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Herrera MT, Guzmán-Beltrán S, Bobadilla K, Santos-Mendoza T, Flores-Valdez MA, Gutiérrez-González LH, González Y. Human Pulmonary Tuberculosis: Understanding the Immune Response in the Bronchoalveolar System. Biomolecules 2022; 12:biom12081148. [PMID: 36009042 PMCID: PMC9405639 DOI: 10.3390/biom12081148] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 08/10/2022] [Accepted: 08/17/2022] [Indexed: 11/23/2022] Open
Abstract
Mycobacterium tuberculosis, the causal agent of one of the most devastating infectious diseases worldwide, can evade or modulate the host immune response and remain dormant for many years. In this review, we focus on identifying the local immune response induced in vivo by M. tuberculosis in the lungs of patients with active tuberculosis by analyzing data from untouched cells from bronchoalveolar lavage fluid (BALF) or exhaled breath condensate (EBC) samples. The most abundant resident cells in patients with active tuberculosis are macrophages and lymphocytes, which facilitate the recruitment of neutrophils. The cellular response is characterized by an inflammatory state and oxidative stress produced mainly by macrophages and T lymphocytes. In the alveolar microenvironment, the levels of cytokines such as interleukins (IL), chemokines, and matrix metalloproteinases (MMP) are increased compared with healthy patients. The production of cytokines such as interferon (IFN)-γ and IL-17 and specific immunoglobulin (Ig) A and G against M. tuberculosis indicate that the adaptive immune response is induced despite the presence of a chronic infection. The role of epithelial cells, the processing and presentation of antigens by macrophages and dendritic cells, as well as the role of tissue-resident memory T cells (Trm) for in situ vaccination remains to be understood.
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Affiliation(s)
- María Teresa Herrera
- Department of Microbiology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
| | - Silvia Guzmán-Beltrán
- Department of Microbiology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
| | - Karen Bobadilla
- Laboratory of Transcriptomics and Molecular Immunology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
| | - Teresa Santos-Mendoza
- Laboratory of Transcriptomics and Molecular Immunology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
| | - Mario Alberto Flores-Valdez
- Biotecnología Médica y Farmacéutica, Centro de Investigación y Asistencia en Tecnología y Diseño del Estado de Jalisco, A.C., Guadalajara 44270, Mexico
| | - Luis Horacio Gutiérrez-González
- Laboratory of Transcriptomics and Molecular Immunology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
- Correspondence: (L.H.G.-G.); (Y.G.); Tel.: +52-55-5487-1700 (ext. 5117) (Y.G.)
| | - Yolanda González
- Department of Microbiology, National Institute for Respiratory Diseases Ismael Cosío Villegas, Mexico City 14080, Mexico
- Correspondence: (L.H.G.-G.); (Y.G.); Tel.: +52-55-5487-1700 (ext. 5117) (Y.G.)
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Chen L, Xiang F, Hu Y. Corticosteroids in patients undergoing cardiac surgery: A meta-analysis of 12,559 patients. Perfusion 2022; 38:853-859. [PMID: 35657725 DOI: 10.1177/02676591221106324] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Corticosteroids can attenuate the inflammatory response to cardiopulmonary bypass, but their benefits on clinical outcomes are unclear. We conducted a meta-analysis to evaluate whether corticosteroid therapy affects outcomes in patients undergoing cardiac surgery. METHODS We searched PubMed, Embase, EBSCO and Cochrane databases from 1 January 2010 to 14 March 2022 for randomized controlled trials (RCTs) that assessed corticosteroid versus non- corticosteroid therapy in patients undergoing cardiac surgery. The primary outcome was in-hospital mortality. Secondary outcomes were renal failure, infection, delirium, intensive care unit (ICU) and hospital stay. RESULTS Four RCTs including 12,559 patients (6265 randomized to corticosteroid therapy and 6294 to non-corticosteroid therapy) were included. One-hundred and 92 of 6265 patients (3.1%) randomized to the corticosteroid group versus 221 of 6294 patients (3.5%) randomized to the non-corticosteroid group experienced death during hospitalization. Compared the control group, corticosteroid therapy did not significantly reduce in-hospital mortality, with an RR of 0.87 (0.72-1.06), p = .16. There was no difference in the incidence of infection (RR 0.78 (0.56-1.10), p = .16), delirium during hospitalization (RR 1.01 (0.90-1.14), p = .85), or the length of hospital stay (MD -0.13 (-0.32 to 0.05), p = .17). However, corticosteroid therapy significantly reduced the risk of renal failure ( RR 0.82 (0.67-0.99), p = .04), and the length of ICU stay (MD -0.41 (-0.65 to -0.17), p < .01). CONCLUSIONS Corticosteroids did not significantly reduce the rates of in-hospital mortality, infection, or delirium, but reduce the incidence of renal failure and the length of ICU stay.
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Affiliation(s)
- Lei Chen
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Feng Xiang
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
| | - Yiyi Hu
- Department of Pharmacy, 26452The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, People's Republic of China
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3
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Kong M, Wei D, Li X, Zhu X, Hong Z, Ni M, Wang Y, Dong A. The dynamic changes in autophagy activity and its role in lung injury after deep hypothermic circulatory arrest. J Cell Mol Med 2022; 26:1113-1127. [PMID: 35014165 PMCID: PMC8831962 DOI: 10.1111/jcmm.17165] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/22/2021] [Accepted: 12/09/2021] [Indexed: 12/27/2022] Open
Abstract
Deep hypothermic circulatory arrest (DHCA) can cause acute lung injury (ALI), and its pathogenesis mimics ischaemia/reperfusion (I/R) injury. Autophagy is also involved in lung I/R injury. The present study aimed to elucidate whether DHCA induces natural autophagy activation and its role in DHCA‐mediated lung injury. Here, rats were randomly assigned to the Sham or DHCA group. The sham group (n = 5) only received anaesthesia and air intubation. DHCA group rats underwent cardiopulmonary bypass (CPB) followed by the DHCA procedure. The rats were then sacrificed at 3, 6 and 24 h after the DHCA procedure (n = 5) to measure lung injury and autophagy activity. Chloroquine (CQ) was delivered to evaluate autophagic flux. DHCA caused lung injury, which was prominent 3–6 h after DHCA, as confirmed by histological examination and inflammatory cytokine quantification. Lung injury subsided at 24 h. Autophagy was suppressed 3 h but was exaggerated at 6 h. At both time points, autophagic flux appeared uninterrupted. To further assess the role of autophagy in DHCA‐mediated lung injury, the autophagy inducer rapamycin and its inhibitor 3‐methyladenine (3‐MA) were applied, and lung injury was reassessed. When rapamycin was administered at an early time point, lung injury worsened, whereas administration of 3‐MA at a late time point ameliorated lung injury, indicating that autophagy contributed to lung injury after DHCA. Our study presents a time course of lung injury following DHCA. Autophagy showed adaptive yet protective suppression 3 h after DHCA, as induction of autophagy caused worsening of lung tissue. In contrast, autophagy was exaggerated 6 h after DHCA, and autophagy inhibition attenuated DHCA‐mediated lung injury.
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Affiliation(s)
- Minjian Kong
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Dongdong Wei
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xuebiao Li
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xian Zhu
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ze Hong
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ming Ni
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Yifan Wang
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Aiqiang Dong
- Department of Cardiovascular Surgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
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4
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Xiaowei M, Wei Z, Qiang W, Yiqian N, Yanjie N, Liyan J. Assessment of systemic immune-inflammation index in predicting postoperative pulmonary complications in patients undergoing lung cancer resection. Surgery 2022; 172:365-370. [DOI: 10.1016/j.surg.2021.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 12/17/2021] [Accepted: 12/19/2021] [Indexed: 12/14/2022]
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Oxidative Stress and Inflammatory Mediators in Exhaled Breath Condensate of Patients with Pulmonary Tuberculosis. A Pilot Study with a Biomarker Perspective. Antioxidants (Basel) 2021; 10:antiox10101572. [PMID: 34679707 PMCID: PMC8533495 DOI: 10.3390/antiox10101572] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/22/2021] [Accepted: 09/23/2021] [Indexed: 12/21/2022] Open
Abstract
Tuberculosis (TB) is one of the highest infectious burdens worldwide. An excess of inflammation and inadequate antioxidant defense mechanisms are believed to lead to chronic inflammation and lung damage in tuberculosis (TB). However, circulating metabolites do not always replicate lung-associated biomarkers that define the pathobiology of the disease. The objective of this study was to determine the utility of exhaled breath condensate (EBC), a non-invasive and straightforward sample, to evaluate alveolar space-derived metabolites of redox state and inflammation. We assessed the levels of exhaled oxidant/antioxidant parameters (8-isoprostane, MDA, GSH), inflammatory markers, such as nucleosomes, cytokines (IL-2, IL-4, IL-6 and IL-8, IL-10, GM-CSF, TNF-α, and IFN-γ) and lipid mediators (PGE2, LTB4, RvD1, and Mar1), in patients with recently diagnosed pulmonary TB and healthy controls’ EBC and serum. The TB patients showed 36% lower GSH levels, and 2-, 1.4-, 1.1-, and 50-fold higher levels of 8-isoprostanes, nucleosomes, IL-6, and LTB4, respectively, in EBC. There was no correlation between EBC and serum, highlighting the importance of measuring local biomarkers. Quantitation of local inflammatory molecules and redox states in EBC would help find biomarkers useful for pharmacological and follow-up studies in pulmonary tuberculosis.
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Yen E, Weinberger BI, Laumbach RJ, Ohman-Strickland PA, Vetrano AM, Gow AM, Ramagopal M. Exhaled breath condensate nitrite in premature infants with bronchopulmonary dysplasia. J Neonatal Perinatal Med 2019; 11:399-407. [PMID: 30040745 DOI: 10.3233/npm-17106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Tracheal aspirate is the conventional method to measure biomarkers of inflammation and oxidation from premature infants on mechanical ventilation at risk for bronchopulmonary dysplasia (BPD), but this method is invasive. Exhaled breath condensate (EBC) is a novel, non-invasive method that has been used in older populations. Nitrite, a stable metabolite of nitric oxide (NO), is elevated in inflammatory conditions. We aim to investigate the feasibility of EBC nitrite collection from ventilated premature infants and to quantify EBC nitrite in infants with and without BPD. We hypothesize that EBC nitrite correlates with TA nitrite, and that EBC nitrite in the first week of life is higher in infants who will develop BPD than those without BPD. METHODS In a pilot prospective cohort study, TA and EBC were collected in the first week of life from mechanically ventilated premature infants. Nitrite levels were measured using chemiluminescence. RESULTS EBC nitrite significantly correlated with TA nitrite (r = 0.45, p = 0.025). Of 40 infants, 33 (82.5%) developed BPD. EBC and TA nitrite levels collected in the first week of life had a higher trend in infants with BPD than those without BPD (p = 0.23 and 0.38 respectively). CONCLUSIONS Higher trend of EBC nitrite in the first week of life was associated with the development of BPD. Correlation of nitrite level in EBC with that in TA (conventional method) highlights the utility of EBC as an alternative, non-invasive method to measure inflammation. Further refinement of conditions and timing may optimize the predictive value of EBC nitrite.
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Affiliation(s)
- E Yen
- Department of Pediatrics, Floating Hospital for Children at Tufts Medical Center, Boston, MA, USA.,Department of Pediatrics, Rutgers Robert Wood Johnson Medical School (RWJMS), New Brunswick, NJ, USA
| | - B I Weinberger
- Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, NY, USA
| | - R J Laumbach
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, NJ, USA
| | - P A Ohman-Strickland
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, NJ, USA
| | - A M Vetrano
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School (RWJMS), New Brunswick, NJ, USA
| | - A M Gow
- Environmental and Occupational Health Sciences Institute, Rutgers University, Piscataway, NJ, USA
| | - M Ramagopal
- Department of Pediatrics, Rutgers Robert Wood Johnson Medical School (RWJMS), New Brunswick, NJ, USA
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Peterová E, Chládek J, Kohoutová D, Knoblochová V, Morávková P, Vávrová J, Řezáčová M, Bureš J. Exhaled Breath Condensate: Pilot Study of the Method and Initial Experience in Healthy Subjects. ACTA MEDICA (HRADEC KRÁLOVÉ) 2018; 61:8-16. [PMID: 30012244 DOI: 10.14712/18059694.2018.17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Analysis of Exhaled breath condensate (EBC) is a re-discovered approach to monitoring the course of the disease and reduce invasive methods of patient investigation. However, the major disadvantage and shortcoming of the EBC is lack of reliable and reproducible standardization of the method. Despite many articles published on EBC, until now there is no clear consensus on whether the analysis of EBC can provide a clue to diagnosis of the diseases. The purpose of this paper is to investigate our own method, to search for possible standardization and to obtain our own initial experience. Thirty healthy volunteers provided the EBC, in which we monitored the density, pH, protein, chloride and urea concentration. Our results show that EBC pH is influenced by smoking, and urea concentrations are affected by the gender of subjects. Age of subjects does not play a role. The smallest coefficient of variation between individual volunteers is for density determination. Current limitations of EBC measurements are the low concentration of many biomarkers. Standardization needs to be specific for each individual biomarker, with focusing on optimal condensate collection. EBC analysis has a potential become diagnostic test, not only for lung diseases.
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Affiliation(s)
- Eva Peterová
- 2nd Department of Internal Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Hospital Hradec Králové, Czech Republic. .,Department of Medical Biochemistry, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic.
| | - Jaroslav Chládek
- Department of Pharmacology, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic
| | - Darina Kohoutová
- 2nd Department of Internal Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Hospital Hradec Králové, Czech Republic
| | - Veronika Knoblochová
- 2nd Department of Internal Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Hospital Hradec Králové, Czech Republic
| | - Paula Morávková
- 2nd Department of Internal Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Hospital Hradec Králové, Czech Republic
| | - Jaroslava Vávrová
- Institute of Clinical Biochemistry and Diagnostics, Charles University, Faculty of Medicine in Hradec Králové, University Hospital Hradec Králové, Czech Republic
| | - Martina Řezáčová
- Department of Medical Biochemistry, Charles University, Faculty of Medicine in Hradec Králové, Czech Republic
| | - Jan Bureš
- 2nd Department of Internal Medicine - Gastroenterology, Charles University, Faculty of Medicine in Hradec Králové, University Hospital Hradec Králové, Czech Republic
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8
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A feasibility study into adenosine triphosphate measurement in exhaled breath condensate: a potential bedside method to monitor alveolar deformation. Purinergic Signal 2018; 14:215-221. [PMID: 29752619 PMCID: PMC6107466 DOI: 10.1007/s11302-018-9607-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 04/24/2018] [Indexed: 12/13/2022] Open
Abstract
Recent research suggested an important role for pulmonary extracellular adenosine triphosphate (ATP) in the development of ventilation-induced lung injury. This injury is induced by mechanical deformation of alveolar epithelial cells, which in turn release ATP to the extracellular space. Measuring extracellular ATP in exhaled breath condensate (EBC) may be a non-invasive biomarker for alveolar deformation. Here, we study the feasibility of bedside ATP measurement in EBC. We measured ATP levels in EBC in ten subjects before and after an exercise test, which increases respiratory parameters and alveolar deformation. EBC lactate concentrations were measured as a dilution marker. We found a significant increase in ATP levels in EBC (before 73 RLU [IQR 50–209] versus after 112 RLU [IQR 86–203]; p value 0.047), and the EBC ATP-to-EBC lactate ratio increased as well (p value 0.037). We present evidence that bedside measurement of ATP in EBC is feasible and that ATP levels in EBC increase after exercise. Future research should measure ATP levels in EBC during mechanical ventilation as a potential biomarker for alveolar deformation.
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Romano R, Cristescu SM, Risby TH, Marczin N. Lipid peroxidation in cardiac surgery: towards consensus on biomonitoring, diagnostic tools and therapeutic implementation. J Breath Res 2018; 12:027109. [PMID: 29104182 DOI: 10.1088/1752-7163/aa9856] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This review focuses on oxidative stress and more specifically lipid peroxidation in cardiac surgery, one of the fundamental theories of perioperative complications. We present the molecular pathways leading to lipid peroxidation and integrate analytical methods that allow detection of lipid peroxidation markers in the fluid phase with those focusing on volatile compounds in exhaled breath. In order to explore the accumulated data in the literature, we present a systematic review of quantitative analysis of malondialdehyde, a widely used lipid peroxidation product at various stages of cardiac surgery. This exploration reveals major limitations of existing studies in terms of variability of reported values and significant gaps due to discrete and variable sampling times during surgery. We also appraise methodologies that allow real-time and continuous monitoring of oxidative stress. Complimentary techniques highlight that beyond the widely acclaimed contribution of the cardiopulmonary bypass technology and myocardial reperfusion injury, the use of diathermy contributes significantly to intraoperative lipid peroxidation. We conclude that there is an urgent need to implement the theory of oxidative stress towards a paradigm change in the clinical practice. Firstly, we need to acquire definite and irrefutable information on the link between lipid peroxidation and post-operative complications by building international consensus on best analytical approaches towards generating qualitatively and quantitatively comparable datasets in coordinated multicentre studies. Secondly, we should move away from routine low-risk surgeries towards higher risk interventions where there is major unmet clinical need for improving patient journey and outcomes. There is also need for consensus on best therapeutic interventions which could be tested in convincing large scale clinical trials. As future directions, we propose combination of fluid phase platforms and 'metabography', an extended form of capnography-including real-time analysis of lipid peroxidation and volatile footprints of metabolism-for better patient phenotyping prior to and during high risk surgery towards molecular prediction, stratification and monitoring of the patient's journey.
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Affiliation(s)
- Rosalba Romano
- Section of Anaesthetics, Pain Medicine and Intensive Care, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, United Kingdom
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Vento DA, Silveira APC, Arcencio L, Albuquerque AAS, Bottura C, Jordão A, Evora PRB, Rodrigues AJ. An adaptation for exhaled breath condensate collection in rabbits. Exp Lung Res 2016; 42:232-6. [PMID: 27362815 DOI: 10.1080/01902148.2016.1196268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AIM To set up and test the feasibility of a handmade apparatus adapted for exhaled breath condensate (EBC) collection in medium-sized animals. MATERIALS AND METHODS The apparatus was produced using an 18-mm thick u-shaped borosilicate glass. The u-shaped tube body is 25 cm in diameter, and the horizontal portions are 12 cm in diameter. The base consists of a tube joint 14/20 or 14 mm thick by 20 cm in diameter, and has a length of 5 cm. This has a hole that is plugged for condensate flow to a 1.5 mL polypropylene microtube that stores the condensate during collection. Was placed inside a styrofoam box and immersed in crushed ice and salt to ensure cooling. The temperature was monitored and maintained throughout the collection at -10°C. One of the outputs of the u-shaped tube was connected to the expiratory limb of the ventilator. RESULTS An experimental model of ALI, induced by oleic acid (OA) was adopted to determine the concentration of biomarkers of oxidative stress: malondialdehyde (MDA), glutathione (GSH), and nitrite/nitrate (NOx). The proposed model allows measurement of NOx, MDA, and GSH. However, the NOx and MDA levels in the EBC were not significant. It was only possible to observe an upward trend, which suggests a temporal evolution of the presence of these markers in the EBC. CONCLUSION The EBC collection method adapted is effective to generate sufficient content that allows to determine the levels of different biomarkers, such as NOx, MDA, and GSH, that are involved in oxidative and inflammatory stress processes during respiratory diseases.
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Affiliation(s)
- Daniella Alves Vento
- a Department of Surgery and Anatomy , Ribeirão Preto School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Ana Paula Cassiano Silveira
- a Department of Surgery and Anatomy , Ribeirão Preto School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Livia Arcencio
- a Department of Surgery and Anatomy , Ribeirão Preto School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Agnes A S Albuquerque
- a Department of Surgery and Anatomy , Ribeirão Preto School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Camila Bottura
- a Department of Surgery and Anatomy , Ribeirão Preto School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Alceu Jordão
- b Department of Metabolism and Nutrition , Ribeirão Preto School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Paulo Roberto Barbosa Evora
- a Department of Surgery and Anatomy , Ribeirão Preto School of Medicine, University of São Paulo , São Paulo , Brazil
| | - Alfredo José Rodrigues
- a Department of Surgery and Anatomy , Ribeirão Preto School of Medicine, University of São Paulo , São Paulo , Brazil
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Bastin AJ, Davies N, Lim E, Quinlan GJ, Griffiths MJ. Systemic inflammation and oxidative stress post-lung resection: Effect of pretreatment with N-acetylcysteine. Respirology 2015; 21:180-7. [PMID: 26503312 DOI: 10.1111/resp.12662] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 06/03/2015] [Accepted: 07/28/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE N-acetylcysteine has been used to treat a variety of lung diseases, where is it thought to have an antioxidant effect. In a randomized placebo-controlled double-blind study, the effect of N-acetylcysteine on systemic inflammation and oxidative damage was examined in patients undergoing lung resection, a human model of acute lung injury. METHODS Eligible adults were randomized to receive preoperative infusion of N-acetylcysteine (240 mg/kg over 12 h) or placebo. Plasma thiols, interleukin-6, 8-isoprostane, ischaemia-modified albumin, red blood cell glutathione and exhaled breath condensate pH were measured pre- and post-operatively as markers of local and systemic inflammation and oxidative stress. RESULTS Patients undergoing lung resection and one-lung ventilation exhibited significant postoperative inflammation and oxidative damage. Postoperative plasma thiol concentration was significantly higher in the N-acetylcysteine-treated group. However, there was no significant difference in any of the measured biomarkers of inflammation or oxidative damage, or in clinical outcomes, between N-acetylcysteine and placebo groups. CONCLUSION Preoperative administration of N-acetylcysteine did not attenuate postoperative systemic or pulmonary inflammation or oxidative damage after lung resection. CLINICAL TRIAL REGISTRATION NCT00655928 at ClinicalTrials.gov.
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Affiliation(s)
| | - Nathan Davies
- Liver Failure Group, UCL Institute for Liver and Digestive Health, Royal Free Hospital Campus, University College of London (UCL), London, UK
| | - Eric Lim
- Academic Division of Thoracic Surgery, Royal Brompton & Harefield NHS Foundation Trust, UK National Heart and Lung Division, Imperial College, London, UK
| | - Greg J Quinlan
- National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK.,Vascular Biology, National Heart and Lung Institute, Imperial College London, London, UK
| | - Mark J Griffiths
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK.,National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust and Imperial College, London, UK.,Leukocyte Biology, National Heart and Lung Institute, Imperial College London, London, UK
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12
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Duffy MJ, O'Kane CM, Stevenson M, Young IS, Harkin DW, Mullan BA, McAuley DF. A randomized clinical trial of ascorbic acid in open abdominal aortic aneurysm repair. Intensive Care Med Exp 2015. [PMID: 26215814 PMCID: PMC4486645 DOI: 10.1186/s40635-015-0050-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background Open AAA repair is associated with ischaemia-reperfusion injury where systemic inflammation and endothelial dysfunction can lead to multiple organ injury including acute lung injury. Oxidative stress plays a role that may be inhibited by ascorbic acid. Methods A double blind, allocation concealed, randomized placebo-controlled trial was performed to test the hypothesis that a single bolus dose (2g) of intra-operative parenteral ascorbic acid would attenuate biomarkers of ischaemia-reperfusion injury in patients undergoing elective open AAA repair. Results Thirty one patients completed the study; 18 received placebo and 13 ascorbic acid. Groups were comparable demographically. Open AAA repair caused an increase in urinary Albumin:Creatinine Ratio (ACR) as well as plasma IL-6 and IL-8. There was a decrease in exhaled breath pH and oxygenation. Lipid hydroperoxides were significantly higher in the ascorbic acid group following open AAA repair. There were no other differences between the ascorbic acid or placebo groups up to 4 hours after removal of the aortic clamping. Conclusions Open AAA repair caused an increase in markers of systemic endothelial damage and systemic inflammation. Administration of 2g parenteral ascorbic acid did not attenuate this response and with higher levels of lipid hydroperoxides post-operatively a pro-oxidant effect could not be excluded. Trial registration ISRCTN27369400
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Affiliation(s)
- Martin J Duffy
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK,
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13
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García-de-la-Asunción J, García-del-Olmo E, Perez-Griera J, Martí F, Galan G, Morcillo A, Wins R, Guijarro R, Arnau A, Sarriá B, García-Raimundo M, Belda J. Oxidative lung injury correlates with one-lung ventilation time during pulmonary lobectomy: a study of exhaled breath condensate and blood. Eur J Cardiothorac Surg 2015; 48:e37-44. [PMID: 26088589 DOI: 10.1093/ejcts/ezv207] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 05/07/2015] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES During lung lobectomy, the operated lung is collapsed and hypoperfused; oxygen deprivation is accompanied by reactive hypoxic pulmonary vasoconstriction. After lung lobectomy, ischaemia present in the collapsed state is followed by expansion-reperfusion and lung injury attributed to the production of reactive oxygen species. The primary objective of this study was to investigate the time course of several markers of oxidative stress simultaneously in exhaled breath condensate and blood and to determine the relationship between oxidative stress and one-lung ventilation time in patients undergoing lung lobectomy. METHODS This single-centre, observational, prospective study included 28 patients with non-small-cell lung cancer who underwent lung lobectomy. We measured the levels of hydrogen peroxide, 8-iso-PGF2α, nitrites plus nitrates and pH in exhaled breath condensate (n = 25). The levels of 8-iso-PGF2α and nitrites plus nitrates were also measured in blood (n = 28). Blood samples and exhaled breath condensate samples were collected from all patients at five time points: preoperatively; during one-lung ventilation, immediately before resuming two-lung ventilation; immediately after resuming two-lung ventilation; 60 min after resuming two-lung ventilation and 180 min after resuming two-lung ventilation. RESULTS Both exhaled breath condensate and blood exhibited significant and simultaneous increases in oxidative-stress markers immediately before two-lung ventilation was resumed. However, all these values underwent larger increases immediately after resuming two-lung ventilation. In both exhaled breath condensate and blood, marker levels significantly and directly correlated with the duration of one-lung ventilation immediately before resuming two-lung ventilation and immediately after resuming two-lung ventilation. Although pH significantly decreased in exhaled breath condensate immediately after resuming two-lung ventilation, these pH values were inversely correlated with the duration of one-lung ventilation. CONCLUSIONS During lung lobectomy, the operated lung is collapsed and oxidative injury occurs, with the levels of markers of oxidative stress increasing simultaneously in exhaled breath condensate and blood during one-lung ventilation. These increases were larger after resuming two-lung ventilation. Increases immediately before resuming two-lung ventilation and immediately after resuming two-lung ventilation were directly correlated with the duration of one-lung ventilation.
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Affiliation(s)
- José García-de-la-Asunción
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valencia, Fundación Investigación Clínico de Valencia, Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain
| | - Eva García-del-Olmo
- Department of Thoracic Surgery, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Jaume Perez-Griera
- Laboratory of Biochemistry, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Francisco Martí
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valencia, Fundación Investigación Clínico de Valencia, Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain
| | - Genaro Galan
- Department of Thoracic Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Alfonso Morcillo
- Department of Thoracic Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Richard Wins
- Department of Thoracic Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Ricardo Guijarro
- Department of Thoracic Surgery, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Antonio Arnau
- Department of Thoracic Surgery, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - Benjamín Sarriá
- Department of Pharmacology, University of Valencia, Valencia, Spain
| | - Miguel García-Raimundo
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valencia, Fundación Investigación Clínico de Valencia, Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain
| | - Javier Belda
- Department of Anaesthesiology and Critical Care, Hospital Clínico Universitario de Valencia, Fundación Investigación Clínico de Valencia, Instituto de Investigación Sanitaria (INCLIVA), Valencia, Spain
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Exhaled Breath Condensate: Technical and Diagnostic Aspects. ScientificWorldJournal 2015; 2015:435160. [PMID: 26106641 PMCID: PMC4461795 DOI: 10.1155/2015/435160] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/21/2015] [Indexed: 01/18/2023] Open
Abstract
Purpose. The aim of this study was to evaluate the 30-year progress of research on exhaled breath condensate in a disease-based approach. Methods. We searched PubMed/Medline, ScienceDirect, and Google Scholar using the following keywords: exhaled breath condensate (EBC), biomarkers, pH, asthma, gastroesophageal reflux (GERD), smoking, COPD, lung cancer, NSCLC, mechanical ventilation, cystic fibrosis, pulmonary arterial hypertension (PAH), idiopathic pulmonary fibrosis, interstitial lung diseases, obstructive sleep apnea (OSA), and drugs. Results. We found 12600 related articles in total in Google Scholar, 1807 in ScienceDirect, and 1081 in PubMed/Medline, published from 1980 to October 2014. 228 original investigation and review articles were eligible. Conclusions. There is rapidly increasing number of innovative articles, covering all the areas of modern respiratory medicine and expanding EBC potential clinical applications to other fields of internal medicine. However, the majority of published papers represent the results of small-scale studies and thus current knowledge must be further evaluated in large cohorts. In regard to the potential clinical use of EBC-analysis, several limitations must be pointed out, including poor reproducibility of biomarkers and absence of large surveys towards determination of reference-normal values. In conclusion, contemporary EBC-analysis is an intriguing achievement, but still in early stage when it comes to its application in clinical practice.
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Early effect of tidal volume on lung injury biomarkers in surgical patients with healthy lungs. Anesthesiology 2014; 121:469-81. [PMID: 24809976 DOI: 10.1097/aln.0000000000000301] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The early biological impact of short-term mechanical ventilation on healthy lungs is unknown. The authors aimed to characterize the immediate tidal volume (VT)-related changes on lung injury biomarkers in patients with healthy lungs and low risk of pulmonary complications. METHODS Twenty-eight healthy patients for knee replacement surgery were prospectively randomized to volume-controlled ventilation with VT 6 (VT6) or 10 (VT10) ml/kg predicted body weight. General anesthesia and other ventilatory parameters (positive end-expiratory pressure, 5 cm H2O, FIO2, 0.5, respiratory rate titrated for normocapnia) were managed similarly in the two groups. Exhaled breath condensate and blood samples were collected for nitrite, nitrate, tumor necrosis factor-α, interleukins-1β, -6, -8, -10, -11, neutrophil elastase, and Clara Cell protein 16 measurements, at the onset of ventilation and 60 min later. RESULTS No significant differences in biomarkers were detected between the VT groups at any time. The coefficient of variation of exhaled breath condensate nitrite and nitrate decreased in the VT6 but increased in the VT10 group after 60-min ventilation. Sixty-minute ventilation significantly increased plasma neutrophil elastase levels in the VT6 (35.2 ± 30.4 vs. 56.4 ± 51.7 ng/ml, P = 0.008) and Clara Cell protein 16 levels in the VT10 group (16.4 ± 8.8 vs. 18.7 ± 9.5 ng/ml, P = 0.015). Exhaled breath condensate nitrite correlated with plateau pressure (r = 0.27, P = 0.042) and plasma neutrophil elastase (r = 0.44, P = 0.001). Plasma Clara Cell protein 16 correlated with compliance (r = 0.34, P = 0.014). CONCLUSIONS No tidal volume-related changes were observed in the selected lung injury biomarkers of patients with healthy lungs after 60-min ventilation. Plasma neutrophil elastase and plasma Clara Cell protein 16 might indicate atelectrauma and lung distention, respectively.
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Jones RO, Brittan M, Anderson NH, Conway Morris A, Murchison JT, Walker WS, Simpson AJ. Serial characterisation of monocyte and neutrophil function after lung resection. BMJ Open Respir Res 2014; 1:e000045. [PMID: 25478189 PMCID: PMC4212786 DOI: 10.1136/bmjresp-2014-000045] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2014] [Revised: 07/15/2014] [Accepted: 07/19/2014] [Indexed: 01/28/2023] Open
Abstract
Objectives The primary aim of this prospective study was to perform a comprehensive serial characterisation of monocyte and neutrophil function, circulating monocyte subsets, and bronchoalveolar lavage (BAL) fluid after lung resection. A secondary aim was to perform a pilot, hypothesis-generating evaluation of whether innate immune parameters were associated with postoperative pneumonia. Methods Forty patients undergoing lung resection were studied in detail. Blood monocytes and neutrophils were isolated preoperatively and at 6, 24 and 48 h postoperatively. BAL was performed preoperatively and immediately postoperatively. Monocyte subsets, monocyte responsiveness to lipopolysaccharide (LPS) and neutrophil phagocytic capacity were quantified at all time points. Differential cell count, protein and cytokine concentrations were measured in BAL. Pneumonia evaluation at 72 h was assessed using predefined criteria. Results After surgery, circulating subsets of classical and intermediate monocytes increased significantly. LPS-induced release of proinflammatory cytokines from monocytes increased significantly and by 48 h a more proinflammatory profile was found. Neutrophil phagocytosis demonstrated a small but significant fall. Factors associated with postoperative pneumonia were: increased release of specific proinflammatory and anti-inflammatory cytokines from monocytes; preoperative neutrophilia; and preoperative BAL cell count. Conclusions We conclude that postoperative lung inflammation is associated with specific changes in the cellular innate immune response, a better understanding of which may improve patient selection and prediction of complications in the future.
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Affiliation(s)
- Richard O Jones
- The University of Edinburgh/Medical Research Council Centre for Inflammation Research, The Queen's Medical Research Institute , Edinburgh , UK ; Department of Thoracic Surgery , The Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Mairi Brittan
- The University of Edinburgh/Medical Research Council Centre for Inflammation Research, The Queen's Medical Research Institute , Edinburgh , UK
| | - Niall H Anderson
- Centre for Population Health Sciences, The University of Edinburgh, Medical School , Edinburgh , UK
| | - Andrew Conway Morris
- The University of Edinburgh/Medical Research Council Centre for Inflammation Research, The Queen's Medical Research Institute , Edinburgh , UK ; Department of Anaesthesia, University of Cambridge, Cambridge Biomedical Campus, Hills Road, Cambridge, UK
| | - John T Murchison
- Department of Radiology , The Royal Infirmary of Edinburgh , Edinburgh , UK
| | - William S Walker
- Department of Thoracic Surgery , The Royal Infirmary of Edinburgh , Edinburgh , UK
| | - A John Simpson
- The University of Edinburgh/Medical Research Council Centre for Inflammation Research, The Queen's Medical Research Institute , Edinburgh , UK ; Institute of Cellular Medicine, Medical School, Newcastle University , Newcastle upon Tyne , UK
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Li C, Xu M, Wu Y, Li YS, Huang WQ, Liu KX. Limb remote ischemic preconditioning attenuates lung injury after pulmonary resection under propofol-remifentanil anesthesia: a randomized controlled study. Anesthesiology 2014; 121:249-259. [PMID: 24743579 DOI: 10.1097/aln.0000000000000266] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Remote ischemic preconditioning (RIPC) may confer the protection in critical organs. The authors hypothesized that limb RIPC would reduce lung injury in patients undergoing pulmonary resection. METHODS In a randomized, prospective, parallel, controlled trial, 216 patients undergoing elective thoracic pulmonary resection under one-lung ventilation with propofol-remifentanil anesthesia were randomized 1:1 to receive either limb RIPC or conventional lung resection (control). Three cycles of 5-min ischemia/5-min reperfusion induced by a blood pressure cuff served as RIPC stimulus. The primary outcome was PaO2/FIO2. Secondary outcomes included other pulmonary variables, the incidence of in-hospital complications, markers of oxidative stress, and inflammatory response. RESULTS Limb RIPC significantly increased PaO2/FIO2 compared with control at 30 and 60 min after one-lung ventilation, 30 min after re-expansion, and 6 h after operation (238 ± 52 vs. 192 ± 67, P = 0.03; 223 ± 66 vs. 184 ± 64, P = 0.01; 385 ± 61 vs. 320 ± 79, P = 0.003; 388 ± 52 vs. 317 ± 46, P = 0.001, respectively). In comparison with control, it also significantly reduced serum levels of interleukin-6 and tumor necrosis factor-α at 6, 12, 24, and 48 h after operation and malondialdehyde levels at 60 min after one-lung ventilation and 30 min after re-expansion (all P < 0.01). The incidence of acute lung injury and the length of postoperative hospital stay were markedly reduced by limb RIPC compared with control (all P < 0.05). CONCLUSION Limb RIPC attenuates acute lung injury via improving intraoperative pulmonary oxygenation in patients without severe pulmonary disease after lung resection under propofol-remifentanil anesthesia.
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Affiliation(s)
- Cai Li
- From the Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Effect of Simvastatin on Physiological and Biological Outcomes in Patients Undergoing Esophagectomy. Ann Surg 2014; 259:26-31. [DOI: 10.1097/sla.0b013e31829d686b] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Breath tests in respiratory and critical care medicine: from research to practice in current perspectives. BIOMED RESEARCH INTERNATIONAL 2013; 2013:702896. [PMID: 24151617 PMCID: PMC3789325 DOI: 10.1155/2013/702896] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Revised: 08/12/2013] [Accepted: 08/14/2013] [Indexed: 12/15/2022]
Abstract
Today, exhaled nitric oxide has been studied the most, and most researches have now focused on asthma. More than a thousand different volatile organic compounds have been observed in low concentrations in normal human breath. Alkanes and methylalkanes, the majority of breath volatile organic compounds, have been increasingly used by physicians as a novel method to diagnose many diseases without discomforts of invasive procedures. None of the individual exhaled volatile organic compound alone is specific for disease. Exhaled breath analysis techniques may be available to diagnose and monitor the diseases in home setting when their sensitivity and specificity are improved in the future.
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Sood A, Qualls C, Seagrave J, McDonald J, Shohreh R, Chiavaroli A, Schuyler M. Effect of allergen inhalation on airway oxidant stress, using exhaled breath condensate 8-isoprostane, in mild asthma. J Asthma 2013; 50:449-56. [PMID: 23461590 DOI: 10.3109/02770903.2013.780609] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Exhaled breath condensate (EBC) 8-isoprostane concentrations are increased in asthma, but it is not known if they acutely change following bronchoprovocation. The objective of this study was to evaluate EBC 8-isoprostane concentrations following allergen-induced bronchoprovocation in asthma. METHODS This comparison study included eight mild atopic asthmatics and six controls. Asthmatics were challenged with inhaled specific allergen, methacholine, and irrelevant allergen in random order. Controls were challenged with irrelevant allergen. EBCs collected at 0, 3, 6, 9, and 23 hours by the R-tube method were measured for 8-isoprostanes by ELISA technique. Repeated measures ANOVA technique was used for analysis. RESULTS EBC 8-isoprostane concentrations did not change following any inhalational challenge, as compared to baseline, in either asthmatics or controls. CONCLUSIONS EBC 8-isoprostane concentrations do not acutely change following bronchoprovocation in subjects with mild asthma.
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Affiliation(s)
- Akshay Sood
- Department of Medicine, University of New Mexico Health Sciences Center School of Medicine, Albuquerque, NM, USA.
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Exhaled breath condensate pH in mechanically ventilated patients. Med Intensiva 2012; 37:593-9. [PMID: 23158868 DOI: 10.1016/j.medin.2012.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 08/29/2012] [Accepted: 10/01/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVES In this prospective clinical trial we aimed to answer if spontaneous exhaled breath condensate (EBC) in the trap of the expiratory arm of the ventilator could replace EBC collected by coolant chamber standardized with Argon as an inert gas. Second, if EBC pH could predict ventilator associated pneumonia (VAP) and mortality. PATIENTS We included 34 critically ill patients (males = 26), aged = 54.85 ± 19.86 (mean ± SD) yrs, that required mechanical ventilation due to non-pulmonary direct cause (APACHE II score = 23.58 ± 14.7; PaO(2)/FiO(2) = 240.00 ± 98.29). SETTING ICU with 9 beds from a regional teaching hospital. INTERVENTION AND RESULTS The patients were followed up until development of VAP, successful weaning or death. There were significant differences between mean EBC pH from the 4 procedures with the exception of spontaneous EBC de-aerated with Argon (n = 79; 6.74 ± 0.28) and coolant chamber deaerated with Argon (n = 79; 6.70 ± 0.36; p = NS by Tukey's Multiple Comparison Test). However, none of the procedures were extrapolated between each other according to Bland & Altman method. The mean EBC pH from the trap without Argon was 6.50 ± 0.28. From the total of 34 patients, 22 survived and were discharged and 12 patients died in the ICU. CONCLUSION Spontaneous EBC pH could not be extrapolated to EBC pH from coolant chamber and it did not change in subjects who dead, neither subject with VAP in comparison with baseline data. The lack of other biomarker in EBC and the lack of a control group determinate the need for further studies in this setting.
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Carter SR, Davis CS, Kovacs EJ. Exhaled breath condensate collection in the mechanically ventilated patient. Respir Med 2012; 106:601-13. [PMID: 22398157 DOI: 10.1016/j.rmed.2012.02.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 02/07/2012] [Accepted: 02/10/2012] [Indexed: 10/28/2022]
Abstract
Collection of exhaled breath condensate (EBC) is a non-invasive means of sampling the airway-lining fluid of the lungs. EBC contains numerous measurable mediators, whose analysis could change the management of patients with certain pulmonary diseases. While initially popularized in investigations involving spontaneously breathing patients, an increasing number of studies have been performed using EBC in association with mechanical ventilation. Collection of EBC in mechanically ventilated patients follows basic principles of condensation, but is influenced by multiple factors. Effective collection requires selection of a collection device, adequate minute ventilation, low cooling temperatures, and sampling times of greater than 10 min. Condensate can be contaminated by saliva, which needs to be filtered. Dilution of samples occurs secondary to distilled water in vapors and humidification in the ventilator circuit. Dilution factors may need to be employed when investigating non-volatile biomarkers. Storage and analysis should occur promptly at -70 °C to -80 °C to prevent rapid degradation of samples. The purpose of this review is to examine and describe methodologies and problems of EBC collection in mechanically ventilated patients. A straightforward and safe framework has been established to investigate disease processes in this population, yet technical aspects of EBC collection still exist that prevent clinical practicality of this technology. These include a lack of standardization of procedure and analysis of biomarkers, and of normal reference ranges for mediators in healthy individuals. Once these procedural aspects have been addressed, EBC could serve as a non-invasive alternative to invasive evaluation of lungs in mechanically ventilated patients.
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Affiliation(s)
- Stewart R Carter
- Department of Surgery, Loyola University Medical Center, Stritch School of Medicine, Building 110, Room 4232, 2160 South First Avenue, Maywood, IL 60153, USA
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ICS Medal and Research Abstract Presentations. J Intensive Care Soc 2012. [DOI: 10.1177/175114371201300120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Proudfoot AG, McAuley DF, Griffiths MJD, Hind M. Human models of acute lung injury. Dis Model Mech 2011; 4:145-53. [PMID: 21357760 PMCID: PMC3046086 DOI: 10.1242/dmm.006213] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Acute lung injury (ALI) is a syndrome that is characterised by acute inflammation and tissue injury that affects normal gas exchange in the lungs. Hallmarks of ALI include dysfunction of the alveolar-capillary membrane resulting in increased vascular permeability, an influx of inflammatory cells into the lung and a local pro-coagulant state. Patients with ALI present with severe hypoxaemia and radiological evidence of bilateral pulmonary oedema. The syndrome has a mortality rate of approximately 35% and usually requires invasive mechanical ventilation. ALI can follow direct pulmonary insults, such as pneumonia, or occur indirectly as a result of blood-borne insults, commonly severe bacterial sepsis. Although animal models of ALI have been developed, none of them fully recapitulate the human disease. The differences between the human syndrome and the phenotype observed in animal models might, in part, explain why interventions that are successful in models have failed to translate into novel therapies. Improved animal models and the development of human in vivo and ex vivo models are therefore required. In this article, we consider the clinical features of ALI, discuss the limitations of current animal models and highlight how emerging human models of ALI might help to answer outstanding questions about this syndrome.
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Affiliation(s)
- Alastair G Proudfoot
- Royal Brompton & Harefield NHS Foundation Trust, Adult Intensive Care Unit, London, UK
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Pro-oxidant iron in exhaled breath condensate: a potential excretory mechanism. Respir Med 2011; 105:1290-5. [PMID: 21514132 DOI: 10.1016/j.rmed.2011.03.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2010] [Revised: 03/28/2011] [Accepted: 03/30/2011] [Indexed: 12/18/2022]
Abstract
AIMS Pro-oxidant iron provides a potential measure of iron-catalysed oxidative stress in biological fluids. This study aimed, to investigate if the Bleomycin technique for measurement of pro-oxidant iron in biological fluids could be utilised for determinations in exhaled breath condensate (EBC). Secondly, to measure levels of pro-oxidant iron in EBC from asthmatics after exposure to polluting city environments. METHODS Retrospective analysis of samples of EBC and bronchoalveolar lavage fluid (BALF). Pro-oxidant iron levels were determined by the Bleomycin method. Transferrin levels were determined by radial diffusion immunoassay and lactoferrin by ELISA. SUBJECTS Patients undergoing surgery necessitating cardiopulmonary bypass, normal healthy controls, "healthy" smokers, and asthmatics (mild and moderate). RESULTS Pro-oxidant iron was significantly decreased (p<0.05) post cardiac surgery in both EBC and BALF. In smokers levels of pro-oxidant iron in EBC were significantly (p<0.05) increased verses healthy controls. In asthmatics with more severe disease, there were significant increases in EBC pro-oxidant iron content post exposure to city environments (p<0.001), with levels most elevated after exposure to the most polluted setting. CONCLUSION Similar patterns in the levels of pro-oxidant iron detectable in EBC and paired BALF from patients undergoing cardiopulmonary bypass (pre and post surgery) suggest a potential for EBC determinations. Significantly elevated levels in EBC from smokers relative to control subjects provide further support for this technique. In asthma disease severity and environmental exposure influenced levels of pro-oxidant iron measured in EBC indicating a potential for enhanced iron-catalysed oxidative stress.
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Changes in cysteinyl leukotrienes during and after cardiac surgery with cardiopulmonary bypass in patients with and without chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 2011; 141:1496-502.e3. [PMID: 21377695 DOI: 10.1016/j.jtcvs.2011.01.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2010] [Revised: 10/13/2010] [Accepted: 01/20/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Pulmonary function frequently deteriorates after cardiopulmonary bypass (CPB). Chronic obstructive pulmonary disease (COPD) increases risk of respiratory complications after CPB. Cysteinyl leukotrienes are important mediators of respiratory dysfunction. Their role during cardiac surgery and its lung complications is incompletely understood. We studied whether production of cysteinyl leukotrienes changes during and after cardiac surgery with CPB and differs between patients with and without COPD. METHODS Patients with (n = 9) and without (n = 10) moderate-to-severe COPD undergoing cardiac surgery with CPB were prospectively included. Plasma and urinary cysteinyl leukotriene and leukotriene B(4) concentrations were measured by enzyme-linked immunosorbent assay after anesthesia induction, at end of CPB, after CPB, and 2 hours after intensive care unit admission. Gas exchange and respiratory mechanics were also assessed. RESULTS Patients with COPD had larger airway resistances after CPB and chest closure (P < .001), lower ratio of arterial Po(2) to inspired oxygen fraction at intensive care unit admission (215 ± 37 vs 328 ± 30 mm Hg, P < .05), and longer postoperative mechanical ventilation (13.7 ± 5.8 vs 6.8 ± 3.4 hours, P < .01). Urinary cysteinyl leukotriene concentrations increased with time in both groups (P < .01), but more in patients with than without COPD (P < .05). Plasma cysteinyl leukotriene concentrations increased significantly between baseline and intensive care unit admission in patients with but not without COPD (P < .01). Concentrations of leukotriene B(4) in plasma and urine did not increase significantly with time and were not different between groups. CONCLUSIONS Release of cysteinyl leukotrienes increases during cardiac surgery with CPB and is larger in patients with than without COPD. This may be related to higher lung and airway production of cysteinyl leukotrienes and neutrophil activation in patients with COPD.
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A stepwise approach to justify phase III randomized clinical trials and enhance the likelihood of a positive result. Crit Care Med 2011; 38:S523-7. [PMID: 21164392 DOI: 10.1097/ccm.0b013e3181f1fcae] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Multiple time-consuming, expensive, and negative phase III clinical trials involving many thousands of patients have been undertaken in critical care and continue to be funded. The vast majority of these clinical trials are negative. Furthermore, phase III studies frequently fail to achieve their planned recruitment target. Often such studies are based on small pilot studies with inadequate phase II trial data and limited mechanistic data to provide a sound scientific rationale. The body of research required to justify undertaking a phase III trial in the critically ill population has not been defined adequately. In particular, guidance on the design of phase II studies for evaluating treatments in the critically ill population is needed. Research to inform critical care practice will progress more efficiently and effectively if this can be achieved. The following article presents a template on the minimum evidence required to justify phase III clinical trials in the critically ill population.
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BASTIN AJ, SATO H, DAVIDSON SJ, QUINLAN GJ, GRIFFITHS MJ. Biomarkers of lung injury after one-lung ventilation for lung resection. Respirology 2010; 16:138-45. [DOI: 10.1111/j.1440-1843.2010.01870.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Isoprostanes-biomarkers of lipid peroxidation: their utility in evaluating oxidative stress and analysis. Int J Mol Sci 2010; 11:4631-59. [PMID: 21151461 PMCID: PMC3000105 DOI: 10.3390/ijms11114631] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Revised: 10/29/2010] [Accepted: 11/16/2010] [Indexed: 11/17/2022] Open
Abstract
Isoprostanes (IsoPs) are key biomarkers for investigating the role of free radical generation in the pathogenesis of human disorders. To solve IsoPs-related problems with regard to isoprostanes, analytical tools are required. This paper reviews the problems and trends in this field focusing on the methodology for assaying biomarkers in exhaled breath condensate (EBC) samples. A large amount of work has been done in the qualitative and quantitative analysis of IsoPs, but a standardized method has yet to emerge. The methodologies described differ, either in the sample preparation steps or in the detection techniques, or both. Requiring a number of chromatographic steps, the relevant extraction and purification procedures are often critical and time-consuming, and they lead to a substantial loss of target compounds. Recent data show that EBC is a promising non-invasive tool for the evaluation of different diseases. Two main analytical approaches have been adopted for IsoPs measurement: immunological methods and mass spectrometry. The methodologies for the extraction, purification and analysis of IsoPs in EBC samples are presented.
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Roca O, Gómez-Ollés S, Cruz MJ, Muñoz X, Griffiths MJD, Masclans JR. Mechanical ventilation induces changes in exhaled breath condensate of patients without lung injury. Respir Med 2010; 104:822-8. [PMID: 20138493 DOI: 10.1016/j.rmed.2010.01.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2009] [Revised: 12/09/2009] [Accepted: 01/17/2010] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Measurement of biomarkers in exhaled breath condensate (EBC) may be useful for monitoring lung inflammation and injury in mechanically ventilated patients. The aim of this study was to analyze changes in biomarkers of inflammation in EBC associated with prolonged mechanical ventilation. METHODS EBC samples were collected from critically ill patients weaning from mechanical ventilation without lung disease and from healthy nonsmokers. The following parameters were measured: pH after helium deaeration, nitrogen oxide and 8-isoprostane concentrations. RESULTS EBC was obtained from 10 patients and 20 controls. Ventilation time before the start of sample collection was 250 (85-714)h. The post-deaeration pH of EBC samples was significantly lower in ventilated patients than controls (7.50 [7.28-7.70] vs 8.07 [7.60-8.40]; P=0.008). Ventilation time before sample collection inversely correlated with pH (r=-0.636; P=0.048). A significantly higher concentration of nitrogen oxide (muM) was seen in ventilated patients vs controls (66.22 [22.26-83.13] vs 15.06 [10.73-23.30]; P=0.002), whereas levels of 8-isoprostane (pg/mL) were not significantly different between both groups (5.73 [4.0-11.4] vs 9.09 [6.63-11.43]; P=0.169). The nitrogen oxide concentration correlated negatively with dynamic compliance (r=-0.952; P<0.001) and positively with respiratory rate (r=0.683; P=0.029). CONCLUSIONS EBC analysis is a non-invasive technique that can be used to monitor ventilated patients. Mechanically ventilated patients had higher EBC acidity and nitrogen oxide concentrations. Duration of ventilation correlated with breath condensate pH.
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Affiliation(s)
- Oriol Roca
- Intensive Care Medicine Department (General Area), Hospital Universitari Vall d'Hebron, Pg. Vall d'Hebron 119-129, C.P. 08035 Barcelona, Spain.
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Jungraithmayr W, Frings C, Zissel G, Prasse A, Passlick B, Stoelben E. Inflammatory markers in exhaled breath condensate following lung resection for bronchial carcinoma. Respirology 2008; 13:1022-7. [PMID: 18764914 DOI: 10.1111/j.1440-1843.2008.01391.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary resection may cause inflammatory changes with subsequent injury to the remaining lung and deterioration in respiratory function. This study investigated the pattern of serum inflammatory markers and exhaled breath condensate (EBC) in patients undergoing major lung resection due to bronchial carcinoma compared with minimally invasive thoracic surgery. METHODS The pro-inflammatory markers IL-1-beta, IL-6, IL-8, tumor necrosis factor-alpha (TNF-alpha) and soluble intercellular adhesion molecule-1 (sICAM-1) were measured preoperatively (day -1) and on three postoperative days (day 1, 3, 7) in serum and EBC in patients after lobectomy or pneumonectomy due to bronchial carcinoma (test group) and in patients undergoing thoracoscopy with minimal wedge resection (control group). RESULTS All mediators were detectable in serum and all but IL-8 were detectable in EBC. No patient suffered postoperative respiratory failure. In the test group, serum IL-6 was significantly higher postoperatively compared with day -1 (P < 0.001). For EBC (test group), the postoperative values of IL-1-beta were significantly higher compared with day -1 (P = 0.005). In EBC (test group), day -1 TNF-alpha and sICAM-1 were significantly higher compared with controls (P < 0.029 and P = 0.032, respectively). There was no correlation between the levels of mediators and the extent of resection. CONCLUSIONS Pro-inflammatory markers are detected in EBC following pulmonary surgery. Mediators are detectable in both serum and EBC in patients with bronchial carcinoma undergoing pulmonary resection, but the levels are higher in EBC.
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Owens RL, Stigler WS, Hess DR. Do newer monitors of exhaled gases, mechanics, and esophageal pressure add value? Clin Chest Med 2008; 29:297-312, vi-vii. [PMID: 18440438 DOI: 10.1016/j.ccm.2008.02.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The current understanding of lung mechanics and ventilator-induced lung injury suggests that patients who have acute respiratory distress syndrome should be ventilated in such a way as to minimize alveolar over-distension and repeated alveolar collapse. Clinical trials have used such lung protective strategies and shown a reduction in mortality; however, there is data that these "one-size fits all" strategies do not work equally well in all patients. This article reviews other methods that may prove useful in monitoring for potential lung injury: exhaled breath condensate, pressure-volume curves, and esophageal manometry. The authors explore the concepts, benefits, difficulties, and relevant clinical trials of each.
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Affiliation(s)
- Robert L Owens
- Department of Medicine, Pulmonary and Critical Care Unit, Cox 2, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Roca O, Gómez-Ollés S, Cruz MJ, Muñoz X, Griffiths MJD, Masclans JR. Effects of salbutamol on exhaled breath condensate biomarkers in acute lung injury: prospective analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R72. [PMID: 18513388 PMCID: PMC2481464 DOI: 10.1186/cc6911] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Revised: 05/08/2008] [Accepted: 05/30/2008] [Indexed: 11/14/2022]
Abstract
Introduction The benefits of β-adrenergic stimulation have been described in acute lung injury (ALI), but there is still no evidence of its anti-inflammatory effect in these patients. Biomarkers in exhaled breath condensate (EBC) were used to study the effects of salbutamol on lung inflammation in mechanically ventilated patients with ALI. Methods EBC was collected before and 30 minutes after administration of inhaled salbutamol (800 μg). The following parameters were measured in the samples: volume obtained, conductivity, pH after helium deaeration, and concentration of nitrites, nitrates and 8-isoprostane. The leukotriene B4 concentration was measured after sample lyophilization and reconstitution. Results are expressed as the median (interquartile range). Results EBC was obtained from six ALI patients, with a median age of 56 (46 to 76) years. At the time of EBC collection, the Lung Injury Score was 3 (2.3 to 3.1) and the PaO2/FIO2 ratio was 133 (96 to 211) mmHg. A significant increase in deaerated EBC pH was observed after salbutamol administration (7.66 (7.58 to 7.75) versus 7.83 (7.67 to 7.91), P = 0.028). Trends toward decreased nitrosative species (18.81 (13.33 to 49.44) μM versus 21.21 (8.07 to 29.83) μM, P = 0.173) and decreased 8-isoprostane concentration (11.64 (7.17 to 17.13) pg/ml versus 6.55 (4.03 to 9.99) pg/ml, P = 0.068) were detected. No changes in leukotriene B4 concentration were found (1.58 (0.47 to 3.57) pg/ml versus 2.06 (1.01 to 3.01) pg/ml, P = 0.753). Conclusion EBC analysis is a noninvasive technique that can be used to monitor ventilated patients. In EBC from a small cohort of patients with ALI, inhaled salbutamol significantly decreased airspace acidosis, a marker of inflammation, and was associated with a trend toward decreased markers of nitrosative and oxidative stress.
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Affiliation(s)
- Oriol Roca
- Intensive Care Department (General Area), Hospital Universitari Vall d'Hebron, Pg. Vall d'Hebron 119-129, C.P. 08035 Barcelona, Spain.
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Abstract
On the basis of the evidence available, the authors would suggest a decision making algorithm to determine the need for ICU admission postoperatively similar to that shown in Fig. 1. First, patients should quit smoking at least 1 month and preferably 2 months before surgery. Those over the age of 70 years should receive elective ICU admission. Second, those at increased risk of general anesthesia, as judged by ASA and performance status scores and cardiovascular risk assessment, should be prebooked into the ICU in the postoperative period. A ppo FEV1 of less than 44% should warrant additional monitoring rather than mandate ICU admission. Pre-existing fibrotic lung disease mandates ICU admission. Third, perioperatively, protective (low tidal volume) ventilatory strategies should be applied during one lung ventilation. Patients undergoing one lung ventilation, and especially those undergoing extensive lymphatic dissection, should be monitored closely for signs of ALI in the first 5 days postoperatively. This, together with any indication of postoperative complications such as POP, BPF or empyema, should mandate immediate transfer to the ICU.
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Affiliation(s)
- Simon Jordan
- Department of Thoracic Surgery, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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Schilling T, Kozian A, Kretzschmar M, Huth C, Welte T, Bühling F, Hedenstierna G, Hachenberg T. Effects of propofol and desflurane anaesthesia on the alveolar inflammatory response to one-lung ventilation. Br J Anaesth 2007; 99:368-75. [PMID: 17621602 DOI: 10.1093/bja/aem184] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND One-lung ventilation (OLV) induces a pro-inflammatory response including cytokine release and leucocyte recruitment in the ventilated lung. Whether volatile or i.v. anaesthetics differentially modulate the alveolar inflammatory response to OLV is unclear. METHODS Thirty patients, ASA II or III, undergoing open thoracic surgery were randomized to receive either propofol 4 mg kg(-1) h(-1) (n = 15) or 1 MAC desflurane in air (n = 15) during thoracic surgery. Analgesia was provided by i.v. infusion of remifentanil (0.25 microg kg(-1) min(-1)) in both groups. The patients were mechanically ventilated according to a standard protocol during two-lung ventilation and OLV. Fibre optic bronchoalveolar lavage (BAL) of the ventilated lung was performed before and after OLV and 2 h postoperatively. Alveolar cells, protein, tumour necrosis factor alpha (TNFalpha), interleukin (IL)-8, soluble intercellular adhesion molecule-1 (sICAM), IL10, and polymorphonuclear (PMN) elastase were determined in the BAL fluid. Data were analysed by parametric or non-parametric tests, as indicated. RESULTS In both groups, an increase in pro-inflammatory markers was found after OLV and 2 h postoperatively; however, the fraction of alveolar granulocytes (median 63.7 vs 31.1%, P < 0.05) was significantly higher in the propofol group compared with the desflurane group. The time courses of alveolar elastase, IL-8, and IL-10 differed between groups, and alveolar TNFalpha (7.4 vs 3.1 pg ml(-1), P < 0.05) and sICAM-1 (52.3 vs 26.3 ng ml(-1), P < 0.05) were significantly higher in the propofol group. CONCLUSIONS These data indicate that pro-inflammatory reactions during OLV were influenced by the type of general anaesthesia. Different patterns of alveolar cytokines may be a result of increased granulocyte recruitment during propofol anaesthesia.
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Affiliation(s)
- T Schilling
- Department of Anaesthesiology and Intensive Care Medicine, Otto-von-Guericke-University Magdeburg, Germany.
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Hunt J, Yu Y, Burns J, Gaston B, Ngamtrakulpanit L, Bunyan D, Walsh BK, Smith A, Hom S. Identification of acid reflux cough using serial assays of exhaled breath condensate pH. COUGH 2006; 2:3. [PMID: 16608520 PMCID: PMC1459194 DOI: 10.1186/1745-9974-2-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 04/11/2006] [Indexed: 11/21/2022]
Abstract
Background Chronic cough is a common problem, frequently caused or exacerbated by acid reflux. Diagnosis of acid reflux cough is haphazard currently, often relying on long therapeutic trials of expensive medications. We tested the hypothesis that the most relevant mechanistic component of acid reflux in chronic cough is when it rises to the level of the airway where acid can potentially be aspirated. We further wished to determine if multi-sample exhaled breath condensate (EBC) pH profiles can identify chronic cough patients likely to respond to proton pump inhibitor therapy. Methods 59 subjects were recruited for this study. Initially we examined EBC pH (gas-standardized with Argon) in the setting of 15 experimental pharyngeal acid challenges to determine duration of EBC acidification. Subsequently, we enrolled 22 healthy subjects to determine a normal multi-sample exhaled breath condensate pH profile over 1–3 days. We additionally obtained multi-sample EBC pH profiles in 22 patients with chronic cough. These samples were timed to occur after coughing episodes. Exhaled breath condensate pH was measured after gas standardization. Results We found that exhaled breath condensate pH is substantially reduced for approximately 15 minutes after pharyngeal acid load. Healthy subjects rarely have any low EBC pH values (defined as < 7.4 based on a normative reference range from 404 healthy subjects). Patients with chronic cough who subsequently responded well to proton pump inhibition (n = 8) invariably had one or more cough episodes associated with EBC acidification. No patient who had normal EBC pH with each of their cough episodes reported a clinically relevant response to proton-pump inhibition. Conclusion Patients whose cough responds to proton pump inhibition have transient exhaled breath condensate acidification with coughing episodes, supporting the role of airway acidification in reflux-triggered cough. Multi-sample EBC pH profiles, involving samples collected immediately subsequent to a coughing episode, may be useful appropriately to direct therapy to those patients with cough who have relevant acid reflux.
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Affiliation(s)
- John Hunt
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Yuanlin Yu
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, Virginia 22908, USA
| | - James Burns
- Center for Laryngeal Surgery and Voice Rehabilitation, Massachusetts General Hospital, One Bowdoin Square, Boston, MA 02114, USA
| | - Benjamin Gaston
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Lina Ngamtrakulpanit
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Dorothy Bunyan
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Brian K Walsh
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Alison Smith
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, Virginia 22908, USA
| | - Stephanie Hom
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, Virginia 22908, USA
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Abstract
PURPOSE OF REVIEW An update is provided for anaesthetists, on recent work investigating the incidence and cause of lung injury following thoracic surgery. Pulmonary damage is also discussed in relation to the management of one-lung ventilation. RECENT FINDINGS The extent of recent original literature on lung injury, following thoracic surgery, is limited for the review period (2004-2005). Increasing evidence that pulmonary oxidative stress and an increase in proinflammatory cytokines are significant contributors to lung injury following thoracic surgery, however, exists. This is particularly the case in patients with lung or oesophageal carcinoma. Animal experiments confirm the above and also indicate that anaesthetic agents may offer some protection against the ischaemia-reperfusion injury sustained as a result of one-lung ventilation. SUMMARY Pulmonary damage in the form of acute lung injury and adult respiratory distress syndrome is a major cause of morbidity and mortality after thoracic surgery. An understanding of the pathogenesis of lung damage, following thoracic surgery, may enable anaesthetists to modify this process and decrease the incidence and severity of the problem.
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Paget-Brown AO, Ngamtrakulpanit L, Smith A, Bunyan D, Hom S, Nguyen A, Hunt JF. Normative Data for pH of Exhaled Breath Condensate. Chest 2006; 129:426-430. [PMID: 16478862 DOI: 10.1378/chest.129.2.426] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
INTRODUCTION Measurement of pH is one of the simplest and most technically validated biomarkers studied in exhaled breath condensate (EBC). The pH of EBC has been found to be lower than controls in many respiratory disorders. Published data from normal control subjects have been reasonably consistent, but the data sets are not large. This study was undertaken to establish normative EBC pH reference values. PARTICIPANTS Four hundred four healthy subjects of all ages were enrolled. INTERVENTIONS Each participant provided a single EBC sample using a disposable collector at modest temperature so that EBC was collected as a liquid. MEASUREMENTS AND RESULTS Samples of EBC were bubbled with argon gas to standardize for carbon dioxide, and pH was recorded with a calibrated and validated glass microelectrode on stabilization. The median EBC pH was 8.0 with interquartile (25 to 75%) range of 7.8 to 8.1. There were no differences based on age, sex, or race. The distribution is skewed, with 6.4% of EBC samples having a pH range < 7.4. CONCLUSIONS An extensive normal data set now exists that reveals EBC pH is maintained in a modestly alkaline and tight range in subjects who consider themselves healthy.
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Affiliation(s)
- Alix O Paget-Brown
- Divisions of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Lina Ngamtrakulpanit
- Divisions of Neonatology, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Alison Smith
- Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Dorothy Bunyan
- Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Stephanie Hom
- Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - Ashley Nguyen
- Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, VA
| | - John F Hunt
- Respiratory Medicine, Department of Pediatrics, University of Virginia, Charlottesville, VA.
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Effros RM, Casaburi R, Su J, Dunning M, Torday J, Biller J, Shaker R. The effects of volatile salivary acids and bases on exhaled breath condensate pH. Am J Respir Crit Care Med 2005; 173:386-92. [PMID: 16284109 PMCID: PMC2662940 DOI: 10.1164/rccm.200507-1059oc] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Recent studies have reported acidification of exhaled breath condensate (EBC) in inflammatory lung diseases. This phenomenon, designated "acidopnea," has been attributed to airway inflammation. OBJECTIVES To determine whether salivary acids and bases can influence EBC pH in chronic obstructive pulmonary disease (COPD). METHODS Measurements were made of pH, electrolytes, and volatile bases and acids in saliva and EBC equilibrated with air in 10 healthy subjects and 10 patients. RESULTS The average EBC pH in COPD was reduced (normal, 7.24 +/- 0.24 SEM; range, 6.11-8.34; COPD, 6.67 +/- 0.18; range, 5.74-7.64; p = 0.079). EBCs were well buffered by NH(4)(+)/NH(3) and CO(2)/HCO(3)(-) in all but four patients, who had NH(4)(+) concentrations under 60 micromol/L, and acetate concentrations that approached or exceeded those of NH(4)(+). Saliva contained high concentrations of acetate (approximately 6,000 micromol/L) and NH(4)(+) (approximately 12,000 micromol/L). EBC acetate increased and EBC NH(4)(+) decreased when salivary pH was low, consistent with a salivary source for these volatile constituents. Nonvolatile acids did not play a significant role in determining pH of condensates because of extreme dilution of respiratory droplets by water vapor (approximately 1:12,000). Transfer of both acetic acid and NH(3) from the saliva to the EBC was in the gas phase rather than droplets. CONCLUSIONS EBC acidification in COPD can be affected by the balance of volatile salivary acids and bases, suggesting that EBC pH may not be a reliable marker of airway acidification. Salivary acidification may play an important role in acidopnea.
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Affiliation(s)
- Richard M Effros
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, 1124 West Carson Street, Torrance, CA 90502-2064, USA.
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González-Mangado N. Análisis del condensado exhalado: ¿una técnica con futuro? Arch Bronconeumol 2005. [DOI: 10.1157/13079836] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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González-Mangado N. [Analysis of exhaled breath condensate: a technique with a future?]. Arch Bronconeumol 2005; 41:540-1. [PMID: 16266665 DOI: 10.1016/s1579-2129(06)60279-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Ward C, Forrest IA, Brownlee IA, Johnson GE, Murphy DM, Pearson JP, Dark JH, Corris PA. Pepsin like activity in bronchoalveolar lavage fluid is suggestive of gastric aspiration in lung allografts. Thorax 2005; 60:872-4. [PMID: 16055614 PMCID: PMC1747219 DOI: 10.1136/thx.2004.036426] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND A biologically plausible link between gastro-oesophageal reflux (GOR), aspiration, and lung allograft dysfunction has been suggested, but there is no systematic evidence indicating the presence of gastric contents in the lung. We have tested the hypothesis that pepsin, as a marker of aspiration, is detectable in bronchoalveolar lavage (BAL) fluid of allograft recipients who had not reported symptoms of GOR. METHODS Standardised 3 x 60 ml surveillance BAL fluid samples from 13 chronologically sequential stable lung allograft recipients without chronic rejection (10 patients treated with a prophylactic proton pump inhibitor) were studied. Lavage supernatants were assayed by an ELISA based on a monospecific goat antibody for pepsin/pepsinogen. Pepsin levels were compared with those from four normal volunteer controls. RESULTS Pepsin levels were measurable in all allograft recipients, in keeping with gastric aspiration (median 109 ng/ml (range 35-1375)). In the control group the pepsin levels were below the limit of detection. Treatment with a proton pump inhibitor was not correlated with pepsin levels. There was no correlation between BAL fluid neutrophils and pepsin levels. CONCLUSION These data demonstrate lung epithelial lining fluid concentrations of pepsin in lung allograft recipients which are much higher than blood reference levels, with no detectable pepsin in controls. This provides direct evidence of gastric aspiration, which is potentially injurious to the allograft.
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Affiliation(s)
- C Ward
- Applied Immunobiology and Transplantation Research Group, Freeman Hospital and University of Newcastle upon Tyne, Newcastle upon Tyne NE7 7DN, UK.
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Ward C, Forrest IA, Brownlee IA, Johnson GE, Murphy DM, Pearson JP, Dark JH, Corris PA. Pepsin like activity in bronchoalveolar lavage fluid is suggestive of gastric aspiration in lung allografts. Thorax 2005. [PMID: 16055614 DOI: 10.1163/thx.2004.036426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND A biologically plausible link between gastro-oesophageal reflux (GOR), aspiration, and lung allograft dysfunction has been suggested, but there is no systematic evidence indicating the presence of gastric contents in the lung. We have tested the hypothesis that pepsin, as a marker of aspiration, is detectable in bronchoalveolar lavage (BAL) fluid of allograft recipients who had not reported symptoms of GOR. METHODS Standardised 3 x 60 ml surveillance BAL fluid samples from 13 chronologically sequential stable lung allograft recipients without chronic rejection (10 patients treated with a prophylactic proton pump inhibitor) were studied. Lavage supernatants were assayed by an ELISA based on a monospecific goat antibody for pepsin/pepsinogen. Pepsin levels were compared with those from four normal volunteer controls. RESULTS Pepsin levels were measurable in all allograft recipients, in keeping with gastric aspiration (median 109 ng/ml (range 35-1375)). In the control group the pepsin levels were below the limit of detection. Treatment with a proton pump inhibitor was not correlated with pepsin levels. There was no correlation between BAL fluid neutrophils and pepsin levels. CONCLUSION These data demonstrate lung epithelial lining fluid concentrations of pepsin in lung allograft recipients which are much higher than blood reference levels, with no detectable pepsin in controls. This provides direct evidence of gastric aspiration, which is potentially injurious to the allograft.
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Affiliation(s)
- C Ward
- Applied Immunobiology and Transplantation Research Group, Freeman Hospital and University of Newcastle upon Tyne, Newcastle upon Tyne NE7 7DN, UK.
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Angus D, Ishizaka A, Matthay M, Lemaire F, Macnee W, Abraham E. Critical care in AJRCCM 2004. Am J Respir Crit Care Med 2005; 171:537-44. [PMID: 15753483 DOI: 10.1164/rccm.2412004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
- Derek Angus
- Division of Pulmonary Sciences and Critical Care Medicine, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Box C272, Room 5503, Denver, CO 80262-0001, USA
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Wells K, Vaughan J, Pajewski TN, Hom S, Ngamtrakulpanit L, Smith A, Nguyen A, Turner R, Hunt J. Exhaled breath condensate pH assays are not influenced by oral ammonia. Thorax 2005; 60:27-31. [PMID: 15618579 PMCID: PMC1747147 DOI: 10.1136/thx.2003.020602] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Measurement of pH in exhaled breath condensate (EBC) is robust and simple. Acidic source fluid (airway lining fluid) traps bases while volatilising acids, leading to EBC acidification in many lung diseases. Lower airway ammonia is one determinant of airway lining fluid pH, raising the concern that addition of the base ammonia by contamination from the mouth might confound EBC pH assays. METHODS Three discrete methods were used to limit oral ammonia contamination of EBC collections: endotracheal intubation, oral rinsing, and -40 degrees C condenser temperatures. Separately, ammonia was removed from collected EBC samples by lyophilisation and resuspension. Intraweek and intraday variability of ammonia concentration was determined in 76 subjects, and ammonia and pH from a further 235 samples were graphically compared. Ammonia was assayed spectrophotometrically and pH was assessed after deaeration. RESULTS Data from 1091 samples are presented. Ammonia was reduced in EBC by all methods. Endotracheal intubation decreased EBC ammonia from a mean (SD) of 619 (124) microM to 80 (24) microM (p<0.001, n=32). Oral rinsing before collection also led to a decline in EBC ammonia from 573 (307) microM to 224 (80) microM (p=0.016, n=7). The colder the condensation temperature used, the less ammonia was trapped in the EBC. Lyophilisation removed 99.4 (1.9)% of ammonia. Most importantly, the pH of EBC never decreased after removal of ammonia by any of these methods. Intraweek and intraday coefficients of variation for ammonia were 64 (27)% and 60 (32)%, which is substantially more variable than EBC pH assays. CONCLUSIONS Although ammonia and pH appear to correlate in EBC, the oral ammonia concentration is not an important determinant of EBC pH. No precautions need to be taken to exclude oral ammonia when EBC pH is of interest. The low pH and low ammonia found in EBC from patients with lung diseases appear to be independent effects of volatile compounds arising from the airway.
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Affiliation(s)
- K Wells
- Division of Pediatric Respiratory Medicine, Box 800386, University of Virginia, Charlottesville, VA 22908, USA
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