Dissertations / Theses on the topic 'Diaphragm – Physiology'

Thesis (MScPhysio)--Stellenbosch University, 2014.
ENGLISH ABSTRACT: Introduction: In the intensive care unit population, approximately 40% of patients require mechanical ventilation and 20-25% of these patients will encounter difficulties in the discontinuation of mechanical ventilation. As mechanical ventilation affects the diaphragm, a better understanding of the structural and functional changes of the diaphragm is warranted. Method: A scoping review was done to determine whether a relationship between diaphragm thickness, diaphragm strength and diaphragm endurance had been established. Seven databases were searched using a specific search strategy. Papers were identified based on pre-defined inclusion criteria. Data was extracted by the primary investigator (PI) into a self-developed excel spreadsheet. Criteria were developed for a more focused review to inform the planning of a primary study. The primary study investigated the relationship between diaphragm thickness, diaphragm strength and diaphragm endurance in young, healthy individuals. A sample of convenience was used; included healthy individuals (18-24); three activity-levels (sedentary; endurance- and strength related sporting activities); stratified for gender and BMI. Measurements included: Sonographic measurement of diaphragm thickness; mouth pressure manometer measurements for diaphragmatic strength; and fatigue resistance index as a measure of endurance. Participants were instructed to breathe through a pressure threshold device at 60% of PImax until task failure. The fatigue resistance index was calculated as PImax final/PImax initial. Intra-rater reliability was established and testing procedures standardised a priori. Results: 405 full texts were retrieved and assessed for inclusion into the review. Papers identified the evaluation of diaphragm function in a variety of populations. 23 papers were included in the focused review. Six papers were published on diaphragm thickness, six on diaphragm strength and eleven on diaphragm endurance. No papers identified the correlation between diaphragm thickness, diaphragm strength and diaphragm endurance. 55 subjects, males and females, were recruited for the primary study. Groups were similar at baseline with regards to gender, age and BMI. The mean age of the sample was 21.16 years (SD = 1.55), with a mean body mass index (BMI) of 25.43 kg/m2 (SD = 3.70). A moderate positive correlation was established between diaphragm thickness and diaphragm strength measurements (r = 0.52; r2 = 0.27; p < 0.01). Diaphragm thickness was not correlated with diaphragm endurance (r = -0.15; r2 = 0.02; p = 0.29). No relationship was found between the strength of the diaphragm and the endurance of the diaphragm (r= -0.19; r2 = 0.04; p= 0.16). Conclusion: Guidelines for the measurement of diaphragm function do exist, but they are not adhered to by the majority of studies. Study procedures are inconsistently reported and this may affect the reproducibility of techniques in future studies. We further conclude that a correlation exists between diaphragm thickness and diaphragm strength. The use of ultrasound to measure diaphragm thickness proved to be a reliable technology and gave a moderate indication of the strength of the diaphragm. This technology may help clinicians to detect and monitor dysfunction of the diaphragm in the early stages of admission to the acute setting.
AFRIKAANSE OPSOMMING: Inleiding: Ongeveer 40% van pasiente wat in intensiewe sorgeenheid behandel word, benodig intubasie en meganiese ventilasie. Tot 25% van hierdie pasiënte sal probleme ondervind in die staking van meganiese ventilasie. Meganiese ventilasie beïnvloed die diafragma, daarom word n beter begrip van die strukturele en funksionele veranderinge van die diafragma benodig. Metode: 'n Literatuur oorsig is gedoen om te bepaal of daar 'n verhouding bestaan tussen die dikte, krag en uithouvermoë van die diafragma. Sewe databasisse is deurgesoek aan die hand van spesifieke databasis gedefinieerde soektog strategie. Relevante artikels is geïdentifiseer aan die hand van pre-gedefinieerde insluiting kriteria. Data is onttrek en in ‘n self-ontwikkelde datablad opgesom deur die primêre ondersoeker (PI). Hierdie inligting is gebruik in die beplanning van ‘n primêre studie. Die doel van die primêre studie was om die verhouding tussen die diafragma dikte, krag en uithouvermoë in jong, gesonde individue te ondersoek. ‘n Gerieflikheids steekproef is gebruik; insluitend gesonde individue (18-24); drie aktiwiteits vlakke (passief; uithouvermoë- en krag verwante sportaktiwiteite) en breë spektrum vir geslag en ligaamsbou (BMI). Metings ingesluit: sonografiese meting van die diafragma se dikte; monddruk manometer metings vir diafragmatiese krag en ‘n moegheid/weerstand indeks as maatstaf van diafragmatiese uithouvermoë. Deelnemers is opdrag gegee om asem te haal deur toestel met druk maksimum gestel 60% van PImax, tot mislukking. Die moegheid/weerstand indeks is bereken as PImax finale / PImax oorspronlik. Intra-meter betroubaarheid is bepaal en toets prosedures is gestandaardiseer voordat data ingesamel is. Resultate: 405 vol teks artikels is uitgelig vir insluiting in die literatuur oorsig. Diafragmatiese funksie is ge-evalueer in 'n verskeidenheid bevolkings. Drie en twintig artikels is in die finale oorsig ingesluit. Ses artikels wat diafragma dikte evalueer, ses wat diafragmatiese krag evalueer en elf wat die diafragma se uithouvermoë evalueer is ingesluit in die oorsig. Geen van die artikels uitgelig het ‘n ooreenkoms tussen diafragma dikte, diafragma krag en diafragma uithouvermoë geïdentifiseer nie. 55 deelnemers is gewerf vir die primêre studie. Groepe was soortgelyk by basislyn met betrekking tot geslag, ouderdom en BMI. Die gemiddelde ouderdom van die toetsgroep was 21.16 jaar (SD=1.55), met 'n gemiddelde BMI van 25.43 kg/m2 (SD = 3.70). ‘n Middelmatige positiewe verhouding is waargeneem tussen diafragma dikte en krag (r = 0.52; r2 = 0.27; p < 0.01). Geen verhouding is gevind tussen diafragma dikte en uithouvermoë nie (r= -0.15; r2 = 0.02; p = 0.29). Daar is ook geen verhouding waargeneem tussen diafragma krag en diafragma uithouvermoë nie. (r= 0.19; r2 = 0.04; p = 0.16). Gevolgtrekking: Daar bestaan wel riglyne vir die meting van die diafragma se funksie, maar in die meerderheid van studies word dit nie nagekom nie. Studie prosedures is nie konsekwent weergegee nie en dit kan die resultate van tegnieke beinvloed in toekomende studies. ‘n Matige sterk verhouding is waargeneem tussen diafragmatiese dikte en krag. Die gebruik van ultraklank om die diafragma se dikte te meet is betroubare tegnologie en kan n redelike aanduiding gee oor die krag van die diafragma. Hierdie tegnologie kan praktisyne help om enige disfunksie van die diafragma te identifiseer en te monitor in die vroeë stadiums van toelating tot die akute omgewing.

Decreased respiratory muscle strength and/or excessive loads imposed on the respiratory muscles by disease may result in respiratory muscle fatigue and ventilatory failure. Once the respiratory muscles fatigue, the only treatment is rest by mechanical ventilation. However, no one has yet determined the best protocol of rest. The purpose of these studies was to develop an animal model in the hamster in order to examine the time course of recovery following fatigue of the diaphragm and specifically, to test whether mechanical ventilation or spontaneous unloaded breathing was a better mode for functional recovery. The studies required the initial development of an anesthetic regimen which produced minimal respiratory depression in the hamster. A new method of stimulating the diaphragm in small animals was developed by apposing plate electrodes directly against the diaphragm. The validity of this technique was examined and comparison of the mechanical and electrophysiological response to that of phrenic nerve stimulation were similar at maximal stimulation. The histological characteristics of the normal hamster diaphragm were determined for fibre type proportions and sizes, oxidative capacity and glycogen levels in the costal and crural regions of this muscle. The examination revealed three distinct areas of the diaphragm with different histological features: the abdominal surface of the crural region, the thoracic surface of the crural region and the sternal and costal region. Diaphragmatic fatigue was induced in vivo by repetitive electrical stimulation which resulted in both high and low frequency fatigue. The fatigue stimulus also produced muscle fibre damage, primarily along the abdominal surface of the diaphragm over the electrodes, and glycogen depletion in the type lib fibres. Rest by continuous mechanical ventilation resulted in recovery of high frequency fatigue in the hamster diaphragm whereas rest by spontaneous unloaded breathing resulted in no recovery. Sham fatigue groups rested by either mechanical ventilation or spontaneous breathing demonstrated progressive deterioration in transdiaphragmatic pressure throughout the rest period. Decreased muscle fibre damage but increased inflammation and glycogen depletion was demonstrated in all four fatigue/sham fatigue and rest groups compared to that demonstrated by the fatigue/sham fatigue only groups. The results suggest that passive rest by continuous mechanical ventilation promotes recovery following fatigue induced by electrical stimulation. Additional factors such as prolonged fasting, loads imposed on the diaphragm by the plate electrode apparatus, positive pressure ventilation, and cumulative effects of intraperitoneal urethane likely contributed to the progressive deterioration of diaphragmatic function demonstrated in the animals of the two sham groups rested by either spontaneous breathing or mechanical ventilation, and confounded the results shown by the two fatigue groups rested by either spontaneous breathing or mechanical ventilation.
Medicine, Faculty of
Pathology and Laboratory Medicine, Department of
Graduate

This thesis is about the development and evaluation of a standardized method to measure the crural diaphragm electromyogram (EMG) in humans, with an esophageal electrode. In order for the diaphragm EMG to be physiologically relevant, its measurement and analysis require objective control of the disturbances and filter effects which can influence the sigma. One issue of importance is the maintenance of diaphragm-to-electrode positioning throughout the inspiration. In the present work, we describe a cross-correlation algorithm by which the position of the diaphragm along a multiple army esophageal electrode can be determined at any instant during a breath, and a second algorithm, the "double subtraction technique", which further minimizes the detrimental effects of diaphragm movement. The double subtraction technique also results in the improvement of the diaphragm EMG signal to noise ratio by 2 dB. By implementing these algorithms, we demonstrate in healthy subjects that there is no artifactual influence of lung volume/chest wall configuration on the diaphragm EMG frequency content nor on the diaphragm EMG signal strength during voluntary isometric contractions of the diaphragm. This is in contrast to the electrically elicited diaphragm compound muscle action potentials which are severely influenced by changes in lung volume. We also show that the volume-activation relationship of the diaphragm (required change in activation for changes in lung volume at a given tension) is directly related to the length-tension properties of the muscle. During dynamic, voluntary breathing maneuvers, we could find no evidence for an increase in diaphragm EMG signal strength when inspirations from functional residual capacity to total lung capacity (TLC) were performed at increasing inspiratory flow rates (velocities of shortening) up to 1.4 l/s. To account for anatomical and physiological differences between subjects, we demonstrate that the diaphragm EMG signal strength can be no

This thesis examines the importance of the length-force relationship and the three-dimensional shape of the diaphragm with regard to its inspiratory function. As well as it reports on the manner in which fatigue and aminophylline affect the length-force properties of the diaphragm. First, I studied the effect of fatigue on diaphragm contractility as a function of sarcomere length using an in vitro rat diaphragm strips. Results indicated that fatigue resulted in disproportionately greater reduction of tetanic force at short sarcomere lengths. Second, I reconstructed the three-dimensional shape of the diaphragm to determine if in vitro results are physiologically relevant in humans. I estimated the changes in fibre length and shape that occurs with lung inflation from residual volume to total lung capacity in normal subjects. Results suggested that the inspiratory function of the human diaphragm can be entirely attributed to its length-force relationship rather than changes in shape under conditions of twitch phrenic nerve stimulations. Finally, I confirmed that fatigue caused a greater percent reduction of transdiaphragmatic pressure at high lung volume in response to single supramaximal shocks delivered bilaterally to the phrenic nerves at high lung volume; and demonstrated that aminophylline potentiated human diaphragm contractility more at high than at low lung volumes, both under fresh and fatigue conditions. I propose an explanation for the effect of fatigue and aminophylline on diaphragm contractility at different sarcomere lengths based on known actions of these factors and muscle shortening on excitation-contraction coupling mechanisms of skeletal muscles.

The respiratory muscles play a role in respiratory failure when the efficient performance of the work of ventilation and/or their supply of metabolic substrates is disrupted. In this report a model of inspiratory muscle action is presented. The inflationary pressure applied to the lungs and the lung apposed rib cage is partitioned into two parts. One component is attributable to the action of rib cage muscles and the other is due to the interaction between upper and lower rib cage compartments. These contributions were found to be equal.
The role of afferent impulses travelling in the phrenic nerve in the control of respiratory muscle activity was investigated by electrical stimulation of its central cut end. Activation of these fibres exerts a non-uniform effect on the activities of the upper airway, rib cage and abdominal muscles and may influence respiratory muscle recruitment.
The roles of blood flow and oxygen delivery in determining diaphragm function was investigated. The rate at which diaphragmatic fatigue develops is diminished at high rates of blood flow and this effect is not related to the associated increase in oxygen delivery. The critical oxygen delivery at which oxygen consumption becomes supply dependent is the same for the resting diaphragm as for the rest of the body tissues. Activation of the diaphragm results in a higher critical oxygen delivery, however, this effect is mitigated by an increase in the critical oxygen extraction ratio.
The role of nitric oxide in regulating diaphragmatic blood flow and oxygen uptake was investigated by infusion of N$ sp{G}$-nitro-L-arginine. This treatment increased diaphragmatic vascular resistance, reduced the duration and magnitude of reactive vasodilation and increased the oxygen consumption and critical extraction ratio in the contracting diaphragm.

Sepsis-induced diaphragmatic force loss and failure are associated with an increased exposure to proinflammatory mediators. The septic diaphragm has recently been reported to overexpresse chemokines, including the CC chemokine MCP-1 (monocyte chemoattractant protein-1). This thesis seeks to address the significance of MCP-1 overproduction in diaphragm proinflammatory mediator expression and skeletal muscle contractile function. Neutralization of endogenous MCP-1, produced following administration of LPS, decreased transcription of iNOS, IL-6, IL-1alpha, IL-1beta and MCP-1 in the diaphragm and prevented a decrease in diaphragm force production. Furthermore, exogenous MCP-1 stimulated IL-6 and MCP-1 transcription in primary diaphragm myotubes, and injection of MCP-1 in the healthy EDL muscle led to contractile weakness. Taken together, these results suggest that increased MCP-1 production in the septic diaphragm stimulates proinflammatory mediator production by diaphragm myocytes, contributing to the muscle's contractile dysfunction.

[Truncated abstract] The function of the diaphragm as a volume pump has not been adequately evaluated because there are no accurate methods to measure the volume displaced by diaphragm motion (ΔVdi). As a consequence, the work done, power output and efficiency of the diaphragm have not been measured. Efficiency of the diaphragm could be measured by relating the power output of the diaphragm to its neural activation. The aims of this thesis were to (a) develop a new biplanar radiographic method to measure ΔVdi and use this to evaluate the effect of costophrenic fibrosis and emphysema on ΔVdi, (b) develop a new fluoroscopic method to enable breath-by-breath measurements of ΔVdi, (c) evaluate a method for quantifying neural activation of the diaphragm, and (d) combine measurements of transdiaphragmatic pressure, ΔVdi, inspiratory duration and neural activation of the diaphragm to quantify the neuromechanical efficiency of the diaphragm

These investigations examined the relative function of costal and crural diaphragm segments. This work produced the first direct measurements of length and electromyogram (EMG) of the diaphragm in an awake, intact animal.
Examination of diaphragm function following laparotomy revealed a consistent pattern of postoperative segmental recovery, and showed the inadequacy of EMG alone as an indicator of diaphragm activity. Segmental contraction during airway occlusion was confirmed to be non-isometric and different per segment. The basic relation between segmental velocity of shortening and mean inspiratory flow, was confirmed for diaphragm but not for intercostal musculature. Anesthesia produced a distinctive alteration in the resting length of crural compared to costal segment, suggesting a difference in inherent segmental tonic activity. Costal and crural activity during hypoxic and hypercapnic stimulated breathing revealed different, stimulant-specific activities of the segments; hypoxia elicited prominent crural post inspiratory activity (PIIA). During thermal panting, peak crural shortening was out of phase with costal shortening and inspiratory airflow. This unique segmental asynchrony may represent a natural analog to high frequency ventilation.
We conclude that costal and crural diaphragm segments can function as individual segment-muscles, exhibiting distinctive, differential activities under certain conditions of respiration.

The Liver Kinase B1 (LKB1)/AMP-Activated Protein Kinase (AMPK) signaling pathway is a major regulator of skeletal muscle metabolic processes. During exercise, LKB1-mediated phosphorylation of AMPK leads to its activation, promoting mitochondrial biogenesis and glucose transport, among other effects. The roles of LKB1 and AMPK have not been fully characterized in the diaphragm. Two methods of AMPK activation were used to characterize LKB1/AMPK signaling in diaphragms from muscle-specific LKB1 knockout (KO) and littermate control (C) mice: (1) acute injection of 5-aminoimidazole-4-carboxamide ribonucleoside (AICAR) and (2) 5-min direct electrical stimulation (ES) of the diaphragm. Diaphragms were excised 60 minutes post-AICAR injection and immediately after ES. AMPK phosphorylation increased with AICAR and ES in C but not KO mice. Acetyl CoA carboxylase (ACC) phosphorylation increased with AICAR in C but not KO mice, but increased in both genotypes with ES. While the majority of mitochondrial enzyme levels were lower in KO diaphragms, uncoupling protein 3 (UCP-3) levels were not different between genotypes. A IIx to IIb fiber type switch was observed in KO diaphragms. While in vitro peak force generation was similar between genotypes, KO diaphragms fatigued more quickly and had an impaired ability to recover. In conclusion, LKB1 regulates AMPK phosphorylation, mitochondrial enzyme expression, fiber type distribution, as well as recovery of the diaphragm from fatigue.

Second cervical segment spinal cord hemisection (C2Hx) results in ipsilateral hemidiaphragm paralysis. However, the intact latent crossed phrenic pathway can restore function spontaneously over time or immediately following drug administration.

WGA bound fluorochromes were administered to identify nuclei associated with diaphragm function in both the acute and chronic C2Hx models. WGA is unique in that it undergoes receptor mediated endocytosis and is transsynaptically transported across select physiologically active synapses. Comparison of labeling in the acutely injured to the chronically injured rat provided an anatomical map of spinal and supraspinal injury induced synaptic plasticity. The plasticity occurs over time in the chronic C2Hx model in an effort to adapt to the loss of hemidiaphragm function.

Utilizing the selectivity of WGA, a nanoconjugate was developed to target drug delivery to nuclei involved in diaphragm function post C2Hx in an effort to restore lost function. Theophylline was selected due to its established history as a respiratory stimulant. Theophylline was attached to gold nanoparticles by a transient bond designed to degrade intracellularly. The gold nanoparticles were then permanently attached to WGA-HRP. Following intradiaphragmatic injection, the WGA portion was identified in the ipsilateral phrenic nuclei and bilaterally in the rVRGs. The location of WGA should reflect the location of the AuNP since the peptide bond between them is permanent.

The effectiveness of the nanoconjugate was verified with EMG analysis of the diaphragm and recordings from the phrenic nerves. All doses administered in the acute C2Hx model resulted in resorted hemidiaphragm and phrenic nerve activity. A dose of 0.14mg/kg had a significantly higher percent recovery on day 3, whereas 0.03mg/kg was significantly higher on day 14. The change in most effective dose over time is likely due to the availability or concentration of the drug and location of drug release. Administration of the nanoconjugate was also characterized in the chronically C2Hx model. The dose 0.06mg/kg resulted in significant recovery when injected 12 weeks post-C2Hx. This data suggests that WGA bound nanoconjugates are able to undergo endocytosis. In addition, the theophylline bound nanoconjugate is capable of restoring hemidiaphragm and phrenic nerve activity.

Physiology
Ph.D.
Supraphysiologic concentrations of oxygen are used in the management of critically ill patients across the lifespan. However, hyperoxia (HO) results in alveolar- capillary membrane destruction, pulmonary edema, pleural effusions, infiltration and activation of inflammatory cells, altered pulmonary mechanics and gas exchange prompting increased loading of the respiratory muscle. These abnormalities of pulmonary structure and function increase the work of breathing necessitating increased respiratory muscle force production to maintain alveolar ventilation. When the load placed on the respiratory muscle pump exceeds its capacity, respiratory failure develops and is ultimately fatal unless therapeutic interventions are able to reduce the ventilatory load. The use of perfluorochemical (PFC) liquids as a respiratory medium has been effective in the treatment of respiratory distress syndrome and acute lung injury (ALI) requiring mechanical ventilation. Mechanistically, by eliminating the air-liquid interface, PFC liquids reduce surface tension enabling lung volume recruitment at low inspiratory pressures and have high respiratory gas solubility which supports gas exchange. Additionally, through mechanical as well as cytoprotective mechanisms, intrapulmonary PFC liquids reduce inflammatory cell activation and recruitment. Cell culture, animal and human studies have suggested that acute and chronic lung injury secondary to prolonged HO may be ameliorated by administration of antioxidant enzymes (AOE), with superoxide dismutases (SOD) having significant protective effects. Because the lung is exposed to the highest O2 concentrations, a logical strategy to reduce HO-induced damage is to specifically target antioxidant enzymes to the lungs. However, intratracheal delivery of AOE by vehicles like normal saline may transiently impair lung function and be poorly distributed. PFC fluids have previously been shown to be effective respiratory media for pulmonary administration of various drugs. The premise of the proposed studies are to to characterize hyperoxic lung injury in a spontaneously breathing animal model and to develop therapeutic strategies to reduce oxidatative stress and supplement endogenous AOE. With respect to the diaphragm, we reason that HO-induced lung damage and oxidative stress will increase contractile demand of the diaphragm. If AOE activity could be increased in the lungs and respiratory muscles with AOE proteins or the genes encoding these enzymes, then cell damage, inflammatory changes, damage to the lung and respiratory "pump" might be ameliorated or prevented. The results show that PFC and SOD can attenuate the HO- induced decline in lung mechanics and gas exchange, ameliorate the inflammatory and oxidative stress profiles, and promote lung and muscle structural integrity resulting in a survival benefit. These findings support the novel application of PFC liquids in a spontaneously breathing model and support the concept that PFC preconditioning and AOE supplementation play a protective role by reducing mortality and morbidity in hyperoxic lung injury.
Temple University--Theses

Orientador: Lourenço Sbragia Neto
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: A Hérnia Diafragmática Congênita (HDC) é um defeito da formação do músculo diafragma que incide em aproximadamente 1:2500 nascidos vivos e apresenta altos índices de mortalidade fetal e neonatal decorrentes da hipoplasia e da hipertensão pulmonares. Este defeito pode ser induzido experimentalmente em ratas grávidas administrando o herbicida nitrofen que causa HDC em 24% dos fetos. A análise microscópica do pulmão da HDC demonstra a presença de hipolasia pulmonar além de alveolização e vascularização alterada. Um dos fatores de crescimento envolvidos no desenvolvimento vascular é o VEGF (vascular endothelial growth factor) e seus receptores, no entanto ainda não se conhece como a expressão desta glicoproteína e de seus receptores varia ao longo do desenvolvimento pulmonar fetal nesta doença. Utilizando o modelo experimental de HDC induzido pelo nitrofen (2,4-dicloro-4'nitrodifenil éter) investigamos o grau de hipoplasia pulmonar e por meio de análise imunoistoquímica, comparamos a expressão dos receptores para o VEGF em três fases do desenvolvimento pulmonar, pseudoglandular, canalicular e sacular de fetos de ratos normais e com HDC. Dividimos o experimento em ratas da raça Sprague-Dawley em três grupos: controle externo (CE), exposto ao óleo de oliva (OO) e expostas ao nitrofen com e sem HDC. Estudamos quatro grupos de 20 fetos cada em cinco dias gestacionais (DG) diferentes 17,5, 18,5, 19,5, 20,5 e 21,5. As variáveis morfológicas estudadas foram: peso corporal (PC), peso pulmonar total (PPT), peso do pulmão esquerdo (PPE), relação PPT/PC, volume pulmonar total (VPT) e volume do pulmão esquerdo (VPE). As variáveis histométricas estudadas foram: parênquima pulmonar (Par), espaço aéreo (EA), densidade do parênquima (DAP) e volume do parênquima do pulmão esquerdo. A avaliação imumohistoquímica foi realizada por meio da contagem de pontos de receptor de VEGFR-1 e 2. Obtivemos 37 % (100/270) de HDC nas ratas expostas ao nitrofen, todas variáveis morfológicas e histométricas indicam diminuição dos resultados no grupo nitrofen com e sem HDC em relação aos demais, mas que se acentuam mais ainda no grupo HDC. Essas alterações são mais evidentes a partir dos DG 18,5 e 19,5. A imunomarcação para os receptores VEGFR-1 aumentou nos grupos nitrofen e foram progressivamente maiores no grupo nitrofen com HDC (p<0,005) que os fetos dos grupo CE e OO a partir do dia gestacional 17,5, fase pseudoglandular com pico máximo no dia gestacional 19,5. O mesmo ocorreu com os receptores de VEGFR-2 a partir do dia gestacional 17,5, fase pseudoglandular até o dia 21,5 fase sacular do desenvolvimento pulmonar. Concluímos que o modelo é valido e que os fetos expostos ao nitrofen com e sem HDC apresentam hipoplasia pulmonar primária sendo mais acentuada nos fetos portadores de HDC. O mesmo resultado ocorre com imunomarcação para os receptores de VEGFR-1 e 2 que foram maiores na HDC.
Abstract: The Congenital Diaphragmatic Hernia (CDH) is a defect in the embryogenesis of the diaphragm with an incidence of 1:2500 liveborns and high fetal and neonatal mortality due to pulmonary hypoplasia and hypertension. This defect can be experimentally induced in fetuses of pregnant rats by the administration of Nitrofen, an herbicide that causes CDH in 24% of the fetuses. The histology of lungs in CDH shows pulmonary hipoplasia and not only the alveolarization but also the vascularization are affected. These changes lead to a high neonatal mortality because of the thickening of the middle layer of the arterioles causing pulmonary hypertension. One of the factors involved in the growth of the arterioles is VEGF (vascular endothelial growth factor) and its receptors; however, it is not known how the expression of this glycoprotein and its receptors change during lung development in this disease. In Brazil, the experimental model has never been tested. So, we tested the model and verified the degree of pulmonary hipoplasia and, using imunohystochemistry, we compared the expression of the receptor of VEGF in three different stages of lung development, pseudoglandular, canalicular and saccular, of normal rat fetuses and fetuses with CDH. Female Sprague-Dawley rats were divided in three groups: external control (EC), exposed to olive oil (OO) and exposed to nitrofen (N). We studied four groups - EC, OO, N with CDH and N without CDH - with 20 fetuses in each five different gestational days (GD) 17,5, 18,5, 19,5, 20,5, 21,5. The morphologic variables studied were: body weight (BW), total lung weight (TLW), left lung weight (LLW), relationship TLW/BW, total lung volume (TLV) and left lung volume (LLV). The hystometric variables studied were: lung parenchyma (LP), air space (AS), left lung parenchyma density (PD) and left lung parenchyma volume (PV). The immunohystochemistry variables were: points positive and negative for the receptor for VEGF 1 and 2. We had 37% (100/270) of CDH frequency in the fetuses exposed to nitrofen. All the morphological and hystometrical variables show a reduction in the nitrofen group with and without CDH, which were more pronounced in the group of fetuses with CDH. These changes are more evident from the GD 18,5 and 19,5 on. The receptors VEGFR-1 e 2 are increased in the nitrofen groups with and without CDH, but this increase is higher in the fetuses with CDH. We conclude that the model is valid and that the fetuses exposed to nitrofen with and without CDH show primary pulmonary hypoplasia that is more pronounced in CDH, the same is also observed in the receptors of VEGFR-1 and 2.
Doutorado
Pesquisa Experimental
Doutor em Cirurgia

Les pathologies respiratoires obstructives de l’enfant (asthme et broncho-alvéolites) sont l’une des principales causes d’admission en réanimation pédiatrique. Depuis plusieurs années, des progrès ont été faits pour réduire l’invasivité des soins se traduisant par une réduction de la morbidité. L’objectif de ce travail de thèse est de s’appuyer sur des mécanismes physiopathologiques pour proposer des stratégies d’optimisation ventilatoire et non ventilatoire chez ces enfants. Nous avons évalué l’impact du décubitus ventral couplé à la ventilation non invasive chez les nourrissons atteints de bronchiolite grave. Le décubitus ventral permet de réduire significativement l’effort inspiratoire et d’améliorer le couplage électromécanique du diaphragme. Ensuite nous avons évalué la « neurally adjusted ventilatory assist » (NAVA) qui est un mode ventilatoire proportionnel basé sur l’activité électrique du diaphragme. Nous avons démontré que la NAVA améliorait la synchronisation patient-respirateur et réduisait le travail respiratoire en comparaison à la « nasal continuous positive airway pressure » (nCPAP). Enfin, dans la pathologie asthmatique nous avons également décrit la faisabilité du haut débit nasal dans cette population. Ces stratégies nécessitent maintenant d’être validées sur des critères cliniques et feront l’objet de deux études multicentriques randomisées
Obstructive lung disease in children (asthma and bronchiolitis) are one of the main causes of admission to pediatric intensive care units. For several years, progress has been made to reduce the invasiveness of care resulting in a decrease in associated morbidity. The main objective of the thesis was to propose new ventilatory and non-ventilatory strategies based on physiopathology to optimize the care of such children.In children with severe bronchiolitis we evaluated the impact of prone position associated with non-invasive ventilation. The prone position decreases significantly the inspiratory work of breathing and improves the neuromechanical efficiency of the diaphragm. We also evaluated the effect of neurally adjusted ventilatory assist (NAVA) that is a proportional ventilatory mode based on the electrical activity of the diaphragm. We demonstrated that NAVA improved the patient-ventilator interactions and decrease the work of breathing in comparison with nasal continuous positive airway pressure (nCPAP). We also evaluated the feasibility of high flow nasal cannula as a respiratory support in children with severe asthma attack. These strategies need now to be validated on clinical outcomes and are the subject of two ongoing multicenter randomized trials

La dysfonction diaphragmatique est responsable des complications respiratoires observees en periode post-operatoire. La sonomicrometrie permet de mesurer directement la contraction diaphragmatique. Nous avons teste a l'aide de cette technique les principales hypotheses sur l'inhibition diaphragmatique. Chez le mouton, la stimulation des centres respiratoires pour l'injection d'aminophylline ou l'injection de digoxine pour ameliorer la contraction diaphragmatique n'ont que peu d'effets sur le raccourcissement diaphragmatique. L'injection d'anesthesique par voie epidurale dans le but de bloquer les afferences inhibitrices du nerf phrenique, augmente le raccourcissement diaphragmatique mais l'effet semble etre lie davantage aux modifications de conformation de la cage thoracique (secondaires a l'anesthesie) plus qu'a la levee de l'inhibition reflexe. Chez l'homme, la chirurgie thoracique entraine une alteration de la fonction diaphragmatique en ventilation spontanee et cette alteration n'est pas amelioree par l'injection d'anesthesique par voie epidurale haute

D'une façon générale, on assimile fréquemment le contrôle de la respiration aux mécanismes automatiques qui prennent naissance dans le tronc cérébral. Ils permettent au diaphragme de se contracter cycliquement 24h sur 24, et au système respiratoire d'assurer l'homéostasie face à des variations métaboliques. Cependant, le cortex cérébral peut avoir une influence majeure sur la respiration, permettant la réalisation d'actions volontaires respiratoires ou extra-respiratoires (langage), et la perception fine des charges respiratoires. Tout ceci implique une représentation corticale tant sur le versant moteur que sur le versant sensitif. Après une brève revue des connaissances et concepts actuels, cette thèse expose en cinq chapitres cinq travaux distincts, qui décrivent, chez l'homme : 1. La réponse du diaphragme à la stimulation magnétique du cortex cérébral en l'absence de contraction facilitatrice sous-jacente ; 2. La possibilité d'évaluer le niveau de la commande volontaire de la contraction diaphragmatique, en utilisant les stimulations magnétiques cervicale et corticale ; 3. L'unilatéralité de la représentation corticae du diaphragme, à partir du modèle des hémiplégies d'origine vasculaire ; 4. Ides potentiels cérébraux et spinaux évoqués par la stimulation phrénique, donc l'existence d'afférences diaphragmatiques chez l'homme ; 5. à partir d'une observation privilégiée (électrodes intra-cérébrales), la localisation de ces projections afférentes au niveau du gyrus cingulaire chez l'homme.

Ce travail de thèse avait pour objet dans un premier temps, de déterminer la durée et l'intensité de l'exercice pour lesquelles une fatigue centrale diaphragmatique était présente. Pour cela, nous avons testé l'apparition de la fatigue centrale du diaphragme pour trois durées d'exercice (5,15 et 40 minutes) en gardant la même intensité (55% de V̇O2max). Il en résultait que la fatigue centrale diaphragmatique était mise en évidence pour une durée de 40 minutes seulement. Ainsi, la fatigue centrale s'installerait avec le temps. Dans un deuxième temps, nous avons cherché à savoir si l'intensité de l'exercice avait une influence sur l'apparition de cette fatigue. Nous avons donc vérifié la présence de fatigue centrale du diaphragme pour différentes intensités d'exercice (40%, 55%, 75% de V̇O2max) en gardant la même durée d'exercice (15 minutes). Or il n'y avait pas de fatigue centrale du diaphragme, quelle que soit l'intensité de l’exercice. Dans une troisième étude nous nous sommes intéressés au contrôle ventilatoire pendant l'exercice. Nous avons vérifié si des potentiels prémoteurs, témoins de l'activation du cortex prémoteur, étaient présents pendant des exercices de différentes intensités (40% et 70% de V̇O2max) et pendant un exercice d'intensité modéré accompagné d'une charge inspiratoire résistive (40% de V̇O2max avec une charge de 5cmH2O). Nous n’avons pas observé d'activité prémotrice pré-inspiratoire pendant les exercices, suggérant une absence de contribution corticale à la ventilation humaine pendant l'exercice
This work aimed firstly to determine the duration and intensity of the exercice inducing diaphragmatic central fatigue. We tested the presence of the diaphragmatic central fatigue for three exercice durations (5,15 and 40 minutes) keeping the same intensity of exercice (55% of V̇O2max). The diaphragmatic central fatigue was present for a duration of 40 minutes. This fatigue would settle in progressively with time. On a second time, we checked if the exercice intensity influenced this fatigue. We checked the presence of diaphragmatic central fatigue for different intensities of exercice (40%, 55%, 75% of V̇O2max) keeping the same duration (15 minutes). The central diaphragmatic fatigue was absent, whatever the intensity of exercice. In a third work, we studied the ventilatory control during exercice. We checked if premotor potentials, which are evidences of the premotor cortex activation, were present during exercices of different intensities (40% et 70% of V̇O2max) and during a moderate exercice with resistive inspiratory load (40% de V̇O2max with a load of 5cmH2O). We did not observe any premotor preinspiratory activity, suggestive of an absence of cortical contribution of human ventilation during exercise

La commande de la ventilation chez l'humain est capable d'adaptation persistante qui repose sur des mécanismes de type LTP. Différentes techniques permettant l'induction de plasticité sont couramment utilisées mais leur application au contrôle ventilatoire n'a fait l'objet que de très peu de travaux.L'objectif de cette thèse est (1) examiner la possibilité d'induire des mécanismes de type LTP par la rTMS et la tsDCS en deux sites de la commande ventilatoire destinée au diaphragme, l'AMS et les métamères C3-C5 ; (2) évaluer les conséquences sur le profil ventilatoire en ventilation de repos et lorsque la ventilation est artificiellement contrainte. Nous avons examiné les effets d'un conditionnement inhibiteur appliqué par rTMS en regard de l'AMS sur l'excitabilité corticophrénique. Nous avons observé la présence d'une diminution persistante de cette excitabilité et en avons tiré la proposition qu'en ventilation de repos l'AMS augmente l'excitabilité de la commande ventilatoire à l'éveil. Nous avons alors considéré les conséquences de la rTMS sur la ventilation expérimentalement contrainte. Les modifications du profil ventilatoire induites par la rTMS sont en faveur d'une participation de l'AMS à la production ou au traitement de la copie d'efférence. Dans une 3ème étude, nous avons examiné les effets de la tsDCS au niveau C3-C5 sur l'excitabilité corticophrénique et sur le profil ventilatoire. L'augmentation de cette excitabilité et du volume courant nous a conduit à suggérer la possibilité d'induire une plasticité respiratoire au niveau spinal.L'ensemble de ces résultats nous permet d'envisager des perspectives thérapeutiques à l'utilisation de la rTMS et de la tsDCS.

Les centres respiratoires du tronc cérébral régulent la ventilation. Les signaux qu’ils émettent sont transmis aux muscles inspiratoires. La commande respiratoire peut être monitorée au lit du patient au moyen de l’activité électrique diaphragmatique (Eadi) ou de la pression d’occlusion à 100 ms (P0.1). Le monitorage de ces paramètres devrait permettre d’optimiser l’assistance ventilatoire délivrée.Il n’existe que peu de données relatives aux valeurs normales d’Eadi et de P0.1 et à leurs variations en situations non physiologiques. La question de la fiabilité des mesures réalisables au lit du patient reste également débattue. Ce projet de thèse visait à augmenter les connaissances relatives à l’Eadi et à la P0.1.Les travaux réalisés ont permis de : 1. mieux caractériser l’amplitude de l’Eadi en situations physiologique et non physiologiques, 2. démontrer que la valeur maximale d’Eadi reflète bien l’intensité de la commande, 3. démontrer que le monitorage de l’Eadi est complémentaire à celui du profil ventilatoire et de l’effort inspiratoire, 4. démontrer que Eadi et P0.1 sont bien corrélés,5. démontrer que l’Eadi peut être utilisé pour optimiser les réglages en aide inspiratoire et que ceci améliore la synchronisation patient-ventilateur, 6. démontrer que les variations de P0.1 sont bien reflétées par les mesures de P0.1 réalisées par les ventilateurs et 7. démontrer que les ventilateurs sous-estiment les P0.1 de référence. Des études complémentaires sur de plus grands collectifs et portant sur le devenir des patients doivent être réalisées avant que le monitorage de l’Eadi et de la P0.1 puissent être recommandés comme techniques de routine chez les patients ventilés
The brainstem respiratory centers are in charge of breathing regulation. Their output is transmitted to the inspiratory muscles. Respiratory drive monitoring can be performed using the electrical activity of the diaphragm (Eadi) or the measurement of the occlusion pressure at 100 ms (P0.1). Monitoring these parameters should allow improving the delivered ventilator assist. Few data regarding the normal values of Eadi and P0.1 and their variations in non-physiological situations are available. The question of the reliability of the bedside measurements also remains opened.This thesis project aimed at increasing our knowledge on Eadi and P0.1 measurements. The studies performed allowed 1. better characterizing Eadi and P0.1 normal values in physiological and non-physiological situations. 2. demonstrating that Eadi maximal value well reflects inspiratory drive intensity, 3. demonstrating that Eadi monitoring provides additional information compared to respiratory profile and inspiratory effort monitoring, 4. demonstrating that Eadi and P0.1 are well correlated, 5. demonstrating that Eadi can be used to improve the ventilator settings during pressure support and that this strategy allows improving patient-ventilator synchrony. 6. showing that the P0.1 variations are well reflected by the P0.1 measured by the ventilators, 7. demonstrating that overall the P0.1 measured by the ventilators underestimate the reference P0.1. Additional studies in more patients and studies designed to assess the impact on patient’s outcome of using Eadi and P0.1 monitoring should be perform before recommaending these monitorings as a standard procedure in ventilated patients

La capacité résiduelle fonctionnelle (CRF), volume pulmonaire en fin d'expiration normale, est un paramètre essentiel des échanges gazeux. Chez le nourrisson, le maintien du niveau de CRF dépend de l'interaction de différents mécanismes, contrairement à l'équilibre passif observé chez l'adulte. Nous avons essayé d'améliorer la compréhension de ces mécanismes. Dans un premier temps, nous avons confirmé la persistance d'une activité tonique du diaphragme jusqu'en fin d'expiration chez des nourrissons intubés. Cette activité augmente en l'absence de pression expiratoire positive, renforçant l'hypothèse de son implication dans le maintien de la CRF. Nous avons ensuite adapté une méthode de pléthysmographie par inductance pour une utilisation chez le prématuré, y compris en présence d'asynchronisme thoraco-abdominal ou d'assistance ventilatoire. Cette méthode a permis de montrer que chez les prématurés, la variabilité de la CRF est élevée, n'est pas purement aléatoire, et contient une part significative d'autocorrélation. En cas de pathologie respiratoire, le profil de variabilité est différent, avec une autocorrélation plus importante. Cela suggère des retours à l'état antérieur plus lents après perturbation du niveau de CRF. Chez les nourrissons sous assistance respiratoire, l'autocorrélation est encore plus élevée.
La caractérisation de la variabilité de la CRF, reflet du degré de liberté du système de contrôle, et la mesure de l'activité tonique du diaphragme, reflet des efforts du nourrisson pour augmenter la CRF, devraient permettre d'améliorer encore la compréhension de la régulation de la CRF, et d'améliorer la prise en charge ventilatoire de ces patients.

The static aspects of the diaphragm under Full Residual Capacity (full lung deflation) were studied. The membrane equations were used to describe the diaphragm. Based on the description, a finite element program was written to determine the position of the diaphragm under various loading conditions. Erect and supine specimens were studied. The results of the finite element model were found to be in agreement with physiological data from X-ray photographs.

Introduction: La ventilation non invasive (VNI) est un outil utilisé en soins intensifs pédiatriques (SIP) pour soutenir la détresse respiratoire aigüe. Un échec survient dans près de 25% des cas et une mauvaise synchronisation patient-ventilateur est un des facteurs impliqués. Le mode de ventilation NAVA (neurally adjusted ventilatory assist) est asservi à la demande ventilatoire du patient. L’objectif de cette étude est d’évaluer la faisabilité et la tolérance des enfants à la VNI NAVA et l’impact de son usage sur la synchronie et la demande respiratoire. Méthode: Étude prospective, physiologique, croisée incluant 13 patients nécessitant une VNI dans les SIP de l’hôpital Ste-Justine entre octobre 2011 et mai 2013. Les patients ont été ventilés successivement en VNI conventionnelle (30 minutes), en VNI NAVA (60 minutes) et en VNI conventionnelle (30 minutes). L’activité électrique du diaphragme (AEdi) et la pression des voies aériennes supérieures ont été enregistrées pour évaluer la synchronie. Résultats: La VNI NAVA est faisable et bien tolérée chez tous les enfants. Un adolescent a demandé l’arrêt précoce de l’étude en raison d’anxiété reliée au masque sans fuite. Les délais inspiratoires et expiratoires étaient significativement plus courts en VNI NAVA comparativement aux périodes de VNI conventionnelle (p< 0.05). Les efforts inefficaces étaient moindres en VNI NAVA (résultats présentés en médiane et interquartiles) : 0% (0 - 0) en VNI NAVA vs 12% (4 - 20) en VNI conventionnelle initiale et 6% (2 - 22) en VNI conventionnelle finale (p< 0.01). Globalement, le temps passé en asynchronie a été réduit à 8% (6 - 10) en VNI NAVA, versus 27% (19 - 56) et 32% (21 - 38) en périodes de VNI conventionnelle initiale et finale, respectivement (p= 0.05). Aucune différence en termes de demande respiratoire n’a été observée. Conclusion: La VNI NAVA est faisable et bien tolérée chez les enfants avec détresse respiratoire aigüe et permet une meilleure synchronisation patient-ventilateur. De plus larges études sont nécessaires pour évaluer l’impact clinique de ces résultats.
Introduction: The need for intubation after noninvasive ventilation (NIV) failure is frequent in the pediatric intensive care unit (PICU). One reason is patient-ventilator asynchrony during NIV. Neurally adjusted ventilatory assist (NAVA) is a mode of ventilation controlled by the patient’s neural respiratory drive. The aim of this study was to assess the feasibility and tolerance of NIV-NAVA in children and to evaluate its impact on synchrony and respiratory effort. Methods: This prospective, physiologic, crossover study included 13 patients requiring NIV in the PICU of Sainte-Justine’s Hospital from October 2011 to May 2013. Patients were successively ventilated in conventional NIV as prescribed by the physician in charge (30 minutes), in NIV-NAVA (60 minutes), and again in conventional NIV (30 minutes). Electrical activity of the diaphragm (EAdi) and airway pressure were simultaneously recorded to assess patient-ventilator synchrony. Results: NIV-NAVA was feasible and well tolerated in all patients. One patient asked to stop the study early because of anxiety related to the leak-free facial mask. Inspiratory trigger dys-synchrony and cycling-off dys-synchrony were significantly shorter in NIV-NAVA versus initial and final conventional NIV periods (both p< 0.05). Wasted efforts were also decreased in NIV-NAVA (all values expressed as median and interquartile values): 0 (0 - 0) in NIV-NAVA versus 12% (4 - 20) and 6% (2 - 22) in initial and final conventional NIV, respectively (p< 0.01). As a whole, total time spent in asynchrony was reduced to 8% (6 - 10) in NIV-NAVA, versus 27% (19 - 56) and 32% (21 - 38) in initial and final conventional NIV, respectively (p= 0.05). No difference in term of respiratory effort was noted. Conclusion: NIV-NAVA is feasible and well tolerated in PICU patients and allows improved patient-ventilator synchronization. Larger controlled studies are warranted to evaluate the clinical impact of these findings.