Short courses of mechanical ventilation with high-O2 levels in elderly rat lungs

Ventilação mecânica de curta duração com altos níveis de O2 em pulmões de ratos idosos

6 - ORIGINAL ARTICLE

MODELS, BIOLOGICAL

Short courses of mechanical ventilation with high-O₂ levels in elderly rat lungs¹

Ventilação mecânica de curta duração com altos níveis de O₂ em pulmões de ratos idosos

Sâmia Santos Cavassani^I; Virginia Berlanga Campos Junqueira^II; Juliana Britto Moraes^III; Karen Kristina Luzo^III; Claudeny Matos Assis Silva^III; Maciel Barros^III; Márcia Marinho^IV; Ricardo Santos Simões^V; Itamar Souza Oliveira-Júnior^VI

^IFellow Master degree, Department of Preventive Medicine, UNIFESP, Sao Paulo-SP, Brazil. Executing the work and writing the manuscript

^IIFull Professor, Department of Biological Science, UNIFESP, Diadema-SP, Brazil. Supervisor and writing the manuscript

^IIIGraduate student, Division of Anesthesiology, Pain and Intensive Therapy, UNIFESP, Sao Paulo-SP, Brazil. Animal anesthesia and handling, literature review and bronchoalveolar counting

^IVAssociate Professor, Department of Production Support and Animal Health, Paulista State University, Araçatuba-SP, Brazil. Analysis of the determination of total proteins content

^VFellow PhD degree, Department of Morphology and Genetics, Histology Division, UNIFESP, Sao Paulo-SP, Brazil. Histological analysis and neutrophil count

^VIAssociate Professor, Division of Geriatrics and Gerontology, UNIFESP, Sao Paulo-SP, Brazil. Co-supervisor and writing the manuscript

^{Correspondence}

ABSTRACT

PURPOSE: To evaluate the effects of mechanical ventilation (MV) of high-oxygen concentration in pulmonary dysfunction in adult and elderly rats.

METHODS: Twenty-eight adult (A) and elderly (E), male rats were ventilated for 1 hour (G-AV1 and G-EV1) or for 3 hours (G-AV3 and G-EV3). A and E groups received a tidal volume of 7 mL/kg, a positive end-expiratory pressure of 5 cm H2O, respiratory rate of 70 cycles per minute, and an inspiratory fraction of oxygen of 1. We evaluated total protein content and malondialdehyde in bronchoalveolar lavages (BAL) and performed lung histomorphometrical analyses.

RESULTS: In G-EV1 animals, total protein in BAL was higher (33.0±1.9 µg/mL) compared with G-AV1 (23.0±2.0 µg/mL). Upon 180 minutes of MV, malondialdehyde levels increased in elderly (G-EV3) compared with adult (G-AV3) groups. Malondialdehyde and total proteins in BAL after 3 hours of MV were higher in elderly group than in adults. In G-EV3 group we observed alveolar septa dilatation and significative increase in neutrofiles number in relation to adult group at 60 and 180 minutes on MV.

CONCLUSION: A higher fraction of inspired oxygen in short courses of mechanical ventilation ameliorates the parameters studied in elderly lungs.

Keywords: Aging. Lung injury. Ventilator-Induced Lung Injury. Neutrophil Infiltration. Oxidative Stress. Rats.

RESUMO

OBJETIVO: Avaliar os efeitos da ventilação mecânica com alta concentração de oxigênio em animais adultos e idosos.

MÉTODOS: Vinte e oito ratos machos (adultos e idosos; n=7 por grupo) foram divididos em ventilados por 1 hora (G-AV1 e G-EV1) e ventilados por 3 horas (G-AV3 e G-EV3). Os grupos receberam volume corrente de 7 mL/kg, pressão positive ao final da expiração de 5 cmH₂O, frequência respiratória de 70 ciclos por minuto e fração inspirada de oxigênio de 100%. Ao final do experimento avaliamos no lavado brônquio-alveolar as proteínas totais, malondialdeído, celularidade e a histomorfometria do parênquima pulmonar.

RESULTADOS: Em animais idosos ventilados por 1 hora (G-EV1) as proteínas totais no lavado brônquio-alveolar aumentaram (33.0±1.9 µg/mL) quando comparados com os adultos (G-AV1; 23.0±2.0 µg/mL). Após 180 minutos de ventilação mecânica os níveis de malondialdeído e as proteínas totais estavam elevadas nos animais idosos (G-EV3) quando comparadas com os adultos (G-AV3; p<0.001). No grupo de animais idosos (G-EV3) observamos ainda dilatação dos septos alveolares e aumento significativo no número de neutrófilos em relação aos adultos ventilados, tanto aos 60 quanto aos 180 minutos de ventilação mecânica (p<0.001).

CONCLUSÃO: A ventilação mecânica com alta fração inspirada de oxigênio por um curto período de tempo favoreceu os parâmetros pulmonares estudados nos animais idosos.

Descritores: Envelhecimento. Lesão Pulmonar. Lesão Pulmonar Induzida por Ventilação Mecânica. Infiltração de Neutrófilos. Estresse Oxidativo. Ratos.

Introduction

Elderly patients have become an increasingly prevalent proportion of the intensive care unit (ICU) population. Outcomes of patients with acute respiratory distress syndrome (ARDS) have been significantly improved in recent years¹.

In the very elderly population (85 years and older), the acute severity of illness is the most significant predictor of mortality after an ICU admission associated with a significant functional deterioration^2,3. The senescence process itself decrease of the muscular strength and aerobics capacity, vasomotor instability, reduction of the bone mass, reduction of the lung ventilation etc.⁴. Regarding the mortality rate post-ICU, a study by Gordo et al.⁵ showed that among patients over 75 years the age can be associated with mortality as an independent factor, whereas Iapichino et al.⁶ demonstrated that after discharging ICU the mortality rate was increased in patients over 78 years.

Artificial ventilation is one of the most important techniques in the ICU, besides being an important tool in the approach of the acute lung injury/acute respiratory distress syndrome (ALI/ARDS) of any nature or in other cases^7,8. In many cases of respiratory diseases, the use of ventilatory support is required. Besides that, a ventilatory support is needed in other situations, including sepsis and sepsis shock; neuromuscular disease; during postoperative state; and in cases of altered mental status with loss of consciousness^9,10.

Several studies consider the age as a factor influencing the clinical prognosis of a patient needing mechanical ventilation^11,12. These are in disagreement with others that consider, in addition to the age, other factors like functional status and the seriousness of the acute process^11-14, and others yet which consider age as an associated factor^15-18. Although no consistent data exist in this scenario, it is presumable that aged individuals have greater susceptibility to the harmful effects of mechanical ventilation than adults.

Animal studies the effects of hyperoxia have employed very high levels of inspired oxygen fraction (FiO₂ > 0.95) for extended periods of time. These experimental models produce severe lung injury and death in 48-72 h¹⁹. Patients without lung dysfunction requiring such high concentrations of supplemental oxygen, however, often receive concurrent ventilatory support. The deleterious effects of hypoxia are well known and physicians may be mostly concerned about avoiding hypoxia and giving additional oxygen 'to remain on the safe side^20,21.

Significant resistance to hyperoxia-induced oxidative stress has been demonstrated in pulmonary endothelial cells overexpressing manganous superoxide dismutase (Mn-SOD)²². Limited literature, however, exists on the role of reactive oxygen species (ROS) in modulating the inflammatory response during early or late phase of acute inflammation^23-25.

The present study tested in an animal model the effect of two different periods of mechanical ventilation and we hypothesize that elderly subjects are more susceptible than adults to the deleterious effects of a large period of mechanical ventilation using a higher fraction of inspired oxygen and to the accompanying oxidative stress.

Methods

Surgical procedure

All procedures were approved by the Institutional Research Committee at Federal University of Sao Paulo, in accordance with the National Institutes of Health (NIH) Guidelines Regarding Animal Experimentation and the principles of the Brazilian College on Animal Experimentation.

Twenty eight male Wistar rats (Rattus norvegicus albinus) from which 14 were adult (4 month-old, body weight [bw] - 320-360 g) and 14 were elderly (24 month-old, bw 430-465 g), were divided in four groups (n = 7 animals each) as follows: adult (G-AV1) and elderly (G-EV1) rats ventilated for 1 hour; and adult (G-AV3) and elderly (G-EV3) rats ventilated for 3 hours. The animals were individually housed, fed rat chow and water ad libitum, and were maintained on a 12-h light/dark cycle for 3 weeks prior to initiation of the experiments.

Mechanical ventilation (MV)

Rats were anesthetized with an intraperitoneal (ip) bolus injection of sodium thiopental (50 mg/kg; Thionembutal^®, Abbott, SP, Brazil). After reaching a surgical plane of anesthesia and after tracheostomy, a 14G cannula was inserted into the trachea. Upon tracheostomy, a sterile PE50 catheter was inserted into the right carotid artery for blood gases sampling and another one into the left carotid artery for mean arterial pressure (MAP) control (Pressure transducer, Gould-Statham, CA, USA). Muscle relaxation was performed with ip succinylcholine chloride (0.8 mg/kg; Uniao Quimica Farmaceutica Nacional, SP, Brazil).

The animals were immediately connected to a rodent ventilator (Harvard Apparatus, MA, USA) and ventilated during 1 or 3 h using a tidal volume (V_T) of 7 mL/kg, a positive endexpiratory pressure (PEEP) of 5 cmH₂O, a fraction of inspired oxygen (FiO₂) of 1 and a respiratory rate (RR) of 70 cycles per minutes (cpm). Body temperature was maintained at nearest 37 ºC by the use of a heating blanket and controlled by a rectal thermometer (YSI Inc., OH, EUA).

Arterial blood gases measurements

Arterial blood gases were collected in sterile vented plastic syringes (PICO 70, Radiometer, Copenhagen, Denmark) and measured at different times: in the groups ventilated for 1 hour at the times 0 min and 60 min; the ventilated groups for 3 h were evaluated at the times 0 min, 60 min and 180 min, using an automatic analyzer (AVL-Compact3, Roche Diagnostic, Germany).

Bronchoalveolar lavage (BAL)

At the end of experiment, the animals were euthanized (ip doses of 1 mL/100 g body weight; T-61 Euthanasia Solution, Schering-Plough, SP, Brazil). A sternotomy was performed and the lungs and structures were removed and weighed. The left main stem bronchus lung was tied and the right lung was washed three

times with 10 mL/kg of sterile saline solution. Lavage fluids were kept separate and centrifuged (400 x g for 10 min, 4 ºC) and the supernatants were immediately frozen on dry ice and stored at -80ºC.

Total cell countings and total protein determinations in BAL

The total number of cells in BAL was counted in a hemocytometer (Neubauer chambers) under 100x magnification. Total protein content was measured (in duplicate) in 1-mL aliquot of BAL by using the method of Lowry and colleagues ²⁶.

Thiobarbituric acid-reactive substances (TBARS)

Products of lipid and protein oxidation were determined in the homogenate of the left lung by using the method of Das²⁷. The concentrations of lipid peroxidation (LPO) products (thiobarbituric acid-reactive substances, TBARS) were determined through the absorbance at 532 nm and expressed as mmol/mg protein.

Morphology and morphometry

Lungs were removed en bloc and inflated at a pressure of 20 cmH₂O with 4% paraformaldehyde in phosphate solution (100 mM phosphate-buffered saline [PBS] pH 7.4) at room temperature for fixation during 12 h. Fragments of the left lung were washed in 50mM phosphate buffer, pH 7.4, dehydrated in graded concentrations of ethanol, and then embedded in paraffin. From every lung, 4-µm sections were obtained and stained with hematoxylin and eosin (HE) to evaluate lung morphology and morphometry. Neutrophils counts were performed in the alveolar septae by image capture with a light microscope using 400X magnification (Axiolab Standart 2.0, Carl Zeiss) coupled to a video camera (AxionCam, Carl Zeiss).

Statistical analyses

Data are presented as mean ± standard deviation (SD). Statistical intergroup comparisons of total cell, total protein, TBARS, and lung neutrophil were performed using one-way ANOVA. Statistical comparisons of mean arterial blood pressure, and blood gas analyses among the groups were performed using two-way ANOVA. Differences among groups were tested by the Tukey's multiple comparisons test. A P value less than 0.05 was considered significant. Statistical analyses were performed using a standard computer software (GraphPad Prisma, GraphPad Software, CA, USA).

Results

Blood gas exchange

Table 1 shows that, upon mechanical ventilation (MV) during 60 min, the partial pressure of arterial oxygen (Pa) of the G-EV1 (355±3.9 mmHg) and G-EV3 (365±4.2 mmHg) groups were higher than that observed in the G-AV1 (342±4.5 mmHg) and G-AV3 (347±3.2 mmHg) groups. The Padecrease in the 3-h ventilated elderly group (G-EV3 = 338±5.9 mmHg) as compared with the adult ventilated group (G-AV3 = 356±5.8 mmHg). The partial pressure of arterial carbon dioxide (Pa), differed between elderly ventilated 1-h (G-EV1: 42±2.5 mmHg) and the adult ventilated group (G-AV1: 37±2.2 mmHg). Pawas higher in the elderly group after 3-h MV (G-EV3: 58±4.1 mmHg) with regard to the adult ventilated animals (G-AV3: 50±2.4 mmHg) (Table 1). There was a pH (Table 2) reduction in elderly animals after 3-h MV (G-EV3: 7.22±0.03) compared with their adult counterparts of the same time (G-AV3: 7.31±0.02).

Mean arterial pressure (MAP)

In elderly animals the MAP decrease in 180 min MV (G-EV3: 97±2.9 mmHg) compared with elderly rats ventilated for 60 min (G-EV1 = 103±3.7 mmHg and G-EV3 = 104±3.2 mmHg). On the other hand, MAP was lower in the elderly animal ventilated during 180 min compared with the adults (P<0.05) (Table 3).

Total cell count and protein leakage in bal

The total cell counting were higher in the G-EV1 (5.0 ± 0.9 x10⁶ mL^-1) compared with AV1 (3.0±0.9 x10⁶ mL^-1) groups, and G-EV3 (7.0 ± 1.0 x10⁶ mL^-1) compared with AV3 group (5.0 ± 1.1 x10⁶ mL^-1) (Figure 1). The total protein (Figure 2) was lower in the G-AV1 group as compared with G-EV1 group (23.0 ± 2.0 µg/mL versus 27.0 ± 1.7 µg/mL, respectively). The total protein was higher in the G-EV3 (43.0 ± 2.3 µg/mL) when compared with G-AV3 (34.0 ± 1.9 µg/mL).

Thiobarbituric acid-reactive substances (TBARS) measurement in BAL

The TBARS concentrations (Figure 3) increased in the G-EV1 (0.22 ± 0.007 nmol/mg of protein) compared with G-AV1 (0.21 ± 0.008 nmol/mg of protein). In the elderly groups MV increased MDA in G-EV3 (0.51 ± 0.009 nmol/mg of protein) as compared with G-AV3 (0.24 ± 0.005 nmol/mg of protein).

Histomorphometric analyses

Lungs from the elderly 3-h MV group showed typical cavities, septs with congested capillaries and few macrophages and neutrophils influx, and dilation of alveolar septae [G-EV3]; in adults ventilated for 3-h this effect was milder [G-AV3] (Figure 4). Lungs from adult [G-AV1] and elderly [G-EV1] ventilated for 1-h presented minimal changes at light microscopy. The neutrophil counting was higher in the elderly animals after 1-h of MV (19.0 ± 2.5/µm²) compared with the adults (11.0 ± 4.5/µm²; P<0.05). In the groups ventilated for 3 h the neutrophils counting were higher in G-EV3 (37.0 ± 2.6/µm²) when compared with group G-AV3 (25.0 ± 3.0/µm²) (Figure 5).

Discussion

We investigated whether bronchoalveolar levels of malondialdehyde, total protein and neutrophil influx in elderly rats submitted to mechanical ventilation for 1 hour and 3 hours.

In a recent study, Nin et al.²⁸ ventilated young and elderly animals during 60 min using respiratory rate 70 cpm, FiO₂ 0.35, and a protective lung strategy (V_T = 9 mL/kg and PEEP = 5 cmH₂O) or with an injurious strategy (V_T = 35 mL/kg and PEEP = 0 cmH₂O, overventilated). In this study elderly rats showed increased susceptibility to injurious mechanical ventilationinduced pulmonary injury, vascular dysfunction, and systemic inflammation in lungs using a lower FiO₂. The higher FiO2 in our study was chosen because the high FiO₂ used under certain circumstances may help to cause redistribution of pulmonary blood flow and to decrease vasoconstriction in atelectatic or nonventilated areas²⁹. Our study showed that higher FiO₂ promoted an increase of Pain adult and elderly animals ventilated for 1 hour, but Padecreased and Pa increased after 180 min in elderly compared with adults mechanically ventilated.

The use of higher FiO₂ was determinate by unclear whether such high FiO₂ will increase oxygen free radical activity. The higher FiO₂ can induce a concomitant increase in free radical activity and the lipid peroxidation causes tissue damage^21,30-33. Moreover, lipid peroxide end-products of tissue damage can disrupt cellular function by formation of disulphide bridges across nucleotide or amino acid chains³² and inhibits lymphocytic activity³³. Whether MV per se initiates pulmonary inflammation in patients with non-injured lungs is still unclear³⁴, although we have shown that a lung protective MV strategy attenuates intrapulmonary coagulation caused by a more conventional MV strategy³⁵.

Some studies have assessed the changes occurring in lungs of aged rats. First, the older lungs might be subjected to greater mechanical stress due to a difference in the alveolar septae, which may result in a greater susceptibility to stretch-induced lung injury.

Second, for any given mechanical stress, the aged lung may have a more vigorous inflammatory response. This potential mechanism would be in line with studies showing that, after certain stimuli, aged animals and humans show a more marked response after an inflammatory challenge^29,36. Although oxygen toxicity is a well known entity³⁷, FiO₂s up to 0.5 are commonly considered 'safe' by physicians²⁰. It appears that physicians are more concerned about avoiding hypoxia and ischaemia than about the risks of hyperoxia. In The Netherlands, no formal guidelines for oxygenation targets are available. This may be related to the fact that the influence of oxygenation targets has never been studied making it impossible to provide evidence-based recommendations. Based on other observational studies, it may well be that also in other countries actual PaO₂s in ICU patients are higher than recommended^38,39.

Our study, using protective strategy and higher FiO₂, expanded the results to demonstrate the increase in total protein and malondialdehyde in BAL in elderly animals ventilated for 180 min when compared with adults. In 1-h ventilated elderly animals, the differences in the biochemical analyses were augmented when compared with adults, but this effect was neither followed by arterial oxygen decrease nor was the alveolar structure affected.

This study has limitations. Animals submitted to MV and PEEP were ventilated with a 100% inspired oxygen fraction, although subsequent hyperoxia may have influenced lung results. However, this protocol was used to avoid any possibility of hypoxia. In fact, hypoxia has been associated with rapid increases in vascular permeability and in leukocyte adherence⁴⁰. Secondly, in our study the tracheal peak pressure was not evaluated. Thirdly, ventilatory strategies using a moderate tidal volume of 10 mL/kg and PEEP levels from zero up to 10 cmH₂O have been used with surgical patients^41,42.

Conclusions

The present study showed that the association of a protective tidal volume and high FiO₂ may be harmful to microcirculation in the setting of elderly normal lungs during a short time of MV. Our findings indicate that aged rats ventilated for 3h and high inspired oxygen concentration developed more marked local changes compared with their adult, younger counterparts. This finding may have relevance in understanding the development of complications related to MV and the use of high fraction of inspired oxygen in elderly subjects.

Received: September 14, 2010

Review: November 16, 2010

Accepted: December 20, 2010

Conflict of interest: none

Financial source: FAPESP

• 1. Eachempati SR, Hydo LJ, Shou J, Barie PS. Outcomes of acute respiratory distress syndrome (ARDS) in elderly patients. J Trauma. 2007;63:344-50.
• 2. Rubenfeld GD, Caldwell E, Peabody E, Weaver J, Martin DP, Neff M, Stern EJ, Hudson LD. Incidence and outcomes of acute lung injury. N Engl J Med. 2005;353:1685-93.
• 3. Cooke CR, Erickson SE, Watkins TR, Matthay MA, Hudson LD, Rubenfeld GD. Age, sex, and race-based differences among patients enrolled versus not enrolled in acute lung injury clinical trials. Crit Care Med. 2010;38:1450-7.
• 4. Sager MA, Rudberg MA. Functional decline associated with hospitalization for acute illness. Clin Geriatr Med. 1998;14:669-79.
• 5. Gordo F, Nuñez A, Calvo E, Algora A. Intrahospital mortality after discharge from the ICU (hidden mortality) in patients who required mechanical ventilation. Med Clin (Barc). 2003;121:241-4.
• 6. Iapichino G, Morabito A, Mistraletti G, Ferla L, Radrizzani D, Reis Miranda D. Determinants of post-intensive care mortality in high-level critically ill patients. Intensive Care Med. 2003; 29:1751-6.
• 7. Oliveira-Junior IS, Pinheiro BV, Silva IDCG, Salomão R, Zollner RL, Beppu OS. Pentoxifylline decreases tumor necrosis factor and interleukin-1 during high tidal volume. Braz J Med Biol Res. 2003;36:1349-57.
• 8. Determann RM, Royakkers AA, Haitsma JJ, Zhang H, Slutsky AS, Ranieri VM, Schultz MJ. Plasma levels of surfactant protein D and KL-6 for evaluation of lung injury in critically ill mechanically ventilated patients. BMC Pulm Med. 2010;10:6.
• 9. Silva DC, Shibata AR, Farias JA, Troster EJ. How is mechanical ventilation employed in a pediatric intensive care unit in Brazil? Clinics (São Paulo). 2009;64:1161-6.
• 10. Estenssoro E, González F, Laffaire E, Canales H, Sáenz G, Reina R, Dubin A. Shock on admission day is the best predictor of prolonged mechanical ventilation in the ICU. Chest. 2005;127:598-603.
• 11. Meinders AJ, Van der Hoeven JG, Meinders AE. The outcome of prolonged mechanical ventilation in elderly patients: are the efforts worthwhile? Age Ageing. 1996;25:353-6.
• 12. Pesau B, Falger S, Berger E, Weimann J, Schuster E, Leithner C, Frass M. Influence of age on outcome of mechanically ventilated patients in an intensive care unit. Crit Care Med. 1992;20:489-92.
• 13. Dardaine V, Constans T, Lasfargues G, Perrotin D, Giniès G. Outcome of elderly patients requiring ventilatory support in intensive care. Aging Clin Exp Res. 1995;7:221-7.
• 14. Ely EW, Evans GW, Haponik EF. Mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit. Ann Intern Med. 1999;131:96-104.
• 15. Swinburne AJ, Fedullo AJ, Bixby K, Lee DK, Wahl GW. Respiratory failure in the elderly. Analysis of outcome after treatment with mechanical ventilation. Arch Intern Med. 1993;153:1657-62.
• 16. Stauffer JL, Fayter NA, Graves B, Cromb M, Lynch JC, Goebel P. Survival following mechanical ventilation for acute respiratory failure in the adult men. Chest. 1993;104:1222-9.
• 17. Cohen IL, Lambrinos J. Investigating the impact of age on outcome of mechanical ventilation using a population of 41.848 patients from a statewide database. Chest. 1995;107:1673-80.
• 18. Yaacob I, Mustafa M. The immediate outcome of ventilation for pulmonary diseases. Singapore Med J. 1994;35:512-4.
• 19. Olivera WG, Ridge KM, Sznajder JI. Lung liquid clearance and Na, K-ATPase during acute hyperoxia and recovery in rats. Am J Respir Crit Care Med. 1995;152:1229-34.
• 20. Altemeier WA and Sinclair SE. Hyperoxia in the intensive care unit: why more is not always better. Curr Opin Crit Care. 2007;13:73-8.
• 21. Khaw KS, Nigan Kee WD, Chu CY, Ng FF, Tam WH, Critchley LA, Rogers MS, Wang CC. Effects of different inspired oxygen fractions on lipid peroxidation during general anaesthesia for elective Caesarean section. Br J Anaesth. 2010;105:355-60.
• 22. Lindau-Shepard B, Shaffer JB, Del Vecchio PJ. Overexpression of manganous superoxide dismutase (MnSOD) in pulmonary endothelial cells confers resistance to hyperoxia. J Cell Physiol. 1994;161:237-42.
• 23. McCord JM, Fridovich I. Superoxide dismutase: an enzymic function for erythrocuprein (hemocuprein). J Biol Chem. 1969; 244:6049-55.
• 24. Petrone WF, English DK, Wong K, McCord JM. Free radicals inflammation: superoxide-dependent activation of a neutrophil chemotactic factors in plasma. Proc Natl Acad Sci. USA. 1980;77:1159-63.
• 25. Kehrer JP. Free radicals as mediators of tissue injury and disease. Crit Rev Toxicol. 1993;23:21-8.
• 26. Lowry OH, Rosebrough NJ, Farr AL, Randall RJ. Protein measurement with the Folin phenol reagent. J Biol Chem. 1951;193:265-75.
• 27. Das DK. Cellular, biochemical, and molecular aspects of reperfusion injury. Introduction. Ann NY Acad Sci. 1994;723:118-24.
• 28. Nin N, Lorente JA, De Paula M, Fernández-Segoviano P, Peñuelas O, Sánchez-Ferrer A, Martínez-Caro L, Esteban A. Aging increases the susceptibility to injurious mechanical ventilation. Intensive Care Med. 2008;34:923-31.
• 29. Marik PE, Zaloga GP, NORASEPT II Study Investigators. North American Sepsis Trial II. The effect of aging on circulating levels of proinflammatory cytokines during septic shock. Norasept II Study Investigators. J Am Geriatr Soc 2001;49:5-9.
• 30. Morrow JD, Hill KE, Burk RF, Nammour TM, Badr KF, Roberts LJ 2nd.. A series of prostaglandin F2-like compounds are produced in vivo in humans by a non-cyclooxygenase. Proc Natl Acad Sci USA 1990;87:9383-7.
• 31. Khaw KS, Ngan Kee WD. Fetal effects of maternal supplementary oxygen during Caesarean section. Curr Opin Anaesthesiol. 2004;17:309-13.
• 32. Milne GL, Sanchez SC, Musiek ES, Morrow JD. Quantification of F2-isoprostanes as a biomarker of oxidative stress. Nat Protoc. 2007;2:221-6.
• 33. Ward RJ, Peters TJ. Free radicals. In: Clinical biochemistry: metabolic and clinical aspects. Marshall WJ, Bangert SK, eds. New York: Churchill Livingstone; 1995. p.765-7.
• 34. Wolthuis EK, Choi G, Dessing MC, Bresser P, Lutter R, Dzoljic M, van der PT, Vroom MB, Hollmann M, Schultz MJ. Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents pulmonary inflammation in patients without preexisting lung injury. Anesthesiology. 2008,108:46-54.
• 35. Choi G, Wolthuis EK, Bresser P, Levi M, van der PT, Dzoljic M, Vroom MB, Schultz MJ. Mechanical ventilation with lower tidal volumes and positive end-expiratory pressure prevents alveolar coagulation in patients without lung injury. Anesthesiology. 2006;105:689-95.
• 36. Turnbull IR, Wizorek JJ, Osborne D, Hotchkiss RS, Coopersmith CM, Buchman TG. Effects of age on mortality and antibiotic efficacy in cecal ligation and puncture. Shock. 2003;19:310-3.
• 37. Mao C, Wong DT, Slutsky AS, Kavanagh BP. A quantitative assessment of how Canadian intensivists believe they utilize oxygen in the intensive care unit. Crit Care Med. 1999;27:2806-11.
• 38. Young MP, Manning HL, Wilson DL, Mette SA, Riker RR, Leiter JC, Liu SK, Bates JT, Parsons PE. Ventilation of patients with acute lung injury and acute respiratory distress syndrome: has new evidence changed clinical practice? Crit Care Med. 2004;32:1260-5.
• 39. Kalhan R, Mikkelsen M, Dedhiya P, Christie J, Gaughan C, Lanken PN, Finkel B, Gallop R, Fuchs BD. Underuse of lung protective ventilation: analysis of potential factors to explain physician behavior. Crit Care Med. 2006;34:300-6.
• 40. Wood JG, Johnson JS, Mattioli LF, Gonzalez NC. Systemic hypoxia increases leukocyte emigration and vascular permeability in conscious rats. J Appl Physiol. 2000;89:1561-8.
• 41. Aneman A, Pontén J, Fändriks L, Eisenhofer G, Friberg P, Biber B. Hemodynamic, sympathetic and angiotensin II responses to PEEP ventilation before and during administration of isoflurane. Acta Anaesthesiol Scand. 1997;41:41-8.
• 42. Krenn CG, Krafft P, Schaefer B, Pokorny H, Schneider B, Pinsky MR, Steltzer H. Effects of positive end-expiratory pressure on hemodynamics and indocyanine green kinetics in patients after orthotopic liver transplantation. Crit Care Med. 2000;28:1760-5.

1

Research performed at Department of Surgery, Department of Morphology and Genetics, Federal University of Sao Paulo (UNIFESP), Brazil.

Part of thesis Master degree. Mentor: Virginia Berlanga Campos Junqueira.

Publication Dates

• Publication in this collection
  21 Mar 2011
• Date of issue
  Apr 2011

History

• Received
  14 Sept 2010
• Reviewed
  16 Nov 2010
• Accepted
  20 Dec 2010