Measurement of functional residual capacity by modified multiple breath nitrogen washout for spontaneously breathing and mechanically ventilated patients.

BACKGROUND: There is a need for a bedside functional residual capacity (FRC) measurement method that performs well in intensive care patients during many modes of ventilation including controlled, assisted, spontaneous, and mixed. We developed a modified multiple breath nitrogen washout method for FRC measurement that relies on end-tidal gas fractions and alveolar tidal volume measurements as inputs but does not require the traditional measurements of volume of nitrogen or oxygen. Using end-tidal measurements, not volume, reduces errors from signal synchronization. This study was designed to assess the accuracy, precision, and repeatability of the proposed FRC system in subjects with variable ventilation patterns including some spontaneous effort. METHODS: The accuracy and precision of measurements were assessed by comparing the novel N2 washout FRC values to the gold standard, body plethysmography, in 20 spontaneously breathing volunteers. Repeatability was assessed by comparing subsequent measurements in 20 intensive care patients whose lungs were under controlled and assisted mechanical ventilation. RESULTS: Compared with body plethysmography, the accuracy (mean bias) of the novel method was -0.004 litre and precision [1 standard deviation (sd)] was 0.209 litre [mean (sd)] [-0.1 (5.9)% of body plethysmography]. The difference between repeated measurements was 0.009 (0.15) litre [mean (sd)] [0.4 (6.4)%]. The coefficient of repeatability was 0.31 litre (12.7%). CONCLUSIONS: The modified multiple breath nitrogen washout method for FRC measurement provides improved precision and equivalent accuracy and repeatability compared with existing methods during ventilation with variable ventilation patterns. Further study of the novel N2 washout method is needed.

Cytokine-induced expression of a nitric oxide synthase in rat renal tubule cells.

Nitric oxide (NO.) has been implicated in the regulation of renal vascular tone and tubular sodium transport. While the endothelial cell is a well known source of NO(.), recent studies suggest that tubular epithelial cells may constitutively generate NO(.). An inducible isoform of nitric oxide synthase which produces far greater quantities of NO. exists in some cell types. We sought to determine whether kidney epithelial cells exposed to cytokines could express an inducible nitric oxide synthase. Primary cultures of rat proximal tubule and inner medullary collecting duct cells generated NO. on exposure to TNF-alpha and IFN-gamma. NO. production by both cell types was inhibited by NG-monomethyl-L-arginine; this inhibition was partially reversed by the addition of excess L-arginine. Stimulation of kidney epithelial cells with TNF-alpha and IFN-gamma dramatically increased the level of inducible nitric oxide synthase mRNA. In summary, renal proximal tubule and inner medullary collecting duct cells can produce NO. via expression of an inducible isoform of nitric oxide synthase.

Regulation of endothelin-1 synthesis in human pulmonary arterial smooth muscle cells. Effects of transforming growth factor-beta and hypoxia.

OBJECTIVE: Endothelin-1 (ET-1) potently regulates pulmonary vascular tone and promotes vascular smooth muscle cell growth. Clinical and animal studies implicate increased ET-1 production in the pathogenesis of primary and secondary pulmonary hypertension. Although pulmonary arterial smooth muscle cells (PASMCs) synthesize ET-1 under basal conditions, it is unknown whether factors that may be important in pulmonary hypertension, such as transforming growth factor-beta (TGF-beta) or hypoxia, augment ET-1 production by these cells. METHODS: We determined the effect of TGF-beta and hypoxia on ET-1 release and preproET-1 mRNA from cultured rat and human PASMCs. RESULTS: In the basal state, rat and human PASMCs synthesize, on average (mean+/-S.E.M.), 872+/-114 and 563+/-57 pg ET-1/mg cell protein over 24 h, respectively, a level that causes autocrine and paracrine effects in other tissues. TGF-beta significantly increases the expression of preproET-1 mRNA and ET-1 production by both rat and human PASMCs. Hypoxia for 24 h, however, does not affect ET-1 release from rat or human PASMCs. CONCLUSIONS: Cultured rat and human PASMCs are a source of ET-1 production. Enhanced ET-1 release from PASMCs may contribute to the pathophysiology of TGF-beta-induced pulmonary hypertension. ET-1 production by PASMCs is unlikely to contribute to the role of ET-1 in hypoxia-induced pulmonary vasoconstriction.

Succinylcholine-induced hyperkalemia following prolonged pharmacologic neuromuscular blockade.

While being treated for the acute respiratory distress syndrome, a 27-year-old woman developed profound hyperkalemia and cardiac arrest following the administration of succinylcholine chloride (SCh). She had none of the risk factors previously described for development of severe hyperkalemia following SCh administrations; however, she had been intermittently treated with nondepolarizing neuromuscular blocking drugs throughout the course of her illness. We suggest that immobilization of critically ill patients with pharmacologic neuromuscular blockade may predispose them to severe hyperkalemia and cardiac arrest following administration of SCh. SCh should be used with great caution in such patients.

The pathogenesis of chronic obstructive pulmonary disease.

Cigarette smoking is the main risk factor for the development of chronic obstructive pulmonary disease (COPD). An accelerated rate of lung function decline that causes clinically significant COPD, however, is present in only a minority of smokers. In addition to the cumulative amount of cigarettes smoked, other environmental and genetic properties contribute to this variable physiological response. This article reviews the role of airway hyperresponsiveness, mucus hypersecretion, infection, and proteases in the development of COPD.

Outpatient management of chronic obstructive pulmonary disease.

The outpatient management of chronic obstructive pulmonary disease (COPD) is designed to limit the decline in respiratory function over time, to relieve the symptoms and improve the patient's functional status, and to manage complications when they arise. Factors that predispose to airway inflammation, including cigarette smoking and respiratory infections, are prevented by behavioral modification programs, measures such as exercise and nutrition to improve general health, and regular vaccination. Symptoms are relieved by bronchodilator and anti-inflammatory therapy, based upon the specific needs of the patient. Hypoxemia and acute infections are treated with oxygen administration and the use of antibiotics when necessary. The management of acute exacerbations of COPD is addressed elsewhere in this symposium (ie, choice of antibiotics is not discussed here). Also, certain aspects of management, such as surgical procedures, chest physical therapy, and other aspects of pulmonary rehabilitation, are also subjects of subsequent articles in this series. Although none of these modalities, except for smoking cessation and oxygen administration, have been shown to alter the course of COPD, the careful choice of the therapeutic measures discussed here can lead to significant relief of symptoms in the patient with chronic airway obstruction.

Surgical treatment of chronic obstructive pulmonary disease.

Over the past several decades, a number of surgical techniques have been developed for the treatment of chronic obstructive pulmonary disease. Many of these procedures have been abandoned because of lack of efficacy and/or high morbidity and mortality. At the present time, lung transplantation, reduction pneumoplasty for giant bullous emphysema, and lung volume reduction surgery are being performed in a number of centers. Data concerning the effectiveness of these procedures is accumulating and will ultimately need careful analysis to determine long-term outcomes in this group of patients.

Role of intrarenal endothelin in the generation and maintenance of hypertension.

Alterations in the renal metabolism and/or actions of endothelin-1 (ET-1) may be involved in the pathogenesis and maintenance of essential and renal parenchymal hypertension. ET-1 has the potential to modify a broad range of renal functions involved in controlling systemic blood pressure. First, the kidney clears a large percentage of ET-1 from the blood; decreased renal ET-1 clearance may contribute to hypertension occurring in the setting of chronic renal failure. Second, ET-1 potently constricts the renal vasculature resulting in increased fluid retention and possibly contributing to glomerular sclerosis; enhanced renal vascular and glomerular ET-1 production and target cell actions may play a role in essential hypertension or hypertension accompanying chronic renal failure, cyclosporine administration, or erythropoietin therapy. Lastly, ET-1 is also an autocrine inhibitor of collecting duct sodium and water reabsorption; reduced nephron ET-1 production may result in fluid retention in essential hypertension. Determination of the true role that ET-1 plays in the pathogenesis of the varied forms of hypertension awaits the development of safe, potent, and specific endothelin antagonists.

Endothelin-1 inhibits the expression of inducible nitric oxide synthase.

Because nitric oxide (NO.) and endothelin (ET)-1 frequently have opposing effects on physiological and inflammatory processes, we sought to determine whether ET-1 regulates NO. synthesis by the inducible isoform of NO. synthase (iNOS). L2 cells are a rat lung epithelial cell line that synthesizes ET-1 and in which ET-1 has an autocrine role. In the current study, we demonstrate that L2 cells generate the oxidative products of NO., nitrite and nitrate, after exposure to tumor necrosis factor-alpha, lipopolysaccharide, and interferon-gamma. Exposure to these cytokines also dramatically increases the expression of iNOS mRNA. NG-monomethyl-L-arginine, dexamethasone, and cycloheximide prevent the cytokine-mediated increase in NO. oxidative products, demonstrating that iNOS accounts for their generation. Because L2 cells synthesize ET-1, to test the effect of removing endogenous ET-1, we used phosphoramidon (an ET-converting enzyme inhibitor) or BQ-123 (an ET receptor A antagonist). Removal of endogenous ET-1 with either phosphoramidon or BQ-123 significantly augments cytokine-stimulated NO. synthesis by approximately 20%. To further test the effect of ET-1 on iNOS, we treated cells with phosphoramidon to inhibit endogenous ET-1 synthesis and then administered ET-1 (10(-9) to 10(-7) M). In this setting, ET-1 significantly decreases inducible NO. production by 33% and iNOS mRNA by 50%. We conclude that ET-1 can decrease inducible NO. synthesis by cytokine-stimulated lung epithelial cells.

Endothelin-1 synthesis, receptors, and signal transduction in alveolar epithelium: evidence for an autocrine role.

In the lung, endothelin-1 (ET-1) is synthesized by several cell types and acts locally to cause vasoconstriction and bronchoconstriction, activate alveolar macrophages, and stimulate chloride secretion. We report ET-1 production, binding, and signal transduction by a previously unrecognized site, the alveolar epithelial cell. L2 cells, a cloned rat alveolar epithelial cell line, secreted ET-1 and contained ET-1 mRNA. Exposure of L2 cells to lipopolysaccharide, tumor necrosis factor-alpha, interleukin-1, or transforming growth factor-beta stimulated ET-1 release, whereas interferon-gamma or platelet-derived growth factor decreased ET-1 secretion. 125I-ET-1 binding to L2 cells revealed a single binding site with a maximal binding capacity of 22.4 fmol/mg protein and a dissociation constant of 4.03 nM. 125I-ET-1 binding was completely inhibited by ET receptor A (ETA) blockade and by unlabeled ET-1 >> ET-3 = sarafotoxin 6c, consistent with the presence of ETA. Exogenous ET-1 increased, whereas blockade of endogenous ET-1 decreased prostaglandin E2 (PGE2) production by L2 cells; exogenous ET-1 also increased adenosine 3',5'-cyclic monophosphate (cAMP) production. We conclude that 1) cloned rat alveolar epithelial cells synthesize ET-1; 2) inflammatory mediators modulate ET-1 production; 3) L2 cells express ETA; 4) ET-1 increases PGE2 and cAMP levels in these cells; and 5) BQ-123, an ETA antagonist, decreases their basal PGE2 production. These studies suggest that ET-1 may function as an autocrine factor in alveolar epithelial cells.

Hypoxia decreases endothelin-1 synthesis by rat lung endothelial cells.

Endothelin-1 (ET-1) is a 21-amino acid peptide synthesized by several cell types in the lung. Locally, ET-1 regulates vascular and airway tone and is mitogenic for vascular and airway smooth muscle cells. Little, however, is known about the regulation of ET-1 in pulmonary endothelial cells. Cultured rat lung endothelial cells (RLECs) release significant amounts of ET-1 into the supernatant, and isolation of RNA followed by reverse transcription and polymerase chain reaction amplification confirms the presence of ET-1 mRNA. Exposure of RLECs to a hypoxic environment for 24 h decreases ET-1 production by approximately 50% compared with normoxic controls. The effect of hypoxia is reversible upon restoration of a normoxic environment. RNase protection studies reveal decreased ET-1 mRNA in hypoxic cells. Inhibition of nitric oxide (NO) synthase increases ET-1 synthesis during normoxia and hypoxia without altering the inhibitory effect of hypoxia. The addition of 10% carbon monoxide (CO) to the hypoxic environment does not erase the effect of hypoxia on ET-1 production, suggesting that the transduction process does not involve a heme sensor. In summary, we conclude that 1) RLECs synthesize ET-1; 2) hypoxia reversibly decreases ET-1 production; 3) constitutive NO production decreases ET-1 release during normoxia and hypoxia; 4) inhibiting constitutive NO synthesis does not prevent the decrease in ET-1 release caused by hypoxia; and 5) this effect of hypoxia appears to be transduced without the involvement of a heme sensor.

Oxidant stress regulates basal endothelin-1 production by cultured rat pulmonary endothelial cells.

Endothelin-1 (ET-1) is a pluripotent mediator that modulates vascular tone and influences the inflammatory response. Patients with inflammatory lung disorders frequently have elevated circulating ET-1 levels. Because these pathophysiological conditions generate reactive oxygen species that can regulate gene expression, we investigated whether the level of oxidant stress influences ET-1 production in cultured rat pulmonary arterial endothelial cells (RPAEC). Treatment with the antioxidant 1,3-dimethyl-2-thiourea (10 mM) or the iron chelator deferoxamine (1.8 microM) doubles basal ET-1 release. Conversely, exposing cells to H2O2 generated by glucose and glucose oxidase (0.1-10 mU/ml) for 4 h causes a concentration-dependent decrease in ET-1 release. This effect occurs at concentrations of glucose oxidase that do not affect [3H]leucine incorporation or specific 51Cr release from RPAEC. Catalase prevents the decrease in ET-1 synthesis caused by glucose and glucose oxidase. Glucose and glucose oxidase decrease not only ET-1 generation but also ET-1 mRNA as assessed by semiquantitative polymerase chain reaction. Our results indicate that changes in oxidative stress can either up- or downregulate basal ET-1 generation by cultured pulmonary endothelial cells.

Treatment of hospital-acquired penumonia.

Hospital-acquired pneumonia (HAP) remains a significant cause of morbidity and attributable mortality, especially among patients undergoing mechanical ventilation. The clinical approach to this disorder continues to evolve. Although our understanding of the epidemiology, risk factors, and pathogenesis of this disorder are expanding, consensus on diagnostic, therapeutic, and preventive strategies is lacking. Although outcome is significantly improved by the rapid introduction of appropriate antimicrobial therapy, presently available diagnostic tests rarely are able to identify a specific pathogen when antimicrobial choices are made. Thus, most therapy is by necessity empirical. The American Thoracic Society (ATS) published guidelines for the empiric treatment of HAP in 1996, this article reviews the recommendations of these guidelines and, if new information is available, updates these recommendations.

Nitric oxide donor prevents hydrogen peroxide-mediated endothelial cell injury.

Because nitric oxide is being used to treat acute lung injury and because it may either reduce or potentiate oxidant-mediated vascular injury, we studied the effect of the nitric oxide donor S-nitroso-N-acetyl-D-penicillamine (SNAP) on hydrogen peroxide (H2O2)-induced injury to cultured rat lung microvascular endothelial cells (RLMVC). Cells were exposed to H2O2 through its enzymatic generation by glucose and glucose oxidase or by its direct application. Glucose oxidase exposure causes a concentration- and time-dependent increase in 51chromium (51Cr) release from RLMVC. Catalase, dimethylthiourea or deferoxamine protects against this oxidant injury. SNAP (100 microM) prevents the increase in 51Cr release resulting from glucose oxidase or direct application of H2O2. N-acetyl-D-penicillamine is ineffective. Photo-decayed SNAP slightly decreases the 51Cr release caused by glucose oxidase but not the injury produced by directly adding H2O2. Treatment with the guanosine 3',5'-cyclic monophosphate (cGMP) analogue 8-BrcGMP (1-10 mM) provides no protection. SNAP decreases in vitro the net oxidation of ferrous to fcrric iron by H2O2, the iron-catalyzed consumption of H2O2 in Fenton's reaction, the iron-mediated generation of hydroxyl radicals, and the Fe(2+)-H2O2-catalyzed peroxidation of lipid membranes. Providing exogenous nitric oxide dramatically prevents H2O2-mediated endothelial injury, likely by reducing iron-mediated oxidant generation and subsequent lipid peroxidation.

Superoxide released from neutrophils causes a reduction in nitric oxide gas.

Exhaled nitric oxide (NO) is increased in some inflammatory airway disorders but not in others such as cystic fibrosis and acute respiratory distress syndrome. NO can combine with superoxide (O-2) to form peroxynitrite, which can decompose into nitrate. Activated polymorphonuclear neutrophils (PMNs) releasing O-2 could account for a reduction in exhaled NO in disorders such as cystic fibrosis. To test this hypothesis in vitro, we stimulated confluent cultures of LA-4 cells, a murine lung epithelial cell line, to produce NO. Subsequently, human PMNs stimulated to produce O-2 were added to the LA-4 cells. A gradual increase in NO in the headspace above the cultures was observed and was markedly reduced by the addition of PMNs. An increase in nitrate in the culture supernatant fluids was measured, but no increase in nitrite was detected. Superoxide dismutase attenuated the PMN effect, and xanthine/xanthine oxidase reproduced the effect. No changes in epithelial cell inducible NO synthase protein or mRNA were observed. These data demonstrate that O-2 released from PMNs can decrease NO by conversion to nitrate and suggest a potential mechanism for modulation of NO levels in vivo.

Inhaled nitric oxide versus conventional therapy: effect on oxygenation in ARDS.

A randomized, controlled clinical trial was performed with patients with acute respiratory distress syndrome (ARDS) to compare the effect of conventional therapy or inhaled nitric oxide (iNO) on oxygenation. Patients were randomized to either conventional therapy or conventional therapy plus iNO for 72 h. We tested the following hypotheses: (1) that iNO would improve oxygenation during the 72 h after randomization, as compared with conventional therapy; and (2) that iNO would increase the likelihood that patients would improve to the extent that the FI(O2) could be decreased by > or = 0.15 within 72 h after randomization. There were two major findings. First, That iNO as compared with conventional therapy increased Pa(O2)/FI(O2) at 1 h, 12 h, and possibly 24 h. Beyond 24 h, the two groups had an equivalent improvement in Pa(O2)/FI(O2). Second, that patients treated with iNO therapy were no more likely to improve so that they could be managed with a persistent decrease in FI(O2) > or = 0.15 during the 72 h following randomization (11 of 20 patients with iNO versus 9 of 20 patients with conventional therapy, p = 0.55). In patients with severe ARDS, our results indicate that iNO does not lead to a sustained improvement in oxygenation as compared with conventional therapy.