Department of Anesthesiology, University of Hirosaki School of Medicine, Hirosaki 036-8562, Japan*Corresponding author
Accepted for publication: August 21, 2000
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Abstract |
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Br J Anaesth 2001; 86: 24953
Keywords: anaesthetics i.v., propofol; receptors, muscarinic; surgery, vagotomy; airway, muscles; equipment, bronchoscopes
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Introduction |
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On the other hand, in vitro studies suggest direct relaxant effects of propofol on airway smooth muscles. The mechanism has been suggested to be through reduction in intracellular Ca2+ concentration by block of L-type voltage-sensitive Ca2+ channels6 and inhibition of Ca2+ release from intracellular stores,7 but not by decreased Ca2+ sensitivity.8
Similarly, volatile anaesthetic agents have also been reported to produce airway relaxation by vagolysis and more direct actions.9 10 Regarding the neural mechanism, several reports9 10 suggest that inhibition of the peripheral vagal motor pathway may be involved.
Muscarinic receptors play an important role in cholinergic effects on the airway,11 and previous reports suggest that muscarinic receptor subtypes m1, m2 and m3 exist in the human airway.12 The m1 receptors facilitate neurotransmission through parasympathetic ganglia and enhance cholinergic reflexes. Activation of m3 receptors produces contraction of airway smooth muscles. Activation of m2 receptors inhibits the release of acetylcholine and may also counteract the bronchodilation produced by ß-agonists.12 Methacholine is a non-selective muscarinic receptor agonist,13 and has been used clinically to quantitate airway responsiveness in asthmatic patients.14
In this study, we determined whether propofol could antagonize the muscarinic receptor-activated bronchoconstriction induced by methacholine. In addition, we compared the relaxant effects in normal dogs with those in vagotomized dogs to determine whether the relaxant effects are centrally mediated.
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Methods |
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The cross-sectional area of third bronchial bifurcation in the right lung was monitored via a superfine fibre-optic bronchoscope (outside diameter 2.2 mm, AF type 22A; Olympus, Tokyo, Japan) to assess bronchial tone, as reported previously.5 1518 Briefly, the image of the third bifurcation was printed with a video printer (VY-170; Hitachi, Tokyo, Japan) during the end-expiratory pause, and was then loaded into a Macintosh computer (Power Macintosh 7100/80 AV, Apple Computer, CA, USA) via a scanner (Scan-Jet 4c; Hewlett Packard, CO, USA) to measure bronchial cross-sectional area with image analysis software (MacScope 2.56; Mitani, Fukui, Japan). Image processing was performed by an investigator who was blinded to the study protocol.
Bronchoconstriction was elicited by i.v. infusion of methacholine (0.5 µg kg1 + 5 µg kg1 min1) until the end of the experiment. Initially we confirmed that this bronchoconstriction could be fully reversed by atropine. Thirty minutes after the start of methacholine infusion, the following doses of propofol were given at 10 min intervals in the order indicated: 0 (saline), 0.2, 2.0, 20 mg kg1. Bronchial cross-sectional area was measured before and 30 min after methacholine infusion started and 5 min after each propofol dose. Bronchial cross-sectional areas are presented as percentages of basal.
Arterial blood samples (6 ml) were centrifuged immediately at 3000 r.p.m. for 10 min at 10°C to separate plasma, which was then frozen at 70°C until measurement of catecholamines and propofol concentrations by high-performance liquid chromatography.19 20 The lower detection limits were 15 pg ml1 for norepinephrine, 20 pg ml1 for epinephrine and 100 ng ml1 for propofol. The intra-assay coefficient of variation was 3.3% for norepinephrine, 6.0% for epinephrine and 2.9% for propofol.
Statistical analysis
All data are expressed as mean (95% confidence interval). Data were analysed by repeated measures analysis of variance followed by Fishers protected least significant difference test using StatView II on a Macintosh computer. P<0.05 was considered significant. To obtain a concentrationresponse curve for propofol-induced relaxation, relaxation was expressed as a percentage: peak constriction by methacholine=0% and full relaxation (baseline)=100%. The sigmoid concentrationresponse curve was fitted using GraphPad Prism 1.03, and the maximal inhibition and log of the concentration (µM) producing 50% inhibition of maximal effect (pIC50) of propofol were obtained from each concentrationresponse curve.
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Results |
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Methacholine decreased the bronchial cross-sectional area to 49.3 (38.560.1) and 45.3 (34.855.7)% of the basal bronchial cross-sectional area in the control and vagotomy groups respectively. In the control group, propofol 2.0 and 20 mg kg1 significantly increased bronchial cross-sectional area, to 61.2 (49.473.1) and 77.8 (66.289.6)% of basal respectively (Fig. 1A). Similarly, in the vagotomy group the bronchial cross-sectional area was significantly increased to 75.9 (64.087.9)% of basal after propofol 20 mg kg1 but not significantly after 2.0 mg kg1 (Fig. 1A).
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Plasma catecholamine concentration was significantly reduced after propofol 20 mg kg1 i.v. in both groups, and the reduction in plasma catecholamines did not differ between groups (Table 1).
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Discussion |
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Figure 1B shows that the in vivo relaxant effect of propofol is concentration-dependent, and the clinical concentration (about 30 µM)22 may reverse methacholine-induced bronchoconstriction by 45%. Azizkhan and colleagues23 reported that tracheal cross-sectional area in respiratory symptomatic paediatric patients with a mediastinal mass was decreased by 3593% of the normal tracheal dimensions. Huysmans and colleagues24 studied the effectiveness of radioiodine therapy in patients with a large goitre compressing the trachea. They found that the tracheal cross-sectional area of the smallest lumen increased by 36% after therapy, and clinical symptoms such as dyspnoea and inspiratory stridor improved in eight of 12 patients. Therefore, 45% relaxation by clinical concentrations of propofol in the present study may be clinically significant.
In this study, propofol 2 mg kg1 significantly reversed bronchoconstriction in the control group, but the reversal effect was not significant in the vagotomy group. However, plasma propofol concentration after 2 mg kg1 i.v. was significantly higher in the control group than in the vagotomy group. In addition, as described above, there were no significant differences between the groups in maximal inhibition and IC50. Therefore, vagotomy may not alter the relaxant effects of propofol, although we cannot explain the difference in plasma propofol concentration.
Direct relaxant effects of propofol should also be considered. As methacholine predominantly activates muscarinic receptors rather than nicotinic receptors, it is possible that propofol inhibits muscarinic receptor responses directly. Similarly, we reported previously that propofol concentration-dependently shifts the concentrationresponse curve of carbachol-induced contraction of guinea-pig tracheal smooth muscle.25 However, using a radioligand binding assay, Lin and colleagues7 reported that propofol (<100 µM) may not interact with muscarinic receptors in airway smooth muscles, although propofol 300 µM significantly decreased the binding affinity of [3H]N-methyl-scopolamine to muscarinic receptors. It was also reported that propofol reduced the intracellular Ca2+ concentration in airway smooth muscle cells by inhibition of Ca2+ influx and of Ca2+ release from internal stores. Similarly, Yamakage and colleagues6 showed that more than 10 µM of propofol significantly reduced Ca2+ current through voltage-sensitive Ca2+ channels in the airway smooth muscle cells. These data suggest that inhibition of Ca2+ mobilization by propofol may be involved in the direct relaxant effects.
Pancuronium was infused to prevent spontaneous respiration and bucking in the present study. As pancuronium has been reported to inhibit m2 rather than m1 or m3 receptors,26 pancuronium may antagonize activation of m2 receptors by methacholine. Although m2 activation causes a reduction in acetylcholine release, the main mechanism of methacholine-induced bronchoconstriction is via m3 activation. In addition, although m2 receptors also counteract ß-agonist-induced relaxation, propofol reduced plasma epinephrine concentrations in the present study. Therefore, pancuronium infusion may not attenuate methacholine-induced bronchoconstriction.
In the present study, plasma catecholamines were significantly reduced by propofol. This is consistent with a previous paper which showed that propofol produces sympatholysis more potently than vagolysis.27 As the direct neural supply of the sympathetic system is limited in the lung, sympathetic influence on the airway tone is dependent on the plasma concentration of catecholamines.28 Therefore, plasma catecholamines, especially epinephrine, may modulate airway smooth muscle tone. Indeed, we observed previously that histamine-induced bronchoconstriction was worsened by phenylephrine16 and lidocaine,17 with a reduction in plasma catecholamines, and reversed by droperidol15 and divalent cations (Mg2+ and Zn2+)18 with an increase in plasma catecholamines. Therefore, the decrease in plasma catecholamines may partially antagonize the relaxant effects of propofol.
In conclusion, the present data suggest that propofol inhibits methacholine-induced bronchoconstriction, but relaxation is not mediated via a central vagal pathway. This result is consistent with clinical reports suggesting potential bronchoprotective effects of propofol. However, it remains to be determined whether the relaxant effects are mediated through the peripheral vagal motor pathway or via direct actions.
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References |
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