Activity of pulmonary surfactant after blocking the associated proteins SP-A and SP-B

Pulmonary Surfactant Proteins Are Inhibited by Immunoglobulin A Autoantibodies in Severe COVID-19

Rationale: Coronavirus disease 2019 (COVID-19) can lead to acute respiratory distress syndrome with fatal outcomes. Evidence suggests that dysregulated immune responses, including autoimmunity, are key pathogenic factors. Objectives: To assess whether IgA autoantibodies target lung-specific proteins and contribute to disease severity. Methods: We collected 147 blood, 9 lung tissue, and 36 BAL fluid samples from three tertiary hospitals in Switzerland and one in Germany. Severe COVID-19 was defined by the need to administer oxygen. We investigated the presence of IgA autoantibodies and their effects on pulmonary surfactant in COVID-19 using the following methods: immunofluorescence on tissue samples, immunoprecipitations followed by mass spectrometry on BAL fluid samples, enzyme-linked immunosorbent assays on blood samples, and surface tension measurements with medical surfactant. Measurements and Main Results: IgA autoantibodies targeting pulmonary surfactant proteins B and C were elevated in patients with severe COVID-19 but not in patients with influenza or bacterial pneumonia. Notably, pulmonary surfactant failed to reduce surface tension after incubation with either plasma or purified IgA from patients with severe COVID-19. Conclusions: Our data suggest that patients with severe COVID-19 harbor IgA autoantibodies against pulmonary surfactant proteins B and C and that these autoantibodies block the function of lung surfactant, potentially contributing to alveolar collapse and poor oxygenation.

Protein modeling and molecular dynamics simulation of the two novel surfactant proteins SP-G and SP-H

Surfactant proteins are well known from the human lung where they are responsible for the stability and flexibility of the pulmonary surfactant system. They are able to influence the surface tension of the gas–liquid interface specifically by directly interacting with single lipids. This work describes the generation of reliable protein structure models to support the experimental characterization of two novel putative surfactant proteins called SP-G and SP-H. The obtained protein models were complemented by predicted posttranslational modifications and placed in a lipid model system mimicking the pulmonary surface. Molecular dynamics simulations of these protein-lipid systems showed the stability of the protein models and the formation of interactions between protein surface and lipid head groups on an atomic scale. Thereby, interaction interface and strength seem to be dependent on orientation and posttranslational modification of the protein. The here presented modeling was fundamental for experimental localization studies and the simulations showed that SP-G and SP-H are theoretically able to interact with lipid systems and thus are members of the surfactant protein family.

Staphylococcus aureus and Pseudomonas aeruginosa express and secrete human surfactant proteins

Surfactant proteins (SP), originally known from human lung surfactant, are essential to proper respiratory function in that they lower the surface tension of the alveoli. They are also important components of the innate immune system. The functional significance of these proteins is currently reflected by a very large and growing number of publications. The objective goal of this study was to elucidate whether Staphylococcus aureus and Pseudomonas aeruginosa is able to express surfactant proteins. 10 different strains of S. aureus and P. aeruginosa were analyzed by means of RT-PCR, Western blot analysis, ELISA, immunofluorescence microscopy and immunoelectron microscopy. The unexpected and surprising finding revealed in this study is that different strains of S. aureus and P. aeruginosa express and secrete proteins that react with currently commercially available antibodies to known human surfactant proteins. Our results strongly suggest that the bacteria are either able to express ‘human-like’ surfactant proteins on their own or that commercially available primers and antibodies to human surfactant proteins detect identical bacterial proteins and genes. The results may reflect the existence of a new group of bacterial surfactant proteins and DNA currently lacking in the relevant sequence and structure databases. At any rate, our knowledge of human surfactant proteins obtained from immunological and molecular biological studies may have been falsified by the presence of bacterial proteins and DNA and therefore requires critical reassessment.

Site of allergic airway narrowing and the influence of exogenous surfactant in the Brown Norway rat

Background

The parameters R_N (Newtonian resistance), G (tissue damping), and H (tissue elastance) of the constant phase model of respiratory mechanics provide information concerning the site of altered mechanical properties of the lung. The aims of this study were to compare the site of allergic airway narrowing implied from respiratory mechanics to a direct assessment by morphometry and to evaluate the effects of exogenous surfactant administration on the site and magnitude of airway narrowing.

Methods

We induced airway narrowing by ovalbumin sensitization and challenge and we tested the effects of a natural surfactant lacking surfactant proteins A and D (Infasurf®) on airway responses. Sensitized, mechanically ventilated Brown Norway rats underwent an aerosol challenge with 5% ovalbumin or vehicle. Other animals received nebulized surfactant prior to challenge. Three or 20 minutes after ovalbumin challenge, airway luminal areas were assessed on snap-frozen lungs by morphometry.

Results

At 3 minutes, R_N and G detected large airway narrowing whereas at 20 minutes G and H detected small airway narrowing. Surfactant inhibited R_N at the peak of the early allergic response and ovalbumin-induced increase in bronchoalveolar lavage fluid cysteinyl leukotrienes and amphiregulin but not IgE-induced mast cell activation in vitro.

Conclusion

Allergen challenge triggers the rapid onset of large airway narrowing, detected by R_N and G, and subsequent peripheral airway narrowing detected by G and H. Surfactant inhibits airway narrowing and reduces mast cell-derived mediators.

Detection and localization of the hydrophobic surfactant proteins B and C in human tear fluid and the human lacrimal system

PURPOSE

To evaluate the expression and presence of the surfactant proteins (SP) B and C in the lacrimal apparatus at the ocular surface and in tear fluid.

METHODS

Expression of SP-B and SP-C was analyzed by RT-PCR in healthy lacrimal gland, conjunctiva, meibomian gland, accessory lacrimal glands, cornea, and nasolacrimal ducts. The deposition of the hydrophobic proteins SP-B and SP-C was determined by Western blot and immunohistochemistry in healthy tissues, tear fluid, and aqueous humor.

RESULTS

The presence of both SP-B and SP-C on mRNA and protein level was evidenced in healthy human lacrimal gland, conjunctiva, cornea, and nasolacrimal ducts. Moreover, both proteins were present in tear fluid but were absent in aqueous humor. Immunohistochemical investigations revealed production of both peptides by acinar epithelial cells of the lacrimal gland and additionally by accessory lacrimal glands of the eyelid as well as epithelial cells of the conjunctiva and nasolacrimal ducts. Immunohistochemically, healthy cornea and goblet cells revealed no reactivity.

CONCLUSIONS

Besides the recently detected surfactant-associated proteins SP-A and SP-D, our results show that SP-B and SP-C are also peptides of the tear film, the ocular surface, and the lacrimal apparatus. Based on the current knowledge of lowering surface tension in alveolar lung cells, a similar effect of SP-B and SP-C may be assumed concerning the tear film.

Long-term outcomes after infant lung transplantation for surfactant protein B deficiency related to other causes of respiratory failure

OBJECTIVE

To determine if the outcomes of lung transplantation for infants with surfactant protein-B (SP-B) deficiency are unique.

STUDY DESIGN

From a prospective analysis to identify infants with genetic causes of surfactant deficiency, we identified 33 SP-B-deficient infants from 1993 to 2005, and, among those undergoing lung transplantation (n = 13), compared their survival, pulmonary function, and developmental progress with infants who underwent transplantation at <1 year of age for parenchymal lung disease (n = 13) or pulmonary vascular disease (n = 11).

RESULTS

Five-year survival rates ( approximately 50%, P = .3) and causes of death were similar for all three groups once the infants underwent transplantation. However, significant pretransplantation mortality decreased 5-year survival from listing to approximately 30% (P = .17). Pulmonary function, development of bronchiolitis obliterans, and school readiness were similar among the three groups. We detected anti SP-B antibody in serum of 3 of 7 SP-B-deficient infants and none of 7 SP-B-sufficient infants but could not identify any associated adverse outcomes.

CONCLUSIONS

Long-term outcomes after infant lung transplantation for SP-B-deficient infants are similar to those of infants transplanted for other indications. These outcomes are important considerations in deciding to pursue lung transplantation for infants with disorders of alveolar homeostasis.

In vitro and in vivo intrapulmonary distribution of fluorescently labeled surfactant

OBJECTIVE

To determine the distribution of endotracheally administered surfactant at the alveolar level in an animal model of acute respiratory distress syndrome.

DESIGN

Prospective, randomized animal study.

SETTING

Research laboratory of a university hospital.

SUBJECTS

Seventy-one male Sprague-Dawley rats, weighing 330-370 g.

INTERVENTIONS

To measure surfactant distribution in vitro, a glass trough mimicking dichotomic lung anatomy was used to determine the spreading properties of bovine lung surfactant extract supplemented with fluorescent Bodipy-labeled surfactant protein B. To measure surfactant distribution in vivo, rats were anesthetized, and lipopolysaccharide was aerosolized (12 mg/kg body weight) to induce lung injury resembling acute respiratory distress syndrome; in control rats, buffered saline was aerosolized. Twenty-four hours later rats were anesthetized, tracheotomized, and mechanically ventilated (peak airway pressure = 20 mbar; positive end-expiratory pressure = 6 mbar; inspiration time = expiration time = 0.6 sec; Fio2 = 50%). Surfactant (bovine lung surfactant extract, supplemented with fluorescent Bodipy-labeled surfactant protein B; 50 mg/kg body weight) was applied as a bolus; in control rats, saline was administered as a bolus. Rats were ventilated for 5, 15, 30, or 60 mins (n = 8 or 9 for each group). Then, lungs were excised and sliced. Lung slices, divided into aerated (open), underinflated (dystelectatic), or collapsed (atelectatic) alveolar areas, were examined by both light and fluorescence microscopy.

RESULTS

In vitro experiments revealed that surfactant spread independent of glass trough geometry and lowered the surface tension to equilibrium values (25 mN/m) within a few seconds. In vivo experiments showed that administered surfactant distributed preferentially into underinflated and aerated alveolar areas. Furthermore, surfactant distribution was not affected by length of mechanical ventilation.

CONCLUSIONS

When conventional mechanical ventilation was used in lipopolysaccharide-induced lung injury, surfactant preferentially distributed into underinflated and aerated alveolar areas. Because surfactant rarely reached collapsed alveolar areas, methods aiding in alveolar recruitment (e.g., open lung concept or body positioning) should precede surfactant administration.

Effect of surfactant and specific antibody on bacterial proliferation and lung function in experimental pneumococcal pneumonia

OBJECTIVE

To investigate the effect of surfactant and specific antibody on bacterial proliferation in experimental pneumococcal pneumonia.

METHODS

Near-term newborn rabbits received a standard dose (10(7)) of type 3 pneumococci via the airways. Control animals were sacrificed 1 minute later. Other animals were ventilated for 5 hours and treated via the tracheal cannula with surfactant (Curosurf 200 mg/kg), a mixture of surfactant and a polyclonal antipneumococcal antibody, the antibody without surfactant, or saline.

RESULTS

There was a significant bacterial proliferation in lung tissue in all animals ventilated for 5 hours. Bacterial growth, expressed as log10 colony forming units (CFU) per gram of lung tissue was less prominent in animals treated with a mixture of surfactant and specific antibody than in animals treated with antibody alone (median, 7.51, range, 6.80--7.70 vs. median, 7.92, range, 7.07--8.50; P < 0.05). Dynamic lung-thorax compliance was improved with surfactant or surfactant plus antibody in comparison with saline or antibody alone.

CONCLUSIONS

The data suggest that the suppressive effect of the antibody on bacterial proliferation becomes evident only when surfactant is administered together with the antibody.

Membrane activity of (Cys48Ser) lung surfactant protein B increases with dimerisation

One of the possible functions of lung surfactant protein B (SP-B), an hydrophobic membrane-associated saposin-like protein, is to reduce the alveolar surface tension by promoting insertion of phospholipids into the air/liquid interface of the lung. SP-B is a covalent homodimer; Cys48 of two polypeptides form an intermolecular disulphide bond. In order to test whether dimerisation of SP-B is important for surfactant function, transgenic mice which express (Cys48Ser) human SP-B in a mouse SP-B null background were generated. In previous studies (Cys48Ser)SP-B showed a concentration-dependent in vitro activity, suggesting that it may form non-covalent dimers. Here (Cys48Ser)SP-B isolated from bronchoalveolar lavage of transgenic mice was studied at different concentrations by circular dichroism (CD) spectroscopy, pulsating bubble surfactometry, mass spectrometry and reversed-phase HPLC. The results indicate that (Cys48Ser)SP-B, both in a phospholipid environment and in organic solvents, is largely monomeric and exhibits low activity at concentrations lower than 1 -2 microM, while at higher concentrations it forms non-covalent dimers, which are nearly functionally equivalent to native SP-B in vitro. Furthermore, electrospray mass spectrometry showed that more dimers were found relative to the monomer when the polarity of the solvent was decreased, and when the concentration of SP-B increased. (Cys48Ser)SP-B also eluted earlier than native SP-B in reversed-phase HPLC. Taken together, these results indicate that a polar surface is buried upon dimerisation, thereby promoting formation of interchain ion pairs between Glu51-Arg52' and Glu51'-Arg52.

Functional Tests for the Characterization of Surfactant Protein B (SP-B) and a Fluorescent SP-B Analog

Surfactant protein B (SP-B) enhances lipid insertion into the alveolar air/liquid interface upon inhalation. The aim of this study was (i) to apply a palette of tests for a detailed biochemical and biophysical characterization of SP-B and (ii) to use these tests to compare native SP-B with a fluorescent (Bodipy) SP-B analog. The method of labeling was fast and resulted in a covalent fluorophore-protein bond. The ability of both proteins to spread a surfactant film on top of a buffer surface was determined in a spreading tray using the Wilhelmy plate technique to allow detection of alterations in surface tension and calculation of spreading velocities. In a captive bubble surfactometer surface tensions of spread films were measured. Similar biophysical properties were found for both native and Bodipy-labeled SP-B. It is concluded that the combination of tests used allows detection of small differences in structure and activity between the two proteins.

Bronchopulmonary segmental lavage with Surfaxin (KL(4)-surfactant) for acute respiratory distress syndrome

We performed a trial to assess the safety and tolerability of sequential bronchopulmonary segmental lavage with a dilute synthetic surfactant (Surfaxin) in 12 adults with ARDS. Patients received one of three dosing regimens in which aliquots of Surfaxin were administered via a wedged bronchoscope to each of the 19 bronchopulmonary segments. Suctioning was performed 10-30 s after instillation of individual aliquots. Group 1 patients (n = 3) received one 30-ml aliquot of a 2.5-mg/ml concentration of Surfaxin in each segment, followed by a second 30-ml aliquot with a 10-mg/ml concentration. Group 2 patients (n = 4) received two 30-ml aliquots of the 2.5-mg/ml concentration followed by a third lavage with the 10-mg/ml concentration. Group 3 patients (n = 5) received therapy identical to that received by patients in Group 2 and were eligible for repeat dosing 6 to 24 h later. All patients tolerated the procedure. There were no serious adverse experiences ascribed to either the procedure or the surfactant. In the 96 h after treatment initiation, FI(O(2)) decreased from 0.80 to 0.52 and PEEP decreased from 10.3 to 7.6 cm H(2)O. Bronchoscopic "cleansing" of the lungs with dilute Surfaxin may offer a safe and feasible approach to improving outcomes in patients with ARDS. Wiswell TE, Smith RM, Katz LB, Mastroianni L, Wong DY, Willms D, Heard S, Wilson M, Hite RD, Anzueto A, Revak SD, Cochrane CG. Bronchopulmonary segmental lavage with Surfaxin (KL(4)-surfactant) for acute respiratory distress syndrome.

Phagocyte-induced lipid peroxidation of lung surfactant

Surfactant therapy is given routinely to premature newborns with respiratory failure. However, alterations in surfactants have been shown to be a significant factor in some forms of respiratory failure in newborns in animal models of lung injury. To investigate whether antioxidant supplementation might help to protect exogenous surfactant from damage by oxygen free radicals, we examined the influence of vitamin E in combination with surfactant on superoxide production as estimated by the nitroblue tetrazolium reduction test, and measured surfactant peroxidation with a new colorimetric method with or without addition of superoxide dismutase (SOD) or vitamin E. Our results showed that surfactant interacts with free radicals; surfactant reduced superoxide production by neutrophils and was peroxidized when incubated with resting and with stimulated cells. Vitamin E supplementation decreased superoxide radical production and in a dose-dependent manner decreased surfactant peroxidation. The decrease in lipid peroxidation by SOD was not significant. These findings suggest that phagocytes induce lipid peroxidation of lung surfactant, a reaction that might be prevented by antioxidants.

Principles of surfactant replacement

Surfactant therapy is an established part of routine clinical management of babies with respiratory distress syndrome. An initial dose of about 100 mg/kg is usually needed to compensate for the well documented deficiency of alveolar surfactant in these babies, and repeated treatment is required in many cases. Recent experimental and clinical data indicate that large doses of exogenous surfactant may be beneficial also in conditions characterized by inactivation of surfactant, caused by, for example, aspiration of meconium, infection, or disturbed alveolar permeability with leakage of plasma proteins into the airspaces. The acute response to surfactant therapy depends on the quality of the exogenous material (modified natural surfactants are generally more effective than protein-free synthetic surfactants), timing of treatment in relation to the clinical course (treatment at an early stage of the disease is better than late treatment, and may reduce the subsequent need for mechanical ventilation), and mode of delivery (rapid instillation via a tracheal tube leads to more uniform distribution and is more effective than slow airway infusion). Treatment with aerosolized surfactant improves lung function in animal models of surfactant deficiency or depletion, but is usually associated with large losses of the nebulized material in the delivery system. Furthermore, data from experiments on immature newborn lambs indicate that treatment response may depend on the mode of resuscitation at birth, and that manual ventilation with just a few large breaths may compromise the effect of subsequent surfactant therapy. The widespread clinical use of surfactant has reduced neonatal mortality and lowered costs for intensive care in developed countries. The hydrophobic surfactant proteins SP-B and SP-C are probably essential for optimal biophysical and physiological activity of exogenous surfactants isolated from mammalian lungs, and the dose-effectiveness (in part reflecting resistance to inactivation) can be further improved by enrichment with SP-A. The development of new artificial surfactant substitutes, based on synthetic analogues of the native surfactant proteins, is an important challenge for future research.

Genetics of the hydrophobic surfactant proteins

The hydrophobic surfactant proteins, SP-B and SP-C, serve important roles in surfactant function and metabolism. Both proteins are encoded by single genes, located on human chromosomes 2 and 8 respectively, which have been characterized and extensively studied. Mutations in the SP-B gene have been shown to cause severe lung disease, and polymorphisms in the SP-B gene may be associated with the development of RDS in premature infants. In contrast, mutations in the SP-C gene have not yet been identified or shown to cause lung disease, although given the apparent importance of SP-C in surfactant function, this remains a possibility.

Regulation and function of pulmonary surfactant protein B

Pulmonary surfactant, a complex mixture of phospholipids and specific associated proteins, reduces the surface tension at the air-liquid interface of the distal conducting airways and gas exchanging alveoli of the lung. Lipids, primarily neutral and phospholipids, compose approximately 90% of the surfactant complex. The remaining 10% of surfactant is composed of at least three surfactant-specific proteins, designated surfactant protein A (SP-A), SP-B, and SP-C. These proteins contribute to the formation, stabilization, and function of organized surfactant structures. This article briefly reviews the normal composition and function of pulmonary surfactant and specifically reviews the structure, function, and regulation of surfactant protein B (SP-B). The recent identification of neonates with refractory respiratory failure due to a genetic absence of SP-B and the study of transgenic mice in which SP-B gene expression has been ablated highlight the importance of the protein to surfactant function, synthesis, and metabolism and to the maintenance of lung function. Gene reconstitution experiments in vitro and in SP-B-deficient transgenic mice suggest specific functions for the amino and carboxyl terminal domains of the protein. SP-B deficiency is a potential target for gene therapy in human patients.

An SP-B gene mutation responsible for SP-B deficiency in fatal congenital alveolar proteinosis: evidence for a mutation hotspot in exon 4

Mutations and polymorphisms within the human SP-B locus have been linked to fatal congenital alveolar proteinosis (CAP) and associated with respiratory distress syndrome (RDS), respectively. In the present study we used PCR and direct sequence analysis of the SP-B gene of three individuals from a family with CAP to search for additional SP-B mutations resulting in CAP and/or polymorphisms that could be used as markers in association studies of RDS and/or CAP. We found three novel mutations/polymorphisms in this family. One is a C/A substitution at nt 1013 at the splice junction of intron 2-exon 3. A second one is a single base T deletion at nt 1553 in exon 4. The single base (T) deletion at nucleotide 1553 (1553delT) shifts the reading frame at amino acid 122(122delT) and creates a premature termination codon at amino acid 214 in exon 6. The mutated gene produces no mature SP-B protein. Genotype analysis from the nuclear family carrying this mutation showed that both parents and three of the four living children are heterozygous for the mutation. One of the four living children is homozygous for the normal allele and a child that died in the perinatal period from CAP is homozygous for the mutation. A third change is a C/T substitution at nt 1580 in exon 4 that changes amino acid 131 from threonine to isoleucine (Thr131Ile). The location of a previously reported mutation, 121ins2 (1), is only 4 nt upstream of 122delT, and the missense mutation Thr131Ile (exon 4) is only 27 nt downstream of 122delT. These changes are within or in close proximity to a CCTG sequence and a poly(C) tract, both of which are shown in other systems to be mutation hotspots. The 122delT occurs within the CCTG and the poly(C) tract sequences, the Thr131Ile occurs 26 nt downstream from the CCTG sequence, and the 121ins2 occurs 2 nt upstream from CCTG sequence and within the poly(C) tract. The present observations suggest that the short SP-B sequence containing the CCTG motif and the poly(C) tract is a mutation hotspot.

Surfactant proteins: molecular genetics of neonatal pulmonary diseases

Genetic and phenotypic complexity has been described for diseases of varied etiology. Groups of patients with varied phenotype can be used in association studies as an initial approach to identify contributing loci. Although association studies have limitations, their value is enhanced by using candidate genes with functions related to disease. Surfactant proteins have been studied in the etiopathogenesis of neonatal pulmonary diseases. SP-A and SP-B polymorphisms are found at a higher frequency in certain groups of patients with respiratory distress syndrome (RDS), and SP-B mutations are linked to the pathogenesis of congenital alveolar proteinosis (CAP). Phenotypic heterogeneity is observed for both CAP and RDS. The available data suggest that a number of factors contribute to the etiology of CAP and RDS and, therefore, a multidisciplinary approach of clinical, genetic, epidemiologic, and statistical considerations is necessary for an in-depth understanding of the pathophysiology of these and other pulmonary diseases.

Regulation of surfactant proteins A and B by TNF-alpha and phorbol ester independent of NF-kappa B

Acute lung inflammation is complicated by altered pulmonary surfactant phospholipid and protein composition. The proinflammatory cytokine tumor necrosis factor-alpha (TNF-alpha) and the phorbol ester 12-O-tetradecanoyl phorbol-13-acetate (TPA) inhibit expression of surfactant-associated proteins A and B (SP-A and SP-B), both important for normal surfactant function. The transcription factor nuclear factor-kappa B (NF-kappa B) frequently mediates regulation of gene expression by TPA and TNF-alpha. In the present study, electrophoretic mobility shift assays (EM-SAs) and pyrrolidine dithiocarbamate (PDTC), an inhibitor of NF-kappa B activation, were utilized to determine the role of NF-kappa B activation in TPA and TNF-alpha inhibition of the surfactant proteins in NCI-H441 cells. Pentoxifylline (PTX), which inhibits TNF-alpha cellular effects without preventing NF-kappa B activation, was also tested. By EMSA, TPA and TNF-alpha increased nuclear NF-kappa B binding activity in temporally distinct patterns. PDTC decreased TPA- and TNF-alpha-induced NF-kappa B binding activity but did not limit their inhibition of SP-A and SP-B mRNAs. PDTC independently decreased both SP-A and SP-B mRNAs. PTX partially reversed TNF-alpha-but not TPA-mediated inhibition of SP-A and SP-B mRNAs without altering NF-kappa B binding. The effects of PDTC and PTX on NF-kappa B and the surfactant proteins suggest that NF-kappa B activation does not mediate TPA or TNF-alpha inhibition of SP-A and SP-B mRNA accumulation.

Effects of surfactant proteins SP-B and SP-C on dynamic and static mechanics of immature lungs

To investigate the effects of surfactant proteins B (SP-B) and C (SP-C) on lung mechanics, we compared tidal and static lung volumes of immature rabbits anesthetized with pentobarbital sodium and given reconstituted test surfactants (RTS). With a series of RTS having various SP-B concentrations (0-0.7%) but a fixed SP-C concentration (1.4%), both the tidal volume with 25-cmH2O insufflation pressure and the static volume deflated to 5-cmH2O airway pressure increased, significantly correlating with the SP-B concentration: the former increased from 6.5 to 26.0 ml/kg (mean), and the latter increased from 6.4 to 31.8 ml/kg. With another series of RTS having a fixed SP-B concentration (0.7%) but various SP-C concentrations (0-1.4%), the tidal volume increased from 5.1 to 24.8 ml/kg, significantly correlating with the SP-C concentration, whereas the static volume increased from 3.4 to 32.0 ml/kg, the ceiling value, in the presence of a minimal concentration of SP-C (0. 18%). In conclusion, certain doses of SP-B and SP-C were indispensable for optimizing dynamic lung mechanics; the static mechanics, however, required significantly less SP-C.

Pathophysiology of neonatal lung injury induced by monoclonal antibody to surfactant protein B

Near-term newborn rabbits were exposed via the airways to a monoclonal antibody to surfactant protein B and ventilated for 0-120 min. Control animals received nonspecific rabbit or mouse immunoglobulin G, saline, or no material via the airways. Administration of the antibody at > or = 40 mg/kg elicited an immediate, significant fall in lung-thorax compliance associated with progressive intra-alveolar edema and/or alveolar collapse and necrosis and desquamation of airway epithelium, and hyaline membranes. The vascular-to-alveolar leak of human albumin and human immunoglobulin G, injected intravenously at birth and determined in lung lavage fluid 60-120 min after instillation of the antibody, was 1.8% for the left lung, with no difference between the markers. The average leak in control animals ventilated for 120 min was < 0.3% (P < 0.05). Cytospin preparations of lung lavage fluid from animals exposed to the antibody showed significantly increased recruitment of neutrophilic granulocytes. The pathology and pathophysiology of neonatal lung injury induced by the monoclonal antibody to surfactant protein B probably reflect a combination of direct inactivation of surfactant and an inflammatory response triggered by the immune reaction.

Molecular structures and interactions of pulmonary surfactant components

The dominating functional property of pulmonary surfactant is to reduce the surface tension at the alveolar air/liquid interface, and thereby prevent the lungs from collapsing at the end of expiration. In addition, the system exhibits host-defense properties. Insufficient amounts of pulmonary surfactant in premature infants causes respiratory distress syndrome, a serious threat which nowadays can be effectively treated by airway instillation of surfactant preparations. Surfactant is a mixture of many molecular species, mainly phospholipids and specific proteins, surfactant protein A (SP-A), SP-B, SP-C and SP-D. SP-A and SP-D are water-soluble and belong to the collectins, a family of large multimeric proteins which structurally exhibit collagenous/lectin hybrid properties and functionally are Ca2+-dependent carbohydrate binding proteins involved in innate host-defence functions. SP-A and SP-D also bind lipids and SP-A is involved in organization of alveolar surfactant phospholipids. SP-B belongs to another family of proteins, which includes also lipid-interacting polypeptides with antibacterial and lytic properties. SP-B is a 17.4-kDa homodimer and each subunit contains three intrachain disulphides and has been proposed to contain four amphipathic helices oriented pairwise in an antiparallel fashion. SP-A, SP-B and SP-D all have been detected also in the gastrointestinal tract. SP-C, in contrast, appears to be a unique protein with extreme structural and stability properties and to exist exclusively in the lungs. SP-C is a lipopeptide containing covalently linked palmitoyl chains and is folded into a 3.7-nm alpha-helix with a central 2.3-nm all-aliphatic part, making it perfectly suited to interact in a transmembranous way with a fluid bilayer composed of dipalmitoylglycerophosphocholine, the main component of surfactant. Homozygous genetic deficiency of proSP-B causes lethal respiratory distress soon after birth and is associated with aberrant processing of the precursor of SP-C. This review focuses on the chemical composition, structures and interactions of the pulmonary surfactant, in particular the associated proteins.

Effects of human polymorphonuclear leukocyte elastase upon surfactant proteins in vitro

Recent evidence has suggested that elastase is released by polymorphonuclear leukocytes (PMN) recruited from the pulmonary microcirculation into the alveoli during acute lung injury. This study was undertaken to test the hypothesis that elastase from PMN (PMN elastase) damages or degrades one or more of the surfactant proteins (SP-A, SP-B and SP-C) of the lung, and thereby alters its function. We attempted to use amounts of PMN elastase and quantities of surfactant that would be plausible in the lungs of patients with ARDS. Surfactant from normal dog lungs (2 mg phospholipid, 200 micrograms protein), and purified SP-A (20 micrograms), SP-B (10 micrograms) and SP-C (10 micrograms) from the surfactant (identified by SDS-PAGE and N-terminal amino acid sequences) were incubated for 4-8 h at 37 degrees C with various amounts (0.25-1.0 U) of human PMN elastase purified by affinity chromatography. SDS-PAGE and amino acid composition analysis of the surfactant as well as of the purified SP-A, SP-B, and SP-C showed that degradation of these proteins progressed with incubation time and with the amount of PMN elastase, and was accompanied by decreases in isopycnic density (g/cm3) and surface adsorption, and increase of surface tension of the surfactant. No effects were observed with heat inactivated PMN elastase (95 degrees C, 30 min) or with PMN elastase in the presence of human alpha-1 protease inhibitor (2 micrograms/microgram elastase). Phospholipid compositions of the surfactant after exposure to PMN elastase were not significantly different from those of the controls, suggesting that SP-A, SP-B, and SP-C play a major role in altering the surfactant properties. SP-A was also degraded by elastase and trypsin from pancreas whereas SP-B and SP-C remained intact, providing a natural surfactant without SP-A. Surface adsorption rate of the SP-A deficient surfactant was lower than that of the control, but was much higher than that of the surfactant with completely degraded SP-A, SP-B, and SP-C, suggesting that hydrophobic SP-B and SP-C are the essential components in enhancing adsorption. We conclude that proteolytic degradation of SP-A, SP-B, and SP-C causes the decrease of surfactant isopycnic density, and is responsible for retarding adsorption resulting in surfactant dysfunction.

Racial differences in allelic distribution at the human pulmonary surfactant protein B gene locus (SP-B)

Variable numbers of composite repetitive motifs are found in different individuals within intron 4 of the surfactant protein B (SP-B) gene (Biochem J. 1995;305:583). This study tests the hypothesis that the distribution of SP-B alleles differs among racial/ethnic groups. A total of 412 SP-B alleles were analyzed: 206 from Caucasian, 68 from African-American, and 138 from Nigerian individuals. Twelve groups of alleles (A-L) carrying 3 to 18 motifs were found. The distribution of the 12 alleles in the Caucasian group differs from that found in the Nigerian (p < .001) and African-American (p < .001) populations. The overall distribution of alleles between the African-American and the Nigerian populations were not statistically different. Specific alleles were also present in different proportions among the groups studied. For example, the most common allele (allele E) in all three populations is present at a significantly higher frequency in Caucasians than in the other two populations, but its frequency does not differ from the Nigerian and African-American groups. A less frequent allele, H, also differs significantly when Caucasians are compared with each of the other two populations, but the frequency of this allele is comparable between the African-American and Nigerian populations. To assess the importance of having comparable racial composition between the control and the case groups, a group of African-Americans with respiratory distress syndrome (RDS) (n = 40) was compared with the African American and the Caucasian groups studied above. No significant difference was observed between the racially matched groups but a significant difference (p = .006) was observed between the racially mixed groups. The results indicate that the distribution of SP-B alleles differs between the racial groups but not between the ethnic groups studied. Thus, racial composition of the groups under study is important when considering whether particular alleles at this locus predispose to inherited disorders.

A synthetic segment of surfactant protein A: structure, in vitro surface activity, and in vivo efficacy

Surfactant protein A (SP-A) is a 248-residue, water-soluble, lipid-associating protein found in lung surfactant. Analysis of the amino acid sequence using the Eisenberg hydrophobic moment algorithm predicts that the SP-A segment spanning residues 114-144 has high hydrophobic moments, typical of lipid-associating amphipathic domains. The secondary structure, in vitro surface activity and in vivo lung activity of this SP-A sequence were studied with a 31-residue synthetic peptide analog (A114-144). Analysis of the secondary structure using circular dichroism and Fourier transform infrared spectroscopy indicated association with lipid dispersions and a dominant helical content. Surface activity measurements of A114-144 with surfactant lipid dispersions and the hydrophobic surfactant proteins B and C (SP-B/C) showed that A114-144 enhances surface activity under conditions of dynamic compression and respreading on a Langmuir/Wilhelmy surface balance. Synthetic surfactant dispersions containing A114-144 improved lung compliance in spontaneously breathing, 28-d premature rabbits to a greater degree than surfactant dispersions with synthetic SP-B/C and synthetic surfactant lipids alone. These observations indicate that inclusion of A114-144 may improve synthetic preparations currently used for surfactant replacement therapy.

Synthetic protein analogues in artificial surfactants

Today, airway instillation of surfactant preparations is a generally used treatment for respiratory distress syndrome in premature infants. Most commercially available surfactants are purified from animal lungs and contain lipids, mainly phospholipids, and about 2% of the hydrophobic surfactant proteins B and C (SP-B and SP-C). During the last half-decade the main structural properties of these proteins have been clarified and this knowledge now makes it possible to design synthetic analogues for future use in artificial surfactants.

Efficacy of synthetic peptide-containing surfactant in the treatment of respiratory distress syndrome in preterm infant rhesus monkeys

Studies were conducted to assess the efficacy and safety of a synthetic peptide-containing surfactant in the treatment of respiratory distress syndrome (RDS) in preterm (approximately 80% of normal gestation) infant rhesus monkeys. Surfactant was prepared consisting of the phospholipids dipalmitoylphosphatidyl choline and palmitoyl-oleoyl phosphatidyl glycerol and a synthetic peptide modeled after surfactant protein B (SP-B), "KL4-Surfactant" contained a peptide having the sequence KLLLLKLLLLKLLLLKLLLLK, where "K" is lysine and "L" is leucine. The peptide was selected because it mimics the repeating stretches of hydrophobic residues with intermittent basic hydrophilic residues seen in SP-B. KL4-Surfactant was shown to have biophysical activity assessed as the ability to lower surface tension at an air-liquid interface in a pulsating bubble surfactometer. Thirty premature rhesus monkeys were treated shortly after birth with one dose of KL4-Surfactant. The arterial to alveolar oxygen partial pressure ratio (a/A) was found to rise from a pretreatment level of 0.11 +/- 0.01 (mean +/- SEM), indicative of severe RDS, to 0.40 +/- 0.02 at 12-13 h post-treatment. The improvement in oxygenation persisted throughout the study period, with a mean a/A at 22-23 h of 0.45 +/- 0.07. Chest radiographs and gross and microscopic examination of the lungs all confirmed the reversal of the atelectasis seen before treatment. Animals treated with a dose of 200 mg/kg showed a faster, more consistent, and greater response than did a group treated with an average dose of 127 mg/kg. There was no evidence of toxicity after treatment with the higher dose as demonstrated by physiologic, hematologic, biochemical, and pathologic data. The importance of the peptide in the synthetic surfactant was apparent from the results obtained with a control group of nine premature monkeys treated with a non-peptide-containing surfactant; the a/A of this group was 0.15 +/- 0.03 at nine hours of age as compared with a value of 0.38 +/- 0.02 for 30 comparable animals receiving KL4-Surfactant.

Glutathione metabolism in newborns: evidence for glutathione deficiency in plasma, bronchoalveolar lavage fluid, and lymphocytes in prematures

Respiratory distress in premature newborns is associated with deficiency of surfactant in the bronchoalveolar lining fluid; this may be influenced by a local deficiency of antioxidants. Severe L-buthionine-S,R-sulfoximine-induced depletion of glutathione (GSH, a major antioxidant) in rodents is associated with lung type 2 cell lamellar body damage and decreased concentrations in lung and bronchoalveolar lavage fluid (BALF) of phosphatidyl choline (a major component of surfactant). At birth, prematurely born newborns (30-34 weeks) had lower peripheral venous plasma GSH concentrations than term (> 36 weeks) babies; these levels decreased further with increasing prematurity (< 27 weeks, with respiratory distress). On day 2, the peripheral venous plasma GSH concentrations reached a nadir, and the lowest levels were found in the most premature newborns. Lymphocyte GSH concentrations were lowest on day 2 and day 7, and in prematures (< 27 weeks, with respiratory distress) remained below adult lymphocyte GSH levels for at least 4 weeks. At birth, prematures (< 27 weeks, with respiratory distress) had a central plasma arterio-venous (A-V) GSH gradient across the lung (an estimate of lung uptake of GSH) of 0.72 +/- 0.15 (mean +/- SD) mumol/L; on day 2, the A-V gradient did not change significantly (0.49 +/- 0.09 mumol/L). At birth, these prematures had markedly decreased BALF GSH concentrations (compared with adult levels), and they were not significantly changed during the first 4 weeks of life. These results suggest that GSH deficiency is present in prematures and that it increases with the degree of prematurity. At birth, GSH deficiency will compromise the lungs' defense against oxidative stress injury. Oxidative stress is likely to increase if hyperoxic treatment is given for respiratory distress in these infants.

In vitro and in vivo transfer and expression of human surfactant SP-A- and SP-B-associated protein cDNAs mediated by replication-deficient, recombinant adenoviral vectors

Congenital pulmonary alveolar proteinosis (CPAP) is a fatal disease of full-term infants that is unresponsive to current medical therapy. It is now recognized that at least some forms of this disorder are associated with a deficiency of SP-B, one of the surfactant-associated proteins, as well as probable aberrations in the surfactant-associated proteins SP-A and SP-C. Given these developments, it is logical to hypothesize that CPAP may be amenable to gene therapy, in which the human SP-B cDNA, and possibly the cDNAs of the other surfactant associated proteins, are transferred to the epithelium of the lower respiratory tract. We constructed replication-deficient, recombinant adenovirus vectors in which a constitutive viral promoter drives the expression of the DNAs for the surfactant-associated proteins, SP-B (AdCMV.SP-B) and SP-A (AdCMV.SP-A). Following infection of the human lung A549 epithelial cell line with these vectors in vitro, the appropriately sized mRNAs for these cDNAs were detected, whereas cells infected with a control virus or uninfected cells produced none. Western blots demonstrated expression of these proteins, including appropriate processing of the hydrophobic protein, SP-B. Following in vivo intratracheal infection of rats with these vectors, Northern analysis of the lungs revealed appropriately sized mRNAs for these cDNAs whereas rats infected with control virus or uninfected rats show no hybridization with the human surfactant-associated protein probes. In the AdCM-V.SP-A-infected rats, Western blots confirmed the overproduction of the human SP-A protein in both the bronchoalveolar lavage and lung homogenates compared to controls. Thus, it is feasible to utilize adenovirus vectors to transfer and express the human surfactant associated protein cDNAs in vitro and in vivo, presenting a possible mode of therapy for CPAP, as well as other surfactant deficiency states such as the neonatal respiratory distress syndrome and possibly the adult respiratory distress syndrome.

Impairment of surfactant activity and ventilation by proteins in lung edema fluid

We investigated the effects of lung edema protein on ventilatory mechanics with special reference to surfactant activity. The edema fluid was obtained from hyperoxia-exposed adult rabbits. In immature newborn rabbits that could not be artificially ventilated at an insufflation pressure of 25 cm H2O, mean tidal volumes of > 27 ml/kg were obtained by supplementation with a natural surfactant (S-alone) or natural surfactant mixed with lung edema fluid (EF), the edema protein-to-surfactant ratio of which was < or = 5.6. A mixture with a ratio of 11.2 (11.2-EF/S), however, decreased the volume to 10.9 ml/kg (P < 0.05 vs S-alone). Surfactant mixed with isolated albumin at a concentration equal to that in 11.2-EF/S decreased the tidal volume to 8.6 ml/kg (NS vs 11.2-EF/S), and with isolated fibrinogen lowered it to 18.1 mg/kg (P < 0.05 vs S-alone). We conclude that lung edema fluid impairs ventilation through surfactant inactivation when the protein-to-surfactant ratio increases, and that albumin and fibrinogen are the main causes of this impairment.

Treatment responses to surfactants containing natural surfactant proteins in preterm rabbits

The in vivo function of surfactants reconstituted using natural surfactant lipid and protein constituents was evaluated in 27-day-gestation preterm rabbits. The animals were treated with protein-free surfactant lipids (LH-20), LH-20 + 5% SP-A, LH-20 + 1% SP-B, LH-20 + 1% SP-C, LH-20 + 5% SP-A + 1% SP-B + 1% SP-C (SP-ABC), natural sheep surfactant, or 4 ml/kg 0.45% NaCl (control) and then ventilated with tidal volumes of 8 ml/kg and 3 cm H2O positive end-expiratory pressure (PEEP). Ventilatory pressures (peak pressures minus PEEP) and dynamic compliances of the LH-20 + SP-C rabbits were greater (p < 0.01) than those of control, LH-20, and LH-20 + SP-A groups but lower (p < 0.05) than in the LH-20 + SP-B, LH-20 + SP-ABC, and sheep surfactant groups. Recoveries of intravascular labeled albumin in the lungs were comparable in the LH-20 + SP-B, LH-20 + SP-C, LH-20 + SP-ABC, and sheep surfactant groups and less (p < 0.01) than in LH-20 + SP-A rabbits, which had lower (p < 0.05) recoveries than did the control and LH-20 groups. The postventilation pressure-volume curves for LH-20 + SP-B and LH-20 + SP-ABC rabbits had significantly lower opening pressures, larger maximal lung volumes, and larger retained volumes on deflation relative to the LH-20 + SP-C, LH-20, and control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Induction of lipid peroxidation of pulmonary surfactant by plasma of preterm babies

Respiratory distress syndrome of the preterm baby is believed to be caused by a deficiency of pulmonary surfactant and leakage of plasma into the alveolar spaces. Since the two pathogenetic factors seem to be inter-related, we postulated that peroxidation of surfactant by plasma iron could be the linking mechanism. We obtained cord blood samples from 22 preterm babies (mean gestational age 32.2 [SD 2.7] weeks) and 24 term babies (40.1 [1.6] weeks), and venous blood samples from 18 healthy adults. No adult had detectable non-protein-bound iron in the plasma, but 10/21 (48%) preterm babies and 6/24 (25%) term babies had detectable concentrations (rate difference 23% [95% Cl -5 to 51%], p = 0.20). Transferrin and haptoglobin concentrations were higher and free haemoglobin concentrations lower in adults than in babies (p < 0.005). Only transferrin differed significantly between term and preterm babies. Plasma from all 18 adults and from 23 (96%) term babies inhibited iron-catalysed lipid peroxidation of pulmonary surfactant liposomes. By contrast, plasma from 11 (50%) preterm babies stimulated such peroxidation (difference in stimulation rate 46% [20-71%], p < 0.005 for preterm vs term babies); the ability to stimulate peroxidation was related to the presence of non-protein-bound iron (p < 0.001). Peroxidation decreased in the babies when apotransferrin was added to plasma and in all subjects when alpha-tocopherol was incorporated into the surfactant liposomes. Lipid peroxidation of surfactant may contribute to the pathogenesis of respiratory distress syndrome. Possible therapeutic approaches are increasing babies' iron-binding capacity by plasma transfusions and increasing the antioxidant capacity of commercial surfactant.