Introduction
Pseudomonas aeruginosa is a Gram negative bacteria producing a wide array of virulence factors frequently responsible for chronic airway infections in cystic fibrosis (CF) or chronic obstructive pneumonia disease (COPD) patients, as well as acute nosocomial airway infections in intensive care units [
1‐
3].
In acute
P. aeruginosa pneumonia, the functional consequences, and particularly lung fluid movements, have been studied extensively. Lung fluid balance is the result of fluid movements following active ion transport by functional alveolar cells, and permeability of the alveolar capillary barrier. In
P. aeruginosa-induced acute lung injury (ALI), distal airspace fluid clearance (DAFC) is typically increased at 24 hours through a TNF-α pathway [
4]. Studies have also shown that the capacity of maintaining alveolar active fluid transport is correlated with patient outcome in ALI [
5,
6]. Lung liquid clearance (LLC) is another functional marker reflecting the capacity of the lung to evacuate fluid instilled in the alveoli outside the lung, LLC involves DAFC, epithelial and endothelial permeabilities [
7]. We previously showed that, even though DAFC is upregulated, LLC is decreased at both 4 and 24 hours in ALI [
7] reflecting a major endothelial injury overwhelming the alveolar response.
In chronic infection, these functional consequences on lung fluid balance are less clear. In the 70's, Cash developed an experimental model of chronic pneumonia by intra tracheal injection of
P. aeruginosa embedded in agar beads [
8]. Most of the work performed with this model has focused on immunological, inflammatory, or nutritional aspects [
9‐
12]. To the best of our knowledge, no previous work has tried to evaluate alveolar permeability and lung fluid transport in
P. aeruginosa chronic lung infection. In order to elucidate these functional aspects we studied lung fluid transport in an experimental model of chronic
P. aeruginosa lung infection in the rat. After the validation of the experimental model, we studied alveolar function: alveolar-capillary barrier permeability, lung liquid clearance, distal airspace fluid clearance and its pharmacologic stimulation.
Materials and Methods
Animals
Specific pathogen-free Sprague Dawley rats (n = 280) (230–270 g), (Depre, St Doulchard, France) were housed in the Lille University Animal Care Facility and allowed food and water ad lib. All experiments were performed with approval of the Lille Institutional Animal Care and Use Committee.
Preparation of the bacterial inoculum
The methodology was adapted from Cash et al [
8]. Briefly,
P. aeruginosa (PAO1 strain) was incubated in 125 ml of tryptic soy broth at 37°C in a rotating shaking water bath for 8 hours. The culture was then washed twice, and resuspended in phosphate-buffered saline. The resulting bacterial suspension was 1 × 10
9 CFU/ml. A sample of 1 mL of this suspension was mixed in agarose and mineral oil (Sigma Diagnoses, St Louis, USA) at 56°C. The resulting oil-agar emulsion was cooled to obtain agar beads. Dilutions of the final suspension were cultured to determine the size of the final inoculum.
Experimental infection
Under a short general anesthesia with ether (Mallinkrodt, Paris, France), with sterile surgical conditions, a small midline incision was made on the neck ventral surface after swabbing it with ethanol. The trachea was exposed by blunt dissection. Using a 28-gauge needle, 0.1 mL of agar beads followed by 0.5 mL of air were inoculated intra-tracheally.
Quantitative bacteriological analysis
After exsanguination of the animal, the lungs were isolated and homogenized in 2 mL of sterile isotonic saline. Bacterial culture after serial dilutions was performed and bacterial colonies counted after 12 h at 37°C.
Antimicrobial therapy
In a subgroup of animals, ceftazidime (GlaxoSmithKline, Marly-le-Roi, France), 100 mg/kg, was administered in the peritoneal cavity every 8 hours during 72 hours. Lungs were harvested, homogenized and cultures were performed to confirm bacterial eradication. Serum ceftazidime levels were measured in HPLC.
Broncho-alveolar lavage (BAL)
Broncho-alveolar lavage (BAL) was performed by cannulating the trachea. Lungs from each experimental group were lavaged with a total of 20 ml in 5-ml aliquots of PBS with EDTA (3 mM). BAL fluid samples were filtered and immediately frozen at -80°C. A cell count was performed directly. Cellular monolayers were prepared with a cytocentrifuge and stained with Wright-Giemsa stain. Cellular morphotype differential was obtained by counting 200 cells/sample and expressing each type of cell as a percentage of the total number counted. Protein concentration in the BAL was measured with an automated analyzer (Hitachi 917, Japan).
Histological study
After a vascular flushing with sterile isotonic saline through the pulmonary artery, the lungs were removed. Samples were fixed by intratracheal instillation of paraformaldehyde 10 %. Samples were included in paraffin and sections of 5 μm were realized. Analysis was performed after coloration with Hematoxyline-Eosine-Safran (Zeiss, LEO 906).
Serum and BAL TNF-α measurement
Levels of tumor necrosis factor α (TNF-α), in the serum, and the BAL fluid, were determined by use of commercial immunoassay kits (ELISA) specific for rat cytokines (Quantikine Murine rat TNFα, R&D Systems, Abingdon OX, UK). The reading was performed with a microplate reader Digiscan (Spectracount Packard Instrument Company; Meriden CT USA).
BAL and serum measurement of epinephrine and nor-epinephrine
Blood and broncho-alveolar lavage fluid were collected on heparin/Na-metabisulfite coated tubes. The samples were centrifuged (2500 g, 4°C), supernatants were frozen (-80°C).
Catecholamines are specifically fixed on alumina (pH = 8.7), the eluent is analyzed with an inversed phase H.P.L.C (Coulochem II ESA). The results are expressed in μg/L.
Functional study
Surgical preparation
Sprague-Dawley male rats were anesthetized with pentobarbital (Sanofi, Libourne, France). A catheter (PE-50) was inserted into the left carotid artery in order to monitor systemic arterial pressure (Acqknowledge Software v 3.7.1, Biopac systems, Santa Barbara, CA, USA) and obtain blood samples. An endotracheal tube (PE-220) was inserted through a tracheostomy. The rats were ventilated with a constant volume pump (Harvard Apparatus, South Natick, MA) with an inspired O2 fraction of 1.0, a peak airway pressure of 8–12 cmH2O, and a positive end expiratory pressure of 2 cmH2O. The animals were placed in left decubitus position until the end of the protocol. The body temperature was maintained at 37°C.
Preparation of the instillate
The test solution, used for alveolar instillation, was prepared as follows : briefly, a 5% bovine albumin solution was prepared using Ringer lactate and was adjusted with NaCl to be isoosmolar with the rat circulating plasma [
13,
14]. A sample of the instilled solution was saved for total protein measurement, and water to dry weight ratio measurements. In different experimental groups, terbutaline (10
-4 M) (Sigma Aldrich, St Quentin Fallavier, France) was added to the instillate or injected intra-peritoneally to the animals.
General Protocol
For all ventilated rats experiments, the following general protocol was used. After the surgical preparation, heart rate and blood pressure were allowed to stabilize for 1 hour. To calculate the flux of plasma protein into the lung interstitium, a vascular tracer, 1 μCi of
131I-labeled human albumin, was injected into the bloodstream [
14,
15].
131I-HSA was prepared in our institution according to a standardized technique. Administration of the instillate (3 ml/kg) was performed into the left lung over a 2-min period, using a 1-ml syringe and polypropylene tube (PE 50, Intramedic, Becton Dickinson, Sparks, MD, USA)[
13].
One hour after the beginning of the alveolar instillation, the rat was exanguinated. The lungs were removed, and fluid from the distal airspaces was obtained (aspirate). The total protein concentration and the radioactivity of the liquid sampled were measured. Right and left lungs were homogenized separately for water to dry weight ratio measurements and radioactivity counts.
Measurements
Systemic arterial pressure and airway pressures were measured continuously. Arterial blood gases were measured at one hour intervals. The arterial PO
2 was used to quantify the oxygenation deficit [
13,
14]. Samples from instillated protein solution, final distal airspace fluid, and from initial and final blood were collected to measure total protein concentration with an automated analyzer (Hitachi 917, Japan).
The flux of albumin across the lung endothelial and epithelial barriers was used to evaluate the permeability. This method requires measurement of the vascular protein tracer,
131I-albumin, in the alveolar and extravascular spaces of the lungs. Endothelial permeability was assessed by measuring the ratio of
131-iodine radioactivity in the aspirate to the radioactivity obtained in the plasma (Asp/plasma), it reflects the leak of the vascular tracer in the alveolar compartment. We estimated the quantity of plasma that entered the instilled lungs by measuring the transfer of the vascular protein tracer,
131I-albumin, into the extravascular spaces of the instilled lung using the equation of plasma equivalents previously described [
7,
13,
14].
The EVLW was estimated by gravimetry: 300 μL of the lung homogenate were weighed, to determine the wet weight, and dessicated at 45°C during 7 days, to obtain the dry weight. The blood fraction was calculated from the homogenate hemoglobin supernatant content. The wet to dry weight ratio (W/D) was estimated using the values of the right lung which was not instilled [
7,
14,
16]. Lung liquid clearance was calculated as previously described [
7].
A change of native bovine albumin concentration over the study period (1 h) was used to measure alveolar fluid movement. DAFC was calculated from the ratio of the final unlabeled alveolar protein concentration, compared to the initial instilled alveolar protein concentration.
Experimental groups
15 experimental groups were constituted for the study:
-
A control group (Ctr), which received an intratracheal instillation of sterile saline at the beginning of the protocol
-
7 Sterile groups (St) received an intratracheal instillation of sterile beads and were studied at different days after inoculation: St 1, St 2, St 5, St 8, St 15, St 21 and St 28.
-
7 Pneumonic groups (Pn) received an intratracheal instillation of Pseudomonas containing beads and were studied at different days after inoculation: Pn 1, Pn 2, Pn 5, Pn 8, Pn 15, Pn 21, Pn 28.
Statistical analysis
Comparisons between two groups were made using an unpaired, two tailed Student's t-test. Comparisons between more than two groups were made using a one way analysis of variance with post hoc test for multiple comparisons. A value of p < 0.05 was considered as significant. The data are expressed as means ± SD.
Discussion
In our study we validated an experimental model allowing us to explore alveolar function in chronic P. aeruginosa lung infection through measurements of lung liquid movements. In this model of chronic P. aeruginosa lung infection, after observing an initial increase of both alveolar permeability and lung fluid movements, we characterized an impairment of DAFC where, even though DAFC returned to baseline, it remained unresponsive to pharmacological stimuli.
In the first part of our work, we validated, on several parameters, the chronic infection model previously described by Cash et al [
8]. After reaching a peak on the second day of the infection and decreasing from the 5
th to the 15
th day, lung bacterial load persisted for 3 weeks. These results, as well as the analysis of the BAL and the histological features, are consistent with the literature [
8,
11,
17,
18].
Since, in this model,
P. aeruginosa is associated with agar beads, we performed, as control groups, instillation of sterile agar beads. Sterile agar bead instilled rats did not show any evidence of weight loss and although they did present an increase in BAL cellularity, there were no PMN's except a slight increase on the second day which failed to reach a statistical significance (data not shown). This result is consistent with the literature, Nacucchio et al showed that agar beads alone could not reproduce the same level of injury than
P. aeruginosa in agar beads [
19].
From this first part of our work, we concluded that the model of chronic infection with P. aeruginosa is adequate, based on clinical, bacteriological, cytological and histological data.
Although a clinical study has reported increased lung permeability in COPD patients infected by
P. aeruginosa [
20], few studies have focused on the consequences of chronic lung infection on alveolar function and particularly fluid movements. In our study, lung fluid movements were maximal on the 2
nd day post infection. We observed an increase of alveolar-capillary barrier permeability, DAFC and overall lung liquid clearance. A normal lung wet to dry weight ratio was a consequence of this adequate alveolar response. This contrasts sharply with the data we obtained in an acute lung injury model where LLC dramatically decreased and W/D weight ratio increased at 4 and 24 hours after
Pseudomonas instillation [
7].
In our chronic model, following the increase in both permeability and lung liquid clearance, we observed an improvement in permeability with a return to baseline of these 2 parameters on the 5th day.
The St group presented a moderate increase in permeability (Asp/plasma ratio: 0.31 ± 0.04), it has previously been reported that agar beads could alone be responsible for a moderate increase in permeability [
19]. However, taking into account the association of the other parameters validating the model (clinical, bacteriological, cytological and histological), this effect does not challenge the model.
Our results showed an increase of the DAFC at 48 hours post infection. In acute lung injury, the initial alveolar response is usually towards an increase of DAFC which many authors have documented in septic shock [
21], or after endotoxin administration [
22]. In septic shock, this increase was related to the release of endogenous catecholamines. In acute
P. aeruginosa pneumonia, increased DAFC can be related to either
Pseudomonas exoproducts [
15] or to a TNF-α dependent mechanism during the first 24 hours of the infection [
4]. We tested in our model whether TNF-α or catecholamines could explain our results. TNF-α was not detectable and systemic endogenous epinephrine or nor-epinephrine not different from controls on the 2
nd or the 5
th day. TNF-α is produced during the early phase of pneumonia, and its short half life probably explains the absence of detectable levels at 48 hours. A dynamic evaluation of TNF-α production with serial samples or antibody neutralization experiments would be helpful to precisely study the role of TNF-α. We therefore did not rule out that TNF-α may have triggered an inflammatory response which could be responsible for the increased DAFC. Other potential mechanisms such as Transforming Growth Factor β remain to be investigated [
23].
Surprisingly, on the fifth day, DAFC returned to baseline along with the improvement in permeability. Although it is logical to see an improvement in permeability, consistent with a decrease of the bacterial burden and an adequate host response, DAFC was expected to remain increased. The persisting presence of the pathogen in the alveoli and many factors only related to its presence would normally lead to a persistent increase of DAFC [
15]. We therefore decided to evaluate if a normal increase in DAFC could be elicited on the 5
th day post infection in response to known pharmacological stimuli [
24,
25]. In the normal lung, intra-alveolar administration of terbutaline generates a DAFC increase of approximately 30% [
26]. We observed comparable results in our study in control animals as well as animals which received only sterile beads. In our model, on the 5
th day, terbutaline intratrachéal administration did not change DAFC. However the lack of effect may be due to airway inflammation and an inability to adequately deliver the drug, we therefore decided to use intraperitoneal administration with the same agent. Our results also show the absence of DAFC increase. We then hypothesized that the absence of response to the stimulation might be related to the persistence of the pathogen in the alveoli. To test this hypothesis, we injected the animals with ceftazidime to sterilize the lungs on the 5
th day. Sterilization was achieved but failed to restore DAFC stimulation with terbutaline. To explain this impairment of DAFC, different hypotheses still remain to be investigated concerning these agonist's receptors and their regulation. Other authors have shown in different situations that either an internalization or a decrease of affinity of the receptors [
27] could be observed. Another hypothesis could be a lost of sensitization through a decrease of the AMPc dependent signal transmission. It was shown, in vitro, on tracheal cells that a continuous or repeated exposure to isoproterenol could lead to a lost of sensitization [
28].
If this unresponsiveness exists in patients, the absence of an adapted DAFC response in chronic lung infection could lead to major damage in the presence of any new lung injury. Although chronic lung infection has not been isolated, per se, as an aggravating factor associated to mortality in COPD patients admitted in an intensive care unit, a pre-existing underlying pathology is associated with a worsening of the prognosis in community and nosocomial pneumonia [
29,
30]. DAFC impairment might be part of the answer to this effect of underlying disease.
In conclusion, chronic P. aeruginosa pneumonia is characterized initially at 48 hours by an increased alveolar-capillary barrier permeability and an adapted host response with an increased DAFC and LLC preserving a normal lung wet to dry weight ratio. On the 5th day, DAFC remains non responsive to pharmacological stimulation even after bacterial elimination. This impairment of DAFC could represent one of the factors responsible for the increased susceptibility of chronically infected patients to other respiratory insults.
Authors' contributions
SB and FA were responsible for the acquisition of the data. KF and MOH made substantial contributions to the drafting of the manuscript and the analysis of the data. TP performed the radioactive labelling of the albumin (I131). EK was involved in the revision of the manuscript and the English editing. XL performed all the histological analysis. BG was involved in the acquisition of the data, the design and the conception of the study as well as the drafting of the article. All the authors read and approved the final manuscript.