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重症监护病房型装置在猪模型急性呼吸窘迫综合征中的卤化剂递送

Published: September 24, 2020
doi:
10.3791/61644
, , , , , , , , , , , , ,
1Department of Perioperative Medicine,CHU Clermont-Ferrand, 2GReD, CNRS, INSERM,Université Clermont Auvergne, 3GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital,Sorbonne University, 4Department of Biochemistry and Molecular Genetics,CHU Clermont-Ferrand, 5Division of Allergy, Pulmonary, and Critical Care Medicine,Vanderbilt University Medical Center

Summary

我们描述了盐酸诱导的急性呼吸窘迫综合征（ARDS）的模型，该模型通过用于吸入重症监护镇静剂的装置接受卤化剂，异氟醚和七氟醚镇静的仔猪。该模型可用于研究卤化剂对肺损伤和修复的生物学机制。

Abstract

急性呼吸窘迫综合征（ARDS）是危重患者低氧血症性呼吸衰竭和死亡的常见原因，迫切需要找到有效的治疗方法。临床前研究表明，吸入卤化剂可能对ARDS的动物模型有益。使用现代重症监护病房（ICU）呼吸机管理卤化剂的新设备的开发大大简化了卤化剂向ICU患者的分配。由于先前的实验和临床研究表明卤化挥发物（如七氟醚或异氟醚）对肺泡上皮损伤和炎症（ARDS期间弥漫性肺泡损伤的两种病理生理学标志物）的潜在益处，因此我们设计了一个动物模型来了解卤化剂对肺损伤和修复的影响机制。在全身麻醉、气管插管和开始机械通气后，通过气管内滴注盐酸在仔猪中诱导ARDS。然后，使用ICU型装置用吸入的七氟醚或异氟醚镇静仔猪，并在4 h期间用肺保护性机械通气对动物进行通气。在研究期间，收集血液和肺泡样本以评估动脉氧合，肺泡毛细血管膜的通透性，肺泡液清除率和肺部炎症。在整个实验过程中还收集了机械通气参数。尽管该模型诱导动脉氧合显著降低，肺泡-毛细血管通透性改变，但其可重复性，其特征是起效快、随时间稳定性好且无致命并发症。

我们开发了一种酸吸入仔猪模型，该模型再现了临床ARDS的大部分生理，生物学和病理学特征，这将有助于我们进一步了解通过用于吸入ICU镇静的装置输送的卤化剂的潜在肺保护作用。

Introduction

急性呼吸窘迫综合征（ARDS）是危重患者低氧血症性呼吸衰竭和死亡的常见原因1。其特征是弥漫性肺泡上皮和内皮损伤，导致通透性和肺水肿增加，肺泡液清除率改变（AFC）和呼吸窘迫恶化2。肺泡水肿的再吸收和ARDS的恢复需要上皮液通过肺泡的运输以保持完整，这表明改善AFC的治疗可能是有用的3，4。尽管肺保护性通气和静脉输液治疗的限制性策略已被证明有益于改善结局2，5，但它们仍然与高死亡率和发病率相关6。因此，迫切需要为该综合征开发有效的治疗方法，并更好地了解这些疗法可能起作用的确切机制。

异氟醚或七氟醚等卤化麻醉剂已被广泛用于手术室的全身麻醉。七氟醚与接受胸外科手术的患者肺部炎症减少以及术后肺部并发症（如ARDS7）的减少有关。在心脏手术后患者的荟萃分析中也发现了类似的结果8。卤化挥发物还具有支气管扩张作用9，10，也许还有一些保护几个器官的特性，如心脏8，11和肾脏12，13，14。最近，人们对在重症监护病房（ICU）中将吸入麻醉剂作为镇静剂的临床使用越来越感兴趣。动物和人类研究都支持在肝脏15，大脑16或心脏11长期缺血之前用卤化剂进行预处理的保护作用。与其他静脉注射药物相比，卤化药物在镇静危重患者方面还具有潜在的药代动力学和药效学优势，包括快速起效和由于组织中积累很少而快速抵消。与接受心脏手术的患者的静脉镇静相比，吸入卤素药物可减少插管时间17。一些研究支持卤化剂在ICU患者镇静中的安全性和有效性18，19，20。在ARDS的实验模型中，吸入七氟醚改善气体交换21，22，减少肺泡水肿21，22，并减轻肺部和全身炎症23。异氟醚还通过维持肺泡 – 毛细血管屏障的完整性来改善损伤后的肺修复，可能是通过调节关键的紧密连接蛋白24，25，26的表达。此外，与未用异氟醚27处理的巨噬细胞相比，用异氟醚培养和处理的小鼠巨噬细胞对嗜中性粒细胞具有更好的吞噬作用。

然而，迄今为止，解释挥发性麻醉剂的肺保护特性的确切生物学途径和机制仍然在很大程度上是未知的，需要进一步研究18。还需要进行其他研究，以调查七氟醚对肺损伤的确切影响，并验证实验证据是否可以转化为患者。我们团队的第一项随机对照试验发现，在ARDS患者中吸入七氟醚的给药与氧合作用改善和促炎细胞因子和肺上皮损伤标志物水平降低有关，如晚期糖基化终产物（sRAGE）的血浆和肺泡可溶性受体评估的那样28.由于sRAGE现在被认为是肺泡1型细胞损伤的标志物和肺泡炎症的关键介质，这些结果可能表明七氟醚对肺泡上皮损伤的一些有益作用21，29，30。

使用卤化剂进行吸入性 ICU 镇静长期以来一直需要在 ICU 中部署手术室麻醉呼吸机和气体蒸发器。从那时起，已经开发了适合与现代重症监护呼吸机一起使用的麻醉反射器，用于ICU31中的特定用途。这些装置具有经过改良的热和水分交换过滤器，插入呼吸回路的Y形件和气管插管之间。它们允许施用卤化剂，其中异氟醚和七氟醚是最常用的，它们由多孔聚丙烯蒸发器棒组成，通过特定的注射器泵输送的液体剂被释放到其中。卤化剂在过期期间被装置中所含的反射介质吸收，并在下一次吸气期间释放，允许约90%的过期卤化剂31，32再循环。最近，开发了该设备的微型版本，仪器死区为50 mL，使其更适合在ARDS患者的超保护通气期间使用，潮气量可低至200 mL31。这种小型化装置从未在ARDS的实验仔猪模型中进行过研究。

由于先前的研究支持卤化挥发物在ARDS期间肺泡炎症和损伤中的有希望的作用，因此我们设计了一个实验动物模型，以实现对卤化剂对肺损伤和修复作用机制的转化理解33，34，35。在这项研究中，我们开发了一种盐酸（HCl）诱导的猪的ARDS模型，其中可以使用麻醉剂保存装置（ICU型装置）的微型版本进行吸入镇静。这种ARDS的大型动物模型可用于进一步了解吸入卤化剂的潜在肺保护作用。

Protocol

该研究方案由法国 国家教育部 动物伦理委员会批准，批准号为01505.03，然后于 preclinicaltrials.eu（临床前注册标识符 PCTE00000129）注册。所有程序均在法国克莱蒙费朗 克莱蒙奥弗涅大学国际儿童内窥镜中心根据动物研究：报告体内实验（ARRIVE）指南36进行。 1. 动物准备和麻醉 仔猪模式 确保实验方案符合动物实验指南，包括3R?…

Representative Results

本实验将25头仔猪麻醉，分为两组：未治疗组（SHAM组）12头仔猪和酸损伤组（HCl组）13头仔猪。在实验结束之前，没有仔猪死亡。双向重复测量方差分析（RM-方差分析）表明，与没有ARDS的假动物相比，组相互作用（P<10−4）存在显着的时间，HCl诱导的ARDS对PaO2/ FiO2具有不利影响（图3）。在机械通气4小时后测量的总蛋白的未稀释肺水肿液水平中，观察?…

Discussion

本文介绍了由小猪气管内滴注HCl诱导的ARDS的可重复实验模型，以研究使用麻醉保存装置输送的卤化挥发物（如七氟醚或异氟醚）的肺保护作用。

本研究的主要目标是开发一种ARDS的实验模型，其中挥发性药物可以通过麻醉剂保存装置（例如ICU患者中使用的装置）输送。虽然卤化剂的一些效应以前已经在动物模型中研究过，但我们模型的优势在于它是一种临床相关的转化模型，…

Offenlegungen

The authors have nothing to disclose.

Acknowledgements

作者要感谢GreD，克莱蒙奥弗涅大学和国际Chirurgie内窥镜中心（均位于法国克莱蒙费朗）的工作人员。

Materials

Tracheal intubation
Endotracheal tube 6-mm Covidien 18860
Animal preparation
Central venous catheter 3-lumens catheter (7 French – 16 cm) Arrow CV-12703
Pulse contour cardiac output monitor PiCCO catheter (3-5 French – 20 cm) Getinge Pulsion Medical System catheter
Warm blankets WarmTouch5300 MedTronic 5300
Monitoring
External monitor IntelliVue MP40 Phillips MNT 142
Point-of-care blood gas analyzer Epoc® Blood Analysis System Siemens 20093
Pulse contour cardiac output monitor PiCCO Device PulsioFlex Monitor Getinge Pulsion Medical System PulsioFlex
Mechanical ventilation
Ventilator Engström Carestation General Electrics Engström
Halogenated anesthetics
Anaconda Syringe SedanaMedical 26022
Anesthetic conserving device AnaConDa-S SedanaMedical 26050
Charcoal filter FlurAbsorb SedanaMedical 26096
Filling Adaptaters SedanaMedical 26042
Ionomer membrane dryer line Nafion SedanaMedical 26053
Products
Propofol Mylan 66617123
Isoflurane Virbac QN01AB06
Pentobarbital PanPharma 68942457
Sevoflurane Abbvie N01AB08
Sufentanil Mylan 62404996
DOWNLOAD MATERIALS LIST

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Keywords: Porcine ModelAcute Respiratory Distress SyndromeHalogenated AgentICU DeviceCentral Venous AccessFemoral ArteryAcid-induced Lung InjuryMechanical Ventilation
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Blondonnet, R., Paquette, B., Audard, J., Guler, R., Roman, F., Zhai, R., Belville, C., Blanchon, L., Godet, T., Futier, E., Bazin, J., Constantin, J., Sapin, V., Jabaudon, M. Halogenated Agent Delivery in Porcine Model of Acute Respiratory Distress Syndrome via an Intensive Care Unit Type Device. J. Vis. Exp. (163), e61644, doi:10.3791/61644 (2020).
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