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Masterson C, Horie S, McCarthy SD, Gonzalez H, Byrnes D, Brady J, Fandiño J, Laffey JG, O'Toole D. Hypercapnia in the critically ill: insights from the bench to the bedside. Interface Focus 2021; 11:20200032. [PMID: 33628425 PMCID: PMC7898152 DOI: 10.1098/rsfs.2020.0032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2020] [Indexed: 01/16/2023] Open
Abstract
Carbon dioxide (CO2) has long been considered, at best, a waste by-product of metabolism, and at worst, a toxic molecule with serious health consequences if physiological concentration is dysregulated. However, clinical observations have revealed that 'permissive' hypercapnia, the deliberate allowance of respiratory produced CO2 to remain in the patient, can have anti-inflammatory effects that may be beneficial in certain circumstances. In parallel, studies at the cell level have demonstrated the profound effect of CO2 on multiple diverse signalling pathways, be it the effect from CO2 itself specifically or from the associated acidosis it generates. At the whole organism level, it now appears likely that there are many biological sensing systems designed to respond to CO2 concentration and tailor respiratory and other responses to atmospheric or local levels. Animal models have been widely employed to study the changes in CO2 levels in various disease states and also to what extent permissive or even directly delivered CO2 can affect patient outcome. These findings have been advanced to the bedside at the same time that further clinical observations have been elucidated at the cell and animal level. Here we present a synopsis of the current understanding of how CO2 affects mammalian biological systems, with a particular emphasis on inflammatory pathways and diseases such as lung specific or systemic sepsis. We also explore some future directions and possibilities, such as direct control of blood CO2 levels, that could lead to improved clinical care in the future.
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Shigemura M, Lecuona E, Angulo M, Homma T, Rodríguez DA, Gonzalez-Gonzalez FJ, Welch LC, Amarelle L, Kim SJ, Kaminski N, Budinger GRS, Solway J, Sznajder JI. Hypercapnia increases airway smooth muscle contractility via caspase-7-mediated miR-133a-RhoA signaling. Sci Transl Med 2018; 10:eaat1662. [PMID: 30185650 PMCID: PMC6889079 DOI: 10.1126/scitranslmed.aat1662] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 06/07/2018] [Accepted: 08/16/2018] [Indexed: 12/12/2022]
Abstract
The elevation of carbon dioxide (CO2) in tissues and the bloodstream (hypercapnia) occurs in patients with severe lung diseases, including chronic obstructive pulmonary disease (COPD). Whereas hypercapnia has been recognized as a marker of COPD severity, a role for hypercapnia in disease pathogenesis remains unclear. We provide evidence that CO2 acts as a signaling molecule in mouse and human airway smooth muscle cells. High CO2 activated calcium-calpain signaling and consequent smooth muscle cell contraction in mouse airway smooth muscle cells. The signaling was mediated by caspase-7-induced down-regulation of the microRNA-133a (miR-133a) and consequent up-regulation of Ras homolog family member A and myosin light-chain phosphorylation. Exposure of wild-type, but not caspase-7-null, mice to hypercapnia increased airway contraction and resistance. Deletion of the Caspase-7 gene prevented hypercapnia-induced airway contractility, which was restored by lentiviral transfection of a miR-133a antagonist. In a cohort of patients with severe COPD, hypercapnic patients had higher airway resistance, which improved after correction of hypercapnia. Our data suggest a specific molecular mechanism by which the development of hypercapnia may drive COPD pathogenesis and progression.
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Affiliation(s)
- Masahiko Shigemura
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL 60611, USA
- First Department of Medicine, Hokkaido University School of Medicine, Sapporo, Japan
| | - Emilia Lecuona
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Martín Angulo
- Pathophysiology Department, School of Medicine, Universidad de la República, Montevideo, Uruguay
| | - Tetsuya Homma
- Division of Allergology and Respiratory Medicine, Department of Internal Medicine, Showa University School of Medicine, Tokyo, Japan
| | - Diego A Rodríguez
- Pulmonology Department, Hospital del Mar, Institut Hospital del Mar d'Investigacions Me`diques, Universitat Pompeu Fabra, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), ISCiii, Barcelona, Spain
| | | | - Lynn C Welch
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Luciano Amarelle
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL 60611, USA
- Pathophysiology Department, School of Medicine, Universidad de la República, Montevideo, Uruguay
| | - Seok-Jo Kim
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL 60611, USA
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Jesse Brown Veterans Affairs Medical Center, Chicago, IL 60612, USA
| | - Naftali Kaminski
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT 06520, USA
| | - G R Scott Budinger
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Julian Solway
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | - Jacob I Sznajder
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL 60611, USA.
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Nin N, Angulo M, Briva A. Effects of hypercapnia in acute respiratory distress syndrome. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:37. [PMID: 29430454 PMCID: PMC5799147 DOI: 10.21037/atm.2018.01.09] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 01/11/2023]
Abstract
In patients with acute respiratory distress syndrome (ARDS) hypercapnia is a marker of poor prognosis, however there is controversial information regarding the effect of hypercapnia on outcomes. Recently two studies in a large population of mechanical ventilation patients showed higher mortality associated independently to hypercapnia. Key roles responsible for the poor clinical outcomes observed in critically ill patients exposed to hypercapnia are not well known, two possible mechanisms involved are the effect of CO2 on the muscle and the alveolar epithelium. Hypercapnia frequently coexists with muscle atrophy and dysfunction, moreover patients surviving ARDS present reduced muscle strength and decreased physical quality of life. One of the possible mechanisms responsible for these abnormalities could be the effects of hypercapnia during the course of ARDS. More over controversy persists about the hypercapnia role in the alveolar space, in the last years there is abundant experimental information on its deleterious effects on essential functions of the alveolar epithelium.
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Affiliation(s)
- Nicolás Nin
- Unidad de Cuidados Intensivos, Hospital Español, Montevideo, Uruguay
| | - Martín Angulo
- Unidad de Cuidados Intensivos, Hospital de Clínicas, Montevideo, Uruguay
| | - Arturo Briva
- Unidad de Cuidados Intensivos, Hospital Español, Montevideo, Uruguay
- Unidad de Cuidados Intensivos, Hospital de Clínicas, Montevideo, Uruguay
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Briva A, Gaiero C. Lung protection: an intervention for tidal volume reduction in a teaching intensive care unit. Rev Bras Ter Intensiva 2016; 28:373-379. [PMID: 27925055 PMCID: PMC5225911 DOI: 10.5935/0103-507x.20160067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 08/16/2016] [Indexed: 11/20/2022] Open
Abstract
Objective To determine the effect of feedback and education regarding the use of
predicted body weight to adjust tidal volume in a lung-protective mechanical
ventilation strategy. Methods The study was performed from October 2014 to November 2015 (12 months) in a
single university polyvalent intensive care unit. We developed a combined
intervention (education and feedback), placing particular attention on the
importance of adjusting tidal volumes to predicted body weight bedside. In
parallel, predicted body weight was estimated from knee height and included
in clinical charts. Results One hundred fifty-nine patients were included. Predicted body weight assessed
by knee height instead of visual evaluation revealed that the delivered
tidal volume was significantly higher than predicted. After the inclusion of
predicted body weight, we observed a sustained reduction in delivered tidal
volume from a mean (standard error) of 8.97 ± 0.32 to 7.49 ±
0.19mL/kg (p < 0.002). Furthermore, the protocol adherence was
subsequently sustained for 12 months (delivered tidal volume 7.49 ±
0.54 versus 7.62 ± 0.20mL/kg; p = 0.103). Conclusion The lack of a reliable method to estimate the predicted body weight is a
significant impairment for the application of a worldwide standard of care
during mechanical ventilation. A combined intervention based on education
and repeated feedbacks promoted sustained tidal volume education during the
study period (12 months).
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Affiliation(s)
- Arturo Briva
- Unidade de Terapia Intensiva, Hospital de Clínicas, Universidad de la República - Montevidéu, Uruguai.,Área de Investigação Respiratória, Departamento de Fisiopatologia, Hospital de Clínicas - Montevidéu, Uruguai
| | - Cristina Gaiero
- Unidade de Terapia Intensiva, Hospital de Clínicas, Universidad de la República - Montevidéu, Uruguai
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Turner MJ, Saint-Criq V, Patel W, Ibrahim SH, Verdon B, Ward C, Garnett JP, Tarran R, Cann MJ, Gray MA. Hypercapnia modulates cAMP signalling and cystic fibrosis transmembrane conductance regulator-dependent anion and fluid secretion in airway epithelia. J Physiol 2015; 594:1643-61. [PMID: 26574187 PMCID: PMC4799982 DOI: 10.1113/jp271309] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 11/05/2015] [Indexed: 12/20/2022] Open
Abstract
Hypercapnia is clinically defined as an arterial blood partial pressure of CO2 of above 40 mmHg and is a feature of chronic lung disease. In previous studies we have demonstrated that hypercapnia modulates agonist-stimulated cAMP levels through effects on transmembrane adenylyl cyclase activity. In the airways, cAMP is known to regulate cystic fibrosis transmembrane conductance regulator (CFTR)-mediated anion and fluid secretion, which contributes to airway surface liquid homeostasis. The aim of the current work was to investigate if hypercapnia could modulate cAMP-regulated ion and fluid transport in human airway epithelial cells. We found that acute exposure to hypercapnia significantly reduced forskolin-stimulated elevations in intracellular cAMP as well as both adenosine- and forskolin-stimulated increases in CFTR-dependent transepithelial short-circuit current, in polarised cultures of Calu-3 human airway cells. This CO2 -induced reduction in anion secretion was not due to a decrease in HCO3 (-) transport given that neither a change in CFTR-dependent HCO3 (-) efflux nor Na(+) /HCO3 (-) cotransporter-dependent HCO3 (-) influx were CO2 -sensitive. Hypercapnia also reduced the volume of forskolin-stimulated fluid secretion over 24 h, yet had no effect on the HCO3 (-) content of the secreted fluid. Our data reveal that hypercapnia reduces CFTR-dependent, electrogenic Cl(-) and fluid secretion, but not CFTR-dependent HCO3 (-) secretion, which highlights a differential sensitivity of Cl(-) and HCO3 (-) transporters to raised CO2 in Calu-3 cells. Hypercapnia also reduced forskolin-stimulated CFTR-dependent anion secretion in primary human airway epithelia. Based on current models of airways biology, a reduction in fluid secretion, associated with hypercapnia, would be predicted to have important consequences for airways hydration and the innate defence mechanisms of the lungs.
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Affiliation(s)
- Mark J Turner
- Institute for Cell & Molecular Biosciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.,Department of Physiology, McIntyre Medical Sciences Building, McGill University, 3655 Promenade Sir William Osler, Montreal, Quebec, Canada, H3G 1Y6
| | - Vinciane Saint-Criq
- Institute for Cell & Molecular Biosciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Waseema Patel
- Institute for Cell & Molecular Biosciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Salam H Ibrahim
- Institute for Cell & Molecular Biosciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Bernard Verdon
- Institute for Cell & Molecular Biosciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Christopher Ward
- Institute for Cellular Medicine, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - James P Garnett
- Institute for Cell & Molecular Biosciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Robert Tarran
- Marsico Lung Institute, University of North Carolina, Chapel Hill, NC, 27599, USA
| | - Martin J Cann
- School of Biological and Biomedical Sciences, Durham University, South Road, Durham, DH1 3LE, UK
| | - Michael A Gray
- Institute for Cell & Molecular Biosciences, The Medical School, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
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Abstract
Pulmonary edema clearance is necessary for patients with lung injury to recover and survive. The mechanisms regulating edema clearance from the lungs are distinct from the factors contributing edema formation during injury. Edema clearance is effected via vectorial transport of Na(+) out of the airspaces which generates an osmotic gradient causing water to follow the gradient out of the cells. This Na(+) transport across the alveolar epithelium is mostly effected via apical Na(+) and chloride channels and basolateral Na,K-ATPase. The Na,K-ATPase pumps Na(+) out of the cell and K(+) into the cell against their respective gradients in an ATP-consuming reaction. Two mechanisms contribute to the regulation of the Na,K-ATPase activity:recruitment of its subunits from intracellular compartments into the basolateral membrane, and transcriptional/translational regulation. Na,K-ATPase activity and edema clearance are increased by catecholamines, aldosterone, vasopressin, overexpression of the pump genes, and others. During lung injury, mechanisms regulating edema clearance are inhibited by yet unclear pathways. Better understanding of the mechanisms that regulate pulmonary edema clearance may lead to therapeutic interventions that counterbalance the inhibition of edema clearance during lung injury and improve the lungs' ability to clear fluid, which is crucial for patient survival.
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Affiliation(s)
- Zaher S. Azzam
- Internal Medicine “B”, Rambam Health Care Campus, Department of Physiology and Biophysics, The Rappaport Family Faculty of Medicine and Research Institute, Technion, Israel Institute of Technology, Haifa, Israel
| | - Jacob I. Sznajder
- Division of Pulmonary and Critical Care Medicine, Northwestern University, Chicago, IL, USA
- To whom correspondence should be addressed. E-mail:
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Sevoflurane anesthesia deteriorates pulmonary surfactant promoting alveolar collapse in male Sprague–Dawley rats. Pulm Pharmacol Ther 2014; 28:122-9. [DOI: 10.1016/j.pupt.2013.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 12/06/2013] [Accepted: 12/24/2013] [Indexed: 01/01/2023]
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Burnstock G, Brouns I, Adriaensen D, Timmermans JP. Purinergic signaling in the airways. Pharmacol Rev 2012; 64:834-68. [PMID: 22885703 DOI: 10.1124/pr.111.005389] [Citation(s) in RCA: 123] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Evidence for a significant role and impact of purinergic signaling in normal and diseased airways is now beyond dispute. The present review intends to provide the current state of knowledge of the involvement of purinergic pathways in the upper and lower airways and lungs, thereby differentiating the involvement of different tissues, such as the epithelial lining, immune cells, airway smooth muscle, vasculature, peripheral and central innervation, and neuroendocrine system. In addition to the vast number of well illustrated functions for purinergic signaling in the healthy respiratory tract, increasing data pointing to enhanced levels of ATP and/or adenosine in airway secretions of patients with airway damage and respiratory diseases corroborates the emerging view that purines act as clinically important mediators resulting in either proinflammatory or protective responses. Purinergic signaling has been implicated in lung injury and in the pathogenesis of a wide range of respiratory disorders and diseases, including asthma, chronic obstructive pulmonary disease, inflammation, cystic fibrosis, lung cancer, and pulmonary hypertension. These ostensibly enigmatic actions are based on widely different mechanisms, which are influenced by the cellular microenvironment, but especially the subtypes of purine receptors involved and the activity of distinct members of the ectonucleotidase family, the latter being potential protein targets for therapeutic implementation.
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Affiliation(s)
- Geoffrey Burnstock
- Autonomic Neuroscience Centre, University College Medical School, Royal Free Campus, London, UK.
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