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Ventilator-induced coagulopathy in experimental Streptococcus pneumoniae pneumonia

¹ Interdepartmental Division of Critical Care Medicine, ⁵ Dept of Pathology, University of Toronto, Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON, Canada, ² Laboratory of Experimental Intensive Care and Anesthesiology, Depts of ³ Intensive Care, and ⁴ Internal Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.

CORRESPONDENCE: J. J. Haitsma, Interdepartmental Division of Critical Care Medicine, University of Toronto, Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael’s Hospital, 30 Bond Street, Queen Wing 4-042, Toronto, ON, M5B 1W8 Canada. Fax: 1 4168645117. E-mail: jack.haitsma{at}utoronto.ca

Keywords: Acute respiratory distress syndrome, biotrauma, coagulation, mechanical ventilation, pneumonia

Received: March 25, 2008
Accepted August 18, 2008

Pneumonia, the main cause of acute lung injury, is characterised by a local pro-inflammatory response and coagulopathy. Mechanical ventilation (MV) is often required. However, MV can lead to additional injury: so-called ventilator-induced lung injury (VILI). Therefore, the current authors investigated the effect of VILI on alveolar fibrin turnover in Streptococcus pneumoniae pneumonia.

Pneumonia was induced in rats, followed 48 h later by either lung-protective MV (lower tidal volumes (LV_T) and positive end-expiratory pressure (PEEP)) or MV causing VILI (high tidal volumes (HV_T) and zero end-expiratory pressure (ZEEP)) for 3 h. Nonventilated pneumonia rats and healthy rats served as controls. Thrombin–antithrombin complexes (TATc), as a measure for coagulation, and plasminogen activator activity, as a measure of fibrinolysis, were determined in bronchoalveolar lavage fluid (BALF) and serum.

Pneumonia was characterised by local (BALF) activation of coagulation, resulting in elevated TATc levels and attenuation of fibrinolysis compared with healthy controls. LV_T-PEEP did not influence alveolar coagulation or fibrinolysis. HV_T-ZEEP did intensify the local procoagulant response: TATc levels rose significantly and levels of the main inhibitor of fibrinolysis, plasminogen activator inhibitor-1, increased significantly. HV_T-ZEEP also resulted in systemic elevation of TATc compared with LV_T-PEEP.

Mechanical ventilation causing ventilator-induced lung injury increases pulmonary coagulopathy in an animal model of Streptococcus pneumoniae pneumonia and results in systemic coagulopathy.