference in mean values within the first 4 hours of intubation. Differences in PaO 2 /FiO 2 using Ti versus Tv resulted in the reclassification of 7.3% of patients into different acute respiratory distress syndrome (ARDS) severity categories.
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Affiliation(s)
- Alexander Makhnevich
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY
| | - Amir Gandomi
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY
- Frank G. Zarb School of Business, Hofstra University, Hempstead, NY
| | - Yiduo Wu
- AiD Technologies, Stony Brook, NY
| | - Michael Qiu
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY
| | - Daniel Jafari
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Daniel Rolston
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Adey Tsegaye
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Negin Hajizadeh
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY
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Analysis of Fluid Balance as Predictor of Length of Assisted Mechanical Ventilation in Children Admitted to Pediatric Intensive Care Unit (PICU). Int J Pediatr 2022; 2022:2090323. [PMID: 35356099 PMCID: PMC8958081 DOI: 10.1155/2022/2090323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/09/2022] [Indexed: 11/27/2022] Open
Abstract
Background Ventilator-associated lung injury (VALI) is a devastating complication of assisted mechanical ventilation (AMV) and is one of the root causes of prolonged AMV. Many strategies were made to decrease the effect of the same. This study is conducted to determine the association of prolonged AMV with fluid balance and pediatric index of mortality 2 (PIM2) score. Methods This prospective observational study was carried out in a PICU of a tertiary care centre over a period of 12 months. Patient's fluid balance was calculated by tabulating fluid input-output over initial 48 hours of AMV. The PIM2 score on admission was documented. The association between qualitative variables was assessed by a chi-square test. Comparison of quantitative data measured between cases with duration of AMV ≥ 7 days and <7 days was done using the Mann–Whitney U test. Correlation between quantitative data was done by using the Pearson product moment correlation. Results Out of 40 patients, 27 patients who had ≥15% positive fluid balance required prolonged mechanical ventilation. Similarly, 27 patients with PIM2 score ≥ 5 required prolonged AMV. On applying the Pearson chi-square test, we found a significant association between positive fluid balance and prolonged mechanical ventilation (P value = 2.25 × 10−7 (<0.05)). Likewise, a statistically significant association was found between PIM2 score and prolonged ventilation (P value = 1.19 × 10−5 (<0.05)). Conclusion There is a significant association of prolonged AMV with positive fluid balance (>15%) and PIM2 score (>5). By strict maintenance of fluid balance with appropriate intervention, the length of AMV and PICU stay can be decreased.
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Prediction and estimation of pulmonary response and elastance evolution for volume-controlled and pressure-controlled ventilation. Biomed Signal Process Control 2022. [DOI: 10.1016/j.bspc.2021.103367] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Scendoni R, Gattari D, Cingolani M. COVID-19 Pulmonary Pathology, Ventilator-Induced Lung Injury (VILI), or Sepsis-Induced Acute Respiratory Distress Syndrome (ARDS)? Healthcare Considerations Arising From an Autopsy Case and Miny-Review. CLINICAL PATHOLOGY (THOUSAND OAKS, VENTURA COUNTY, CALIF.) 2022; 15:2632010X221083223. [PMID: 35284825 PMCID: PMC8905213 DOI: 10.1177/2632010x221083223] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/30/2022] [Indexed: 01/20/2023]
Abstract
Acute respiratory distress syndrome (ARDS) caused by coronavirus disease (COVID-19) is a serious complication that requires early recognition. Autopsy reports or biopsies of the lungs in patients with COVID-19 revealed diffuse alveolar damage (DAD) at different stages; the fibrotic phase is usually associated with long-standing severe disease. Care management of hospitalized patients is not easy, given that the risk of incurring a ventilator-induced lung injury (VILI) is high. Additionally, if the patient develops nosocomial infections, sepsis-induced ARDS should be considered in the study of the pathophysiological processes. We present an autopsy case of a hospitalized patient whose death was linked to COVID-19 infection, with the histopathological pattern of advanced pulmonary fibrosis. After prolonged use of non-invasive and invasive ventilation, the patient developed polymicrobial superinfection oh the lungs. After analyzing the individual’s clinical history and pulmonary anatomopathological findings, we consider healthcare issues that should lead to an improvement in diagnosis and to more adequate standards of care management among health professionals.
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Affiliation(s)
- Roberto Scendoni
- Department of Law, Institute of Legal Medicine, University of Macerata, Macerata, Italy
| | - Diego Gattari
- Anesthesia and Resuscitation Unit, ASUR Marche AV3, Macerata, Italy
| | - Mariano Cingolani
- Department of Law, Institute of Legal Medicine, University of Macerata, Macerata, Italy
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Over-distension prediction via hysteresis loop analysis and patient-specific basis functions in a virtual patient model. Comput Biol Med 2021; 141:105022. [PMID: 34801244 DOI: 10.1016/j.compbiomed.2021.105022] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 11/02/2021] [Accepted: 11/04/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Recruitment maneuvers (RMs) with subsequent positive-end-expiratory-pressure (PEEP) have proven effective in recruiting lung volume and preventing alveolar collapse. However, a suboptimal PEEP could induce undesired injury in lungs by insufficient or excessive breath support. Thus, a predictive model for patient response under PEEP changes could improve clinical care and lower risks. METHODS This research adds novel elements to a virtual patient model to identify and predict patient-specific lung distension to optimise and personalise care. Model validity and accuracy are validated using data from 18 volume-controlled ventilation (VCV) patients at 7 different baseline PEEP levels (0-12cmH2O), yielding 623 prediction cases. Predictions were made up to ΔPEEP = 12cmH2O ahead covering 6x2cmH2O PEEP steps. RESULTS Using the proposed lung distension model, 90% of absolute peak inspiratory pressure (PIP) prediction errors compared to clinical measurement are within 3.95cmH2O, compared with 4.76cmH2O without this distension term. Comparing model-predicted and clinically measured distension had high correlation increasing to R2 = 0.93-0.95 if maximum ΔPEEP ≤ 6cmH2O. Predicted dynamic functional residual capacity (Vfrc) changes as PEEP rises yield 0.013L median prediction error for both prediction groups and overall R2 of 0.84. CONCLUSIONS Overall results demonstrate nonlinear distension mechanics are accurately captured in virtual lung mechanics patients for mechanical ventilation, for the first time. This result can minimise the risk of lung injury by predicting its potential occurrence of distension before changing ventilator settings. The overall outcomes significantly extend and more fully validate this virtual mechanical ventilation patient model.
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Knopp JL, Chase JG, Kim KT, Shaw GM. Model-based estimation of negative inspiratory driving pressure in patients receiving invasive NAVA mechanical ventilation. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2021; 208:106300. [PMID: 34348200 DOI: 10.1016/j.cmpb.2021.106300] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/17/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Optimisation of mechanical ventilation (MV) and weaning requires insight into underlying patient breathing effort. Current identifiable models effectively describe lung mechanics, such as elastance (E) and resistance (R) at the bedside in sedated patients, but are less effective when spontaneous breathing is present. This research derives and regularises a single compartment model to identify patient-specific inspiratory effort. METHODS Constrained second-order b-spline basis functions (knot width 0.05 s) are used to describe negative inspiratory drive (Pp, cmH2O) as a function of time. Breath-breath Pp are identified with single E and R values over inspiration and expiration from n = 20 breaths for N = 22 patients on NAVA ventilation. Pp is compared to measured electrical activity of the diaphragm (Eadi) and published results. RESULTS Average per-patient root-mean-squared model fit error was (median [interquartile range, IQR]) 0.9 [0.6-1.3] cmH2O, and average per-patient median Pp was -3.9 [-4.5- -3.0] cmH2O, with range -7.9 - -1.9 cmH2O. Per-patient E and R were 16.4 [13.6-21.8] cmH2O/L and 9.2 [6.4-13.1] cmH2O.s/L, respectively. Most patients showed an inspiratory volume threshold beyond which Pp started to return to baseline, and Pp at peak Eadi (end-inspiration) was often strongly correlated with peak Eadi (R2=0.25-0.86). Similarly, average transpulmonary pressure was consistent breath-breath in most patients, despite differences in peak Eadi and thus peak airway pressure. CONCLUSIONS The model-based inspiratory effort aligns with electrical muscle activity and published studies showing neuro-muscular decoupling as a function of pressure and/or volume. Consistency in coupling/dynamics were patient-specific. Quantification of patient and ventilator work of breathing contributions may aid optimisation of MV modes and weaning.
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Affiliation(s)
- Jennifer L Knopp
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand.
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand
| | - Kyeong Tae Kim
- Department of Mechanical Engineering, University of Canterbury, Private Bag 4800, Christchurch 8140, New Zealand
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Private Bag 4710, Christchurch, New Zealand
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Mining the key genes for ventilator-induced lung injury using co-expression network analysis. Biosci Rep 2021; 41:228048. [PMID: 33687057 PMCID: PMC7969703 DOI: 10.1042/bsr20203235] [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: 09/09/2020] [Revised: 02/24/2021] [Accepted: 03/09/2021] [Indexed: 12/30/2022] Open
Abstract
Mechanical ventilation is extensively adopted in general anesthesia and respiratory failure management, but it can also induce ventilator-induced lung injury (VILI). Therefore, it is of great urgency to explore the mechanisms involved in the VILI pathogenesis, which might contribute to its future prevention and treatment. Four microarray datasets from the GEO database were selected in our investigation, and were subjected to the Weighted Gene Co-Expression Network Analysis (WGCNA) to identify the VILI-correlated gene modules. The limma package in R software was used to identify the differentially expressed genes (DEGs) between the VILI and control groups. WGCNA was constructed by merging the GSE9314, GSE9368, GSE11434 and GSE11662 datasets. A total of 49 co-expression network modules were determined as associated with VILI. The intersected genes between hub genes screened from DEGs for VILI and those identified using WGCNA were as follows: Tlr2, Hmox1, Serpine1, Mmp9, Il6, Il1b, Ptgs2, Fos and Atf3, which were determined to be key genes for VILI. Those key genes were validated by GSE86229 and quantitative PCR (qPCR) experiment to have significantly statistical difference in their expression between the VILI and control groups. In a nutshell, nine key genes with expression differences in VILI were screened by WGCNA by integrating multiple datasets.
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Physiologic Improvement in Respiratory Acidosis Using Extracorporeal Co 2 Removal With Hemolung Respiratory Assist System in the Management of Severe Respiratory Failure From Coronavirus Disease 2019. Crit Care Explor 2021; 3:e0372. [PMID: 33786448 PMCID: PMC7994071 DOI: 10.1097/cce.0000000000000372] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objectives About 15% of hospitalized coronavirus disease 2019 patients require ICU admission, and most (80%) of these require invasive mechanical ventilation. Lung-protective ventilation in coronavirus disease 2019 acute respiratory failure may result in severe respiratory acidosis without significant hypoxemia. Low-flow extracorporeal Co2 removal can facilitate lung-protective ventilation and avoid the adverse effects of severe respiratory acidosis. The objective was to evaluate the efficacy of extracorporeal Co2 removal using the Hemolung Respiratory Assist System in correcting severe respiratory acidosis in mechanically ventilated coronavirus disease 2019 patients with severe acute respiratory failure. Design Retrospective cohort analysis of patients with coronavirus disease 2019 mechanically ventilated with severe hypercapnia and respiratory acidosis and treated with low-flow extracorporeal Co2 removal. Setting Eight tertiary ICUs in the United States. Patients Adult patients supported with the Hemolung Respiratory Assist System from March 1, to September 30, 2020. Interventions Extracorporeal Co2 removal with Hemolung Respiratory Assist System under a Food and Drug Administration emergency use authorization for coronavirus disease 2019. Measurements and Main Results The primary outcome was improvement in pH and Paco2 from baseline. Secondary outcomes included survival to decannulation, mortality, time on ventilator, and adverse events. Thirty-one patients were treated with Hemolung Respiratory Assist System with significant improvement in pH and Pco2 in this cohort. Two patients experienced complications that prevented treatment. Of the 29 treated patients, 58% survived to 48 hours post treatment and 38% to hospital discharge. No difference in age or comorbidities were noted between survivors and nonsurvivors. There was significant improvement in pH (7.24 ± 0.12 to 7.35 ± 0.07; p < 0.0001) and Paco2 (79 ± 23 to 58 ± 14; p < 0.0001) from baseline to 24 hours. Conclusions In this retrospective case series of 29 patients, we have demonstrated efficacy of extracorporeal Co2 removal using the Hemolung Respiratory Assist System to improve respiratory acidosis in patients with severe hypercapnic respiratory failure due to coronavirus disease 2019.
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Abstract
Despite substantial advances in anesthesia safety within the past decades, perioperative mortality remains a prevalent problem and can be considered among the top causes of death worldwide. Acute organ failure is a major risk factor of morbidity and mortality in surgical patients and develops primarily as a consequence of a dysregulated inflammatory response and insufficient tissue perfusion. Neurological dysfunction, myocardial ischemia, acute kidney injury, respiratory failure, intestinal dysfunction, and hepatic impairment are among the most serious complications impacting patient outcome and recovery. Pre-, intra-, and postoperative arrangements, such as enhanced recovery after surgery programs, can contribute to lowering the occurrence of organ dysfunction, and mortality rates have improved with the advent of specialized intensive care units and advances in procedures relating to extracorporeal organ support. However, no specific pharmacological therapies have proven effective in the prevention or reversal of perioperative organ injury. Therefore, understanding the underlying mechanisms of organ dysfunction is essential to identify novel treatment strategies to improve perioperative care and outcomes for surgical patients. This review focuses on recent knowledge of pathophysiological and molecular pathways leading to perioperative organ injury. Additionally, we highlight potential therapeutic targets relevant to the network of events that occur in clinical settings with organ failure.
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Affiliation(s)
- Catharina Conrad
- From the Department of Anesthesiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas.,Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Holger K Eltzschig
- From the Department of Anesthesiology, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
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13
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Abstract
Recent studies show improved outcomes in ambulated lung failure patients. Ambulation still remains a challenge in these patients. This necessitates development of more compact and less cumbersome respiratory support specifically designed to be wearable. The Paracorporeal Ambulatory Assist Lung (PAAL) is being designed for providing ambulatory support in lung failure patients during bridge to transplant or recovery. We previously published in vitro and acute in vivo results of the PAAL. This study further evaluates the PAAL for 5 days. Five-day in vivo studies with the PAAL were conducted in 50-60 kg sheep after heparinization (activated clotting time range: 190-250 s) and cannulation with a 27 Fr. Avalon Elite dual-lumen cannula. The animals were able to move freely in a stanchion while device flow, resistance, and hemodynamics were recorded hourly. Oxygenation and hemolysis were measured daily. Platelet activation, blood chemistry, and comprehensive blood counts are reported for preoperatively, on POD 0, and POD 5. Three animals survived for 5 days. No study termination resulted from device failure. One animal was terminated on POD 0 and one animal was terminated at POD 3. The device was operated between 1.93 and 2.15 L/min. Blood left the device 100% oxygenated. Plasma-free hemoglobin ranged 10.8-14.5 mg/dl. CD62-P expression was under 10%. Minimal thrombus was seen in devices at explant. Chronic use of the PAAL in awake sheep is promising based on our study. There were no device-related complications over the study course. This study represents the next step in our pathway to eventual clinical translation.
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Mohamed T, Abdul-Hafez A, Gewolb IH, Uhal BD. Oxygen injury in neonates: which is worse? hyperoxia, hypoxia, or alternating hyperoxia/hypoxia. JOURNAL OF LUNG, PULMONARY & RESPIRATORY RESEARCH 2020; 7:4-13. [PMID: 34337150 PMCID: PMC8320601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Premature birth results in an increased risk of respiratory distress and often requires oxygen therapy. While the supplemental oxygen has been implicated as a cause of bronchopulmonary dysplasia (BPD), in clinical practice this supplementation usually only occurs after the patient's oxygen saturation levels have dropped. The effect of hyperoxia on neonates has been extensively studied. However, there is an unanswered fundamental question: which has the most impact-hyperoxia, hypoxia or fluctuating oxygen levels? In this review, we will summarize the reported effect of hypoxia, hyperoxia or a fluctuation of oxygen levels (hypoxia/hyperoxia cycling) in preterm neonates, with special emphasis on the lungs.
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Affiliation(s)
- Tarek Mohamed
- Department of Pediatrics and Human Development, Michigan State University, USA
| | - Amal Abdul-Hafez
- Department of Pediatrics and Human Development, Michigan State University, USA
| | - Ira H Gewolb
- Department of Pediatrics and Human Development, Michigan State University, USA
| | - Bruce D Uhal
- Department of Physiology, Michigan State University, USA
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15
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Abstract
First successfully described in 1967, acute respiratory distress syndrome has since garnered much interest and debate. Extensive studies and clinical trials have been carried out in efforts to address the associated high mortality; however, it remains a significant burden on health care. Despite the heterogeneous etiologies that lead to the development of acute respiratory distress syndrome, this rapidly progressing form of respiratory failure, characterized by severe hypoxemia and nonhydrostatic pulmonary edema, has a recognizable pattern of lung injury. In this chapter, we will review the clinical manifestations, definitions, causes, and a brief overview of the pathophysiology of this complex syndrome.
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Zhang W, Dai H, Lin F, Zhao C, Wang X, Zhang S, Ge W, Pei S, Pan L. Ly-6C high inflammatory-monocyte recruitment is regulated by p38 MAPK/MCP-1 activation and promotes ventilator-induced lung injury. Int Immunopharmacol 2019; 78:106015. [PMID: 31780369 DOI: 10.1016/j.intimp.2019.106015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/23/2019] [Accepted: 10/28/2019] [Indexed: 12/14/2022]
Abstract
Lymphocyte antigen 6Chigh (Ly-6Chigh) inflammatory monocytes, as novel mononuclear cells in the innate immune system, participate in infectious diseases. In this study, we investigated the potential role of these monocytes in ventilator-induced lung injury (VILI) and the possible mechanism involved in their migration to lung tissue. Our results showed that mechanical ventilation with high tidal volume (HTV) increased the accumulation of Ly-6Chigh inflammatory monocytes in lung tissues and that blocking C‑C chemokine receptor 2 (CCR2) could significantly reduce Ly-6Chigh inflammatory-monocyte migration and attenuate the degree of inflammation of lung tissues. In addition, inhibition of p38 mitogen-activated protein kinase (p38 MAPK) activity could decrease the secretion of monocyte chemoattractant protein 1 (MCP-1), which in turn decreased the migration of Ly-6Chigh inflammatory monocytes into lung tissue. We also demonstrated that high ventilation caused Ly-6Chigh inflammatory monocytes in the bone marrow to migrate into and aggregate in the lungs, creating inflammation, and that the mechanism was quite different from that of infectious diseases. Ly-6Chigh inflammatory monocytes might play a pro-inflammatory role in VILI, and blocking their infiltration into lung tissue might become a new target for the treatment of this injury.
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Affiliation(s)
- Weikang Zhang
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China
| | - Huijun Dai
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China
| | - Fei Lin
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China
| | - Chen Zhao
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China
| | - Xiaoxia Wang
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China
| | - SuiSui Zhang
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China
| | - Wanyun Ge
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China
| | - Shenglin Pei
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China
| | - Linghui Pan
- Department of Anesthesiology, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China; Perioperative Medical Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi 530021, China.
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17
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Liu G, Gu C, Liu M, Liu H, Wang D, Liu X, Wang Y. Protective role of p120-catenin on mitochondria by inhibiting NLRP3 in ventilator-induced lung injury. J Cell Mol Med 2019; 23:7360-7371. [PMID: 31507096 PMCID: PMC6815848 DOI: 10.1111/jcmm.14595] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 06/17/2019] [Accepted: 07/14/2019] [Indexed: 01/21/2023] Open
Abstract
Mitochondria supply energy to maintain the integrity of cell junctions. NLRP3, as the core component of the inflammatory response, is crucial in mechanical stretching. Mechanical stretching could activate NLRP3 and induce mitochondrial dysfunction. The relationship between p120 and mitochondria in ventilator-induced lung injury (VILI) has not been elucidated. MLE-12 cells and wild-type male C57BL/6 mice were pre-treated with MCC950 (specific and highly efficient inhibitor of NLRP3) or a p120 siRNA-liposome complex. Then, the cells were subjected to 20% cyclic stretching, and the mice were subjected to mechanical ventilation at a high tidal volume. Cell lysates and lung tissues were obtained to detect the expression of NLRP3, p120, TLR4 pathway components, IL-6 and IL-1β, to determine the functions and structures of mitochondria, and the wet/dry ratio of the lung, and to perform pathological staining and an Evans blue dye assay. Mechanical stretching could increase the levels of NLRP3, ROS and damaged mitochondria, while these changes could be reversed by MCC950. Moreover, p120 prevented the activation of NLRP3 and regulated NLRP3 by inhibiting the TLR4 pathway and ROS production. Additionally, p120 played a vital role in protecting mitochondrial structures and functions after mechanical stretching. Taken together, these findings suggest that p120 depletion during mechanical stretching aggravates mitochondrial dysfunction by activating NLRP3, which indicates that p120 has a protective role on mitochondria in VILI by inhibiting NLRP3 activation.
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Affiliation(s)
- Ge Liu
- Department of AnesthesiologyShandong Provincial Qianfoshan Hospital, Shandong UniversityJinanChina
| | - Changping Gu
- Department of AnesthesiologyShandong Provincial Qianfoshan Hospital, Shandong UniversityJinanChina
| | - Mengjie Liu
- Department of AnesthesiologyShandong Provincial Qianfoshan Hospital, Shandong UniversityJinanChina
| | - Huan Liu
- Department of AnesthesiologyShandong Provincial Qianfoshan Hospital, Shandong UniversityJinanChina
| | - Dong Wang
- Department of AnesthesiologyShandong Provincial Qianfoshan Hospital, Shandong UniversityJinanChina
| | - Xiaobin Liu
- Department of AnesthesiologyShandong Provincial Qianfoshan Hospital, Shandong UniversityJinanChina
| | - Yuelan Wang
- Department of AnesthesiologyShandong Provincial Qianfoshan Hospital, Shandong UniversityJinanChina
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18
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Meyers M, Rodrigues N, Ari A. High-frequency oscillatory ventilation: A narrative review. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2019; 55:40-46. [PMID: 31297448 PMCID: PMC6591785 DOI: 10.29390/cjrt-2019-004] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
High-frequency oscillatory ventilation (HFOV) is a lung-protective strategy that can be utilized in the full spectrum of patient populations ranging from neonatal to adults with acute lung injury. HFOV is often utilized as a rescue strategy when conventional mechanical ventilation (CV) has failed. HFOV uses low tidal volumes and constant mean airway pressures in conjunction with high respiratory rates to provide beneficial effects on oxygenation and ventilation, while eliminating the traumatic “inflate–deflate” cycle imposed by CV. Although statistical evidence supporting HFOV is particularly low, potential benefits for its application in many clinical manifestations still remain. High-frequency oscillation is a safe and effective rescue mode of ventilation for the treatment of acute respiratory distress syndrome (ARDS). All patients who have ventilator-induced lung injury (VILI) or are at risk of developing VILI or ARDS would be suitable candidates for HFOV, especially those who have failed conventional mechanical ventilation. This narrative aims to provide a review of HFOV vis-à-vis its indications, contraindications, hazards, parameters to monitoring, patient selection, clinical goals, mechanisms of action, controls for optimizing ventilation and oxygenation, clinical application in ARDS, and a comparison with other modes of mechanical ventilation.
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Affiliation(s)
| | - Nathan Rodrigues
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
| | - Arzu Ari
- Department of Respiratory Care, Texas State University, Round Rock, TX, USA
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Das A, Camporota L, Hardman JG, Bates DG. What links ventilator driving pressure with survival in the acute respiratory distress syndrome? A computational study. Respir Res 2019; 20:29. [PMID: 30744629 PMCID: PMC6371576 DOI: 10.1186/s12931-019-0990-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 01/23/2019] [Indexed: 01/07/2023] Open
Abstract
Background Recent analyses of patient data in acute respiratory distress syndrome (ARDS) showed that a lower ventilator driving pressure was associated with reduced relative risk of mortality. These findings await full validation in prospective clinical trials. Methods To investigate the association between driving pressures and ventilator induced lung injury (VILI), we calibrated a high fidelity computational simulator of cardiopulmonary pathophysiology against a clinical dataset, capturing the responses to changes in mechanical ventilation of 25 adult ARDS patients. Each of these in silico patients was subjected to the same range of values of driving pressure and positive end expiratory pressure (PEEP) used in the previous analyses of clinical trial data. The resulting effects on several physiological variables and proposed indices of VILI were computed and compared with data relating ventilator settings with relative risk of death. Results Three VILI indices: dynamic strain, mechanical power and tidal recruitment, showed a strong correlation with the reported relative risk of death across all ranges of driving pressures and PEEP. Other variables, such as alveolar pressure, oxygen delivery and lung compliance, correlated poorly with the data on relative risk of death. Conclusions Our results suggest a credible mechanistic explanation for the proposed association between driving pressure and relative risk of death. While dynamic strain and tidal recruitment are difficult to measure routinely in patients, the easily computed VILI indicator known as mechanical power also showed a strong correlation with mortality risk, highlighting its potential usefulness in designing more protective ventilation strategies for this patient group. Electronic supplementary material The online version of this article (10.1186/s12931-019-0990-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anup Das
- School of Engineering, University of Warwick, Coventry, UK
| | - Luigi Camporota
- Intensive Care Medicine, Guy's and St Thomas' NHS Foundation Trust and Division of Asthma Allergy and Lung Biology, King's College London, London, UK
| | - Jonathan G Hardman
- Queen's Medical Centre, Nottingham University Hospitals NHS Trust and School of Medicine, University of Nottingham, Nottingham, UK
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, UK.
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Abstract
Respiratory failure affects a significant percentage of critically ill children, necessitating both invasive and non-invasive respiratory support. As the outcomes of these patients have improved, children with higher acuity and more complex respiratory pathophysiology require mechanical ventilation. Despite growing understanding of lung-protective strategies and ventilation induced lung injury, certain patients still require harmful ventilatory settings with conventional mechanical ventilation (CMV). High frequency ventilation, neurally adjusted ventilatory assist, and airway pressure release ventilation offer feasible alternatives to CMV. In addition to minimizing the risk of ventilatory induced lung injury when used appropriately, they provide a unique environment to facilitate operations on certain neonates and older children. Finally, non-invasive ventilation is now commonly employed in children with surgical conditions.
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Affiliation(s)
- Ana Ruzic
- Department of Surgery, UK Healthcare Kentucky Children's Hospital, 800 Rose St, Lexington KY 40536, USA.
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Song X, Liu Y, Dong L, Wang Y. Stromal-Interacting Molecule 1 (Stim1)/Orai1 Modulates Endothelial Permeability in Ventilator-Induced Lung Injury. Med Sci Monit 2018; 24:9413-9423. [PMID: 30589833 PMCID: PMC6322368 DOI: 10.12659/msm.911268] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Increased endothelial permeability is involved in ventilator-induced lung injury (VILI). Stim1/Orai1 mediates store-operated Ca2+ activation, which modulates endothelial permeability. However, the underlying mechanisms of the Stim1/Orai1 pathway in VILI are poorly understood. Material/Methods Wistar rats were exposed to low tidal volume (7 mL/kg) or high tidal volume (40 mL/kg) ventilation. Human Lung Microvascular Endothelial Cells (HULEC) were subjected to 8% or 18% cyclic stretching (CS). BTP2 pretreatment was performed. Lung wet/dry weight ratio, histological changes of lung injury, and bronchoalveolar lavage fluid (BALF) protein were measured. Endothelial permeability and intracellular calcium concentration were evaluated in HULECs. Protein expression was determined by Western blotting. Results High tidal volume mechanical ventilation-induced lung injury (such as severe congestion and hemorrhage) and BTP2 pretreatment protected lungs from injury. The expression of Stim1, Orai1, and PKCα, lung wet/dry weight ratio, and BALF protein level significantly increased in the high tidal volume group compared to the control group and low tidal volume group. Importantly, BTP2 pretreatment alleviated the above-mentioned effects. Compared with exposure to 8% CS, the protein levels of Stim1, Orai1, and PKCα in HULECs significantly increased after exposure to 18% CS for 4 h, whereas BTP2 pretreatment significantly inhibited the increase (P<0.05). BTP2 pretreatment also suppressed increase of endothelial permeability and the intracellular calcium induced by 18% CS (P<0.05). Conclusions When exposed to high tidal volume or large-magnitude CS, Stim1 and Orai1 expression are upregulated, which further activates calcium-sensitive PKCα and results in calcium overload, endothelial hyperpermeability, and, finally, lung injury.
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Affiliation(s)
- Xiumei Song
- Department of Anesthesiology, Qianfoshan Hospital, Shandong University, Jinan, Shandong, China (mainland)
| | - Yang Liu
- Department of Anesthesiology, Qianfoshan Hospital, Shandong University, Jinan, Shandong, China (mainland)
| | - Ling Dong
- Department of Anesthesiology, Qianfoshan Hospital, Shandong University, Jinan, Shandong, China (mainland)
| | - Yuelan Wang
- Department of Anesthesiology, Qianfoshan Hospital, Shandong University, Jinan, Shandong, China (mainland)
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Patry C, Kranig S, Rafat N, Schaible T, Toenshoff B, Hoffmann GF, Ries M. Cross-sectional analysis on publication status and age representation of clinical studies addressing mechanical ventilation and ventilator-induced lung injury in infants and children. BMJ Open 2018; 8:e023524. [PMID: 30455388 PMCID: PMC6252714 DOI: 10.1136/bmjopen-2018-023524] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES We determined the number and time-to-public availability of study results of published and unpublished clinical studies in paediatric mechanical ventilation (MV) and ventilator-induced lung injury (VILI), which were registered as completed on ClinicalTrials.gov. Furthermore, we explored the pattern of represented research study subtopics and the corresponding study populations. SETTING Literature search based on ClinicalTrials.gov, PubMed and Google Scholar from 9 July 2017 to 27 September 2017. PRIMARY AND SECONDARY OUTCOME MEASURES Assessment, if studies included in our analysis had been published. Assessment of primary research focus, patient enrolment and age representation of the analysed studies. RESULTS We identified n=109 registered and completed clinical studies on paediatric MV and VILI (enrolment: 22 233 participants). 71% were published, including data from 18 647 subjects. 29% of studies were unpublished, containing data from 3586 subjects. Median time-to-public availability of study results was 22 (IQR, 12.8-41.5) months. The most important study subtopics were biophysical and technical aspects of MV (32 studies), administration of drugs to mitigate VILI through various mechanisms (40 studies) and diagnostic procedures (16 studies). n=66/109 (61%) studies exclusively focused on children below 1 year of age and n=2/109 (2%) exclusively on children between 1 and 14 years. CONCLUSIONS One-third of clinical studies in paediatric MV and VILI registered as completed on ClinicalTrials.gov remained unpublished and contained data on 3586 study participants. The overall median time-to-public availability of study results was longer than the deadline of 12 months mandated by the Food and Drug Administration Amendment Act of 2007. Important and clinically relevant research study subtopics were represented in the research questions investigated in paediatric MV and VILI. The study population was skewed towards children younger than 1 year which indicates, that there is a substantial need for clinical VILI research in older children.
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Affiliation(s)
- Christian Patry
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
- Institute for Physiology and Pathophysiology, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Simon Kranig
- Department of Neonatology, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Neysan Rafat
- Clinic for Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Thomas Schaible
- Clinic for Neonatology, University Medical Center Mannheim, Mannheim, Germany
| | - Burkhard Toenshoff
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Georg F Hoffmann
- Department of Pediatrics I, University Children’s Hospital Heidelberg, Heidelberg, Germany
| | - Markus Ries
- Pediatric Neurology and Metabolic Medicine, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
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Major VJ, Chiew YS, Shaw GM, Chase JG. Biomedical engineer's guide to the clinical aspects of intensive care mechanical ventilation. Biomed Eng Online 2018; 17:169. [PMID: 30419903 PMCID: PMC6233601 DOI: 10.1186/s12938-018-0599-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 11/01/2018] [Indexed: 12/16/2022] Open
Abstract
Background Mechanical ventilation is an essential therapy to support critically ill respiratory failure patients. Current standards of care consist of generalised approaches, such as the use of positive end expiratory pressure to inspired oxygen fraction (PEEP–FiO2) tables, which fail to account for the inter- and intra-patient variability between and within patients. The benefits of higher or lower tidal volume, PEEP, and other settings are highly debated and no consensus has been reached. Moreover, clinicians implicitly account for patient-specific factors such as disease condition and progression as they manually titrate ventilator settings. Hence, care is highly variable and potentially often non-optimal. These conditions create a situation that could benefit greatly from an engineered approach. The overall goal is a review of ventilation that is accessible to both clinicians and engineers, to bridge the divide between the two fields and enable collaboration to improve patient care and outcomes. This review does not take the form of a typical systematic review. Instead, it defines the standard terminology and introduces key clinical and biomedical measurements before introducing the key clinical studies and their influence in clinical practice which in turn flows into the needs and requirements around how biomedical engineering research can play a role in improving care. Given the significant clinical research to date and its impact on this complex area of care, this review thus provides a tutorial introduction around the review of the state of the art relevant to a biomedical engineering perspective. Discussion This review presents the significant clinical aspects and variables of ventilation management, the potential risks associated with suboptimal ventilation management, and a review of the major recent attempts to improve ventilation in the context of these variables. The unique aspect of this review is a focus on these key elements relevant to engineering new approaches. In particular, the need for ventilation strategies which consider, and directly account for, the significant differences in patient condition, disease etiology, and progression within patients is demonstrated with the subsequent requirement for optimal ventilation strategies to titrate for patient- and time-specific conditions. Conclusion Engineered, protective lung strategies that can directly account for and manage inter- and intra-patient variability thus offer great potential to improve both individual care, as well as cohort clinical outcomes.
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Affiliation(s)
- Vincent J Major
- Department of Population Health, NYU Langone Health, New York, NY, USA.
| | - Yeong Shiong Chiew
- School of Engineering, Monash University Malaysia, Subang Jaya, Malaysia
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
| | - J Geoffrey Chase
- Centre for Bioengineering, University of Canterbury, Christchurch, New Zealand
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Wan B, Xu WJ, Zhan P, Jin JJ, Xi GM, Chen MZ, Hu YB, Zhu SH, Liu HB, Wang XX, Zhang XW, Lv TF, Song Y. Topotecan alleviates ventilator-induced lung injury via NF-κB pathway inhibition. Cytokine 2018; 110:381-388. [DOI: 10.1016/j.cyto.2018.04.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 03/26/2018] [Accepted: 04/15/2018] [Indexed: 11/25/2022]
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Cicko S, Köhler TC, Ayata CK, Müller T, Ehrat N, Meyer A, Hossfeld M, Zech A, Di Virgilio F, Idzko M. Extracellular ATP is a danger signal activating P2X7 receptor in a LPS mediated inflammation (ARDS/ALI). Oncotarget 2018; 9:30635-30648. [PMID: 30093975 PMCID: PMC6078145 DOI: 10.18632/oncotarget.25761] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 06/19/2018] [Indexed: 02/06/2023] Open
Abstract
Acute respiratory distress syndrome (ARDS) is a life-threating lung condition resulting from a direct and indirect injury to the lungs [1, 2]. Pathophysiologically it is characterized by an acute alveolar damage, an increased permeability of the microvascular-barrier, leading to protein-rich pulmonary edema and subsequent impairment of arterial oxygenation and respiratory failure [1]. This study examined the role of extracellular ATP in recruiting inflammatory cells to the lung after induction of acute lung injury with lipopolysaccharide (LPS). However, the precise mechanism is poorly understood. Our objective was to investigate the functional role of the P2X7 receptor in the pathogenesis of acute respiratory distress syndrome (ARDS/ acute lung injury (ALI)) in vitro and in vivo. We show that intratracheally applied LPS causes an acute accumulation of ATP in the BALF (bronchoalveolar lavage) and lungs of mice. Prophylactic and therapeutic inhibition of P2X7R signalling by a specific antagonist and knock-out experiments was able to ameliorate the inflammatory response demonstrated by reduced ATP-levels, number of neutrophils and concentration of pro-inflammatory cytokine levels in the BALF. Experiments with chimeric mice showed that P2X7R expression on immune cells was responsible for the observed effect. Consistently, the inflammatory response is diminished only by a cell-type specific knockdown of P2X7 receptor on non-stationary immune cells. Since the results of BALF from patients with acute ARDS or pneumonia simulated the in vivo data after LPS exposure, the P2X7 receptor may be a new therapeutic target for treatment in acute respiratory distress syndrome (ARDS/ALI).
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Affiliation(s)
- Sanja Cicko
- University Hospital Freiburg, Department of Pneumology, Freiburg, Germany
| | | | - Cemil Korcan Ayata
- University Hospital Freiburg, Department of Pneumology, Freiburg, Germany
| | - Tobias Müller
- University Hospital Freiburg, Department of Pneumology, Freiburg, Germany.,Division of Pneumology, University Hospital RWTH Aachen, Aachen, Germany
| | - Nicolas Ehrat
- University Hospital Freiburg, Department of Pneumology, Freiburg, Germany
| | - Anja Meyer
- University Hospital Freiburg, Department of Pneumology, Freiburg, Germany
| | - Madelon Hossfeld
- University Hospital Freiburg, Department of Pneumology, Freiburg, Germany
| | - Andreas Zech
- University Hospital Freiburg, Department of Pneumology, Freiburg, Germany
| | - Francesco Di Virgilio
- Department of Experimental and Diagnostic Medicine, University of Ferrara, Ferrara, Italy
| | - Marco Idzko
- University Hospital Freiburg, Department of Pneumology, Freiburg, Germany
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Huang Y, Pan L, Helou K, Xia Q, Parris TZ, Li H, Xu B, Li H. Mechanical ventilation promotes lung metastasis in experimental 4T1 breast cancer lung-metastasized models. Cancer Manag Res 2018; 10:545-555. [PMID: 29593433 PMCID: PMC5865578 DOI: 10.2147/cmar.s142650] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND/PURPOSE The aim of this study was to test the hypothesis that mechanical ventilation (MV) during cancer surgery induces lung stroma/tissue milieu changes, creating a favorable microenvironment for postoperative lung metastatic tumor establishment. MATERIALS AND METHODS In Protocol A, female BALB/c mice were divided into an MV group and a control (no MV) group, both of which were anesthetized and subjected to intravenous injection of green fluorescent protein (GFP)-labeled mouse mammary carcinoma cell line (4T1) cells. After 24 h, the lung tissue was removed and the number of GFP-labeled 4T1 cells was calculated. In Protocol B, the clinically relevant mouse model of spontaneous breast cancer lung metastasis was used with surgical resection of the primary tumor to investigate the MV event that dictates postoperative lung metastasis. Female BALB/c mice were inoculated in the mammary fat pad with 4T1 cells. After 14-d growth, mice were anesthetized and divided into an MV group and a control (no MV) group during surgical procedures (mastectomy). Metastatic tumor burden was assessed two weeks after mastectomy by both macroscopic metastatic nodule count, hematoxylin-eosin histology, immunohistochemistry for the macrophage marker (CD68), and epithelial cell adhesion molecule (EpCAM). RESULTS MV was associated with a significant increase in the number of circulating breast tumor cells (GFP-labeled 4T1 cells) remaining in the microvasculature of the lung (P<0.01). Immunohistochemical results showed increased infiltration of CD68-positive macrophages within injured lung parenchyma and metastatic tumor as well as increased expression of EpCAM in metastatic nodules. Postoperative metastases were more prevalent in the mechanically ventilated mice group compared to the non-ventilated group (P<0.05). CONCLUSION MV-induced lung metastasis occurs by attracting circulating tumor cells to the site of the lung injury and by accelerating the proliferation of preexisting micro-metastases in the lung. These observations indicate that the metastasis-enhancing effect of MV should be considered in general anesthesia during cancer surgery.
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Affiliation(s)
- Yinglai Huang
- Division of Breast and Endocrine Surgery, Department of Surgery, Borås Hospital, Borås
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Lin Pan
- Department of Biochemistry and Molecular Biology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Khalil Helou
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Qisheng Xia
- Department of Biochemistry and Molecular Biology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Toshima Z Parris
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Cancer Center, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Hongyan Li
- Department of Biochemistry and Molecular Biology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Bo Xu
- Department of Biochemistry and Molecular Biology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
| | - Hon Li
- Department of Biochemistry and Molecular Biology, China-Japan Friendship Hospital, Beijing, People’s Republic of China
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Abstract
IMPORTANCE Acute respiratory distress syndrome (ARDS) is a life-threatening form of respiratory failure that affects approximately 200 000 patients each year in the United States, resulting in nearly 75 000 deaths annually. Globally, ARDS accounts for 10% of intensive care unit admissions, representing more than 3 million patients with ARDS annually. OBJECTIVE To review advances in diagnosis and treatment of ARDS over the last 5 years. EVIDENCE REVIEW We searched MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews from 2012 to 2017 focusing on randomized clinical trials, meta-analyses, systematic reviews, and clinical practice guidelines. Articles were identified for full text review with manual review of bibliographies generating additional references. FINDINGS After screening 1662 citations, 31 articles detailing major advances in the diagnosis or treatment of ARDS were selected. The Berlin definition proposed 3 categories of ARDS based on the severity of hypoxemia: mild (200 mm Hg<Pao2/Fio2≤300 mm Hg), moderate (100 mm Hg<Pao2/Fio2≤200 mm Hg), and severe (Pao2/Fio2 ≤100 mm Hg), along with explicit criteria related to timing of the syndrome's onset, origin of edema, and the chest radiograph findings. The Berlin definition has significantly greater predictive validity for mortality than the prior American-European Consensus Conference definition. Clinician interpretation of the origin of edema and chest radiograph criteria may be less reliable in making a diagnosis of ARDS. The cornerstone of management remains mechanical ventilation, with a goal to minimize ventilator-induced lung injury (VILI). Aspirin was not effective in preventing ARDS in patients at high-risk for the syndrome. Adjunctive interventions to further minimize VILI, such as prone positioning in patients with a Pao2/Fio2 ratio less than 150 mm Hg, were associated with a significant mortality benefit whereas others (eg, extracorporeal carbon dioxide removal) remain experimental. Pharmacologic therapies such as β2 agonists, statins, and keratinocyte growth factor, which targeted pathophysiologic alterations in ARDS, were not beneficial and demonstrated possible harm. Recent guidelines on mechanical ventilation in ARDS provide evidence-based recommendations related to 6 interventions, including low tidal volume and inspiratory pressure ventilation, prone positioning, high-frequency oscillatory ventilation, higher vs lower positive end-expiratory pressure, lung recruitment maneuvers, and extracorporeal membrane oxygenation. CONCLUSIONS AND RELEVANCE The Berlin definition of acute respiratory distress syndrome addressed limitations of the American-European Consensus Conference definition, but poor reliability of some criteria may contribute to underrecognition by clinicians. No pharmacologic treatments aimed at the underlying pathology have been shown to be effective, and management remains supportive with lung-protective mechanical ventilation. Guidelines on mechanical ventilation in patients with acute respiratory distress syndrome can assist clinicians in delivering evidence-based interventions that may lead to improved outcomes.
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Affiliation(s)
- Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York
| | - Arthur S Slutsky
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
- Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada
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28
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Suryadevara V, Fu P, Ebenezer DL, Berdyshev E, Bronova IA, Huang LS, Harijith A, Natarajan V. Sphingolipids in Ventilator Induced Lung Injury: Role of Sphingosine-1-Phosphate Lyase. Int J Mol Sci 2018; 19:E114. [PMID: 29301259 PMCID: PMC5796063 DOI: 10.3390/ijms19010114] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 12/21/2017] [Accepted: 12/27/2017] [Indexed: 12/14/2022] Open
Abstract
Mechanical ventilation (MV) performed in respiratory failure patients to maintain lung function leads to ventilator-induced lung injury (VILI). This study investigates the role of sphingolipids and sphingolipid metabolizing enzymes in VILI using a rodent model of VILI and alveolar epithelial cells subjected to cyclic stretch (CS). MV (0 PEEP (Positive End Expiratory Pressure), 30 mL/kg, 4 h) in mice enhanced sphingosine-1-phosphate lyase (S1PL) expression, and ceramide levels, and decreased S1P levels in lung tissue, thereby leading to lung inflammation, injury and apoptosis. Accumulation of S1P in cells is a balance between its synthesis catalyzed by sphingosine kinase (SphK) 1 and 2 and catabolism mediated by S1P phosphatases and S1PL. Thus, the role of S1PL and SphK1 in VILI was investigated using Sgpl1+/- and Sphk1-/- mice. Partial genetic deletion of Sgpl1 protected mice against VILI, whereas deletion of SphK1 accentuated VILI in mice. Alveolar epithelial MLE-12 cells subjected to pathophysiological 18% cyclic stretch (CS) exhibited increased S1PL protein expression and dysregulation of sphingoid bases levels as compared to physiological 5% CS. Pre-treatment of MLE-12 cells with S1PL inhibitor, 4-deoxypyridoxine, attenuated 18% CS-induced barrier dysfunction, minimized cell apoptosis and cytokine secretion. These results suggest that inhibition of S1PL that increases S1P levels may offer protection against VILI.
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Affiliation(s)
- Vidyani Suryadevara
- Department of Bioengineering, University of Illinois at Chicago (UIC), Chicago, IL 60607, USA.
| | - Panfeng Fu
- Department of Pharmacology, University of Illinois at Chicago (UIC), Chicago, IL 60612, USA.
| | - David Lenin Ebenezer
- Department of Pharmacology, University of Illinois at Chicago (UIC), Chicago, IL 60612, USA.
| | - Evgeny Berdyshev
- Department of Pharmacology, Department of Medicine, National Jewish Health Center, Denver, CO 80206, USA.
| | - Irina A Bronova
- Department of Pharmacology, Department of Medicine, National Jewish Health Center, Denver, CO 80206, USA.
| | - Long Shuang Huang
- Department of Pharmacology, University of Illinois at Chicago (UIC), Chicago, IL 60612, USA.
| | - Anantha Harijith
- Department of Pediatrics, University of Illinois at Chicago (UIC), Chicago, IL 60612, USA.
| | - Viswanathan Natarajan
- Department of Pharmacology, University of Illinois at Chicago (UIC), Chicago, IL 60612, USA.
- Department of Medicine, University of Illinois at Chicago (UIC), Chicago, IL 60612, USA.
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29
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Langdon R, Docherty PD, Schranz C, Chase JG. Prediction of high airway pressure using a non-linear autoregressive model of pulmonary mechanics. Biomed Eng Online 2017; 16:126. [PMID: 29096634 PMCID: PMC5668972 DOI: 10.1186/s12938-017-0415-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 10/25/2017] [Indexed: 11/25/2022] Open
Abstract
Background For mechanically ventilated patients with acute respiratory distress syndrome (ARDS), suboptimal PEEP levels can cause ventilator induced lung injury (VILI). In particular, high PEEP and high peak inspiratory pressures (PIP) can cause over distension of alveoli that is associated with VILI. However, PEEP must also be sufficient to maintain recruitment in ARDS lungs. A lung model that accurately and precisely predicts the outcome of an increase in PEEP may allow dangerous high PIP to be avoided, and reduce the incidence of VILI. Methods and results Sixteen pressure-flow data sets were collected from nine mechanically ventilated ARDs patients that underwent one or more recruitment manoeuvres. A nonlinear autoregressive (NARX) model was identified on one or more adjacent PEEP steps, and extrapolated to predict PIP at 2, 4, and 6 cmH2O PEEP horizons. The analysis considered whether the predicted and measured PIP exceeded a threshold of 40 cmH2O. A direct comparison of the method was made using the first order model of pulmonary mechanics (FOM(I)). Additionally, a further, more clinically appropriate method for the FOM was tested, in which the FOM was trained on a single PEEP prior to prediction (FOM(II)). The NARX model exhibited very high sensitivity (> 0.96) in all cases, and a high specificity (> 0.88). While both FOM methods had a high specificity (> 0.96), the sensitivity was much lower, with a mean of 0.68 for FOM(I), and 0.82 for FOM(II). Conclusions Clinically, false negatives are more harmful than false positives, as a high PIP may result in distension and VILI. Thus, the NARX model may be more effective than the FOM in allowing clinicians to reduce the risk of applying a PEEP that results in dangerously high airway pressures.
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Affiliation(s)
- Ruby Langdon
- Department of Mechanical Engineering, University of Canterbury, Private bag 4800, Christchurch, 8140, New Zealand
| | - Paul D Docherty
- Department of Mechanical Engineering, University of Canterbury, Private bag 4800, Christchurch, 8140, New Zealand.
| | | | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Private bag 4800, Christchurch, 8140, New Zealand
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30
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Heidemann SM, Nair A, Bulut Y, Sapru A. Pathophysiology and Management of Acute Respiratory Distress Syndrome in Children. Pediatr Clin North Am 2017; 64:1017-1037. [PMID: 28941533 PMCID: PMC9683071 DOI: 10.1016/j.pcl.2017.06.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute respiratory distress syndrome (ARDS) is a syndrome of noncardiogenic pulmonary edema and hypoxia that accompanies up to 30% of deaths in pediatric intensive care units. Pediatric ARDS (PARDS) is diagnosed by the presence of hypoxia, defined by oxygenation index or Pao2/Fio2 ratio cutoffs, and new chest infiltrate occurring within 7 days of a known insult. Hallmarks of ARDS include hypoxemia and decreased lung compliance, increased work of breathing, and impaired gas exchange. Mortality is often accompanied by multiple organ failure. Although many modalities to treat PARDS have been investigated, supportive therapies and lung protective ventilator support remain the mainstay.
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Affiliation(s)
| | - Alison Nair
- Department of Pediatrics, University of California, San Francisco, CA
| | - Yonca Bulut
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, CA
| | - Anil Sapru
- Department of Pediatrics, University of California, San Francisco, 550 16th Street, Box 0110 San Francisco, CA 94143, USA; Department of Pediatrics, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
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31
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Higuita-Castro N, Nelson MT, Shukla V, Agudelo-Garcia PA, Zhang W, Duarte-Sanmiguel SM, Englert JA, Lannutti JJ, Hansford DJ, Ghadiali SN. Using a Novel Microfabricated Model of the Alveolar-Capillary Barrier to Investigate the Effect of Matrix Structure on Atelectrauma. Sci Rep 2017; 7:11623. [PMID: 28912466 PMCID: PMC5599538 DOI: 10.1038/s41598-017-12044-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 09/01/2017] [Indexed: 11/25/2022] Open
Abstract
The alveolar-capillary barrier is composed of epithelial and endothelial cells interacting across a fibrous extracelluar matrix (ECM). Although remodeling of the ECM occurs during several lung disorders, it is not known how fiber structure and mechanics influences cell injury during cyclic airway reopening as occurs during mechanical ventilation (atelectrauma). We have developed a novel in vitro platform that mimics the micro/nano-scale architecture of the alveolar microenvironment and have used this system to investigate how ECM microstructural properties influence epithelial cell injury during airway reopening. In addition to epithelial-endothelial interactions, our platform accounts for the fibrous topography of the basal membrane and allows for easy modulation of fiber size/diameter, density and stiffness. Results indicate that fiber stiffness and topography significantly influence epithelial/endothelial barrier function where increased fiber stiffness/density resulted in altered cytoskeletal structure, increased tight junction (TJ) formation and reduced barrier permeability. However, cells on rigid/dense fibers were also more susceptible to injury during airway reopening. These results indicate that changes in the mechanics and architecture of the lung microenvironment can significantly alter cell function and injury and demonstrate the importance of implementing in vitro models that more closely resemble the natural conditions of the lung microenvironment.
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Affiliation(s)
- N Higuita-Castro
- Biomedical Engineering Department, The Ohio State University, Columbus, Ohio, United States.,Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - M T Nelson
- Biomedical Engineering Department, The Ohio State University, Columbus, Ohio, United States
| | - V Shukla
- Biomedical Engineering Department, The Ohio State University, Columbus, Ohio, United States.,Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - P A Agudelo-Garcia
- Department of Molecular and Cellular Biochemistry, The Ohio State University, Columbus, Ohio, United States
| | - W Zhang
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - S M Duarte-Sanmiguel
- Biomedical Engineering Department, The Ohio State University, Columbus, Ohio, United States.,Human Nutrition Program, The Ohio State University, Columbus, Ohio, United States
| | - J A Englert
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States
| | - J J Lannutti
- Department of Material Sciences and Engineering, The Ohio State University, Columbus, Ohio, United States
| | - D J Hansford
- Biomedical Engineering Department, The Ohio State University, Columbus, Ohio, United States
| | - S N Ghadiali
- Biomedical Engineering Department, The Ohio State University, Columbus, Ohio, United States. .,Dorothy M. Davis Heart and Lung Research Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States. .,Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States.
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32
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[Extreme obesity-particular aspect of invasive and noninvasive ventilation]. Med Klin Intensivmed Notfmed 2017; 114:533-540. [PMID: 28875324 DOI: 10.1007/s00063-017-0332-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 06/27/2017] [Accepted: 07/19/2017] [Indexed: 10/18/2022]
Abstract
The obesity rate is increasing worldwide and the percentage of obese patients in the intensive care unit (ICU) is rising concomitantly. Ventilatory support strategies in obese patients must take into account the altered pathophysiological conditions. Unfortunately, prospective randomized multicenter trials on this subject are lacking. Therefore, current strategies are based on the individual experiences of ICU physicians and single-center studies. Noninvasive ventilation (NIV) in critically ill patients with acute respiratory failure and obesity hypoventilation syndrome (OHS) is an efficient treatment option and should be provided as early as possible is an effort to avoid intubation. Patient positioning is also crucial: half-sitting positions (>45°) improve lung compliance and functional residual capacity in patients with respiratory failure. Transpulmonary pressure measurements or the Acute Respiratory Distress Syndrome (ARDS) Network tables may help to adjust the optimal positive end-expiratory pressure (PEEP). The tidal volume should be adapted to the ideal and not the actual bodyweight (Vt = 6 ml/kg of ideal bodyweight) to avoid lung damage and (additional) right ventricular stress. Under particular conditions, inspiratory pressures >30 cmH2O may be tolerated for a limited duration. Early tracheostomy combined with termination/reduction of sedation and relaxation is controversy discussed in the literature as a therapeutic option during invasive ventilation of morbidly obese patients. However, data on early tracheotomy in obese respiratory failure patients are rare and this should be regarded as an individual treatment attempt only. In cases of refractory lung failure, venovenous extracorporeal membrane oxygenation (vv-ECMO) is an option despite anatomic changes in morbid obesity.
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33
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Zhu XW, Zhao JN, Tang SF, Yan J, Shi Y. Noninvasive high-frequency oscillatory ventilation versus nasal continuous positive airway pressure in preterm infants with moderate-severe respiratory distress syndrome: A preliminary report. Pediatr Pulmonol 2017; 52:1038-1042. [PMID: 28672094 DOI: 10.1002/ppul.23755] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 06/06/2017] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The aim of this study was to compare the effect of noninvasive high-frequency oscillatory ventilation (nHFOV) with nasal continuous positive airway pressure (nCPAP) in preterm infants with moderate-severe respiratory distress syndrome (RDS) after surfactant administration via INSURE (intubation, surfactant, extubation) method on the need for invasive mechanical ventilation (IMV). METHODS A total of 81 infants with a gestational age (GA) of 28-34 weeks were eligible and were randomized to nCPAP (n = 42) or to nHFOV (n = 39). The need for IMV was the primary outcome. The incidence of bronchopulmonary dysplasia (BPD), occurrence of intraventricular hemorrhage (IVH), and air leaks, and mortality were considered as secondary outcomes. RESULT A total 76 infants finally completed the study. The need for IMV was significantlylower in the nHFOV group compared with the nCPAP group(24.3% vs 56.4%, P < 0.01). The incidence of IVH, air leaks or BPD was similar between the two groups. In addition, the mortality rate was not statistically different. CONCLUSION In this prospective, randomized controlled study, nHFOV significantly reduced the need for IMV as compared with nCPAP in preterm infants with moderate-severe RDS without increase in adverse effects.
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Affiliation(s)
- Xing-Wang Zhu
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China.,Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Department of Neonatology, Jiulongpo People's Hospital, Chongqing, China
| | - Jin-Ning Zhao
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China
| | - Shi-Fang Tang
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China
| | - Jun Yan
- Department of Neonatology, Jiulongpo People's Hospital, Chongqing, China
| | - Yuan Shi
- Department of Pediatrics, Daping Hospital, Research Institute of Surgery, Third Military Medical University, Chongqing, China.,Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
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34
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Maximizing survival: lung protective ventilation. Lab Anim (NY) 2017; 46:213-216. [PMID: 28422110 DOI: 10.1038/laban.1254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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35
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Binmanee A, El Helou S, Shivananda S, Fusch C, Mukerji A. Use of high noninvasive respiratory support pressures in preterm neonates: a single-center experience. J Matern Fetal Neonatal Med 2017; 30:2838-2843. [PMID: 27892756 DOI: 10.1080/14767058.2016.1265931] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
PURPOSE To describe the incidence, indications and clinical outcomes following high pressures on noninvasive respiratory support (NRS) in preterm neonates. STUDY DESIGN Retrospective cohort study of all neonates with BW <1.500 g admitted from July 2012 to June 2014 and placed on high noninvasive respiratory support (NRS), defined as mean airway pressure ≥10 cm H2O for at least 12 continuous hours using nasal continuous positive airway pressure (NCPAP) and/or nasal high-frequency ventilation (NIHFV). Clinical and physiological outcomes following high NRS were ascertained. Median (IQR) and percentages were used to describe continuous and categorical data, respectively. RESULTS There were 131 instances of high NRS use in 70 of 315 eligible infants. Most common indication was post-extubation, observed in 37% (49/131) of high NRS instances. Intubation was avoided in 71% (93/131) of instances in the first 7 days following high NRS initiation. There were no physiological perturbations in heart rate, blood pressure or oxygen requirement. Furthermore, there were no instances of lung hyperinflation, pneumothoraces or spontaneous intestinal perforation following high NRS. CONCLUSION The use of high NRS pressure was followed by avoidance of intubation in the majority of cases without adverse effects. Further research on high NRS use including its indications, clinical outcomes and safety profile is warranted.
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Affiliation(s)
| | - Salhab El Helou
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
| | | | - Christoph Fusch
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
| | - Amit Mukerji
- a McMaster Children's Hospital , Hamilton , Ontario , Canada
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36
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Kellner P, Müller M, Piegeler T, Eugster P, Booy C, Schläpfer M, Beck-Schimmer B. Sevoflurane Abolishes Oxygenation Impairment in a Long-Term Rat Model of Acute Lung Injury. Anesth Analg 2017; 124:194-203. [DOI: 10.1213/ane.0000000000001530] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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37
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Ghiasi F, Sadeghian M, Emami M, Kiaie BA, Mousavi S. A Pilot Study of Nebulized Heparin for Prevention of Ventilator Induced Lung Injury: Comparative Effects with an Inhaled Corticosteroid. Indian J Crit Care Med 2017; 21:634-639. [PMID: 29142373 PMCID: PMC5672667 DOI: 10.4103/ijccm.ijccm_183_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Ventilator-induced lung injury (VILI) is a side effect of mechanical ventilation. Lung inflammation and pulmonary activation of coagulation are induced by mechanical stress. Clinical and preclinical studies show that heparin possesses anti-inflammatory properties. Therefore, we assessed the effects of nebulized heparin in VILI. Methods: Sixty critically ill adult patients who require mechanical ventilation for more than 48 h were included in this prospective, nonrandomized controlled study. Patients received nebulized heparin (10,000 U every 6 h) for 5 days. The matched control group received nebulized budesonide as routine practice in our center. This study assessed changes in partial pressure of oxygen to inspired fraction of oxygen ratio (PaO2/FiO2) and rapid shallow breathing index (RSBI) during the study as primary endpoints. Results: The average daily PaO2/FiO2 ratio was not statistically significant between both groups (187 ± 11.6 vs. 171 ± 11.6, P = 0.35). The RSBI also did not differ between groups (P = 0.58). Heparin administration was associated with a higher number of ventilator-free days among survivors but not significantly (7.7 ± 10.6 vs. 5.1 ± 8, 95% confidence interval − 2.2–7.5, P = 0.28). Successful weaning from mechanical ventilation was higher in the heparin group (P = 0.42). We did not observe any serious or increased adverse effects from nebulized heparin. Conclusion: The results of this study show that the overall effectiveness of nebulized heparin is at least as comparable with a potent corticosteroid (budesonide). Heparin could be a safe and effective modality for patients who at risk of VILI.
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Affiliation(s)
- Farzin Ghiasi
- Department of Pulmonology, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohsen Sadeghian
- Department of Internal Medicine, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Emami
- Department of Pulmonology, Medical School, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Babak Ali Kiaie
- Department of Anesthesiology and Intensive Care, Anesthesiology and Critical Care Research Center, Isfahan, Iran
| | - Sarah Mousavi
- Department of Clinical Pharmacy and Pharmacy Practice, Faculty of Pharmacy and Pharmaceutical Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
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38
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Mukerji A, Sarmiento K, Lee B, Hassall K, Shah V. Non-invasive high-frequency ventilation versus bi-phasic continuous positive airway pressure (BP-CPAP) following CPAP failure in infants <1250 g: a pilot randomized controlled trial. J Perinatol 2017; 37:49-53. [PMID: 27684415 DOI: 10.1038/jp.2016.172] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/26/2016] [Accepted: 08/30/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Non-invasive high-frequency ventilation (NIHFV), a relatively new modality, is gaining popularity despite limited data. We sought to evaluate the effectiveness of NIHFV versus bi-phasic continuous positive airway pressure (BP-CPAP) in preterm infants failing CPAP. STUDY DESIGN Infants with BW<1250 g on CPAP were randomly assigned to NIHFV or BP-CPAP if they met pre-determined criteria for CPAP failure. Infants were eligible for randomization after 72 h age and until 2000 g. Guidelines for adjustment of settings and criteria for failure of assigned mode were implemented. The primary aim was to assess feasibility of a larger trial. In addition, failure of assigned non-invasive respiratory support (NRS) mode, invasive mechanical ventilation (MV) 72 h and 7 days post-randomization, and bronchopulmonary dysplasia (BPD) were assessed. RESULTS Thirty-nine infants were randomized to NIHFV (N=16) or BP-CPAP (N=23). There were no significant differences in mean (s.d.) postmenstrual age (28.6 (1.5) versus 29.0 (2.3) weeks, P=0.47), mean (s.d.) weight at randomization (965.0 (227.0) versus 958.1 (310.4) g, P=0.94) or other baseline demographics between the groups. Failure of assigned NRS mode was lower with NIHFV (37.5 versus 65.2%, P=0.09), although not statistically significant. There were no differences in rates of invasive MV 72 h and 7 days post-randomization or BPD. CONCLUSION NIHFV was not superior to BP-CPAP in this pilot study. Effectiveness of NIHFV needs to be proven in larger multi-center, appropriately powered trials before widespread implementation.
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Affiliation(s)
- A Mukerji
- Department of Paediatrics, McMaster University, Hamilton, ON, Canada
| | - K Sarmiento
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - B Lee
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - K Hassall
- Department of Respiratory Therapy, Mount Sinai Hospital, Toronto, ON, Canada
| | - V Shah
- Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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39
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Abstract
High-frequency ventilation (HFV) as a mode of noninvasive respiratory support (NRS) in preterm neonates is gaining popularity. Benefits may accrue from combining the ventilatory efficiency of HFV delivered through a noninvasive interface, enhancing respiratory support while potentially limiting lung injury. Current evidence suggests that noninvasive HFV (NIHFV) may be superior to other NRS modes in eliminating carbon dioxide and preventing endotracheal ventilation after failure of other NRS modes. Animal data suggest NIHFV may promote improved alveolar development compared to endotracheal ventilation. However, adequately powered large-scale controlled trials are required to evaluate efficacy and safety prior to widespread use of NIHFV.
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Affiliation(s)
- Amit Mukerji
- Division of Neonatology, Department of Pediatrics, McMaster Children's Hospital, McMaster University, 1280 Main Street West, HSC-4F1E, Hamilton, Ontario L8S 4K1, Canada.
| | - Michael Dunn
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada; Department of Newborn and Developmental Pediatrics, Sunnybrook Health Sciences Centre, Room M4-222, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada
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40
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Variable ventilation improves pulmonary function and reduces lung damage without increasing bacterial translocation in a rat model of experimental pneumonia. Respir Res 2016; 17:158. [PMID: 27887604 PMCID: PMC5124241 DOI: 10.1186/s12931-016-0476-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 11/22/2016] [Indexed: 01/08/2023] Open
Abstract
Background Variable ventilation has been shown to improve pulmonary function and reduce lung damage in different models of acute respiratory distress syndrome. Nevertheless, variable ventilation has not been tested during pneumonia. Theoretically, periodic increases in tidal volume (VT) and airway pressures might worsen the impairment of alveolar barrier function usually seen in pneumonia and could increase bacterial translocation into the bloodstream. We investigated the impact of variable ventilation on lung function and histologic damage, as well as markers of lung inflammation, epithelial and endothelial cell damage, and alveolar stress, and bacterial translocation in experimental pneumonia. Methods Thirty-two Wistar rats were randomly assigned to receive intratracheal of Pseudomonas aeruginosa (PA) or saline (SAL) (n = 16/group). After 24-h, animals were anesthetized and ventilated for 2 h with either conventional volume-controlled (VCV) or variable volume-controlled ventilation (VV), with mean VT = 6 mL/kg, PEEP = 5cmH2O, and FiO2 = 0.4. During VV, tidal volume varied randomly with a coefficient of variation of 30% and a Gaussian distribution. Additional animals assigned to receive either PA or SAL (n = 8/group) were not ventilated (NV) to serve as controls. Results In both SAL and PA, VV improved oxygenation and lung elastance compared to VCV. In SAL, VV decreased interleukin (IL)-6 expression compared to VCV (median [interquartile range]: 1.3 [0.3–2.3] vs. 5.3 [3.6–7.0]; p = 0.02) and increased surfactant protein-D expression compared to NV (2.5 [1.9–3.5] vs. 1.2 [0.8–1.2]; p = 0.0005). In PA, compared to VCV, VV reduced perivascular edema (2.5 [2.0–3.75] vs. 6.0 [4.5–6.0]; p < 0.0001), septum neutrophils (2.0 [1.0–4.0] vs. 5.0 [3.3–6.0]; p = 0.0008), necrotizing vasculitis (3.0 [2.0–5.5] vs. 6.0 [6.0–6.0]; p = 0.0003), and ultrastructural lung damage scores (16 [14–17] vs. 24 [14–27], p < 0.0001). Blood colony-forming-unit (CFU) counts were comparable (7 [0–28] vs. 6 [0–26], p = 0.77). Compared to NV, VCV, but not VV, increased expression amphiregulin, IL-6, and cytokine-induced neutrophil chemoattractant (CINC)-1 (2.1 [1.6–2.5] vs. 0.9 [0.7–1.2], p = 0.025; 12.3 [7.9–22.0] vs. 0.8 [0.6–1.9], p = 0.006; and 4.4 [2.9–5.6] vs. 0.9 [0.8–1.4], p = 0.003, respectively). Angiopoietin-2 expression was lower in VV compared to NV animals (0.5 [0.3–0.8] vs. 1.3 [1.0–1.5], p = 0.01). Conclusion In this rat model of pneumonia, VV improved pulmonary function and reduced lung damage as compared to VCV, without increasing bacterial translocation. Electronic supplementary material The online version of this article (doi:10.1186/s12931-016-0476-7) contains supplementary material, which is available to authorized users.
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Abstract
PURPOSE OF REVIEW This article discusses recently published articles reporting the incidence and outcome of patients with the acute respiratory distress syndrome (ARDS). This is a difficult task since there is a marked variability regarding the methodology of the few, large epidemiological, and observational studies on ARDS. RECENT FINDINGS The review will mainly focus on publications from the past 18 months. We have reviewed new epidemiological studies reporting population-based incidence of ARDS. Also, we have reviewed the data on survival reported in observational and randomized controlled trials, discussed how the current ARDS definition modifies the true incidence of ARDS, and briefly mentioned recent approaches that appear to improve ARDS outcome. SUMMARY On the basis of current evidence, it seems that the incidence and overall hospital mortality of ARDS has not changed substantially in the last decade. Independent of the definition used for identification of ARDS patients, reported population-based incidence of ARDS is an order of magnitude lower in Europe than in the USA. Current hospital mortality of combined moderate and severe ARDS reported in observational studies is greater than 40%.
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Retamal J, Borges JB, Bruhn A, Feinstein R, Hedenstierna G, Suarez-Sipmann F, Larsson A. Open lung approach ventilation abolishes the negative effects of respiratory rate in experimental lung injury. Acta Anaesthesiol Scand 2016; 60:1131-41. [PMID: 27110871 DOI: 10.1111/aas.12735] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 03/09/2016] [Accepted: 03/11/2016] [Indexed: 01/05/2023]
Abstract
BACKGROUND We recently reported that a high respiratory rate was associated with less inflammation than a low respiratory rate, but caused more pulmonary edema in a model of ARDS when an ARDSNet ventilatory strategy was used. We hypothesized that an open lung approach (OLA) strategy would neutralize the independent effects of respiratory rate on lung inflammation and edema. This hypothesis was tested in an ARDS model using two clinically relevant respiratory rates during OLA strategy. METHODS Twelve piglets were subjected to an experimental model of ARDS and randomized into two groups: LRR (20 breaths/min) and HRR (40 breaths/min). They were mechanically ventilated for 6 h according to an OLA strategy. We assessed respiratory mechanics, hemodynamics, and extravascular lung water (EVLW). At the end of the experiment, wet/dry ratio, regional histology, and cytokines were evaluated. RESULTS After the ARDS model was established, Cdyn,rs decreased from 21 ± 3.3 to 9.0 ± 1.8 ml/cmH2 O (P < 0.0001). After the lung recruitment maneuver, Cdyn,rs increased to the pre-injury value. During OLA ventilation, no differences in respiratory mechanics, hemodynamics, or EVLW were observed between groups. Wet/dry ratio and histological scores were not different between groups. Cytokine quantification was similar and showed a homogeneous distribution throughout the lung in both groups. CONCLUSION Contrary to previous findings with the ARDSNet strategy, respiratory rate did not influence lung inflammatory response or pulmonary edema during OLA ventilation in experimental ARDS. This indicates that changing the respiratory rate when OLA ventilation is used will not exacerbate lung injury.
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Affiliation(s)
- J. Retamal
- Hedenstierna Laboratory; Department of Surgical Sciences; Section of Anaesthesiology & Critical Care; Uppsala University; Uppsala Sweden
- Departamento de Medicina Intensiva; Pontificia Universidad Católica de Chile; Santiago Chile
| | - J. B. Borges
- Hedenstierna Laboratory; Department of Surgical Sciences; Section of Anaesthesiology & Critical Care; Uppsala University; Uppsala Sweden
- Cardio-Pulmonary Department; Pulmonary Divison; Heart Institute (Incor); University of São Paulo; São Paulo Brazil
| | - A. Bruhn
- Departamento de Medicina Intensiva; Pontificia Universidad Católica de Chile; Santiago Chile
| | - R. Feinstein
- Department of Pathology and Wildlife Diseases; National Veterinary Institute; Uppsala Sweden
| | - G. Hedenstierna
- Department of Medical Science; Clinical Physiology; Uppsala University Hospital; Uppsala Sweden
| | - F. Suarez-Sipmann
- Hedenstierna Laboratory; Department of Surgical Sciences; Section of Anaesthesiology & Critical Care; Uppsala University; Uppsala Sweden
| | - A. Larsson
- Hedenstierna Laboratory; Department of Surgical Sciences; Section of Anaesthesiology & Critical Care; Uppsala University; Uppsala Sweden
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Langdon R, Docherty PD, Chiew YS, Chase JG. Extrapolation of a non-linear autoregressive model of pulmonary mechanics. Math Biosci 2016; 284:32-39. [PMID: 27513728 DOI: 10.1016/j.mbs.2016.08.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 06/25/2016] [Accepted: 08/01/2016] [Indexed: 11/26/2022]
Abstract
For patients with acute respiratory distress syndrome (ARDS), mechanical ventilation (MV) is an essential therapy in the intensive care unit (ICU). Suboptimal PEEP levels in MV can cause ventilator induced lung injury, which is associated with increased mortality, extended ICU stay, and high cost. The ability to predict the outcome of respiratory mechanics in response to changes in PEEP would thus provide a critical advantage in personalising and improving care. Testing the potentially dangerous high pressures would not be required to assess their impact. A nonlinear autoregressive (NARX) model was used to predict airway pressure in 19 data sets from 10 mechanically ventilated ARDS patients. Patient-specific NARX models were identified from pressure and flow data over one, two, three, or four adjacent PEEP levels in a recruitment manoeuvre. Extrapolation of NARX model elastance functions allowed prediction of patient responses to PEEP changes to higher or lower pressures. NARX model predictions were more successful than those using a well validated first order model (FOM). The most clinically important results were for extrapolation up one PEEP step of 2cmH2O from the highest PEEP in the training data. When the NARX model was trained on one PEEP level, the mean RMS residual for the extrapolation PEEP level was 0.52 (90% CI: 0.47-0.57) cmH2O, compared to 1.50 (90% CI: 1.38-1.62) cmH2O for the FOM. When trained on four PEEP levels, the NARX result was 0.50 (90% CI: 0.42-0.58) cmH2O, and was 1.95 (90% CI: 1.71-2.19) cmH2O for the FOM. The results suggest that a full recruitment manoeuvre may not be required for the NARX model to obtain a useful estimate of the pressure waveform at higher PEEP levels. The methodology could thus allow clinicians to make informed decisions about ventilator PEEP settings while reducing the risk associated with high PEEP, and subsequent high peak airway pressures.
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Affiliation(s)
- Ruby Langdon
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand.
| | - Paul D Docherty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Yeong Shiong Chiew
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand; School of Engineering, Monash University Malaysia, Bandar Sunway, Malaysia
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
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Morales Pinzón A, Hernández Hoyos M, Richard JC, Flórez-Valencia L, Orkisz M. A tree-matching algorithm: Application to airways in CT images of subjects with the acute respiratory distress syndrome. Med Image Anal 2016; 35:101-115. [PMID: 27352141 DOI: 10.1016/j.media.2016.06.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Revised: 06/09/2016] [Accepted: 06/15/2016] [Indexed: 11/15/2022]
Abstract
To match anatomical trees such as airways, we propose a graph-based strategy combined with an appropriate distance function. The strategy was devised to cope with topological and geometrical differences that may arise between trees corresponding to the same subject, but extracted from images acquired in different conditions. The proposed distance function, called father/family distance, combines topological and geometrical information in a single measure, by calculating a sum of path-to-path distances between sub-trees of limited extent. To use it successfully, the branches of these sub-trees need to be brought closer, which is obtained by successively translating the roots of these sub-trees prior to their actual matching. The work herein presented contributes to a study of the acute respiratory distress syndrome, where a series of pulmonary CT images from the same subject is acquired at varying settings (pressure and volume) of the mechanical ventilation. The method was evaluated on 45 combinations of synthetic trees, as well as on 15 pairs of real airway trees: nine corresponding to end-expiration and end-inspiration with the same pressure, and six corresponding to end-inspiration with significantly different pressures. It achieved a high rate of successful matches with respect to a hand-made reference containing a total of 2391 matches in real data: sensitivity of 94.3% and precision of 92.8%, when using the basic parameter settings of the algorithm.
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Affiliation(s)
- Alfredo Morales Pinzón
- Systems and Computing Engineering Department, School of Engineering, Universidad de los Andes, Bogotá, Colombia; Univ Lyon, CNRS UMR5220, Inserm U1206, INSA-Lyon, Université Lyon 1, CREATIS, F-69621, Lyon, France.
| | - Marcela Hernández Hoyos
- Systems and Computing Engineering Department, School of Engineering, Universidad de los Andes, Bogotá, Colombia.
| | - Jean-Christophe Richard
- Univ Lyon, CNRS UMR5220, Inserm U1206, INSA-Lyon, Université Lyon 1, CREATIS, F-69621, Lyon, France; Service de Réanimation Médicale, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France.
| | | | - Maciej Orkisz
- Univ Lyon, CNRS UMR5220, Inserm U1206, INSA-Lyon, Université Lyon 1, CREATIS, F-69621, Lyon, France.
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Use of basis functions within a non-linear autoregressive model of pulmonary mechanics. Biomed Signal Process Control 2016. [DOI: 10.1016/j.bspc.2016.01.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Retamal J, Sörensen J, Lubberink M, Suarez-Sipmann F, Borges JB, Feinstein R, Jalkanen S, Antoni G, Hedenstierna G, Roivainen A, Larsson A, Velikyan I. Feasibility of (68)Ga-labeled Siglec-9 peptide for the imaging of acute lung inflammation: a pilot study in a porcine model of acute respiratory distress syndrome. AMERICAN JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING 2016; 6:18-31. [PMID: 27069763 PMCID: PMC4749502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 12/04/2015] [Indexed: 06/05/2023]
Abstract
There is an unmet need for noninvasive, specific and quantitative imaging of inherent inflammatory activity. Vascular adhesion protein-1 (VAP-1) translocates to the luminal surface of endothelial cells upon inflammatory challenge. We hypothesized that in a porcine model of acute respiratory distress syndrome (ARDS), positron emission tomography (PET) with sialic acid-binding immunoglobulin-like lectin 9 (Siglec-9) based imaging agent targeting VAP-1 would allow quantification of regional pulmonary inflammation. ARDS was induced by lung lavages and injurious mechanical ventilation. Hemodynamics, respiratory system compliance (Crs) and blood gases were monitored. Dynamic examination using [(15)O]water PET-CT (10 min) was followed by dynamic (90 min) and whole-body examination using VAP-1 targeting (68)Ga-labeled 1,4,7,10-tetraaza cyclododecane-1,4,7-tris-acetic acid-10-ethylene glycol-conjugated Siglec-9 motif peptide ([(68)Ga]Ga-DOTA-Siglec-9). The animals received an anti-VAP-1 antibody for post-mortem immunohistochemistry assay of VAP-1 receptors. Tissue samples were collected post-mortem for the radioactivity uptake, histology and immunohistochemistry assessment. Marked reduction of oxygenation and Crs, and higher degree of inflammation were observed in ARDS animals. [(68)Ga]Ga-DOTA-Siglec-9 PET showed significant uptake in lungs, kidneys and urinary bladder. Normalization of the net uptake rate (Ki) for the tissue perfusion resulted in 4-fold higher uptake rate of [(68)Ga]Ga-DOTA-Siglec-9 in the ARDS lungs. Immunohistochemistry showed positive VAP-1 signal in the injured lungs. Detection of pulmonary inflammation associated with a porcine model of ARDS was possible with [(68)Ga]Ga-DOTA-Siglec-9 PET when using kinetic modeling and normalization for tissue perfusion.
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Affiliation(s)
- Jaime Retamal
- Department of Surgical Sciences, Hedenstierna laboratory, Uppsala UniversityUppsala, Sweden
- Departament de Medicina Intensiva, Pontificia Universidad Católica de ChileSantiago, Chile
| | - Jens Sörensen
- Department of Surgical Sciences, Section of Nuclear Medicine and PET, Uppsala UniversityUppsala, Sweden
| | - Mark Lubberink
- Department of Surgical Sciences, Section of Nuclear Medicine and PET, Uppsala UniversityUppsala, Sweden
| | - Fernando Suarez-Sipmann
- Department of Surgical Sciences, Hedenstierna laboratory, Uppsala UniversityUppsala, Sweden
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos IIIMadrid, Spain
| | - João Batista Borges
- Department of Surgical Sciences, Hedenstierna laboratory, Uppsala UniversityUppsala, Sweden
- Pulmonary Divison, Heart Institute (Incor) Hospital das Clínicas da Faculdade de Medicina da Universidade de São PauloBrazil
| | | | - Sirpa Jalkanen
- MediCity Research Laboratory, Department of Medical Microbiology and Immunology, University of TurkuTurku, Finland
| | - Gunnar Antoni
- Department of Medicinal Chemistry, Uppsala UniversityUppsala, Sweden
| | - Göran Hedenstierna
- Department of Surgical Sciences, Hedenstierna laboratory, Uppsala UniversityUppsala, Sweden
| | - Anne Roivainen
- Turku PET Centre, University of Turku and Turku University HospitalTurku, Finland
- Turku Center for Disease Modelling, University of TurkuFurku, Finland
| | - Anders Larsson
- Department of Surgical Sciences, Hedenstierna laboratory, Uppsala UniversityUppsala, Sweden
| | - Irina Velikyan
- Department of Surgical Sciences, Section of Nuclear Medicine and PET, Uppsala UniversityUppsala, Sweden
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Nair AB, Oishi P. Venovenous Extracorporeal Life Support in Single-Ventricle Patients with Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:66. [PMID: 27446889 PMCID: PMC4923132 DOI: 10.3389/fped.2016.00066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/01/2016] [Indexed: 02/05/2023] Open
Abstract
There is new and growing experience with venovenous extracorporeal life support (VV ECLS) for neonatal and pediatric patients with single-ventricle physiology and acute respiratory distress syndrome (ARDS). Outcomes in this population have been defined but could be improved; survival rates in single-ventricle patients on VV ECLS for respiratory failure are slightly higher than those in single-ventricle patients on venoarterial ECLS for cardiac failure (48 vs. 32-43%), but are lower than in patients with biventricular anatomy (58-74%). To that end, special consideration is necessary for patients with single-ventricle physiology who require VV ECLS for ARDS. Specifically, ARDS disrupts the balance between pulmonary and systemic blood flow through dynamic alterations in cardiopulmonary mechanics. This complexity impacts how to run the VV ECLS circuit and the transition back to conventional support. Furthermore, these patients have a complicated coagulation profile. Both venous and arterial thrombi carry marked risk in single-ventricle patients due to the vulnerability of the pulmonary, coronary, and cerebral circulations. Finally, single-ventricle palliation requires the preservation of low resistance across the pulmonary circulation, unobstructed venous return, and optimal cardiac performance including valve function. As such, the proper timing as well as the particular conduct of ECLS might differ between this population and patients without single-ventricle physiology. The goal of this review is to summarize the current state of knowledge of VV ECLS in the single-ventricle population in the context of these special considerations.
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Affiliation(s)
- Alison B Nair
- Department of Pediatrics, University of California San Francisco , San Francisco, CA , USA
| | - Peter Oishi
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
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Open Lung in Lateral Decubitus With Differential Selective Positive End-Expiratory Pressure in an Experimental Model of Early Acute Respiratory Distress Syndrome. Crit Care Med 2015; 43:e404-11. [PMID: 26131598 DOI: 10.1097/ccm.0000000000001143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE After lung recruitment, lateral decubitus and differential lung ventilation may enable the titration and application of optimum-selective positive end-expiratory pressure values for the dependent and nondependent lungs. We aimed at compare the effects of optimum-selective positive end-expiratory pressure with optimum global positive end-expiratory pressure on regional collapse and aeration distribution in an experimental model of acute respiratory distress syndrome. DESIGN Prospective laboratory investigation. SETTING University animal research laboratory. SUBJECTS Seven piglets. INTERVENTIONS A one-hit injury acute respiratory distress syndrome model was established by repeated lung lavages. After replacing the tracheal tube by a double-lumen one, we initiated lateral decubitus and differential ventilation. After maximum-recruitment maneuver, decremental positive end-expiratory pressure titration was performed. The positive end-expiratory pressure corresponding to maximum dynamic compliance was defined globally (optimum global positive end-expiratory pressure) and for each individual lung (optimum-selective positive end-expiratory pressure). After new maximum-recruitment maneuver, two steps were performed in randomized order (15 min each): ventilation applying the optimum global positive end-expiratory pressure and the optimum-selective positive end-expiratory pressure. CT scans were acquired at end expiration and end inspiration. MEASUREMENTS AND MAIN RESULTS Aeration homogeneity was evaluated as a nondependent/dependent ratio (percent of total gas content in upper lung/percent of total gas content in lower lung) and tidal recruitment as the difference in the percent mass of nonaerated tissue between expiration and inspiration. At the end of the 15-minute optimum-selective positive end-expiratory pressure, compared with the optimum global positive end-expiratory pressure, resulted in 1) decrease in the percent mass of collapse in the lower lung at expiratory CT (19% ± 15% vs 4% ± 5%; p = 0.03); 2) decrease in the nondependent/dependent ratio between the optimum global positive end-expiratory pressure-expiratory-CT and optimum-selective positive end-expiratory pressure-expiratory-CT (3.7 ± 1.2 vs 0.8 ± 0.5; p = 0.01); 3) decrease in the nondependent/dependent ratio between the optimum global positive end-expiratory pressure-inspiratory-CT and optimum-selective positive end-expiratory pressure-inspiratory-CT (2.8 ± 1.1 vs 0.6 ± 0.3; p = 0.01); and 4) less tidal recruitment (p = 0.049). CONCLUSIONS After maximum lung recruitment, lateral decubitus and differential lung ventilation enabled the titration of optimum-selective positive end-expiratory pressure values for the dependent and the nondependent lungs, made possible the application of an optimized regional open lung approach, promoted better aeration distribution, and minimized lung tissue inhomogeneities.
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Karadottir H, Kulkarni NN, Gudjonsson T, Karason S, Gudmundsson GH. Cyclic mechanical stretch down-regulates cathelicidin antimicrobial peptide expression and activates a pro-inflammatory response in human bronchial epithelial cells. PeerJ 2015; 3:e1483. [PMID: 26664810 PMCID: PMC4675098 DOI: 10.7717/peerj.1483] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Accepted: 11/18/2015] [Indexed: 12/25/2022] Open
Abstract
Mechanical ventilation (MV) of patients can cause damage to bronchoalveolar epithelium, leading to a sterile inflammatory response, infection and in severe cases sepsis. Limited knowledge is available on the effects of MV on the innate immune defense system in the human lung. In this study, we demonstrate that cyclic stretch of the human bronchial epithelial cell lines VA10 and BCi NS 1.1 leads to down-regulation of cathelicidin antimicrobial peptide (CAMP) gene expression. We show that treatment of VA10 cells with vitamin D3 and/or 4-phenyl butyric acid counteracted cyclic stretch mediated down-regulation of CAMP mRNA and protein expression (LL-37). Further, we observed an increase in pro-inflammatory responses in the VA10 cell line subjected to cyclic stretch. The mRNA expression of the genes encoding pro-inflammatory cytokines IL-8 and IL-1β was increased after cyclic stretching, where as a decrease in gene expression of chemokines IP-10 and RANTES was observed. Cyclic stretch enhanced oxidative stress in the VA10 cells. The mRNA expression of toll-like receptor (TLR) 3, TLR5 and TLR8 was reduced, while the gene expression of TLR2 was increased in VA10 cells after cyclic stretch. In conclusion, our in vitro results indicate that cyclic stretch may differentially modulate innate immunity by down-regulation of antimicrobial peptide expression and increase in pro-inflammatory responses.
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Affiliation(s)
- Harpa Karadottir
- Biomedical Center and Department of Life and Environmental Sciences, University of Iceland, Reykjavik, Iceland
| | - Nikhil Nitin Kulkarni
- Biomedical Center and Department of Life and Environmental Sciences, University of Iceland, Reykjavik, Iceland
| | - Thorarinn Gudjonsson
- Stem Cell Research Unit, Biomedical Center, Department of Anatomy, Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,Department of Laboratory Hematology, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Sigurbergur Karason
- Department of Anaesthesia and Intensive Care and Faculty of Medicine, Landspitali University Hospital and University of Iceland, Reykjavik, Iceland
| | - Gudmundur Hrafn Gudmundsson
- Biomedical Center and Department of Life and Environmental Sciences, University of Iceland, Reykjavik, Iceland
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Radke OC, Schneider T, Vogel E, Koch T. Effect of Trigger Sensitivity on Redistribution of Ventilation During Pressure Support Ventilation Detected by Electrical Impedance Tomography. Anesth Pain Med 2015; 5:e27439. [PMID: 26478865 PMCID: PMC4604485 DOI: 10.5812/aapm.27439v2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Revised: 03/15/2015] [Accepted: 03/30/2015] [Indexed: 11/16/2022] Open
Abstract
Background: In supine position, pressure support ventilation causes a redistribution of ventilation towards the ventral regions of the lung. Theoretically, a less sensitive support trigger would cause the patient to breathe more actively, potentially attenuating the effect of positive pressure ventilation. Objectives: To quantify the effect of trigger setting, we assessed redistribution of ventilation during pressure support ventilation (PSV) using electrical impedance tomography (EIT). Patients and Methods: With approval from the local ethics committee, six orthopedic patients were enrolled. All patients had general anesthesia with a laryngeal mask airway and a standardized anesthetic regimen (sufentanil, propofol and sevoflurane). Pressure support trigger settings varied between 2 and 15 L/minute and compared to unassisted spontaneous breathing. From EIT data, the center of ventilation (COV), the fraction of the total ventilation per region of interest (ROI) and intratidal gas distribution were calculated. Results: At all trigger settings, pressure support ventilation caused a significant ventral shift of the center of ventilation compared with during spontaneous breathing, confirmed by the analysis by regions of interest. During spontaneous breathing, COV was not different from baseline values obtained before induction of anesthesia. During PSV, the intratidal regional gas distribution (ITV-analysis) revealed subtle changes during the early inspiratory phase not detected by the COV-analysis. Conclusions: Pressure support ventilation, but not spontaneous breathing, induces a significant redistribution of ventilation towards the ventral region. The sensitivity of the support trigger appears to influence the distribution of ventilation only during the early phase of inspiration.
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Affiliation(s)
- Oliver C. Radke
- Department of Anesthesiology and Intensive Care Medicine,Klinikum Bremerhaven-Reinkenheide, Postbrookstr. 103, 27574 Bremerhaven, Germany
- Department of Anesthesia and Perioperative Care, San Francisco General Hospital, University of California San Francisco, San Francisco, California, USA
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universitat Dresden, Germany
- Corresponding author: Oliver C. Radke, Department of Anesthesiology and Intensive Care Medicine, Klinikum Bremerhaven-Reinkenheide, Postbrookstr. 103, 27574 Bremerhaven, Germany. Tel: +49-471 2993268, Fax: +49-4712993286, E-mail:
| | - Thomas Schneider
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universitat Dresden, Germany
| | - Elisabeth Vogel
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universitat Dresden, Germany
| | - Thea Koch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Technische Universitat Dresden, Germany
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