Ventilator-induced lung injury (VILI) is an inflammatory process that threatens patients requiring ventilatory support such as the 17 million surgical or the 751,000 septic patients/year in the US. Our long-term goal is to understand and advance methods to detect and prevent VILI. Excessive lung strain (=change in volume/initial volume) is understood as a fundamental mechanism of VILI. Recent data show that clinical outcomes during mechanical ventilation are influenced by ventilator settings and importantly associated with a lung mechanics measure related to global lung strain (driving pressure). Yet, knowledge is scant on the effects of ventilatory settings on the spatial distribution of strains in lungs of size comparable to those of humans and on the ensuing lung injury. In the previous period of this project, we advanced Computed Tomography (CT)-based registration methods to show that a current clinical standard ventilatory strategy does not prevent deterioration of local lung strain and aeration in supine animal and human lungs, with progressive derecruitment of dependent lung and increased strain in the well-aerated nondependent lung. We challenged current paradigms as we found local strains lower than proposed global injurious thresholds. Using Positron Emission Tomography (PET), we showed that local 18F-FDG uptake is a marker of neutrophilic inflammation and that it changes directly with the interaction of local lung strain and blood volume (higher exposure to inflammatory mediators) in a model of protective mechanical ventilation and endotoxemia. This implied the novel concept of the two-hit mechanism as the main factor for local VILI at usual clinical strains. We also found that homogeneous distributions of strain and aeration prevented that mechanical deterioration, suggesting that lung expansion homogenization could protect from VILI. Our exciting pilot imaging data indicate tidal local capillary closure with current ventilatory settings providing novel evidence for endothelial injury in presumably protective settings. We hypothesize that regional lung mechanical deterioration characterized by an increase in strain and aeration heterogeneity with current clinical ventilatory strategies produces changes in pulmonary blood volume conducive to endothelial injury, and composes the substrate for inflammation and early VILI in large heterogeneously inflated lungs. We will test this hypothesis with respiratory-gated PET/CT by using CT-derived lung strains and aeration to ascertain global mechanics measures best indicative of the positive end-expiratory pressure (PEEP) leading to homogenous stretch distributions in sheep. We will use such measures to personalize PEEP and assess its effect on: (a) strain deterioration, and the spatial relation of this deterioration with tidal capillary closure, endothelial damage, and lung injury in clinically relevant 48h sheep studies; and (b) local distributions of strain and aeration in septic patients. At the end of this project, we will have tested a strategy translatable to humans to minimize VILI; ascertained relations between global respiratory mechanics, endothelial and parenchymal injury to enhance lung protection; and established imaging methods to assess local VILI.

Public Health Relevance

Mechanical ventilation is a life support method used in intensive care and surgical patients, which can paradoxically injure the lungs. We will use novel lung imaging techniques to optimize the delivery of mechanical ventilation to patients without severe lung disease and to generate fundamental knowledge on regional lung vascular damage in the early stages of lung injury. The results are expected to improve pulmonary outcomes of a large fraction of the ~17 million US surgical patients/year receiving general anesthesia and of mechanically ventilated critical care patients, and to provide new understanding on ventilator associated mechanisms of vascular injury.

Agency
National Institute of Health (NIH)
Institute
National Heart, Lung, and Blood Institute (NHLBI)
Type
Research Project (R01)
Project #
5R01HL121228-06
Application #
9920187
Study Section
Medical Imaging Study Section (MEDI)
Program Officer
Reineck, Lora A
Project Start
2014-01-01
Project End
2024-04-30
Budget Start
2020-05-01
Budget End
2021-04-30
Support Year
6
Fiscal Year
2020
Total Cost
Indirect Cost
Name
Massachusetts General Hospital
Department
Type
DUNS #
073130411
City
Boston
State
MA
Country
United States
Zip Code
02114
Motta-Ribeiro, Gabriel; Winkler, Tilo; Hashimoto, Soshi et al. (2018) Spatial Heterogeneity of Lung Strain and Aeration and Regional Inflammation During Early Lung Injury Assessed with PET/CT. Acad Radiol :
Bagchi, Aranya; Vidal Melo, Marcos F (2018) Follow the Voxel-A New Method for the Analysis of Regional Strain in Lung Injury. Crit Care Med 46:1033-1035
Morais, Caio C A; Koyama, Yukiko; Yoshida, Takeshi et al. (2018) High Positive End-Expiratory Pressure Renders Spontaneous Effort Noninjurious. Am J Respir Crit Care Med 197:1285-1296
Motta-Ribeiro, Gabriel C; Hashimoto, Soshi; Winkler, Tilo et al. (2018) Deterioration of Regional Lung Strain and Inflammation during Early Lung Injury. Am J Respir Crit Care Med 198:891-902
Serpa Neto, Ary; Campos, Pedro P Z A; Hemmes, Sabrine N T et al. (2017) Kinetics of plasma biomarkers of inflammation and lung injury in surgical patients with or without postoperative pulmonary complications. Eur J Anaesthesiol 34:229-238
G├╝ldner, Andreas; Braune, Anja; Ball, Lorenzo et al. (2017) The authors reply. Crit Care Med 45:e328-e329
Wellman, Tyler J; de Prost, Nicolas; Tucci, Mauro et al. (2016) Lung Metabolic Activation as an Early Biomarker of Acute Respiratory Distress Syndrome and Local Gene Expression Heterogeneity. Anesthesiology 125:992-1004
Paula, Luis Felipe; Wellman, Tyler J; Winkler, Tilo et al. (2016) Regional tidal lung strain in mechanically ventilated normal lungs. J Appl Physiol (1985) 121:1335-1347
de Jong, Myrthe A C; Ladha, Karim S; Vidal Melo, Marcos F et al. (2016) Differential Effects of Intraoperative Positive End-expiratory Pressure (PEEP) on Respiratory Outcome in Major Abdominal Surgery Versus Craniotomy. Ann Surg 264:362-369
Freitas, Claudia Regina da Costa; Malbouisson, Luiz Marcelo Sa; Benicio, Anderson et al. (2016) Lung Perfusion and Ventilation During Cardiopulmonary Bypass Reduces Early Structural Damage to Pulmonary Parenchyma. Anesth Analg 122:943-52

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