Lung microvascular lesions with and without inhalation injury in thermally injured sheep.
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Biomedical subjects
L D Traber
Publications and source records attributed to L D Traber.
The effect of leukocyte depletion on smoke inhalation injury in sheep.
Leukocytes and the production of oxygen radicals and proteolytic enzymes have been implicated in the pathogenesis of lung injury after smoke inhalation. We investigated the mechanism responsible for this form of pulmonary damage in chronically prepared sheep previously made leukopenic with intra-arterial infusions of nitrogen mustard (mechlorethamine hydrochloride). A control air insufflated group (sham: n = 6), a cotton smoke insufflated group (smoke: n = 12), and a leukopenic cotton smoke insufflation group (smoked + depleted: n = 6) were compared. Although both smoke insufflation groups had equivalent smoke exposure, which was indexed by carboxyhemoglobin, the smoked + depleted group had significant attenuation in the increases in pulmonary artery pressure, pulmonary vascular resistance, and pulmonary lymph flow. The PaO2 to FiO2 ratio (P:F) did not fall to the same extent, nor was there a fall in PaO2. The production of oxygen radicals, which was measured as plasma-conjugated dienes, and the consumption of antiprotease, as measured by alpha 2-macroglobulin levels in lung lymph, were not changed in the smoked + depleted group, whereas it was elevated in the smoked group. We conclude that circulating leukocytes and the release of oxygen radicals and proteolytic enzymes contribute to the lung injury, pulmonary microvascular permeability increase, and pulmonary edema seen after smoke inhalation.
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The use of venovenous extracorporeal membrane oxygenation in sheep receiving severe smoke inhalation injury.
Smoke inhalation injury now represents the most frequent cause of death in burn patients, and accounts for 20-80 per cent of overall mortality. We have studied the use of extracorporeal membrane oxygenation (ECMO) to support sheep which have received lethal pulmonary smoke damage. The animals (n = 19) received inhalation injury induced by insufflation with smoke derived from burning cotton delivered with a bee smoker. The treatment group, those placed on ECMO at the time of injury (n=6), were systemically heparinized and placed on a venovenous perfusion circuit consisting of a roller pump, membrane oxygenator and heat exchanger. Blood flow rate in the circuit approximated 20-25 per cent of cardiac output. The animals remained on partial venovenous bypass until the termination of the experiment 96 h after injury. All animals in the treatment group survived. The control sheep (n = 7) received inhalation injury alone and had a 100 per cent mortality (P = 0.0015 ECMO vs. control). Ventilatory management of treatment and control groups followed an identical protocol. We have also studied a third group (n = 6) composed of animals receiving inhalation injury with systemic heparinization but not ECMO. This group had a 66 per cent mortality at 96 h. These studies suggest that partial venovenous ECMO may be a valuable form of adjunctive treatment in severe inhalation injury.
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Pulmonary edema with smoke inhalation, undetected by indicator-dilution technique.
Despite experimental evidence for an increase in extravascular lung water (EVLW) after inhalation injury, thermal-dye estimations of EVLW, extravascular thermal volume (EVTV), have repeatedly failed to demonstrate its presence in patients. This situation was evaluated in a sheep model. Under halothane anesthesia one lung was insufflated with cotton smoke and the other with air. EVTV values were 8.4 +/- 0.48 ml/kg at base line and were not elevated at 24 h after smoke inhalation (8.3 +/- 0.45 ml/kg; means +/- SE). Gravimetric analysis 24 h after smoke inhalation showed the development of edema in smoke-exposed lungs. The blood-free wet weight-to-dry weight ratio of the smoke-exposed lungs (5.4 +/- 0.32) was significantly higher compared with the contralateral unsmoked lungs (4.3 +/- 0.15; P less than or equal to 0.05). The thermal-dye technique thus underestimates EVLW. Poor perfusion of the smoke-exposed lungs 24 h after injury was demonstrated indirectly by killing a group of sheep with T-61, an agent that causes a dark red coloration of well-perfused lung areas, as well as directly by measurement of blood flow utilizing a radiolabeled microsphere technique. Thus the inability of the thermal-dye technique to detect the lung edema may be the result of poor perfusion of the injured lung.
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Pulmonary microvascular changes during hyperdynamic sepsis in an ovine model.
Hyperdynamic sepsis (increased cardiac output and reduced peripheral vascular resistance) was created in sheep with chronic lung lymph fistulae (n = 8) by giving them a 30-min infusion of 1.5 micrograms/kg of endotoxin (LPS) iv. Four hours after LPS the cardiac output (CO) was reduced (6.56 +/- 0.43 to 4.96 +/- 0.33 liters/min) and lymph flow was increased (5.4 +/- 1.0 to 18.6 +/- 3.1 ml/h). Nine hours after LPS the CO output was increased (8.42 +/- 0.60 liters/min). Early cardiopulmonary changes were associated with a fall in neutrophils (PMNs) (2,667 +/- 748 to 450 +/- 90 cells/microliter) and an elevation of their chemiluminescence (CL), an indication of increased O2 free-radical formation in the blood (1,250 +/- 160 to 3,340 +/- 744 units/1,000 leukocytes). The granulocytic enzyme, aryl sulfatase, was increased in the lymph (0.19 +/- 0.03 to 0.37 +/- 0.05 microgram/h/mg protein) indicating degranulation (activation) of PMNs. When CO was increased (9 h after LPS), blood CL rose even higher (5,330 +/- 173 units/1,000 leukocytes) and CL in the lung lymph decreased (1,160 +/- 220 units/1,000 leukocytes). At this time, lymphatic aryl sulfatase had returned to baseline levels (0.25 +/- 0.02 microgram/h/mg protein). These data suggest that pulmonary microcirculatory injury produced by LPS may be the result of margination of PMNs in the lung and their release of permeability-inducing mediators. Later, as the CO increases, the PMNs or their lesion-producing mediators may be washed from the lung and the lung injury thus may be made less severe.
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Etiology of the pulmonary pathophysiology associated with inhalation injury.
This study describes an experimental model of smoke inhalation injury in sheep in which the same pathophysiologic alterations occur as with clinical inhalation injury in man. Diffuse pulmonary mucosal sloughing with atelectasis and emphysema with concomitant development of pulmonary edema results in a decrease in arterial oxygen and progressive pulmonary deterioration which results in a substantial mortality. Increased pulmonary edema fluid is shown to be caused by an increased microvascular permeability to protein with pulmonary lymph and tracheobronchial fluid, a filtrate of plasma. Concomitant with this increase in microvascular permeability is an influx of neutrophils, release of proteolytic enzymes and an identified presence of the metabolite of the prostanoid thromboxane A2 which are postulated as contributors to the progressive pulmonary dysfunction post inhalation injury.
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Effect of a proteolytic enzyme inhibitor on the cardiopulmonary response to endotoxin.
Gabexate mesilate (GM), a proteolytic enzyme inhibitor, was given to 31 chronically instrumented sheep either as a pretreatment or treatment to determine its effects on the cardiopulmonary response to endotoxin (ET). Twelve sheep received GM prior to endotoxin (0.75 microgram/kg), 10 after ET and 9 received GM without ET. A typical biphasic response was noted; phase I showed increased lymph flow (QL), reduced lymph to plasma protein ratio (L/P) and increased pulmonary artery pressure (PAP). Phase II occurred two hours after ET; the lymph flow remained elevated and the L/P ratio rose slightly above control. Both phases demonstrated an elevation in total peripheral vascular resistance (TPR) and hematocrit but a reduction in cardiac output (CO). In phase II, QL was reduced 35% with pretreatment; the L/P ratio did not rise as much and the PAP was unchanged. There was also a 35% reduction in lymph flow; no change in the lymph to plasma protein ratio but there was an elevation in pulmonary microvascular pressure. Pretreatment with GM diminished the fall in CO and the rise in TPR seen with endotoxin. The values were unaffected by treatment alone.
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The pulmonary lesion of smoke inhalation in an ovine model.
Inhalation injury was induced in chronically instrumented sheep (n = 9) by insufflating them with smoke from burning cotton cloth. Sham animals (n = 9) were insufflated with air. There were no temporal changes in any measured parameter of the sham animals. Smoke induced a depression in PaO2. There was a threefold elevation in protein-rich pulmonary lymph which was sustained for over 48 hours. The lymph-to-plasma oncotic pressure ratio was increased. The cardiac index, left atrial pressure, and pulmonary arterial pressure remained unchanged in both groups. After smoke inhalation, the interstitial levels of neutrophils increased while interstitial antiprotease activity was depressed. The lung lymph concentration of 6-keto prostaglandin F1a, the major metabolite of prostacyclin, was increased. These data suggest that the pulmonary injury following smoke inhalation is the result of an increase in lung microvascular permeability to protein with resultant pulmonary edema. The mechanisms responsible for these changes appear to be related to direct injury to the tracheobronchial tree by cytotoxic agents in the smoke; polymorphonuclear leukocytes; and, possibly, eicosanoids.
6-Ketoprostaglandin F1 alpha↗
The effect of resuscitation on inhalation injury.
Eighteen chronically instrumented sheep with lung-lymph catheters were studied. Inhalation injury was produced in 12 animals under halothane anesthesia and then studied for 24 hours. Six of the animals received 70 ml/m2/hr body surface area of 5% dextrose in Ringer's lactated solution (normal maintenance fluid requirements for sheep), and six received 140 ml/m2/hr (twice normal maintenance fluid requirements for sheep). Six additional animals were anesthetized, insufflated with air instead of smoke, and received 70 ml/m2/hr of resuscitation fluid (sham group). Twelve hours after injury, the recorded variables from the animals that were smoked and had received a high fluid resuscitation were not different from the sham group whereas the group with low-volume fluid resuscitation had a much higher lung-lymph flow and lymph-to-plasma protein concentration ratio and a lower cardiac output. The lung microvascular permeability changes seen with smoke inhalation are made worse by inadequate fluid resuscitation.
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Ibuprofen and diphenhydramine reduce the lung lesion of endotoxemia in sheep.
Endotoxin (0.75 micrograms/kg) was administered to unanesthetized sheep with and without premedication with ibuprofen, a cyclooxygenase inhibitor, and diphenhydramine, an antihistamine. The effect of the endotoxin on cardiopulmonary and lung lymph data and their alteration by the drug regimen was assessed. The cardiopulmonary responses to endotoxin can be defined into two phases. In phase I there is an elevation in protein-poor lung lymph flow, in pulmonary artery pressure (PA), and in hematocrit, and a reduction in cardiac index and leukocyte count. Phase II occurs late and shows much the same changes as phase I except that the PA is not as high and the lymph protein is increased. The drug combination (ibuprofen and diphenhydramine) virtually eliminates the phase I response. The phase II changes in lymph flow and protein content are affected by diphenhydramine but not ibuprofen. The cardiovascular changes which occur during this period are not affected by either agent.
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The pathophysiology of smoke inhalation injury in a sheep model.
This study describes an experimental model of smoke inhalation injury in sheep, in which the same pathophysiologic alterations occur as with clinical inhalation in man. Both the patients and the experimental sheep develop diffuse pulmonary mucosal sloughing, pulmonary edema, and a decrease in systemic oxygen tension. The results of this study indicate that the pulmonary edema is the result of an increase in microvascular permeability, characterized by increases in lung lymph flow (Qlym), lymph-to-plasma protein concentration ratio (L/P), and transvascular protein flux (Qlym X lung lymph protein concentration), while pulmonary vascular pressures remain constant. Neutrophil degranulation may contribute to the increased microvascular permeability.
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Inhalation injury and positive pressure ventilation in a sheep model.
The mortality rate of inhalation injury was lowered in six chronically instrumented sheep through positive pressure ventilation and positive end-expiratory pressure (PEEP). Six range ewes were prepared for study by implanting catheters to measure lung lymph flow and cardiopulmonary variables. After surgery, these animals were studied in the unanesthetized state and then subjected to an inhalation by insufflating them with smoke from burning cotton. Following the smoking procedure, the animals were studied for 72 hr. All had marked falls in arterial oxygen tension and they developed dyspnea within 24 hr. The inhalation injury produced a marked change in lung lymph flow concomitant with an elevation in the lymph to plasma (L/P) oncotic pressure ratio. This is characteristic of a change in microvascular permeability to protein. A tracheostomy was performed at 72 hr and the animals were connected to positive pressure ventilators with PEEP. All six animals survived. It was concluded that the sheep lung lymph preparation is a very suitable model for the study of inhalation injury and positive pressure ventilation.
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Failure of a protease inhibitor to affect the cardiopulmonary response to endotoxin when combined with a cyclooxygenase inhibitor.
The administration of endotoxin produces an early increase in hydrostatic pressure and pulmonary lymph flow, which is associated with elevated levels of thromboxane A2 in the lymph and can be blocked by the cyclooxygenase inhibitor ibuprofen. Two hours after the administration of endotoxin a secondary response is seen. The pulmonary lymph flow is elevated in association with a change in microvascular permeability to protein, this phase of the response can be reduced by the administration of the proteolytic enzyme inhibitor gabexate mesilate. In the present study we administered both compounds to eight sheep prepared for chronic cardiopulmonary and lung lymph studies to reduce both phases with the drug combination. The phase I response was reduced but the changes in lung lymph flow, associated with the phase II response, were unaffected by treatment. It is concluded that the effect of gabexate mesilate on the secondary response to endotoxin must in some way be related to the release of prostanoids.
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Action of an opiate receptor blocker on ovine cardiopulmonary responses to endotoxin.
The involvement of endorphins in the ovine cardiopulmonary response to endotoxin was evaluated by measuring blood levels of opiate receptor binding substances and administering the opiate receptor blocking agent naloxone prior to and after the administration of lipopolysaccharide. The animals were prepared for chronic study by placement of cardiovascular catheters and cannulation of the lung lymphatic at least 1 wk prior to study. The sheep were given endotoxin (0.75 micrograms/kg) and studied for 6 h. This was accomplished twice in the same animal. Naloxone (2 mg/kg bolus + 2 mg X kg-1 X h-1) was given with one of the two doses of the lipopolysaccharide. The response to endotoxin could be divided into two phases. In phase 1, there was an increase in protein-poor lung lymph and a marked increase in pulmonary artery pressure. In phase 2, the pulmonary lymph flow was elevated but the lymph protein level was higher than in phase 1. The pulmonary artery pressure, however, was near normal. During both phases leukocytes and cardiac output were reduced and the hematocrit was elevated. There was an increase in opiatelike materials in the plasma of these animals, and the response to endotoxin was partially blocked by naloxone. This suggested that endorphin-like materials were involved in the response to endotoxin.
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Reproducibility of cardiopulmonary effects of different endotoxins in the same sheep.
This study compares qualitative and quantitative differences between the cardiopulmonary responses to Salmonella typhimurium and Escherichia coli 055:B5 endotoxins (Difco) in the same sheep model. Lipopolysaccharides, 0.75 micrograms/kg, were infused into chronically instrumented sheep over 30 min. Cardiopulmonary and pulmonary lymph flux data were collected for 2 h prior to and 6 h following this. One week later the sequence was repeated with another endotoxin. The administration of the two endotoxins was varied: some received S. typhimurium first; others received E. coli. A total of 13 animals were studied; 8 had intact pulmonary lymphatic catheters. Following each injection of endotoxin these animals showed a typical response of early high pressure-mediated increase in pulmonary lymph flow and later lymph flow elevation associated with a very mild increase in microvascular pressure and lymph with normal protein levels. These changes were associated with hemoconcentration, lowered arterial oxygen partial pressure, cardiac index, and blood neutrophil count. It is concluded that Difco S. typhimurium and E. coli endotoxins are similar in their mechanism of action and potency and can be studied in the same animal.
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Role of lymphocytes in the ovine response to endotoxin.
The involvement of thymocytes in the cardiopulmonary response to endotoxin was studied in chronically instrumented sheep. Four hours after the administration of 0.75 microgram/kg of endotoxin the blood levels of thymocytes were less than 25% of the control value, at a time when there was a marked fall in the cardiac index and a rise in pulmonary lymph flow. In a second series of experiments sheep were depleted of their thymocytes by the administration of antithymocyte serum. When endotoxin was given to these animals the cardiac output did not fall to the same extent, nor did the hematocrit rise as much as it did in the intact animal. It thus appears that the thymocyte may play a contributing role in the cardiopulmonary response to endotoxin.
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Effect of naloxone treatment on the cardiopulmonary response to endotoxin in sheep.
The administration of small dosages of endotoxin to sheep results in cardiopulmonary changes characterized by an elevation in pulmonary lymph flow, vascular resistance, and hemoconcentration, and a reduction in cardiac output. These changes are not as great when the narcotic antagonist, naloxone (2 mg/kg/h for 5 h), is infused prior to and during the endotoxin response. The present study evaluates the ovine response to endotoxin when naloxone is administered 1 h after the endotoxin infusion. Sheep were prepared by implanting cardiopulmonary and lung lymphatic catheters. One week following the last surgical procedure, the sheep, in the awake state, were given 0.75 micrograms/kg of endotoxin and the variables were measured. Three days later, a second dose of endotoxin was administered and variables were again measured. An infusion of naloxone was given with one of the dosages of lipopolysaccharide. Two dosages of the narcotic antagonist were used. One group received 2 mg/kg bolus + 2 mg/kg/h for 5 h; another group was given twice this amount. Both dosages were started 1 h after endotoxin. The response to endotoxin was essentially the same whether or not the sheep were treated with naloxone. If naloxone pretreatment is effective and posttreatment is not, then it is possible that an opiatelike substance might be released by endotoxin which in turn results in the ultimate release of the lesion-producing substance.
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Is endotoxin responsible for the cardiopulmonary lesions seen during acute burn wound sepsis?
Acute burn wound sepsis is a common clinical entity resulting from a showering of the circulation with gram-negative organisms which grow abundantly in the burn. We duplicate this state in our laboratory by creating 40%, third degree burns (anesthetic burns) in chronically instrumented sheep. Three days following the thermal insult, the burn wound is infected by injecting gram-negative organisms (3 X 10(10)) into it. Cardiopulmonary variables and pulmonary lymph flux data are monitored two hours prior to the injection of organisms and for three hours following it. Three different organisms were used in this study; Pseudomonas aeruginosa (N = 12), Escherichia coli (N = 9), and Klebsiella pneumoniae (N = 2). The injection of all three organisms resulted in a similar response; an early marked pulmonary hypertension and a late increase in microvascular permeability. These changes occur concomitantly with an elevation in hematocrit and an early marked fall in neutrophils. The cardiac output gradually falls over the period of observation despite vigorous body shivering associated with a febrile response. The data from the sheep were compared to similarly instrumented animals (N = 12) which were not burned, but received a very small dosage of E coli endotoxin (0.75 micrograms/kg). The cardiopulmonary response was qualitatively identical to that seen with live organisms. However, the quantitative changes in several of the cardiopulmonary variables were much more marked with endotoxin. It is concluded that the cardiopulmonary response noted with burn wound sepsis is produced by endotoxin.
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