Elevation of fibronectin levels in lung secretions of infants with respiratory distress syndrome and development of bronchopulmonary dysplasia

Comparison of secretory component for immunoglobulin A with albumin as reference proteins in tracheal aspirate from preterm infants

OBJECTIVES

To determine whether the concentration of secretory component (SC) in tracheal aspirate samples is less altered by changes in alveolar-capillary permeability and thus is a more reliable reference standard than albumin for the measurement of other components obtained by saline lavage in preterm infants.

METHODS

A total of 1229 tracheal aspirate and 1530 blood samples were collected from 195 neonates to evaluate the effects of advancing postnatal and gestational age, resolution of acute respiratory distress syndrome (RDS), steroid therapy for chronic lung disease, and acute sepsis on tracheal aspirate SC and albumin levels. The tracheal aspirate and blood samples were analyzed by enzyme-linked immunosorbent assay techniques for SC and albumin concentrations.

RESULTS

The mean values for the concentrations of aspirate and plasma SC did not vary significantly during an 8-week study period (n = 100) and did not vary with either gestational age (23 to 36 weeks) or postnatal age. Albumin concentration significantly decreased in aspirate samples from 1.67 +/- 0.77 mg/dl at week 1 to 0.41 +/- 0.21 mg/dl at week 8 (p < 0.001), whereas serum levels increased from 2.65 +/- 0.36 to 2.99 +/- 0.54 gm/dl (p < 0.001), suggesting a decrease in alveolar-capillary leakage with advancing postnatal age. The concentration of SC in aspirate samples from 51 infants who received dexamethasone remained constant during the first week of therapy, whereas the concentration of albumin decreased from 1.33 +/- 0.91 mg/dl at the initiation of therapy to 0.51 +/- 0.34 mg/dl on treatment day 7 (p < 0.001). The onset of sepsis (n = 40) was not accompanied by a significant change in either aspirate SC or albumin levels. However, in infants who had a deterioration in respiratory status concomitant with the onset of sepsis (n = 10), the levels of aspirate albumin increased whereas serum levels decreased (p < 0.001), suggesting an increase in alveolar-capillary leakage; the levels of aspirate SC remained unaltered.

CONCLUSIONS

Secretory component may serve as a more valid reference protein for the standardization of tracheal aspirate collection in preterm infants during evaluation of changes in inflammatory mediators in disease states and therapeutic interventions that alter alveolar-capillary integrity.

Levels of SP-A-anti-SP-A immune complexes in neonatal respiratory distress syndrome correlate with subsequent development of bronchopulmonary dysplasia

As part of a double-blind, randomized, placebo-controlled study of human surfactant therapy for neonatal respiratory distress syndrome (NRDS), we measured circulating immune complexes between surfactant protein-A and anti-surfactant protein-A antibodies (SAS). Plasma from almost all infants contained detectable immune complexes. Immune complex levels in surfactant-treated infants were comparable with those of placebo-treated controls. Despite the relatively small sample size, maximum SAS immune complex values between 2 and 4 weeks after birth correlated significantly with subsequent development of BPD. Levels of these immune complexes correlated with eventual BPD independently of, and more strongly than, gestational age and birth weight. Thus, plasma SAS immune complex measurements may be useful in analyzing the course and outcome of NRDS, in particular the likelihood of subsequent development of BPD. This assay may also help to identify infants at risk for BPD and to target preventative therapy to them.

Bronchoalveolar lavage

Bronchoalveolar lavage has a well established role in the diagnosis of pulmonary infections, particularly those due to opportunistic organisms in an immunocompromised host. Recent studies of infants and adults with inflammatory lung disease have helped our understanding of the mechanisms underlying these disorders and their responses to treatment. With increasing recognition that pulmonary events in utero and in early infancy are important in the pathogenesis of lung diseases such as asthma, studies of the lung's responses to various environmental insults in this population might guide us to developing effective preventative and therapeutic strategies. Bronchoalveolar lavage is one method for assessing a number of pulmonary components and may be useful in this regard, particularly if combined with new methods for examining inflammatory responses, such as those utilising the polymerase chain reaction to assess cellular expression for inflammatory cytokines and growth factors.

Gene transfer into respiratory epithelial cells by targeting the polymeric immunoglobulin receptor

A system for targeting foreign DNA to epithelial cells in vitro has been developed by exploiting receptor-mediated endocytosis. The polymeric immunoglobulin receptor transports dimeric immunoglobulin A and immunoglobulin M through epithelial cells, including those of the respiratory tract, by binding the immunoglobulins at the basolateral surface and transporting them across the cell. Fab fragments of antibodies directed against the extracellular portion of the receptor, secretory component, are similarly transported. Anti-human secretory component Fab fragments were covalently linked to a polycation, and complexed to various expression plasmids. When bound to an expression plasmid containing the Escherichia coli lacZ gene ligated to the Rous sarcoma virus promoter, the complexes transfected HT29.74 human colon carcinoma cells induced to express polymeric immunoglobulin receptor, but not those lacking the receptor. Primary cultures of human tracheal epithelial cells grown on collagen gels, which induce the expression of polymeric immunoglobulin receptor, were also transfected with the complexes. From 5 to 66% of the respiratory epithelial cells had beta-galactosidase activity after treatment, comparable to the percentage of cultured human tracheal epithelial cells that express polymeric immunoglobulin receptor (8-35%). The addition of excess human secretory component (Fab ligand) to the culture medium at the time of transfection blocked the delivery of DNA. The expression plasmid, either alone, complexed to the polycation, or complexed to a carrier based on an irrelevant Fab fragment, was not effective in transfecting either cell type. This DNA carrier system introduces DNA specifically into epithelial cells that contain pIgR in vitro.

Effects of dexamethasone on chemotactic activity and inflammatory mediators in tracheobronchial aspirates of preterm infants at risk for chronic lung disease

To evaluate the effects of dexamethasone on pulmonary inflammation and permeability in preterm infants at high risk for chronic lung disease (birth weight < 1200 gm), we assessed tracheobronchial aspirate fluid for chemotactic activity and concentrations of mediators of inflammation. In a prospective study, 21 infants still undergoing mechanical ventilation at day 10 of postnatal age who required a fraction of inspired oxygen > or = 0.3, a peak inspiratory pressure > or = 16 cm H2O, or both were randomly assigned to treatment with dexamethasone at day 10 (early treatment group, n = 10) or day 16 (late treatment group, n = 11). The groups were compared with respect to all measurements on day 15; the late treatment group served as a control group. Additionally, the effects of dexamethasone within both groups were evaluated. In the early treatment group, the chemotactic response of peripheral blood neutrophils exposed to tracheobronchial aspirate fluid was significantly reduced 5 days after initiation of dexamethasone treatment compared with pretreatment values of the late treatment group (median (25th to 75th percentile): migratory distance before dexamethasone, 149 microns (140 to 173 microns); after dexamethasone, 81 microns (68 to 114 microns); p < 0.01). In addition, the following values were decreased after dexamethasone therapy in the early treatment group: number of neutrophils in tracheobronchial aspirate fluid (p < 0.05), and concentrations of leukotriene B4 (p < 0.01), interleukin-1 (p < 0.01), elastase-alpha 1-proteinase inhibitor (p < 0.01), and albumin (p < 0.01). Free elastase activity was found in only two infants; detectable activity of protective alpha 1-proteinase inhibitor was present in the others. Analysis of dexamethasone effects within the groups showed that all measurements were significantly decreased after both the early and the late treatment regimens, with the exception of leukotriene B4 and interleukin-1, which declined only after early dexamethasone treatment. Our results indicate that the pulmonary inflammatory response and microvascular permeability are decreased by dexamethasone, which affects the release of inflammatory mediators and neutrophil influx into the airways of preterm infants who require mechanical ventilation.

Effect of dexamethasone therapy on fibronectin and albumin levels in lung secretions of infants with bronchopulmonary dysplasia

The influence of dexamethasone on levels of total fibronectin (tFn), cellular fibronectin (cFn), plasma fibronectin (pFn), and albumin in lung secretions was determined in tracheal aspirate samples collected from 45 infants with bronchopulmonary dysplasia during a 6-week course of dexamethasone therapy. Secretory component for IgA (SC) was used as a reference protein. Thirty-seven infants (82%) survived and had their endotracheal tubes successfully removed. Corticosteroid therapy was associated with a significant decrease in the cFn/SC ratio. There was also a significant decrease in albumin/SC and pFn/SC ratios, suggesting decreased capillary permeability with corticosteroid therapy. Four of the remaining infants did not improve while receiving corticosteroids and died of respiratory failure at 3 to 8 weeks of age. In these "no response" infants, tFn/SC, cFn/SC, pFn/SC, and albumin/SC ratios when corticosteroid therapy was initiated were threefold to fourfold greater (p < 0.01) than ratios in survivors. Another group of four infants initially responded to corticosteroids but subsequently died with severe pulmonary cystic degeneration at 4 to 6 months of age; in these infants, tracheal aspirate tFn/SC, cFn/SC, and albumin/SC ratios were significantly lower than in survivors and remained unchanged during corticosteroid therapy. The decrease in the concentrations of plasma fibronectin and albumin in tracheal aspirate samples from the survivors suggests that the rapid clinical improvement seen in infants with bronchopulmonary dysplasia after the initiation of dexamethasone therapy is due in part to improvement in the integrity of the alveolar-capillary barrier. In addition, the decrease in the aspirate levels of cFn suggests the potential for corticosteroids to limit pulmonary fibrosis in the surviving infants. The depressed levels of fibronectin observed in the infants with severe cystic lung disease may represent an impaired healing response to lung injury.