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Spinelli E, Pesenti A, Lopez G, Damia A, Damarco F, Garbelli E, Dal Santo G, Caccioppola A, Giudici G, Figgiaconi V, Biancolilli O, Battistin M, Lonati C, Vaira V, Rosso L, Ferrero S, Gatti S, Mauri T. Inhaled CO2 vs. Hypercapnia Obtained by Low Tidal Volume or Instrumental Dead Space in Unilateral Pulmonary Artery Ligation: Any Difference for Lung Protection? Front Med (Lausanne) 2022; 9:901809. [PMID: 35669918 PMCID: PMC9163369 DOI: 10.3389/fmed.2022.901809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 04/19/2022] [Indexed: 11/20/2022] Open
Abstract
Background Unilateral ligation of the pulmonary artery (UPAL) induces bilateral lung injury in pigs undergoing controlled mechanical ventilation. Possible mechanisms include redistribution of ventilation toward the non-ligated lung and hypoperfusion of the ligated lung. The addition of 5% CO2 to the inspiratory gas (FiCO2) prevents the injury, but it is not clear whether lung protection is a direct effect of CO2 inhalation or it is mediated by plasmatic hypercapnia. This study aims to compare the effects and mechanisms of FiCO2vs. hypercapnia induced by low tidal volume ventilation or instrumental dead space. Methods Healthy pigs underwent left UPAL and were allocated for 48 h to the following: Volume-controlled ventilation (VCV) with VT 10 ml/kg (injury, n = 6); VCV plus 5% FiCO2 (FiCO2, n = 7); VCV with VT 6 ml/kg (low VT, n = 6); VCV plus additional circuit dead space (instrumental VD, n = 6). Histological score, regional compliance, wet-to-dry ratio, and inflammatory infiltrate were assessed to evaluate lung injury at the end of the study. To investigate the mechanisms of protection, we quantified the redistribution of ventilation to the non-ligated lung, as the ratio between the percentage of tidal volume to the right and to the left lung (VTRIGHT/LEFT), and the hypoperfusion of the ligated lung as the percentage of blood flow reaching the left lung (PerfusionLEFT). Results In the left ligated lung, injury was prevented only in the FiCO2 group, as indicated by lower histological score, higher regional compliance, lower wet-to-dry ratio and lower density of inflammatory cells compared to other groups. For the right lung, the histological score was lower both in the FiCO2 and in the low VT groups, but the other measures of injury showed lower intensity only in the FiCO2 group. VTRIGHT/LEFT was lower and PerfusionLEFT was higher in the FiCO2 group compared to other groups. Conclusion In a model of UPAL, inhaled CO2 but not hypercapnia grants bilateral lung protection. Mechanisms of protection include reduced overdistension of the non-ligated and increased perfusion of the ligated lung.
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Affiliation(s)
- Elena Spinelli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Pesenti
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Gianluca Lopez
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Anna Damia
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Francesco Damarco
- Division of Thoracic Surgery and Lung Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Erica Garbelli
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Gaia Dal Santo
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Alessio Caccioppola
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Giorgio Giudici
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Virginia Figgiaconi
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Osvaldo Biancolilli
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Michele Battistin
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Caterina Lonati
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Vaira
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Division of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Lorenzo Rosso
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- Division of Thoracic Surgery and Lung Transplantation, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Ferrero
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
- Division of Pathology, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Stefano Gatti
- Center for Preclinical Research, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Tommaso Mauri
- Department of Anesthesia, Critical Care and Emergency, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
- *Correspondence: Tommaso Mauri
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Marongiu I, Spinelli E, Scotti E, Mazzucco A, Wang YM, Manesso L, Colussi G, Biancolilli O, Battistin M, Langer T, Roma F, Lopez G, Lonati C, Vaira V, Rosso L, Ferrero S, Gatti S, Zanella A, Pesenti A, Mauri T. Addition of 5% CO 2 to Inspiratory Gas Prevents Lung Injury in an Experimental Model of Pulmonary Artery Ligation. Am J Respir Crit Care Med 2021; 204:933-942. [PMID: 34252009 PMCID: PMC8534619 DOI: 10.1164/rccm.202101-0122oc] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 07/12/2021] [Indexed: 11/19/2022] Open
Abstract
Rationale: Unilateral ligation of the pulmonary artery may induce lung injury through multiple mechanisms, which might be dampened by inhaled CO2. Objectives: This study aims to characterize bilateral lung injury owing to unilateral ligation of the pulmonary artery in healthy swine undergoing controlled mechanical ventilation and its prevention by 5% CO2 inhalation and to investigate relevant pathophysiological mechanisms. Methods: Sixteen healthy pigs were allocated to surgical ligation of the left pulmonary artery (ligation group), seven to surgical ligation of the left pulmonary artery and inhalation of 5% CO2 (ligation + FiCO2 5%), and six to no intervention (no ligation). Then, all animals received mechanical ventilation with Vt 10 ml/kg, positive end-expiratory pressure 5 cm H2O, respiratory rate 25 breaths/min, and FiO2 50% (±FiCO2 5%) for 48 hours or until development of severe lung injury. Measurements and Main Results: Histological, physiological, and quantitative computed tomography scan data were compared between groups to characterize lung injury. Electrical impedance tomography and immunohistochemistry analysis were performed in a subset of animals to explore mechanisms of injury. Animals from the ligation group developed bilateral lung injury as assessed by significantly higher histological score, larger increase in lung weight, poorer oxygenation, and worse respiratory mechanics compared with the ligation + FiCO2 5% group. In the ligation group, the right lung received a larger fraction of Vt and inflammation was more represented, whereas CO2 dampened both processes. Conclusions: Mechanical ventilation induces bilateral lung injury within 48 hours in healthy pigs undergoing left pulmonary artery ligation. Inhalation of 5% CO2 prevents injury, likely through decreased stress to the right lung and antiinflammatory effects.
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Affiliation(s)
| | | | | | | | - Yu-Mei Wang
- Department of Anesthesia, Critical Care and Emergency
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; and
| | | | | | | | | | - Thomas Langer
- School of Medicine and Surgery, University of Milan–Bicocca, Niguarda Ca’ Granda Hospital, Milan, Italy
| | | | - Gianluca Lopez
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
- Division of Pathology, and
| | - Caterina Lonati
- Center for Preclinical Research, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Valentina Vaira
- Department of Pathophysiology and Transplantation
- Division of Pathology, and
| | | | - Stefano Ferrero
- Department of Biomedical Surgical and Dental Sciences, University of Milan, Milan, Italy
- Division of Pathology, and
| | - Stefano Gatti
- Center for Preclinical Research, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Alberto Zanella
- Department of Pathophysiology and Transplantation
- Department of Anesthesia, Critical Care and Emergency
| | - Antonio Pesenti
- Department of Pathophysiology and Transplantation
- Department of Anesthesia, Critical Care and Emergency
| | - Tommaso Mauri
- Department of Pathophysiology and Transplantation
- Department of Anesthesia, Critical Care and Emergency
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Masterson CH, O'Toole D, Laffey JG. Inhaled CO2 to Reduce Lung Ischemia and Reperfusion Injuries: Moving Towards Clinical Translation? Am J Respir Crit Care Med 2021; 204:878-879. [PMID: 34375575 PMCID: PMC8534625 DOI: 10.1164/rccm.202107-1665ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Claire H Masterson
- National University of Ireland Galway, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Galway, Ireland
| | - Daniel O'Toole
- National University of Ireland Galway, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Galway, Ireland
| | - John G Laffey
- National University of Ireland, Galway, Lung Biology Group, Galway, Ireland;
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Does Iso-mechanical Power Lead to Iso-lung Damage?: An Experimental Study in a Porcine Model. Anesthesiology 2020; 132:1126-1137. [PMID: 32032095 DOI: 10.1097/aln.0000000000003189] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Excessive tidal volume, respiratory rate, and positive end-expiratory pressure (PEEP) are all potential causes of ventilator-induced lung injury, and all contribute to a single variable: the mechanical power. The authors aimed to determine whether high tidal volume or high respiratory rate or high PEEP at iso-mechanical power produce similar or different ventilator-induced lung injury. METHODS Three ventilatory strategies-high tidal volume (twice baseline functional residual capacity), high respiratory rate (40 bpm), and high PEEP (25 cm H2O)-were each applied at two levels of mechanical power (15 and 30 J/min) for 48 h in six groups of seven healthy female piglets (weight: 24.2 ± 2.0 kg, mean ± SD). RESULTS At iso-mechanical power, the high tidal volume groups immediately and sharply increased plateau, driving pressure, stress, and strain, which all further deteriorated with time. In high respiratory rate groups, they changed minimally at the beginning, but steadily increased during the 48 h. In contrast, after a sudden huge increase, they decreased with time in the high PEEP groups. End-experiment specific lung elastance was 6.5 ± 1.7 cm H2O in high tidal volume groups, 10.1 ± 3.9 cm H2O in high respiratory rate groups, and 4.5 ± 0.9 cm H2O in high PEEP groups. Functional residual capacity decreased and extravascular lung water increased similarly in these three categories. Lung weight, wet-to-dry ratio, and histologic scores were similar, regardless of ventilatory strategies and power levels. However, the alveolar edema score was higher in the low power groups. High PEEP had the greatest impact on hemodynamics, leading to increased need for fluids. Adverse events (early mortality and pneumothorax) also occurred more frequently in the high PEEP groups. CONCLUSIONS Different ventilatory strategies, delivered at iso-power, led to similar anatomical lung injury. The different systemic consequences of high PEEP underline that ventilator-induced lung injury must be evaluated in the context of the whole body.
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Fumagalli J, Berra L. What does the Acute Respiratory Distress Syndrome trial (ART) teach us?-it is time for precision medicine and precision trials in critical care! J Thorac Dis 2018; 10:1300-1303. [PMID: 29707281 DOI: 10.21037/jtd.2018.03.31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Jacopo Fumagalli
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, USA
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