title: Inhaled activated protein C protects mice from ventilator-induced lung injury.
abstract: BACKGROUND
  Activated Protein C (APC), an endogenous anticoagulant, improves tissue microperfusion and endothelial cell survival in systemic inflammatory states such as sepsis, but intravenous administration may cause severe bleeding. We have thus addressed the role of APC delivered locally by inhalation in preventing acute lung injury from alveolar overdistention and the subsequent ventilator-induced lung injury (VILI). We also assessed the effects of APC on the activation status of Extracellular- Regulated Kinase 1/2 (ERK) pathway, which has been shown to be involved in regulating pulmonary responses to mechanical stretch.
  
  
  METHODS
  Inhaled APC (12.5 microg drotrecogin-alpha x 4 doses) or saline was given to tracheotomized C57/Bl6 mice starting 20 min prior to initiation of injurious mechanical ventilation with tidal volume 25 mL/Kg for 4 hours and then hourly thereafter; control groups receiving inhaled saline were ventilated with 8 mL/Kg for 30 min or 4 hr. We measured lung function (respiratory system elastance H), arterial blood gases, surrogates of vascular leak (broncho-alveolar lavage (BAL) total protein and angiotensin-converting enzyme (ACE)-activity), and parameters of inflammation (BAL neutrophils and lung tissue myeloperoxidase (MPO) activity). Morphological alterations induced by mechanical ventilation were examined in hematoxylin-eosin lung tissue sections. The activation status of ERK was probed in lung tissue homogenates by immunoblotting and in paraffin sections by immunohistochemistry. The effect of APC on ERK signaling downstream of the thrombin receptor was tested on A549 human lung epithelial cells by immunoblotting. Statistical analyses were performed using ANOVA with appropriate post-hoc testing.
  
  
  RESULTS
  In mice subjected to VILI without APC, we observed hypoxemia, increased respiratory system elastance and inflammation, assessed by BAL neutrophil counts and tissue MPO activity. BAL total protein levels and ACE activity were also elevated by VILI, indicating compromise of the alveolo-capillary barrier. In addition to preserving lung function, inhaled APC prevented endothelial barrier disruption and attenuated hypoxemia and the inflammatory response. Mechanistically, we found a strong activation of ERK in lung tissues by VILI, which was prevented by APC, suggestive of pathogenetic involvement of the Mitogen-Activated Kinase pathway. In cultured human lung epithelial cells challenged by thrombin, APC abrogated the activation of ERK and its downstream effector, cytosolic Phospholipase A2.
  
  
  CONCLUSIONS
  Topical application of APC by inhalation may effectively reduce lung injury induced by mechanical ventilation in mice.
authors.affiliation: 2nd Dept, of Critical Care, Attikon Hospital, National and Kapodistrian University of Athens Medical School, Rimini 1, Haidari, Greece. maniatisnikolaos@yahoo.com
authors.forename: Nikolaos A
authors.initials: NA
authors.lastname: Maniatis
authors.forename: Eleftheria
authors.initials: E
authors.lastname: Letsiou
authors.forename: Stylianos E
authors.initials: SE
authors.lastname: Orfanos
authors.forename: Matina
authors.initials: M
authors.lastname: Kardara
authors.forename: Ioanna
authors.initials: I
authors.lastname: Dimopoulou
authors.forename: Georgios
authors.initials: G
authors.lastname: Nakos
authors.forename: Marilena E
authors.initials: ME
authors.lastname: Lekka
authors.forename: Charalambos
authors.initials: C
authors.lastname: Roussos
authors.forename: Apostolos
authors.initials: A
authors.lastname: Armaganidis
authors.forename: Anastasia
authors.initials: A
authors.lastname: Kotanidou
mesh_terms: D000280:Administration, Inhalation; D000818:Animals; D000925:Anticoagulants / Q000008:administration & dosage* / Q000494:pharmacology*; D004305:Dose-Response Relationship, Drug; D008297:Male; D051379:Mice; D008810:Mice, Inbred C57BL; D011486:Protein C / Q000008:administration & dosage* / Q000494:pharmacology*; D055397:Ventilator-Induced Lung Injury / Q000517:prevention & control*
chemical_list: D000925:Anticoagulants; D011486:Protein C
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