ABSTRACT Heaves is triggered by exposure to dust and its components, such as endotoxin, and is characterized by clinical signs such as coughing, decreased exercise tolerance, difficulty breathing and abnormal lung sounds which are due to bronchoconstriction and accumulation of neutrophils in the airways. Pulmonary intravascular macrophages (PIMs) are believed to increase horses sensitivity to endotoxemia-induced lung inflammation. The first objective of this study was to investigate a hitherto unknown role of PIMs in equine heaves. I used mouldy hay (MH) to induce heaves and gadolinium chloride (GC) to deplete PIMs in order to compare responses between non-treated and GC-treated heaves horses. A modified randomized crossover study (2X2 factorial) was conducted in which mares (N=9) were exposed to 4 different treatments: alfalfa cubes (Cb), alfalfa cubes + GC (Cb-GC), mouldy hay (MH) and MH + GC (MH-GC). Each treatment was followed by broncholaveolar lavage (BAL). MH was fed for 7 days to induce heaves followed by Cb for 21 days to achieve remission, whereas the treatments in which heaves was not induced (Cb; Cb-GC), the cubes were fed prior to the BAL and for 14 days after the BAL to allow recovery from the BAL procedure. BAL fluids were processed to investigate total cell, neutrophil and alveolar macrophage concentrations. In addition, TNFá protein levels as well as TNFá, IL-8, and TLR4 mRNA expression in BAL cells were assessed in order to infer on their activation state.<p> Data showed higher concentration of dust (3X), endotoxin (20X), and endotoxin per milligram of dust (7X) in MH compared to the Cb environment. Clinical scores and neutrophil concentrations in BAL were higher when mares received MH compared to MH and GC (MH-GC). Real time reverse transcriptase PCR revealed a significant lower expression of IL-8 and TLR4 mRNA in BAL cells from MH-GC mares compared to MH. TNFá mRNA expression as well as protein concentration were not affected by the different treatments. In vitro secondary LPS challenge significantly increased IL-8 mRNA expression in cells from MH treatment compared to without LPS, but not in the MH-GC treatment. TLR4 expression was not affected by the secondary challenge. Although secondary LPS challenge increased expression of TNFá mRNA and protein, the differences among treatment groups were not meaningful. In conclusion, PIM depletion attenuates clinical scores, migration of inflammatory cells into the alveolar space and expression of pro-inflammatory molecules in BAL cells of heaves horses.<p> The observations on the role of PIMs in heaves in horses prompted me to examine the occurrence of PIMs in human lungs. I found a trend for higher numbers of septal macrophages in autopsied lungs from human patients who died of non-pulmonary pathologies compared to those having either COPD or asthma. If these septal macrophages indeed represent the PIMs, this finding is contrary to existing belief that humans, unlike horses, do not have PIMs.

Introduction: The use of heat moisture exchangers (HMEs) is becoming more popular with many institutions delivering aerosolized medications between the HME and the endotracheal tube of patients being mechanically ventilated. When HMEs become saturated resistance can increase which can cause changes that can lead to patient-ventilator dysnchrony, development of intrinsic PEEP, and weaning difficulty. The purpose of this study was to determine the effects of aerosol drug delivery on resistance through heat-moisture exchangers. Method: An in-vitro model to simulate exhaled heat and humidity from a patient’s lungs was developed by connecting the test lung to a cascade humidifier that was placed between the endotracheal tube and the test lung. Temperature (37 ºC) and relative humidity (100%) were held constant through all test runs. Ventilator settings used for the study were as follows: Tidal volume 500 mL, frequency 15/min, PEF 60 L/min, PEEP 5 cmH2O, bias flow 2 L/min and I:E ratio 1:3.The pressurized metered-dose inhaler (pMDI; ProAir HFA) with a minispacer (Thayer Medical), hand-held nebulizer (HHN; Salter Labs) and placebo (No aerosol generator or medication) were compared. Albuterol sulfate (2.5 mg/3 ml) was administered through continuous HHN and six puffs of albuterol were given from a pMDI equaling one treatment. Neither medication nor aerosol device was used with the placebo group in order to determine the effect of HME on airway resistance during mechanical ventilation. Six aerosolized treatments were given to simulate a patient receiving albuterol every four hours over a twenty-four hour period. While five minutes was allowed between treatments, airway resistance was measured via the ventilator before and after the administration of the placebo, pMDI and HHN, which equaled five-minute intervals. Data Analysis: Descriptive statistics, dependent t-tests, one-way analysis of variance (ANOVA), repeated measures ANOVA and post-hoc multiple comparisons were utilized for the data analysis of this study, using SPSS version 16.0. A p-value<0.05 was considered significant. Results: There is a linear time effect with means of airway resistance increasing overtime not only with the placebo but also with the pMDI and nebulizer. At the end of all treatments, the means of resistance with the placebo, pMDI and nebulizer were 9.31 cmH2O/L/sec, 9.37 cmH2O/L/sec and 11.20 cmH2O/L/sec, respectively. While no significant difference was found between the placebo and the pMDI (p=0.452), the nebulizer significantly increased airway resistance when compared to placebo (p=0.004) and the pMDI (p=0.02). Conclusion: Airway resistance increases with use of the placebo, pMDI, and JN groups. Aerosol generators showed a greater increase in resistance when compared to placebo with the greater increase in resistance by HHN.

The cystic fibrosis transmembrane conductance regulator (CFTR), a cAMP activated chloride channel in the apical membrane of epithelial cells, is defective in patients with cystic fibrosis (CF). Research efforts are focused on chloride channel function in order to find a cure for the disease. Genistein increased chloride transport in normal and delF508-CFTR cultured airway epithelial cells without cAMP stimulation. Prior pretreatment with phenylbutyrate did not affect the rate of the genistein-stimulated chloride efflux in these cells. S-nitrosoglutathione is an endogenous bronchodilator, present in decreased amounts in the lungs of CF patients. We studied the effect of GSNO on chloride (Cl-) transport in primary nasal epithelial cells from CF patients homozygous for the delF508-CFTR mutation, as well as in two CF cell lines, using a fluorescent Cl- indicator and X-ray microanalysis. GSNO increased chloride efflux in the CF cell lines and in primary nasal epithelial cells from CF patients. This effect was partly mediated by CFTR. If the cells were exposed to GSNO in the presence of L-cysteine, Cl- transport was enhanced after 5 min, but not after 4 h. GSNO may be a candidate for pharmacological treatment of CF patients. Chloride transport properties of cultured NCL-SG3 sweat gland cells were investigated. The CFTR protein was neither functional nor expressed in these cells. Ca2+-activated chloride conductance was confirmed and the putative Ca2+-activated chloride channel (CaCC) was further characterized in term of its pharmacological sensitivity. Corticosteroids, the primary treatment for asthma, cause necrosis/apoptosis of airway epithelial cells. It was investigated whether a newer generation of drugs used in asthma, leukotriene receptor antagonists, had similar effects. Both montelukast and dexamethasone, but not beclomethasone or budesonide induced apoptosis/necrosis in superficial airway epithelial cells. Montelukast and corticosteroids also caused decreased expression of intercellular adhesion molecule -1 (ICAM-1) in epithelial but not endothelial cells.

We report herein that IL-10-treated dendritic cells (DC) can be used effectively to reverse established severe asthma-like disease in a mouse model. Our lab had shown previously that allergen-presenting splenic CD8¦Á+ DCs could ¡Ö50% reduce airway hyper responsiveness (AHR), eosinophilia, and Th2 responses in asthma-phenotype mice, but only marginally reduce IgE/IgG1 levels. We now show that bone marrow-derived DCs that have been differentiated in the presence of IL-10 (DCIL-10) are effective in reversing the asthma phenotype. Co-culture of DCIL-10 with T memory (TM) cells from asthma-phenotype mice was associated with lack of Th2 responses, and this was partially reversed by IL-2. Immunostimulatory DC activated these Th2 cells. <i>In vivo</i>, delivery of allergen-pulsed DCIL-10, either into the airway or intraperitoneally abrogated AHR from weeks 3-10 post-treatment, and ameliorated lung eosinophilia and Th2 (IL-4, -5, -9, & -13, IgE) responses, as well as circulating allergen-specific IgE responses for at least 32 weeks following treatment. Repeated OVADCIL-10 treatments kept AHR normalized for 8 weeks as well as Th2 responses significantly low. In vivo, delivery of anti-IL-10R, but not anti-TGF-¦Â from day 12-21 after treatment had moderate effects on DCIL-10-driven tolerance, but 1-methyl tryptophan (inhibitor of indoleamine-2,3-dioxygenase) treatment had significant effects on Th2 responses. The mechanisms mediating tolerance in vivo are likely complex, but we speculate that infectious tolerance sustains this regulatory activity during the 32-week period in which we have observed tolerance to be in place.

ABSTRACT Heaves is triggered by exposure to dust and its components, such as endotoxin, and is characterized by clinical signs such as coughing, decreased exercise tolerance, difficulty breathing and abnormal lung sounds which are due to bronchoconstriction and accumulation of neutrophils in the airways. Pulmonary intravascular macrophages (PIMs) are believed to increase horses sensitivity to endotoxemia-induced lung inflammation. The first objective of this study was to investigate a hitherto unknown role of PIMs in equine heaves. I used mouldy hay (MH) to induce heaves and gadolinium chloride (GC) to deplete PIMs in order to compare responses between non-treated and GC-treated heaves horses. A modified randomized crossover study (2X2 factorial) was conducted in which mares (N=9) were exposed to 4 different treatments: alfalfa cubes (Cb), alfalfa cubes + GC (Cb-GC), mouldy hay (MH) and MH + GC (MH-GC). Each treatment was followed by broncholaveolar lavage (BAL). MH was fed for 7 days to induce heaves followed by Cb for 21 days to achieve remission, whereas the treatments in which heaves was not induced (Cb; Cb-GC), the cubes were fed prior to the BAL and for 14 days after the BAL to allow recovery from the BAL procedure. BAL fluids were processed to investigate total cell, neutrophil and alveolar macrophage concentrations. In addition, TNFá protein levels as well as TNFá, IL-8, and TLR4 mRNA expression in BAL cells were assessed in order to infer on their activation state.<p> Data showed higher concentration of dust (3X), endotoxin (20X), and endotoxin per milligram of dust (7X) in MH compared to the Cb environment. Clinical scores and neutrophil concentrations in BAL were higher when mares received MH compared to MH and GC (MH-GC). Real time reverse transcriptase PCR revealed a significant lower expression of IL-8 and TLR4 mRNA in BAL cells from MH-GC mares compared to MH. TNFá mRNA expression as well as protein concentration were not affected by the different treatments. In vitro secondary LPS challenge significantly increased IL-8 mRNA expression in cells from MH treatment compared to without LPS, but not in the MH-GC treatment. TLR4 expression was not affected by the secondary challenge. Although secondary LPS challenge increased expression of TNFá mRNA and protein, the differences among treatment groups were not meaningful. In conclusion, PIM depletion attenuates clinical scores, migration of inflammatory cells into the alveolar space and expression of pro-inflammatory molecules in BAL cells of heaves horses.<p> The observations on the role of PIMs in heaves in horses prompted me to examine the occurrence of PIMs in human lungs. I found a trend for higher numbers of septal macrophages in autopsied lungs from human patients who died of non-pulmonary pathologies compared to those having either COPD or asthma. If these septal macrophages indeed represent the PIMs, this finding is contrary to existing belief that humans, unlike horses, do not have PIMs.

Ofri luftväg kan uppstå på grund av bakåtfallen tunga hos den medvetslösa patienten eller om luftvägen blir tilltäppt av sekret, blod, maginnehåll eller främmande kropp. Att kunna säkerställa fri luftväg hos den medvetandesänkta patienten är en kompetens som varje anestesisjuksköterska måste behärska för att kunna säkerställa adekvat ventilation. Syftet med studien var att beskriva om larynxmask (LMA) är en patientsäker metod för att skapa fri luftväg och upprätthålla adekvat ventilation. Studien genomfördes som en litteraturstudie där 19 vetenskapliga artiklar analyserades. Resultatet av de granskade artiklarna gav följande fem teman; LMA är en säker metod för att skapa fri luftväg, LMA är en säker metod för att upprätthålla adekvat ventilation, personalens kompetens vid användning av LMA, aspirationsrisk vid användning av LMA med undertema LMA vid övervikt samt LMA vid elektiva- och akuta situationer. Litteraturstudiens resultat visar att LMA är en säker metod för att skapa fri luftväg och upprätthålla adekvat ventilation. Framtida studier skulle kunna belysa om LMA kan användas vid kirurgi till patienter med ökad aspirationsrisk, till exempel vid sectio och obesitaskirurgi. Studier skulle också kunna fokuseras på patienternas postoperativa upplevelser av att ha haft LMA jämfört med trakeal intubation. / Airway obstruction can in the case of an unconsciousness patient be caused by the tounge that falls back in the throat or by secretion, blood, stomach fluid or foreign body. The knowledge of airway management of the unconsciousness patient is a necessary qualification in every nurse anesthetist. The purpose of this study was to describe if laryngeal mask airway is a safe method to establish a secure airway and adequate ventilation. The study was performed as a literature study in which 19 articles were analysed. During the analyse five themes occurred: LMA is a secure way for airway management, LMA is a secure way to maintain adequate ventilation, the staff competence when using LMA, the risk of aspiration when using LMA with subtheme LMA in overweight and LMA in elective and acute situations. The result of the study shows that LMA is a secure way to establish a safe airway and adequate ventilation. Further studies could study if LMA can be used to elective patients with increased risk of aspiration, for example in cesarean and obesity surgery. Studies could also focuse on the patients´ postoperative experiences between LMA and tracheal intubation.

In this thesis an integrated, dynamic model for cardiovascular and respiratory systems has been developed. Models of cardiopulmonary system, airway mechanics and gas exchange that preexisted in literature have been reviewed, modified and combined. Combined model composes the systemic and pulmonary circulations, left/right ventricles, tissue/lung compartments, airway/lung mechanics and gas transportation. Airway resistance is partitioned into three parts (upper, middle, small airways). A collapsible airways segment and a viscoelastic element describing lung tissue dynamics and a static chest wall compliance are included. Frank-Starling Law, Bowditch effect and variable cerebral flow are also employed in the model. The combined model predictions have been validated by laboratory data collected from two healthy, young, male subjects, by performing dynamic bicycle exercise tests, using Vmax 229 Sensormedics, Cardiopulmonary Exercise Testing Instrument. The transition from rest to exercise under a constant ergometric workload is simulated. The initial anaerobic energy supply, autoregulation and the dilatation of pulmonary vessels are considered. Mean arterial blood pressure and the blood gas concentrations are assumed to be regulated by the controllers of the central nervous system namely, the heart rate and alveolar ventilation. Cardiovascular and respiratory regulation is modeled by a linear feedback control which minimizes a quadratic cost functional.

The pathogens causing pneumonia are difficult to identify because a high quality specimen from the lower lung is difficult to obtain. A specimen collection device, named the PneumoniaCheck, was previously designed to collect aerosol specimens selectively from the lower lung generated during deep coughing to aid in the diagnosis of specific pathogens causing pneumonia. The device also includes several specially designed features to exclude oral contaminants from the sample, and a filter to collect the aerosolized pathogens. The objective of this thesis is to develop tests to verify the functionality of the device, called the Design Inputs. Nine verification tests were performed to demonstrate the ability to collect lower airway aerosols separate from upper airway aerosols, successful exclusion of oral contents, and capture of pathogens in the filter. Further, the PneumoniaCheck was tested for proper sampling of the lower airway aerosols during deep cough at a very low volumetric flow rate to simulate patients with severe restrictive lung disease and with mal-positioning to simulate incorrect patient placement. Verification testing of the PneumoniaCheck demonstrates effective separation of upper airway gas from the lower airway gas (p<0.0001) and exclusion of both liquid and viscous oral material (p<0.0001) from the collection chamber. Testing also demonstrated the selective sampling of the lower airway, even during low volumetric flow rates or incorrect positioning of the device. The complex shape of the PneumoniaCheck presents a manufacturing challenge. Making the device from a solid and then drilling out the tubes would be difficult because the outer channels do not align with the inner channel. Rapid prototyping, vacuum molding, and injection molding are all manufacturing options. Rapid prototyping is slow, and usually only economic for small numbers of parts. For vacuum molding or injection molding, the PneumoniaCheck would need to be cut in half and molded, and then the halves connected with fasteners, glued, or welded. Vacuum molding is inexpensive, but there would be a lip at the connection that may be uncomfortable for patients. If the lip is on the inside of the device, it may interrupt air flow through the device. Injection molding is inexpensive and fast. The PneumoniaCheck could be injection molded in halves, and then glued or sonically welded together. Injection molding would be an efficient and economical way to manufacture the device. Verification tests were developed and performed, and the results demonstrate that the PneumoniaCheck successfully collects lower airway aerosols separate from upper airway aerosols, excludes oral contents, and captures pathogens in the filter, even during non-ideal conditions. After considering three different manufacturing options, injection molding was recommended for the device.

Asthma is a chronic respiratory disease characterized by inflammation of the airway and the presence of recurrent attacks (exacerbations) of breathlessness, wheezing, cough, chest tightness, or some combination of these symptoms. In the US, about 53% of people with asthma had an asthma attack in 2008, and 57% of these, were children. One in ten children (10%) had asthma in 2009, and boys were more likely than girls to have asthma. Internationally, the prevalence of asthma varies widely in different countries, but the disparity is narrowing due to rising prevalence in low and middle income countries. Unfortunately, we do not have statistics for asthma in the Republic of Panama, neither epidemiological data nor costs, which is the reason why this research is needed. The Panamanian Social Security Fund (CSS) provides protection to workers, their immediate families and the pensioned. By the end of 2010, the total insured population was 2,862,202 (83% of the total population of Panama). Of the total insured population 58% were dependent. Of this, 1,205,607 (42%) were children. On the basis of this information, we decided to develop the research study using information from the CSS, specifically in the Hospital de Especialidades Pediatricas (HEPOTH). It is the only tertiary level of healthcare children's hospital of the CSS. A quantitative-descriptive design was used to develop this study. Data was collected from medical records of patients diagnosed with asthma in the HEPOTH from January to June 2012. We reviewed the medical records of each care area by month, and numbered each clinical record of children diagnosed with asthma in crisis and randomly selected 10% of the medical records from a minimum of 2000 records. Information on treatment costs was also obtained. Once all the information was collected, it was typed in the digital data log created for this study and the responses were code converted and the information was entered into a database. The data were exported to IBM SPSS Statistics 21. The average cost of asthma attacks in Panama is estimated at $205.52. We were able to confirm that there are variations in this average by gender, age, geographic area of residence, season, severity, whether treated in the emergency department or hospitalization, and the type of treatment received. It was also possible to obtain secondary information about the epidemiology of asthma that allowed us to confirm that our statistics matched international statistics.

Morbidity and mortality attributable to asthma arise mainly from contraction of airway smooth muscle (ASM) and resulting bronchospasm. Bronchospasm that is induced in the laboratory is easily reversed by a spontaneous deep inspiration (DI) whereas bronchospasm that occurs spontaneously in asthma is not. In response to a spontaneous DI, contracted ASM fluidizes rapidly and then resolidifies slowly, but molecular mechanisms accounting for these salutary bronchodilatory responses -and their dramatic breakdown in asthma- are unknown. Using a multi-scale approach, I show here that both the baseline contractile force and the fluidization response of ASM are independent of the cytoskeletal protein zyxin, whereas the resolidification response is zyxin-dependent. At the levels of the stress fiber, the isolated cell, and the integrated airway, zyxin acts to stabilize the contractile apparatus and promote the resolidification response. More than just the motor of contraction, ASM is thus viewed in the broader context of a self-healing active material wherein resolidification and its molecular determinants contribute to the biology of bronchospasm.