Effect of different ventilatory strategies on local and systemic cytokine production in intact swine lungs in vivo

Constant Tidal Volume Ventilation and Surfactant Dysfunction: An Overlooked Cause of Ventilator-Induced Lung Injury

Ventilator-induced lung injury (VILI) is currently ascribed to volutrauma and/or atelectrauma but the effect of constant tidal volume ventilation (CVTV) has received little attention. This Perspective summarizes the literature documenting that CVTV causes VILI and reviews the mechanisms by which it occurs. Surfactant is continuously inactivated, depleted, displaced or desorbed as a function of the duration of ventilation, the tidal volume, the level of PEEP and possibly the respiratory rate. Accordingly, surfactant must be continuously replenished and secretion primarily depends on intermittent delivery of large ventilatory excursions. The surfactant abnormalities resulting from CVTV result in atelectasis and VILI. While surfactant secretion is reduced by the absence of intermittent deep breaths continuous administration of large tidal volumes depletes surfactant and impairs subsequent secretion. Low or normal lung volumes result in desorption of surfactant. PEEP can be protective by reducing surface film collapse and subsequent film rupture on re-expansion, and/or by reducing surfactant displacement into the airways, but PEEP can also down-regulate surfactant release. Conclusions: The effect of CVTV on surfactant is complex. If attention is not paid to facilitating surfactant secretion and limiting its inactivation, depletion, desorption or displacement surface tension will increase and atelectasis and VILI will occur.

Ventilation with lower tidal volumes for critically ill patients without the acute respiratory distress syndrome: a systematic translational review and meta-analysis

PURPOSE OF REVIEW

There is convincing evidence for benefit from lung-protective mechanical ventilation with lower tidal volumes in patients with the acute respiratory distress syndrome (ARDS). It is uncertain whether this strategy benefits critically ill patients without ARDS as well. This manuscript systematically reviews recent preclinical studies of ventilation in animals with uninjured lungs, and clinical trials of ventilation in ICU patients without ARDS on the association between tidal volume size and pulmonary complications and outcome.

RECENT FINDINGS

Successive preclinical studies almost without exception show that ventilation with lower tidal volumes reduces the injurious effects of ventilation in animals with uninjured lungs. This finding is in line with results from recent trials in ICU patients without ARDS, demonstrating that ventilation with lower tidal volumes has a strong potential to prevent development of pulmonary complications and maybe even to improve survival. However, evidence mostly comes from nonrandomized clinical trials, and concerns are expressed regarding unselected use of lower tidal volumes in the ICU, that is, in all ventilated critically ill patients, since this strategy could also increase needs for sedation and/or neuromuscular blockade, and maybe even cause respiratory muscle fatigue. These all then could in fact worsen outcome, possibly counteracting the beneficial effects of ventilation with lower tidal volumes.

SUMMARY

Ventilation with lower tidal volumes protects against pulmonary complications, but well-powered randomized controlled trials are urgently needed to determine whether this ventilation strategy truly benefits all ventilated ICU patients without ARDS.

Expression levels of immune markers in Actinobacillus pleuropneumoniae infected pigs and their relation to breed and clinical symptoms

Background

In pigs little is known about the role of innate immune defence in bacterial infections of the respiratory tract, despite their major role in pig production. In the present study we characterized and compared in vitro and in vivo activation of immune markers of different pig breeds 7 days before, and 4 and 21 days after an experimental aerosol infection with Actinobacillus (A.) pleuropneumoniae.

Results

In vitro stimulation of bronchoalveolar lavage fluid (BALF) and blood leukocytes with A. pleuropneumoniae, Streptococcus suis, PMA and LPS led to production of different amounts of H₂O₂, NO and TNF-α, depending on the stimulus, individual, breed and time of infection. Generally, significant responses to in vitro stimulation were observed only in blood leukocytes, whereas the alveolar macrophages showed a high basal activation. In addition, the production of haptoglobin and cytokines (TNF-α, IFN-γ and IL-10) in vivo was measured in plasma and BALF. Plasma haptoglobin levels mirrored the clinical manifestations at 4 days post-infection. In plasma and BALF TNF-α could not be detected, whereas variable levels of IFN-γ were found at pre- and post-infection times. IL-10 was found in some plasma but in none of the BALF samples. The different expression levels in individuals within the breeds correlated for some markers with the severity of clinical manifestations, e.g. H₂O_2, plasma haptoglobin and BALF IFN-γ for German Landrace pigs.

Conclusion

Our findings revealed differences in the activation of the immune markers with respect to infection time, individuals and breeds. Moreover, results showed different correlation grades between the immune markers produced in vitro or in vivo and the clinical manifestations. Further analyses will have to show whether these markers may serve as correlates of protection against porcine respiratory infections.