Tracheal ligation increases mitogen-activated protein kinase activity and attenuates surfactant protein B mRNA in fetal sheep lungs

Evolution, Development, and Function of the Pulmonary Surfactant System in Normal and Perturbed Environments

Surfactant lipids and proteins form a surface active film at the air-liquid interface of internal gas exchange organs, including swim bladders and lungs. The system is uniquely positioned to meet both the physical challenges associated with a dynamically changing internal air-liquid interface, and the environmental challenges associated with the foreign pathogens and particles to which the internal surface is exposed. Lungs range from simple, transparent, bag-like units to complex, multilobed, compartmentalized structures. Despite this anatomical variability, the surfactant system is remarkably conserved. Here, we discuss the evolutionary origin of the surfactant system, which likely predates lungs. We describe the evolution of surfactant structure and function in invertebrates and vertebrates. We focus on changes in lipid and protein composition and surfactant function from its antiadhesive and innate immune to its alveolar stability and structural integrity functions. We discuss the biochemical, hormonal, autonomic, and mechanical factors that regulate normal surfactant secretion in mature animals. We present an analysis of the ontogeny of surfactant development among the vertebrates and the contribution of different regulatory mechanisms that control this development. We also discuss environmental (oxygen), hormonal and biochemical (glucocorticoids and glucose) and pollutant (maternal smoking, alcohol, and common "recreational" drugs) effects that impact surfactant development. On the adult surfactant system, we focus on environmental variables including temperature, pressure, and hypoxia that have shaped its evolution and we discuss the resultant biochemical, biophysical, and cellular adaptations. Finally, we discuss the effect of major modern gaseous and particulate pollutants on the lung and surfactant system.

Magnetic resonance angiography of fetal vessels: feasibility study in the sheep fetus

PURPOSE

The aim of this study was to perform fetal magnetic resonance angiography (MRA) in utero in a sheep model.

MATERIAL AND METHODS

Images of the great vessels, the heart, and the tracheal tree were performed on four pregnant ewes with a 1.5-T scanner (Philips Medical Systems, Best, The Netherlands). MRA was achieved in utero using a nontriggered free-breathing three-dimensional balanced fast field echo (FFE) technique. All obtained MRA images were evaluated in consensus on a three-point scale by two radiologists with 9 and 4 years of experience in fetal MRI, respectively.

RESULTS

The fetal heart frequencies were between 130 and 160 bpm. The aorta from the aortic bulb to the bifurcation as well as some of the main aortic branches could be depicted. The pulmonary trunk and arteries, the superior and inferior caval veins, and the subsegmental branches of the trachea could also be visualized.

CONCLUSION

The nontriggered MRA of the fetal great vessels with images of the tracheal tree allowed an excellent evaluation of anatomical structures.

Prenatal intervention for congenital diaphragmatic hernia

Advances in prenatal ultrasound have revealed the poor natural history of fetal congenital diaphragmatic hernia (CDH) and its hidden mortality during gestation and immediately after birth. Attempts to improve this poor outcome led to the development of prenatal surgical intervention for severe CDH by Harrison and his colleagues at the University of California San Francisco. Prenatal surgical intervention for CDH has seen four phases: open fetal surgical repair, open surgical tracheal occlusion, endoscopic external tracheal occlusion, and endoscopic endoluminal tracheal occlusion. After extensive work in the laboratory, prenatal intervention has been applied in humans since 1984. With the most recent techniques, maternal risk is significantly reduced as is the incidence of preterm labor. In the meantime, the survival rate of fetuses with CDH without fetal intervention has improved mainly due to the minimization of iatrogenic lung injury by gentle ventilation, first described in 1985. However, the morbidity of the survivors with severe CDH remains high. Prenatal intervention for CDH will be justified if improvement in survival or morbidity can be demonstrated when compared to planned delivery and postnatal management with gentle ventilation strategy.

Role of platelet-derived growth factor-B, vascular endothelial growth factor, insulin-like growth factor-II, mitogen-activated protein kinase and transforming growth factor-beta1 in expansion-induced lung growth in fetal sheep

Increased fetal lung expansion induces lung growth, cell differentiation and extracellular matrix remodelling, although the mechanisms involved are unknown. Platelet-derived growth factor (PDGF)-B, vascular endothelial growth factor (VEGF) and insulin-like growth factor (IGF)-II are mitogens activating the mitogen-activated protein kinase (MAPK) pathway, whereas transforming growth factor (TGF)-beta1 induces differentiation and extracellular matrix remodelling. In the present study, we investigated the mRNA levels of PDGF-B, VEGF, IGF-II and TGF-beta1, as well as active MAPK levels, during increased fetal lung expansion induced by tracheal obstruction (TO) in sheep for 0 (controls), 36 h or 2, 4, or 10 days (n = 5 in each group). The 3.7-kb VEGF transcript increased by 30% (P < 0.05) at 36 h TO. The expression of PDGF-B decreased by approximately 25% (P < 0.01) at 2-10 days TO. In contrast, TGF-beta1 mRNA increased by 96% (P < 0.05) at 10 days TO, when bioactive TGF-beta1 decreased by 55% (P < 0.05). Insulin-like growth factor-II mRNA tended to increase at 10 days TO (37% above controls; P = 0.07), whereas mRNA for its receptor, IGF1R, was reduced by TO. There was no change in active MAPK levels preceding or at the time of a TO-induced 800% increase in cell proliferation. We conclude that VEGF is likely to promote expansion-induced endothelial cell proliferation, but the mechanisms underlying expansion-induced proliferation of fibroblasts and alveolar epithelial cells are unlikely to be mediated by increases in PDGF-B or IGF-II expression or activation of the MAPK pathway.

Congenital diaphragmatic hernia: searching for answers

BACKGROUND

Pulmonary hypoplasia and hypertension are the primary causes of morbidity and mortality in infants with congenital diaphragmatic hernia (CDH). At present, the origin of CDH and the causes of pulmonary hypoplasia and hypertension are unknown.

DATA SOURCES

This article reviews the available published data regarding the origin of CDH and the pathogenesis of the associated pulmonary hypertension and hypoplasia. These investigations have employed human tissues as well as two types of CDH animal models.

CONCLUSIONS

Investigations performed to date have not yet provided definitive answers regarding the pathogenesis of CDH. However, they have yielded many new and exciting discoveries and several opportunities for intervention. Ongoing research should open new possibilities to improve the outcome for these unfortunate babies with CDH.

Fetal Sheep with Tracheal Occlusion: Monitoring Lung Development with MR Imaging and B-Mode US

PURPOSE

To assess the accuracy of magnetic resonance (MR) imaging in determining fetal lung volume (FLV) and to observe fetal lung development with B-mode ultrasonography (US) and MR imaging.

MATERIALS AND METHODS

Seven sheep fetuses between 92 and 141 gestational days (term, 145 days) with and without tracheal occlusion (controls) underwent serial MR imaging and US. FLV at MR imaging was measured with true fast imaging with steady-state precession in coronal and transverse planes. The combined cross-sectional left- and right-lung area was measured with US at three transverse levels. FLV was measured at autopsy. Statistical evaluations included linear regression analysis and calculation of the mean and 95% CI.

RESULTS

No differences in FLV were observed on coronal or transverse MR images (r2 = 0.98; slope = 0.91; 95% CI: 0.82, 1.01). FLV at MR imaging at termination of the experiment was significantly related to FLV at autopsy (r2 = 0.96; slope = 1.27; 95% CI: 0.97, 1.57; n = 6). FLV at MR imaging increased more rapidly with gestational age in fetuses with tracheal occlusion (21.0 mL/d; 95% CI: 10.7, 31.3) than in controls (4.7 mL/d; 95% CI: 1.7, 7.7). Increase in left- and right-lung area at US was accelerated in fetuses with tracheal occlusion (1.60 cm2/d; 95% CI: 1.3, 1.9) compared with controls (0.38 cm2/d; 95% CI: 0.23, 0.53). Left- and right-lung area at US and FLV at MR imaging were significantly correlated (r2 = 0.82).

CONCLUSION

FLV can be measured with moderate accuracy at MR imaging on both coronal and transverse images. MR imaging and B-mode US are useful tools for monitoring and quantifying tracheal occlusion-stimulated fetal lung growth in sheep fetuses.

Congenital diaphragmatic hernia

Congenital diaphragmatic hernia occurs in approximately 1 in every 2500 live births and is associated with a reported mortality of almost 35% in live-born patients and a higher mortality when in utero deaths are counted. Ventilator-induced lung injury, pulmonary hypoplasia, and other associated anomalies account for the high death rate. Numerous adjunctive measures have been used to treat these patients. Inhaled vasodilators (nitric oxide), intravenous vasodilators, and fetal therapy have no proven benefit. While animal models of congenital diaphragmatic hernia are surfactant deficient, controversy remains over the use of surfactant in infants. There has been no clinical trial showing any clear benefit with the use of exogenous surfactant in these patients. Similarly, prenatal corticosteroids show some improvements in animal models, but again, there is a complete absence of supportive data to show benefit in humans. Mechanical ventilator strategies that limit ventilator-induced lung injury by avoiding hyperventilation and lung over inflation are the strategies currently in use that have been associated with improved survival. Long-term follow-up of these patients is quite important since gastroesophageal reflux, developmental delay, chronic lung disease, and chest wall deformity are all seen with increased frequency in these children.

Fetal lung growth after short-term tracheal occlusion is linearly related to intratracheal pressure

Prenatal tracheal occlusion (TO) has been shown to accelerate fetal lung growth, yet the mechanism is poorly understood. The goal of this study was to determine the relationship between fetal intratracheal pressure (Pitr) and fetal lung growth after TO. Fetal lambs underwent placement of an intratracheal catheter and a reference catheter at 115--120 days gestation (term, 145 days). Fetal Pitr was continuously controlled at three levels (high, 8 mmHg; moderate, 4 mmHg; low, 1 mmHg) by a servo-regulated pump. The animals were killed after 4 days, and the parameters of lung growth were compared. Lung volume (136.0 +/- 16.7, 94.9 +/- 9.7, 55.5 +/- 12.4 ml/kg), lung-to-body weight ratio (6.31 +/- 0.70, 4.89 +/- 0.38, 3.39 +/- 0.22%), whole right lung dry weight (3.01 +/- 0.29, 2.53 +/- 0.15, 2.07 +/- 0.24 g/kg), right lung DNA (130.0 +/- 11.3, 116.7 +/- 8.6, 97.5 +/- 10.9 mg/kg), and protein contents (1,865.5 +/- 92.5, 1,657.6 +/- 106.8, 1,312.0 +/- 142.5 mg/kg) in high, moderate, and low groups, respectively, all increased in the moderate compared with the low group and increased further in the high compared with the moderate group. Morphometry confirmed a stepwise increase in the volume of respiratory region and alveolar surface area. We conclude that lung growth in the first 4 days after TO is closely correlated with fetal Pitr, offering additional evidence that an increase in lung expansion is one of the major factors responsible for TO-induced lung growth.

Effect of lung fluid composition on type II cellular activity after tracheal occlusion in the fetal lamb

BACKGROUND/PURPOSE

Fetal tracheal occlusion (TO) causes accelerated lung growth. However, prolonged TO is associated with a decline in the type II cell number. Type II cell function after TO is unclear. Herein, the authors examine type II cell function after TO and the role of tracheal fluid.

METHODS

Fetal lambs (term, 145 days) underwent TO at 122 days. Tracheal pressure was recorded daily. In one group of animals (TF; n = 6), lung fluid was aspirated, measured, and reinfused daily. In their respective twins, NS group, lung fluid was replaced milliliter per milliliter with normal saline (NS; n = 6). At death near term, lung weight was obtained, and tissues were processed for stereologic volumetry. Type II cells were quantitated using antisurfactant protein B immunohistochemistry. Surfactant protein B-mRNA expression was studied by Northern analysis. Wilcoxon signed rank test and single factor analysis of variance (ANOVA) were used for statistical analysis (P<.05 was significant).

RESULTS

In both experimental groups, intratracheal pressure rose from 1.9+/-1.0 torr to 3.7 to 4.8 torr by day 1, and remained constant thereafter. Lung fluid volume increased from 11.9+/-4.2 on day 0 to 36.8+/-8.0 mL/kg in TF, and to 28.4+/-9.3 mL/kg in NS by day 1 (P<.05). At death, lung weight/body weight ratio was higher in TF (5.45% +/- 0.91%) than in NS (4.40% +/- 0. 67%) or control (3.83%+/-0.58%; P<.05). Type II numerical density was substantially reduced after TO: 57.7+/-12.8 x 10(6)/mL (TF) and 45.0 +/-25.9 x 10(6)/mL (NS), versus 82.3+/-13.6 x 10(6)/mL in controls. Ultrastructurally, remaining type II cells in TF were enlarged and engorged with lamellar bodies; in NS, they were smaller and contained fewer lamellar bodies. Surfactant protein B mRNA expression was significantly decreased in NS, but not in TF, compared with controls.

CONCLUSIONS

Type II cell function as well as overall lung growth are stimulated by TO. Lung growth after TO is therefore not unavoidably detrimental to type II cells. After isobaric saline exchange of lung fluid, type II cell function is severely inhibited, confirming the role of tracheal fluid composition in type II stimulating type II cell function.

Requirements for fetal surgery: the diaphragmatic hernia model

Fetal surgery for congenital diaphragmatic hernia and other fetal conditions can only be considered if (1) the morbidity of antenatal intervention is acceptable, (2) the diagnosis of the condition can be made accurately, (3) the condition can be differentiated from other, non-surgical anomalies. In addition, (4) the natural evolution of the disease, if left untreated, should be predictable, and the condition should be lethal or severely debilitating, (5) there should not exist adequate postnatal treatment, and (6) the proposed in utero operation should be technically feasible. Open fetal surgery has proven too invasive to be justified for the treatment of diaphragmatic hernia, and progress in postnatal therapy (including ECMO) has dramatically improved the neonatal outcome in all but a severe subgroup of patients. Recently, advances in endoscopic fetal surgery (which appears to be less stressful for the fetus and the gravid uterus) and a new approach to accelerate fetal lung growth and maturation have renewed the feasibility of in utero intervention for diaphragmatic hernia.

In vitro effects of growth factors on lung hypoplasia in a model of congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Pulmonary hypoplasia, a leading contributor to the lethality of congenital diaphragmatic hernia (CDH), precedes diaphragmatic malformation in the nitrofen model and persists to allow experimental manipulations in organ culture. Fibroblast growth factors (FGFs) are crucial to early lung development. Acidic FGF (FGF-1) binds to all FGF receptors and enhances in vitro branching morphogenesis. Basic FGF (FGF-2) is localized to developing airway epithelium, basement membrane, and extracellular matrix. Heparin (HEP) modulates FGF kinetics and inhibits smooth muscle proliferation in lung primordia. The aim of this study was to examine the morphological effects of fibroblast growth factors and heparin on lung hypoplasia in an organ culture model.

METHODS

Sprague-Dawley rats were fed nitrofen on day 9.5 of pregnancy to induce lung hypoplasia and CDH in newborns. Control rats received olive oil. Normal and hypoplastic lung primordia were microdissected on day 13.5 of gestation and cultured up to 78 hours in plain media with or without FGF-1 or FGF-2, with or without HEP. In vitro morphological development was studied by serial measurements of terminal bud count, lung area, and lung perimeter.

RESULTS

Over 120 fetal lung specimens were studied (n > or = 4 per group). Significant increases in area, perimeter, and bud count were seen in normal lungs cultured with FGF-1 plus HEP compared with control media (P < .05). In the nitrofen lungs, FGF1 plus HEP yielded reductions in all parameters compared with those in control media (P < .05), whereas FGF-2 produced significant expansion in lung area but marked reductions in bud count and lung perimeter divided by square root of area (P < .05). Heparin did not produce substantial or sustained alteration of morphology in normal or hypoplastic lungs.

CONCLUSIONS

These observations may indicate an intrinsic abnormality of FGF processing in the hypoplastic nitrofen lung before diaphragmatic malformation. Heparin did not rescue abnormal lung development. Mechanisms underlying the differential effects of these agents now need to be explored to target fetal lung growth and improve the dismal prognosis of human CDH.