京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第18884号 / 医博第3995号 / 新制||医||1009(附属図書館) / 31835 / 京都大学大学院医学研究科医学専攻 / (主査)教授 三森 経世, 教授 横出 正之, 教授 伊達 洋至 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Summer pasture-associated recurrent airway obstruction (SPARAO) is characterized by reversible airway obstruction resulting from airway hyper-reactivity to aeroallergens, mucus accumulation, and airway inflammation. These are key clinical features that are shared with human asthma, suggesting SPARAO’s utility as an animal asthma model. SPARAO affects horses maintained on pasture in conditions of high heat and humidity. Common in the southeastern United States, the cause of SPARAO is unknown, but is presumed to reflect reactivity to seasonally inhaled pasture-associated aeroallergens. This investigation sought to identify well-characterized histopathological lesions of human asthma, collectively termed ‘asthmatic remodeling’, in lung tissue from horses with SPARAO. Two histological staining techniques were used: H&E and Movat’s Pentachrome. Similar to chronic asthma, lung tissue from horses with SPARAO demonstrates statistically significant increases in airway smooth muscle, fibrosis, airway occlusion and inflammation, goblet cell hyperplasia, and remodeling of terminal bronchioles and elastin fibers.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24501号 / 医博第4943号 / 新制||医||1064(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 永井 洋士, 教授 大鶴 繁, 教授 江木 盛時 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

The human body encounters a number of chemical exposures on a daily basis, which may have short- or long-term health implications. Previously it has been demonstrated that the entire respiratory tract of an individual reacts to exposures like tobacco smoke in a similar manner, and that common molecular changes can be measured in airway epithelium. I propose that cataloguing the exposure of airway epithelial cells to tobacco cigarette (TCIG) smoke and its constituents, electronic cigarette (ECIG) aerosol and other drugs and small molecules can significantly increase the understanding of chemical exposure and identify common gene expression alterations. First, I determined the molecular impact of ECIG aerosol exposure on human airway epithelium in vitro, including alterations in genes related to xenobiotic metabolism, oxidative stress, and ciliated cells. These changes were generally less pronounced than the effects of TCIG exposure, and were more pronounced in ECIG products containing nicotine than those without nicotine. Furthermore, gene expression differences observed in vitro were concordant with differences observed in airway epithelium collected from ECIG users. Second, I examined the impact of TCIG exposure and TCIG constituents on premalignant airway cells, to better understand the progression or regression of precancerous lesions. These data could also identify the constituents of TCIGs and the precancerous mutations that increase the risk for malignancy. Third, in an effort to build a high-throughput methodology for chemical exposures, I exposed primary lung cell lines to small molecule therapeutics and identified lung-specific and lung cell-type-specific effects of exposure, suggesting that profiling additional cell lines would further inform airway gene expression in response to exposure and that organ-specific exposure profiling may provide valuable insight into drug discovery for common diseases. Overall, transcriptomic profiles from the airway epithelium reflect exposure to various inhaled and chemical perturbations. These gene expression profiles indicate common changes across a multitude of airway exposures as well as unique alterations specific to a given perturbation. Gene expression profiling can therefore be used to detail the potential response to a compendium of chemical exposures including those that are either well-established or potential risk factors for chronic lung diseases. / 2019-07-09T00:00:00Z

Increased airway smooth muscle (ASM) mass contributes to airway hyperresponsiveness (AHR) in asthma and is orchestrated by growth factors, cytokines and chemokines. Airway contractile responses are influenced by neuromediators, such as acetylcholine, and glutamate released by parasympathetic and sympathetic airway nerves. Hyperactivity of these neural elements, termed neurogenic inflammation, is linked with hypercontractility and AHR. Glutamate is a non-essential amino acid derivative, and its physiological role is traditionally considered with respect to its being the primary excitatory neurotransmitter in brain, and regulation of neuronal development and memory. In allergic inflammation, immune cells including dendritic cells, neutrophils and eosinophils, constitutively synthesize and release glutamate, which signals through activation of glutamate receptors, most important among which are ionotrophic N-methyl D-aspartate receptors (NMDA-R). We hypothesized that glutamatergic signaling mediated through NMDA-Rs plays an important role in inducing functional Ca2+ responses in human (H) ASM cells that can underpin airway hypercontractility. We investigated the expression and function of NMDA-Rs in HASM cells, and assessed the effects of pro-inflammatory cytokines on NMDA-R expression and functional responses. Moreover, we measured airway responses to NMDA in mice, murine thin cut lung slice preparations, and floating collagen gels seeded with HASMs. Our data reveal that airway myocytes express multi-subunit NMDA-R complexes that function as receptor-operated calcium channels (ROCCs), mobilizing intracellular Ca2+ in ASM in vitro and airway contraction ex vivo. Individual airway myocytes treated with NMDA-R agonist exhibit disparate temporal patterns of intercellular Ca2+ flux that can be partitioned into four discrete function sub-groups. Further we show that tumor necrosis factor (TNF) exposure modulates NMDA-R subunit expression, and these changes are associated with a shift in the distribution of myocytes in individual Ca2+-mobilization sub-groups in vitro. Further, post-TNF exposure, NMDA-R agonists’ treatment induced Ca2+-dependent airway dilation in murine lung slice preparations, an effect that was prevented by co-treatment with inhibitors of nitric oxide synthase (NOS) or cyclooxygenase (COX). Taken together, we conclude that NMDA-R regulate HASM-mediated airway contraction and their role can be affected upon exposure to asthma-associated inflammatory mediators. Thus, NMDA-Rs are of relevance to mechanisms that determine airway narrowing and AHR associated with chronic respiratory diseases. / October 2015

Bakgrund: Inom den prehospitala akutsjukvården kan specialistsjuksköterskan möta en stor variation av luftvägsproblematik. Att ställas inför situationer med patienter med ofri luftväg prehospitalt ställer höga krav på specialistsjuksköterskans kunskap och erfarenhet. En ofri luftväg är ett livshotande tillstånd där snabb och korrekt handläggning krävs för att minimera risken för hypoxi, med risk för efterföljande men som fatal utgång. Att identifiera ett luftvägsproblem och sätta in adekvata metoder för att skapa fria luftvägar är något som specialistsjuksköterskan behöver känna sig säker att utföra, vilket innebär att ha en god förmåga att hantera de tekniker och hjälpmedel som finns att tillgå. Syfte: Syftet med studien är att undersöka anestesisjuksköterskors och ambulanssjuksköterskors kunskapsnivå och erfarenhet av att hantera patientens ofria luftväg prehospitalt. Metod: Studien har en kvantitativ ansats. Specialistsjuksköterskor (n=145) verksamma inom den prehospitala akutsjukvården i en region i södra Sverige deltog i studien. Datainsamlingen genomfördes i form av enkäter och datan analyserades i programmet SPSS. Resultat: Studiens fyra huvudsakliga fynd var att ungefär 20 % av respondenterna hade minst en gång under det senaste året varit med om att inte lyckas skapa fria luftvägar. Anestesisjuksköterskor hade en högre självskattad säkerhet inför ofria luftvägar än ambulanssjuksköterskor. Två tredjedelar av respondenterna ville genomföra en repetitionsutbildning i hantering av ofria luftvägar, och hela 83 % av ambulanssjuksköterskorna ansåg att de var i behov av en repetitionsutbildning i att hantera ofri luftväg. Slutsats: Det finns en signifikant skillnad mellan yrkesgrupperna där anestesisjuksköterskor skattar sig säkrare med att hantera utrustningen vid ofria luftvägar jämfört med ambulanssjuksköterskor. Specialistsjuksköterskorna upplever ett behov av ytterligare utbildning samt kompetenskontroll av luftvägshantering.

Bakgrund: Specialistsjuksköterskor ska kunna identifiera och hantera ofri luftväg utifrån kunskap och fastställda riktlinjer inom den prehospitala vården. Att kunna identifiera svårigheter kan vara livräddande för en kritiskt sjuk eller skadad patient. Sverige är en av få länder i världen som bemannar ambulansen med minst en sjuksköterska, och som därtill utbildar sjuksköterskor till specialister. Specialistsjuksköterskor som jobbar prehospitalt skiljer sig i mängd erfarenhet och kunskap om prehospital vård. Syfte: Syftet med studien var att beskriva vilka faktorer som försvårar specialistsjuksköterskors luftvägshantering prehospitalt. Metod: Kvantitativ tvärsnittsstudie med enkäter samt fritextsvar. Deltagarna var specialistsjuksköterskor (n=37) vilka hade haft svårt och/eller misslyckats skapa en fri luftväg under senaste året. Det kvantitativa resultatet analyserades med student–t test, chi-två test samt Fishers Exakta test och det kvalitativa resultatet analyserades med kvalitativ innehållsanalys. Resultat: De faktorer som identifierades var Svårigheter relaterat till hjälpmedel, Svårigheter relaterat till patient samt Utveckling och utbildning. Resultatet visade en signifikant skillnad i hur trygga specialistsjuksköterskor inom olika inriktningar upplever sig vara vid hanteringen av de olika hjälpmedlen och en signifikant variation mellan antal yrkesverksamma år. Anestesisjuksköterskorna skattade sig högst och hade längst erfarenhet. Ambulanssjuksköterskorna och anestesisjuksköterskorna upplevde att deras utbildning hade hjälpt dem i deras hantering av svår luftväg, men ansåg ändå att mer utbildning och årlig repetition rörande luftvägshanteringen är nödvändig. Slutsats: Studiens resultat tyder på att teoretisk kunskap tillsammans med reell kompetens har betydelse för adekvat vård vid luftvägshantering och därmed kan öka patientsäkerheten. Vidare att specialistsjuksköterskorna önskar återkommande repetitionsutbildning i luftvägshantering via arbetsgivaren. Slutligen indikerar denna studies resultat ett behov av att se över de olika akutspecialistutbildningarna verksamma inom ambulanssjukvården för att luftvägsutbildningen skall bli mer jämställd.

<p>Asthma is a disease characterized by transient airway smooth muscle contraction leading to episodes of reversible airway narrowing. It affects over 300 million people worldwide and is implicated in over 250 000 deaths annually. The primary clinical features of asthma include airway inflammation, hyperresponsiveness, and remodeling. Generally, asthmatic patients experience exacerbations between periods of diminished symptoms. Interestingly, in addition to these above mentioned hallmarks, asthmatics have also been shown to react differently to ventilatory mechanical strain. This is most evident when assessing the effect of a deep inspiration (DI), clinically measured as a breath taken from functional residual capacity to total lung capacity, in healthy individuals <em>versus</em> asthmatics. These deep inspiratory efforts have been shown to produce a bronchodilatory response in healthy individuals, whereas in asthmatics, DIs are less effective in producing bronchodilation, can cause more rapid airway re-narrowing, and even bronchoconstriction in moderate to severe asthmatics. The mechanism by which a DI is able to cause bronchoconstriction remains ambiguous. Previous theories suggest that this phenomenon is intrinsic to airway smooth muscle (ASM) itself. However, the airway inflammation present in asthmatic airways may also add to the increased ASM contractility following stretch, by the release of mediators that can prime the contractile apparatus to react excessively in the presence of stretch.</p> <p>Thus, collectively, the studies contained in this thesis are linked to the general theme of greater characterization of the signalling mechanisms that regulate airway stretch-activated contractions using a pharmacological approach in intact bovine bronchial segments, with the hope of providing novel insights into the mechanisms that regulate the DI-induced bronchoconstriction seen in asthmatics.</p> / Doctor of Philosophy (Medical Science)

Objective - evaluate horses with acute airway obstruction using three treatment regimens: tapering doses of dexamethasone (DEX), environmental modification (ENV), and a combination of both treatments (DEX + ENV) by analyzing clinical parameters, pulmonary function testing, bronchoalveolar lavage fluid (BALF) cytology and BALF cell expression of the cytokines IFN-? and IL-4 Animals - 6 horses with recurrent airway obstruction (RAO) Procedures - Clinical examination, pulmonary function test, and collection of BALF prior to treatment and during 22 day treatment period Hypothesis - Alterations in clinical parameters, pulmonary function and airway inflammation in acute equine RAO will return to remission values by treating with DEX, ENV or DEX + ENV Results - All horses demonstrated clinical disease, reduced pulmonary dynamic compliance (Cdyn) and an increased maximum change in pleural pressures (?Pplmax) when in a challenge environment. All treatments improved clinical parameters, ?Pplmax and Cdyn. BALF cytology during an RAO crisis demonstrated neutrophilic inflammation. ENV or DEX + ENV resulted in a significant decrease in airway neutrophilia that was maintained throughout the treatment period. In contrast, treatment with DEX caused a reduction in airway neutrophilia initially followed by a rebound neutrophilia as the period between administrations of dexamethasone (0.05mg/kg) was increased to 72 hours. The rebound neutrophilia was not accompanied by equivalent deterioration in clinical parameters or pulmonary function. Conclusions - Environmental modification is important in the management of RAO horses. Treatment of clinical RAO with a decreasing dosage protocol of corticosteroids in the absence of environmental modification results in the persistence of airway inflammation without recrudescence of clinical disease. / Master of Science

The overall aim of the present thesis was to study aspects of patient safety in critically ill patients with special focus on airway management, respiratory complications and nursing procedures. Study I describes a method called pharyngeal oxygen administration during intubation in an experimental acute lung injury model. The study showed that pharyngeal oxygenation prevented or considerably increased the time to life-threatening hypoxemia at shunt fractions by at least up to 25% and that this technique could be implemented in airway algorithms for the intubation of hypoxemic patients. In study II, we investigated short-term disconnection of the expiratory circuit from the ventilator during filter exchange in critically ill patients. We demonstrated that when using pressure modes in the ventilator, there was no indication of any significant deterioration in the patient's lung function. A bench test suggests that this result is explained by auto-triggering with high inspiratory flows during the filter exchange, maintaining the airway pressure. Study III was a clinical observational study of critically ill patients in which adverse events were studied in connection with routine nursing procedures. We found that adverse events were common, not well documented, and potentially harmful, indicating that it is important to weigh the risks and benefits of routine nursing when caring for unstable, critically ill patients. In study IV, we conducted a retrospective database study in patients with pelvis fractures treated in the intensive care unit. We found that the incidence of respiratory failure was high, that the procedure involved in surgical stabilization affected the respiratory status in patients with lung contusion, and that the mortality was low and probably not influenced by the respiratory condition. In conclusion, the results obtained in the present thesis have increase our knowledge in important areas in the most severely ill patients and have underlined the need for improvements in the field of patient safety.