Effects of acute hypercapnia with and without acidosis on lung inflammation and apoptosis in experimental acute lung injury

Effects of Similar Mechanical Power Resulting From Different Combinations of Respiratory Variables on Lung Damage in Experimental Acute Respiratory Distress Syndrome

OBJECTIVES

Mechanical power is a crucial concept in understanding ventilator-induced lung injury (VILI). We adopted the null hypothesis that under the same mechanical power, resulting from combinations of different static and dynamic variables-some with high stress per cycle and others without-would inflict similar degrees of damage on lung epithelial and endothelial cells as well as on the extracellular matrix in experimental acute respiratory distress syndrome (ARDS). To test this hypothesis, we varied tidal volume (Vt), which correlates with the stretching force per cycle, while adjusting respiratory rate (RR) to yield similar mechanical power values for identical durations across all experimental groups.

DESIGN

Animal study.

SETTING

Laboratory investigation.

SUBJECTS

Thirty male Wistar rats (333 ± 26 g).

INTERVENTIONS

Twenty-four hours after intratracheal administration of Escherichia coli lipopolysaccharide, animals were anesthetized and mechanically ventilated (positive end-expiratory pressure = 3 cm H2O) with combination of Vt and RR sufficient to induce similar mechanical power (n = 8/group): Vt = 6 mL/kg, RR = 140 breaths/minute (low Vt-high RR [LVT-HRR]); Vt = 12 mL/kg, RR = 70 breaths/minute (high Vt-low RR [HVT-LRR]); and Vt = 18 mL/kg, RR = 50 breaths/minute (very-high Vt-very-low RR [VHVT-VLRR]). All groups were ventilated for 80 minutes. A control group, not subjected to mechanical ventilation (MV), was used for molecular biology analyses.

MEASUREMENTS AND MAIN RESULTS

After 80 minutes of MV, lung overdistension, alveolar/interstitial edema, fractional area of E-cadherin, and biomarkers of lung inflammation (interleukin-6), lung stretch (amphiregulin), damage to epithelial (surfactant protein B) and endothelial cells (vascular cell adhesion molecule 1 and angiopoietin-2), and extracellular matrix (versican and syndecan) were higher in group VHVT-VLRR than LVT-HRR. Plateau pressure and driving pressure increased progressively from LVT-HRR to HVT-LRR and VHVT-VLRR.

CONCLUSIONS

In the current experimental model of ARDS, mechanical power alone is insufficient to account for VILI. Instead, the manner in which its components are applied determines the extent of injury at a given mechanical power value.

Carbon dioxide and MAPK signalling: towards therapy for inflammation

Inflammation, although necessary to fight infections, becomes a threat when it exceeds the capability of the immune system to control it. In addition, inflammation is a cause and/or symptom of many different disorders, including metabolic, neurodegenerative, autoimmune and cardiovascular diseases. Comorbidities and advanced age are typical predictors of more severe cases of seasonal viral infection, with COVID-19 a clear example. The primary importance of mitogen-activated protein kinases (MAPKs) in the course of COVID-19 is evident in the mechanisms by which cells are infected with SARS-CoV-2; the cytokine storm that profoundly worsens a patient's condition; the pathogenesis of diseases, such as diabetes, obesity, and hypertension, that contribute to a worsened prognosis; and post-COVID-19 complications, such as brain fog and thrombosis. An increasing number of reports have revealed that MAPKs are regulated by carbon dioxide (CO2); hence, we reviewed the literature to identify associations between CO2 and MAPKs and possible therapeutic benefits resulting from the elevation of CO2 levels. CO2 regulates key processes leading to and resulting from inflammation, and the therapeutic effects of CO2 (or bicarbonate, HCO3-) have been documented in all of the abovementioned comorbidities and complications of COVID-19 in which MAPKs play roles. The overlapping MAPK and CO2 signalling pathways in the contexts of allergy, apoptosis and cell survival, pulmonary oedema (alveolar fluid resorption), and mechanical ventilation-induced responses in lungs and related to mitochondria are also discussed. Video Abstract.

Hypercapnia in the critically ill: insights from the bench to the bedside

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.

Hypercapnic acidosis induces mitochondrial dysfunction and impairs the ability of mesenchymal stem cells to promote distal lung epithelial repair

Acute respiratory distress syndrome (ARDS) is a devastating disorder characterized by diffuse inflammation and edema formation. The main management strategy, low tidal volume ventilation, can be associated with the development of hypercapnic acidosis (HCA). Mesenchymal stem cells (MSCs) are a promising therapeutic candidate currently in early-phase clinical trials. The effects of HCA on the alveolar epithelium and capillary endothelium are not well established. The therapeutic efficacy of MSCs has never been reported in HCA. In the present study, we evaluated the effects of HCA on inflammatory response and reparative potential of the primary human small airway epithelial and lung microvasculature endothelial cells as well as on the capacity of bone marrow-derived MSCs to promote wound healing in vitro. We demonstrate that HCA attenuates the inflammatory response and reparative potential of primary human small airway epithelium and capillary endothelium and induces mitochondrial dysfunction. It was found that MSCs promote lung epithelial wound repair via the transfer of functional mitochondria; however, this proreparative effect of MSCs was lost in the setting of HCA. Therefore, HCA may adversely impact recovery from ARDS at the cellular level, whereas MSCs may not be therapeutically beneficial in patients with ARDS who develop HCA.-Fergie, N., Todd, N., McClements, L., McAuley, D., O'Kane, C., Krasnodembskaya, A. Hypercapnic acidosis induces mitochondrial dysfunction and impairs the ability of mesenchymal stem cells to promote distal lung epithelial repair.

Protective effects of hypercapnic acidosis on Ischemia-reperfusion-induced retinal injury

Ischemia–reperfusion (I/R) injury is associated with numerous retinal diseases, such as diabetic retinopathy, acute glaucoma, and other vascular retinopathies. Hypercapnic acidosis (HCA) has a protective effect on lung, myocardial, and central nervous system ischemic injury models. However, no study has evaluated its protective effects in an experimental retinal I/R injury model. In this study, retinal I/R injury was induced in Sprague Dawley rats by elevating the intraocular pressure to 110 mmHg for 60 minutes. HCA was induced before and after the injury. After 24 hours, the terminal dUTP nick end labeling assay was performed. Moreover, the ratios of cleaved caspase-3/total caspase-3, phosphorylated IκB/IκB, and phosphorylated p38 were measured through Western blotting. After 7 days, the rats’ aqueous humor was analyzed. In addition, electroretinography and retinal thickness measurement were performed in the rats. Moreover, the retinal neural cell line RGC-5 was exposed to 500 μM H₂O₂ for 24 hours to induce a sustained oxidative stress in vitro. The effects of HCA were evaluated by comparing oxidative stress, MAPK signals, NF-κB signals, survival rates, and apoptosis rates in the RGC-5 cells before and after H₂O₂ exposure. We further investigated whether the potent I/R-protective heat shock protein (HSP) 32 contribute to protective effects of HCA. Our results indicated that HCA has protective effects against retinal I/R injury both in vivo and in vitro, at multiple levels, including antiapoptotic, anti-inflammatory, antioxidative, and functional retinal cell protection. Further research clarifying the role of HCA in retinal I/R injury prevention and treatment is warranted.

The HMGB1-RAGE/TLR-TNF-α signaling pathway may contribute to kidney injury induced by hypoxia

The hypoxia-reoxygenation process of obstructive sleep apnea (OSA) may cause oxidative stress injury of the kidney, but the molecular mechanisms are not clear. The present study aimed to investigate whether high mobility group box 1 protein (HMGB1) and its subsequent inflammatory pathway served a role in kidney injury. Adult Sprague Dawley rats were used to establish hypoxia models: Continuous hypoxia, intermittent hypoxia and intermittent hypoxia with hypercapnia. Rat kidney tissues and peripheral blood samples were obtained. Histopathological and ultrastructural changes were observed by light and electron microscopy. Immunohistochemical (IHC) staining was used to detect the distribution of HMGB1. Reverse transcription-quantitative polymerase chain reaction (RT-qPCR) was used to detect the expression of HMGB1, receptor for advanced glycosylation end products (RAGE), toll-like receptor 4 (TLR4), nuclear factor kappa-light-chain-enhancer of active B cells (NF-κB) p65 subunit, tumor necrosis factor-α (TNF-α), interleukin (IL)-6, NAD-dependent protein deacetylase sirtuin-1 (SIRT1), peroxisome proliferator-activated receptor (PPAR) mRNA in renal tissues. An ELISA was used to detect the expression of soluble TLR2, TLR4, PPAR-γ, TNF-α, IL-6 in peripheral blood. Hematoxylin & eosin staining demonstrated that there was no serious injury to the kidneys due to hypoxia, with the exception of a certain degree of renal tubular epithelial cell vacuolation. By contrast, ultrastructural changes by electron microscopy were more significant in the hypoxia groups compared with the control, including foot process fusion in the glomerulus and degeneration of mitochondria in the proximal convoluted tubules. IHC also indicated increased expression of HMGB1 and nuclear translocation in the hypoxia groups. The results of the RT-qPCR demonstrated that hypoxia stimulation increased the expression of HMGB1, PPAR, RAGE and TNF-α mRNA, and decreased the expression of SIRT1 mRNA in kidney tissues (P<0.05). The results of the ELISA suggested that hypoxia stimulation increased the expression of soluble TLR4, TNF-α and IL-6 in the peripheral blood, and decreased the expression of soluble TLR2 and PPAR-γ. In summary, hypoxia stimulation may cause early renal injury at the subcellular level and increase the expression and translocation of HMGB1. Hypoxia also upregulated the mRNA expression of the HMGB1-RAGE-TNF-α pathway in kidney tissue and increased the expression of soluble TLR4, TNF-α and IL-6 in the peripheral blood. This suggested that the HMGB1-RAGE/TLR-TNF-α pathway may contribute to the molecular mechanisms of early renal injury induced by hypoxia. The pathway may contain potential markers for OSA-associated early renal injury and drug intervention targets in the future.

Intermittent living; the use of ancient challenges as a vaccine against the deleterious effects of modern life - A hypothesis

Chronic non-communicable diseases (CNCD) are the leading cause of mortality in developed countries. They ensue from the sum of modern anthropogenic risk factors, including high calorie nutrition, malnutrition, sedentary lifestyle, social stress, environmental toxins, politics and economic factors. Many of these factors are beyond the span of control of individuals, suggesting that CNCD are inevitable. However, various studies, ours included, show that the use of intermittent challenges with hormetic effects improve subjective and objective wellbeing of individuals with CNCD, while having favourable effects on immunological, metabolic and behavioural indices. Intermittent cold, heat, fasting and hypoxia, together with phytochemicals in multiple food products, have widespread influence on many pathways related with overall health. Until recently, most of the employed challenges with hormetic effects belonged to the usual transient live experiences of our ancestors. Our hypothesis; we conclude that, whereas the total inflammatory load of multi-metabolic and psychological risk factors causes low grade inflammation and aging, the use of intermittent challenges, united in a 7-10 days lasting hormetic intervention, might serve as a vaccine against the deleterious effects of chronic low grade inflammation and it's metabolic and (premature) aging consequences.

Inflammatory Mediators in Tracheal Aspirates of Preterm Infants Participating in a Randomized Trial of Permissive Hypercapnia

BACKGROUND

Ventilator-induced lung injury is considered to be a main factor in the pathogenesis of bronchopulmonary dysplasia (BPD). Optimizing ventilator strategies may reduce respiratory morbidities in preterm infants. Permissive hypercapnia has been suggested to attenuate lung injury. We aimed to determine if a higher PCO₂ target range results in less lung injury compared to the control target range and possibly reduces pro-inflammatory cytokines and acid sphingomyelinase (ASM) in tracheal aspirates (TA), which has not been addressed before.

METHODS

During a multicenter trial of permissive hypercapnia in extremely low birthweight infants (PHELBI), preterm infants (birthweight 400-1,000 g, gestational age 23 0/7-28 6/7 weeks) requiring mechanical ventilation within 24 h of birth were randomly assigned to a high PCO₂ target or a control group. The high target group aimed at PCO₂ values of 55-65, 60-70, and 65-75 mmHg and the control group at PCO₂ values of 40-50, 45-55 and 50-60 mmHg on postnatal days 1-3, 4-6, and 7-14, respectively. TA was analyzed for pro-inflammatory cytokines from postnatal day 2-21. BPD was determined at a postmenstrual age of 36 weeks ± 2 days.

MAIN FINDINGS

Levels of inflammatory cytokines and ASM were similar in both groups: interleukin (IL)-6 (p = 0.14), IL-8 (p = 0.43), IL-10 (p = 0.24), IL-1β (p = 0.11), macrophage inflammatory protein 1α (p = 0.44), albumin (p = 0.41), neuropeptide Y (p = 0.52), leukotriene B₄ (p = 0.11), transforming growth factor-β₁ (p = 0.68), nitrite (p = 0.15), and ASM (p = 0.94). Furthermore, most inflammatory mediators were strongly affected by the age of the infants and increased from postnatal day 2 to 21. BPD or death was observed in 14 out of 62 infants, who were distributed evenly between both groups.

CONCLUSION

The results suggest that high PCO₂ target levels did not result in lower pulmonary inflammatory activity and thus reflect clinical results. This indicates that high PCO₂ target ranges are not effective in reducing ventilator-induced lung injury in preterm infants, as compared to control targets.

TRIAL REGISTRATION

ISRCTN56143743.