Mechanical Ventilation Induces Neutrophil Extracellular Trap Formation

Background: Mechanical ventilation can injure the lung and induce a proinflammatory state; such ventilator-induced lung injury (VILI) is associated with neutrophil influx. Neutrophils release DNA and granular proteins as cytotoxic neutrophil extracellular traps (NETs). The authors hypothesized that NETs were produced in a VILI model and may contribute to injury. Methods: In a two-hit lipopolysaccharide/VILI mouse model with and without intratracheal deoxyribonuclease (DNase) treatment or blockade of known inducers of NET formation (NETosis), the authors assessed compliance, bronchoalveolar lavage fluid protein, markers of NETs (citrullinated histone-3 and DNA), and markers of inflammation. Results: Although lipopolysaccharide recruited neutrophils to airways, the addition of high tidal mechanical ventilation was required for significant induction of NETs markers (e.g., bronchoalveolar lavage fluid DNA: 0.4 +/- 0.07 mu g/ml [mean +/- SEM], P < 0.05 vs. all others, n = 10 per group). High tidal volume mechanical ventilation increased airway high-mobility group box 1 protein (0.91 +/- 0.138 vs. 0.60 +/- 0.095) and interleukin-1 beta in lipopolysaccharide-treated mice (22.4 +/- 0.87 vs. 17.0 +/- 0.50 pg/ml, P < 0.001) and tended to increase monocyte chemoattractant protein-1 and interleukin-6. Intratracheal DNase treatment reduced NET markers (bronchoalveolar lavage fluid DNA: 0.23 +/- 0.038 vs. 0.88 +/- 0.135 mu g/ml, P < 0.001; citrullinated histone-3: 443 +/- 170 vs. 1,824 +/- 403, P < 0.01, n = 8 to 10) and attenuated the loss of static compliance (0.9 +/- 0.14 vs. 1.58 +/- 0.17 ml/mmHg, P < 0.01, n = 19 to 20) without significantly impacting other measures of injury. Blockade of high-mobility group box 1 (with glycyrrhizin) or interleukin-1 beta (with anakinra) did not prevent NETosis or protect against injury. Conclusions: NETosis was induced in VILI, and DNase treatment eliminated NETs. In contrast to experimental transfusion-related acute lung injury, NETs do not play a major pathogenic role in the current model of VILI.