Nitric Oxide In Exhaled Gas Research Articles

Monitoring of endogenous nitric oxide exhaled by pig lungs during ex-vivo lung perfusion

In the context of organ shortage for transplantation, new criteria for better organ evaluation should be investigated. Ex-vivo lung perfusion (EVLP) allows extra-corporal lung re-conditioning and evaluation, under controlled parameters of the organ reperfusion and mechanical ventilation. This work reports on the interest of exhaled gas analysis during the EVLP procedure. After a 1 h cold ischemia, the endogenous gas production by an isolated lung of nitric oxide and carbon monoxide is simultaneously monitored in real time. The exhaled gas is analysed with two very sensitive and selective laser spectrometers developed upon the technique of optical-feedback cavity-enhanced absorption spectroscopy. Exhaled gas concentration measured for an ex-vivo lung is compared to the corresponding production by the whole living pig, measured before euthanasia. On-line measurements of the fraction of nitric oxide in exhaled gas (FENO) in isolated lungs are reported here for the first time, allowing to resolve the respiratory cycles. In this study, performed on 9 animals, FENO by isolated lungs range from 3.3 to 10.6 ppb with a median value of 4.4 ppb. Pairing ex-vivo lung and pig measurements allows to demonstrate a systematic increase of FENO in the ex-vivo lung as compared to the living animal, by a factor of 3 ± 1.2. Measurements of the fraction of carbon monoxide in exhaled gas (FECO) confirm levels recorded during previous studies driven to evaluate FECO as a potential marker of ischemia reperfusion injuries. FECO production by ex-vivo lungs ranges from 0.31 to 2.3 ppm with a median value of 0.8 ppm. As expected, these FECO values are lower than the production by the corresponding whole pig body, by a factor of 6.9 ± 2.7.

Nitric oxide in exhaled gas and tetrahydrobiopterin in plasma after exposure to hyperoxia

The fraction of nitric oxide in exhaled gas (FENO) is decreased after exposure to hyperoxia in vivo, although the mechanisms for this decrease is not clear. A key co-factor for nitric oxide synthase (NOS), tetrahydrobiopterin (BH4), has been shown to be oxidized in vitro when exposed to hyperoxia. We hypothesized that the decrease of FENO is due to decreased enzymatic generation of NO due to oxidation of BH4. The present study was performed to investigate the relationship between levels of FENO and plasma BH4 following hyperoxic exposure in humans. Two groups of healthy subjects were exposed to 100% oxygen for 90 minutes. FENO was measured before and 10 minutes (n = 13) or 60 minutes (n = 14) after the exposure. Blood samples were collected at the same time points for quantification of biopterin levels (BH4, BH2 and B) using LC-MS/MS. Each subject was his or her own control, breathing air for 90 minutes on a separate day. Hyperoxia resulted in a 28.6 % decrease in FENO 10 minutes after exposure (p < 0.001), confirming previous findings. Moreover, hyperoxia also caused a 14.2% decrease in plasma BH4 (p = 0.012). No significant differences were observed in the group measured 60 minutes after exposure. No significant correlation was found between the changes in FENO and BH4 after the hyperoxic exposure (r = 0.052, p = 0.795), this might be due to the recovery of BH4 being faster than the recovery of FENO.

Exhaled Nitric Oxide Using End-Tidal Concentration during Methacholine Challenge

Increased nitric oxide in exhaled gas in patients with asthma is thought to reflect the severity of airway inflammation and perhaps airway reactivity. Several studies attempted to identify a relationship between exhaled NO levels and airway reactivity or severity of airway inflammation for the purpose of finding out if exhaled NO could be used in place of pulmonary function testing and airway provocation test. Unfortunately, the relationship is not always evident. In recent years, it has become clearer that exhaled NO becomes elevated primarily in atopic asthma patients. All previous studies have used the single vital capacity slow exhalation maneuver to measure ENO (FeNO50). This method is subject to errors because it requires patient cooperation, is flow rate dependent and adds more stress on the patient. Recently, we showed that end tidal NO concentration (NOet) is clinically relevant, is much easier to measure and is not subject to flow variation or patient cooperation. We used NOet (ppb) measurement before and during methacholine challenge in patients with symptoms of mild, persistent asthma. In addition we calculated NO production (NOpr) (nmole/ min) to correct for possible changes in ventilation. Eleven patients exhibited hyper-responsiveness to methacholine (responders) and 17 exhibited negative response (non-responders). The responders had a slightly higher NO level than the non-responders whether expressed in ppb or in nmol/min but did not reach statistical significance: NOet values were 15.1±2.4 ppb (±SE) and 11.7±2.3 ppb respectively and NOpr values were 5.83±0.86 nmol/min and 5.12±1.13 nmol/min respectively. There was no correlation between baseline NOet levels and the change in FEV1 in the responders. Furthermore, there was no consistent change in NOet or NOpr levels during broncho-constriction with methacholine. We conclude that although exhaled NO levels may serve as a helpful adjunct in treatment of asthma, its level alone does not reflect severity of the disease in mild asthmatics nor the airway responsiveness to methacholine. Exhaled NO was estimated using the average NO value at end expiration during normal tidal breathing. This method was quicker, repeatable and much easier on the patients and none of the patients objected to doing the measurement. There was no need to put patients through the complicated single full vital capacity slow exhaled maneuver to obtain this information.

Exhaled nitric oxide after high-intensity exercise at 2800 m altitude

Nitric oxide (NO) concentration in exhaled gas is a marker of some inflammatory processes in the lung, and endogenous NO plays a role in the physiological responses to exercise and altitude. The aim of this study was to compare changes in exhaled NO concentration 5-60 mins after high-intensity exercise at 2800 m and at 180 m altitude. Twenty trained healthy volunteers (12 men), aged 19-28 years, were included in this open, crossover study. Subjects performed two exercise tests at different altitudes, 2800 m and 180 m, in a randomized order. The fraction of NO in exhaled gas (FE(NO)) was measured 5 mins before and 5-60 mins after 8 mins of running on a treadmill at a heart rate (HR) of 90% of peak HR. Peak HR was assessed during a pretest at 180 m. Ambient temperature was 20.1°C (SD = 1.2) and relative humidity 40.2% (SD = 3.2). FE(NO) measurements were corrected for altitude gas density effects and converted to partial pressure of NO (PE(NOcorr)). PE(NOcorr) was reduced from 1.47 (1.21, 1.73) millipascal (mPa) at baseline to 1.11 (0.87, 1.34) mPa 5 mins after exercise at 2800 m and from 1.54 (1.24, 1.84) to 1.04 (0.87, 1.22) mPa 5 mins after exercise at 180 m. There was no difference in PE(NOcorr) between exercise at 2800 m and 180 m, and PE(NOcorr) was normalized within 20 mins. Exercise at 2800 m induces a similar acute reduction in exhaled nitric oxide concentration as compared with 180 m in healthy subjects.

Exhaled nitric oxide concentration upon acute exposure to moderate altitude

The purpose of this study was to assess immediate changes in the partial pressure of nitric oxide (NO) in exhaled gas (PE NO ) in healthy trained subjects who were acutely exposed to moderate altitude. One group of nine and another group of 20 healthy subjects were exposed to an ambient pressure of 728 hPa (546 mmHg) corresponding to an altitude of 2800 m for 5 and 90 min, respectively, in an altitude chamber. PE NO was measured offline by sampling exhaled gas in tight metal foil bags at 5, 30, 60, and 90 min. A correction for increased expiratory flow rate due to gas density effects at altitude was performed (PE NO corr). PE NO was significantly decreased by 13-16%, while the fraction of NO in exhaled gas (FE NO) was increased by 16-19% compared to sea level. There was no significant change in PE NO corr after exposure to altitude for 5, 30, 60, and 90 min. We conclude that there was no change in PENO upon arrival at altitude after correcting for gas density effects on expiratory flow rate. Corrections for altitude effects must be done before comparing measurements performed at different altitudes when using measurements of FENO to monitor athletes who have asthma during training at altitude.

Bronchial Nitric Oxide Flux and Alveolar Nitric Oxide Concentration After Exposure to Hyperoxia

The fraction of nitric oxide in exhaled gas (FE(NO)) is reduced by 30-70% after exposure to partial pressures of oxygen (Po2) of 200-240 kPa for 90 min. The purpose of this study was to partition FE(NO) into its flow-independent alveolar and bronchial components. A reduced bronchial NO flux (JawNO) is associated with induced bronchoconstriction, while increased alveolar NO concentration (C(A)NO) is associated with increased alveolar dead space. There were 12 patients undergoing hyperbaric oxygen (HBO) therapy for 90 min at a Po2 of 240 kPa and 20 healthy subjects exposed to normobaric hyperoxia (NBO) breathing 100% oxygen for 90 min who were compared to a control group of 6 subjects breathing ambient air. FE(NO) was measured at flow rates from 30 to 250 ml x s(-1) before and after the exposures and the Högman Märilainen algorithm was used to calculate JawNO and C(A)NO. FE(NO) at an expiratory flow rate of 50 ml x s(-1) was reduced from 17.6 +/- 8.3 to 12.3 +/- 6.3 ppb after HBO exposure and from 17.8 +/- 6.2 to 13.3 +/- 5.2 ppb after NBO exposure. There was a significant reduction in JawNO, but unchanged C(A)NO. There were no changes in the control experiment. The reduction in FE(NO) after exposure to normobaric and hyperbaric hyperoxia appears to be predominantly an airway effect. An unchanged and low C(A)NO indicate preserved integrity of the gas exchange units without increased alveolar dead space at rest.

Nebulization of the acidified sodium nitrite formulation attenuates acute hypoxic pulmonary vasoconstriction

BackgroundGeneralized hypoxic pulmonary vasoconstriction (HPV) occurring during exposure to hypoxia is a detrimental process resulting in an increase in lung vascular resistance. Nebulization of sodium nitrite has been shown to inhibit HPV. The aim of this project was to investigate and compare the effects of nebulization of nitrite and different formulations of acidified sodium nitrite on acute HPV.MethodsEx vivo isolated rabbit lungs perfused with erythrocytes in Krebs-Henseleit buffer (adjusted to 10% hematocrit) and in vivo anesthetized catheterized rabbits were challenged with periods of hypoxic ventilation alternating with periods of normoxic ventilation. After baseline hypoxic challenges, vehicle, sodium nitrite or acidified sodium nitrite was delivered via nebulization. In the ex vivo model, pulmonary arterial pressure and nitric oxide concentrations in exhaled gas were monitored. Nitrite and nitrite/nitrate were measured in samples of perfusion buffer. Pulmonary arterial pressure, systemic arterial pressure, cardiac output and blood gases were monitored in the in vivo model.ResultsIn the ex vivo model, nitrite nebulization attenuated HPV and increased nitric oxide concentrations in exhaled gas and nitrite concentrations in the perfusate. The acidified forms of sodium nitrite induced higher levels of nitric oxide in exhaled gas and had longer vasodilating effects compared to nitrite alone. All nitrite formulations increased concentrations of circulating nitrite to the same degree. In the in vivo model, inhaled nitrite inhibited HPV, while pulmonary arterial pressure, cardiac output and blood gases were not affected. All nitrite formulations had similar potency to inhibit HPV. The tested concentration of appeared tolerable.ConclusionNitrite alone and in acidified forms effectively and similarly attenuates HPV. However, acidified nitrite formulations induce a more pronounced increase in nitric oxide exhalation.

Influence of ventilatory settings on exhaled nitric oxide during high frequency oscillatory ventilation

Nitric oxide (NO), which is produced in the lower airways, diffuses from cells into the air space and can be measured in exhaled air. The influence of high frequency oscillatory ventilation on the production of exhaled NO (eNO) has not been thoroughly studied. The objectives of this study are to establish an animal model for evaluation of lower airway NO and to evaluate settings in terms of frequency, mean airway pressure (MAP), amplitude pressure (amplitude), and inspiratory time ratio (t(I)/t(E)) during high frequency oscillatory ventilation on the production of eNO. An observational animal study was performed on 12 female New Zealand White rabbits, which were anesthetized, tracheotomized and ventilated using a SensorMedics 3100A HFOV ventilator (SM3100A). The concentration of NO in exhaled gas was measured by chemiluminescence continuously from the nose and the side hole of the adaptor of endotracheal tube. The individual effects of the respiratory settings were evaluated. The results were analyzed by paired t-test or by the generalized estimating equation method. We found that the lower airway was the main source of the eNO, that amplitude, MAP, and t(I)/t(E) were positively correlated with the level of eNO and that frequency was negatively correlated with the level of eNO. These findings fit the stretch theory for the production of endogenous NO. Monitoring of eNO during HFOV may provide insights into lung mechanics and ventilation efficiency and be used in the future as a guide during clinical practice.

Basal and nitroglycerin-induced exhaled nitric oxide before and after cardiac surgery with cardiopulmonary bypass

Exhaled nitric oxide (NO) may reflect NO production and consumption but the pulmonary origin of NO in exhaled gas is not clear. There are also conflicting data on exhaled NO after cardiopulmonary bypass (CPB). Because intravenous nitrovasodilators increase exhaled NO by conversion to NO in the lung, we measured basal and nitroglycerin (GTN)-induced exhaled NO in patients having low-risk coronary artery bypass graft (CABG) operations using routine CPB. We reasoned that GTN-induced exhaled NO would be a primarily vascular mechanism, which would contrast with the airway epithelial origin of basal exhaled NO, and that they might be differentially influenced by CPB. Breath-to-breath concentrations of gas phase NO were measured in 12 CABG patients before and 1, 3 and 6 h after CPB. After the baseline measurements, three increasing doses of 1, 2 and 3 micro g kg(-1) intravenous GTN were given by a central venous catheter and exhaled NO and haemodynamic responses were recorded. Intravenous administration of 1, 2 and 3 micro g kg(-1) doses of GTN produced a dose-dependent increase in exhaled NO and a reduction in systemic blood pressure. Baseline exhaled NO remained unchanged. Exhaled NO but not blood pressure responses were reduced 1 and 3 h after CPB. The capacity of the lungs to increase exhaled NO in response to intravenous GTN is reduced after CPB, suggesting microvascular injury and/or atelectasis after routine open-heart surgery.

Increased Nitric Oxide in Exhaled Gas Is an Early Marker of Hypovolemic States

Acute hemorrhage is associated with a variety of physiologic and metabolic alterations, including vascular hyporeactivity and endothelial cell dysfunction. The lung is a major target organ during hemorrhagic shock. The effect of acute hemorrhage on NO production in the lung is not well described. In the present study we examined the effect of acute hemorrhage on exhaled NO (NOe), and studied how changes in blood volume and flow affect NOe. Anesthetized and mechanically ventilated rabbits were used. The effect of acute hemorrhage by slow exsanguination on NOe was examined using chemiluminescence. Because hemorrhagic shock is associated with decreased pulmonary blood flow, we established an isolated lung preparation perfused with autologous blood (Hct = 17.4%) and studied the effect of pulmonary flow rate on NOe independent of metabolic changes. In order to separate the effect of flow from the effect of changes in blood volume, we examined the effect of flow in isolated lungs perfused with a blood-free albumin solution (PAS). In the isolated lung, ventilation was similar to that used in the intact animal, and temperature, pH,pCO2, andPO2were kept normal. Prior to exsanguination, baseline NOe in the intact animal was 24 ± 3 ppb. At 5, 10, 15, and 20 min after initiating the hemorrhage, NOe rose to 31 ± 3, 51 ± 7, 94 ± 10, and 154 ± 16 ppb, respectively (P< 0.05). During baseline conditions in the blood-perfused isolated lungs (200 ml/min), NOe was 35 ± 3 ppb. When flow was decreased to 70 and 0 ml/min, NOe increased to 37 ± 3 and 56 ± 6 ppb, respectively (P< 0.001). During baseline conditions in the PAS-perfused lungs (70 ml/min), NOe was 94 ± 13 ppb and was unaffected by changes in flow. The perfusion pressure in the isolated lungs was in the normal range. Reduction in blood flow rate in the isolated lung was associated with less than twofold increase in NOe. This was attributed to reduction in red blood cell volume and not due to changes in blood flow rate. Reduction in flow in the intact animal during hemorrhage generated more than threefold increase in NOe, suggesting that neurohumoral mediators, in addition to changes in flow, play an important role in determining NOe in the intact condition. NOe began to rise immediately after exsanguination began, and therefore may be a useful early marker of acute hemorrhagic shock and hypovolemia. This information may be useful in the intensive care setting.

Determinants of nitric oxide in exhaled gas in the isolated rabbit lung.

Nitric oxide concentrations in the exhaled gas (NOe) increases during various inflammatory conditions in humans and animals. Little is known about the sources and factors that influence NOe. NOe at end expiration was measured by chemiluminescence in an isolated, blood-perfused rabbit lung. The average end-expiratory concentration over 10 breaths was used. The effect of positive end-expiratory pressure (PEEP), flow rate, pH, hypoxia, venous pressure, and flow pulsatility on NOe were determined. At constant blood flow, increasing PEEP from 1 to 5 cm H2O elicited a reproducible increase in NOe from 49 +/- 7 to 53 +/- 8 parts per billion (ppb) (p < 0.05). When blood pH was increased from 7.40 to 7.74 by breathing low CO2 gas, NOe rose from 45 +/- 7 to 55 +/- 7 ppb (p < 0.001). Hypoxia caused a dose-dependent decrease in NOe from 37 +/- 3 during baseline to 23 +/- 2 during ventilation with 0% O2 (p < 0.01). Venous pressure elevation from 0 to 5 and 10 mm Hg decreased NOe from 32 +/- 5, to 26 +/- 5 and 24 +/- 5 ppb, respectively (p < 0.05). Switching from steady to pulsatile flow (same man flow) resulted in a small, albeit significant reduction in NOe; 30 +/- 4 to 28 +/- 4 ppb (p < 0.05). Changes in flow rate between 200 and 20 ml/min were associated with small changes in NOe; however, when flow was stopped, NOe rose substantially to 56 +/- 6 ppb (p < 0.05). The changes in NOe were rapid (1 to 2 min) and reversible. The results suggest that NOe is influenced by ventilatory and hemodynamic variables, pH, and hypoxia. We suggest that caution must be taken when interpreting changes in exhaled NO in humans or experimental animals. Changes in total and regional blood flow, capillary blood volume, ventilation, hypoxia, and pH should not be overlooked.

Increased Nitric Oxide in Exhaled Gas as an Early Marker of Lung Inflammation in a Model of Sepsis

Nitric Oxide (NO) has been implicated in the pathologic vasodilation of sepsis. Because NO can be measured in the exhaled gas of animals and humans, we hypothesized that increases in exhaled NO would occur in a septic model. Using a blinded design, 10 male Sprague-Dawley rats (300 to 400 g) were anesthetized, paralyzed, tracheotomized, and randomized (5/group) to receive an intravenous injection of either lipopolysaccharide (LPS) (Salmonella typhosa, 20 mg/kg) or placebo (equal volume of saline). Thereafter, exhaled gas was collected and measurements of NO concentration were made using chemiluminescence every 20 min for 300 min during ventilation (RR 40 breaths/min, Vt 3 ml, PEEP 0, FiO2 0.21). Another group of 10 animals (5 LPS; 5 control) were treated in the same fashion and then killed at 240 min and an arterial blood sample obtained for blood gas and TNFα determinations. Pressure volume (PV) curves were constructed and lungs removed, preserved, and submitted for histologic evaluation. LPS-treated rats had lower mean arterial pressures than the control group, p < 0.0001. No significant differences in static lung compliance and PV curves were found in the two groups. TNFα levels were greater in the LPS group (1.40 ± 0.24 ng/ml) versus control group (0.09 ± 0.04 ng/ml), p < 0.001. By contrast to the control group, exhaled NO concentration rose in all LPS-treated rats at approximately 100 min and at about 160 min reached a plateau that was 6 times greater than control levels (p < 0.0001). There was greater interstitial, airspace, and total lung injury in the LPS group (p = 0.01). Hypotension alone was not responsible for the rise in exhaled NO because no increase in NO was noted over 300 min in another two rats that did not receive LPS and that were slowly exsanguinated to maintain mean systemic arterial pressure 40 to 60 mm Hg. In two rats that were completely exsanguinated at 240 min we observed marked increases in exhaled NO concentration compared with LPS-treated rats with intact circulation. We conclude that in this model of sepsis, increases in exhaled NO concentration originate in the lungs and appear to be a relatively early marker of lung inflammation.