Inactivation of surfactant in rat lungs

A REVIEW OF THE EFFECTS OF BODY TEMPERATURE VARIATIONS ON RESPIRATORY MECHANICS: MEASUREMENTS BY THE END-INFLATION OCCLUSION METHOD IN THE RAT

The temperature of body fluids is expected to affect tissues mechanical properties, including respiratory system tissues. This is because of the changes in airway smooth muscle tone and contractile properties, influencing airway frictional resistance to airflow, and because of the temperature effects on the stress–strain relationships of elastin and collagen, which determinates the elastic behavior of the lungs as reflected by their pressure–volume relationship. Alveolar surfactant biological and physical properties have also been shown to be affected by temperature changes, suggesting influences on the respiratory system hysteretic properties.

Experimental works describing the effects of body temperature variations on respiratory mechanics are reviewed, including recent findings dealing with investigations on respiratory mechanics carried out by the end-inflation occlusion method in the rat. This method allows to determine, together with the elastance of the respiratory system, its resistive properties too. In particular, both the ohmic airway resistance due to frictional forces in the airway and the additional visco-elastic resistance exerted because of tissues stress-relaxation may be quantified.

The effects of body temperature variations were assessed, and experimentally induced temperature increments and/or decrements allowed to conclude that respiratory system tissues stiffness, both the ohmic and the stress-relaxation linked resistances, and the hysteretic behavior of the respiratory system, decrease with temperature increments. The mechanisms responsible for these effects are analyzed.

Association of Rewarming Rate on Neonatal Outcomes in Extremely Low Birth Weight Infants with Hypothermia

OBJECTIVE

To explore the possible association between rewarming rate and neonatal outcomes in extremely low birth weight infants (ELBWIs) with hypothermia.

STUDY DESIGN

All ELBWIs with hypothermia (temperature < 36.0°C) on neonatal intensive care unit (NICU) admission were retrospectively evaluated. Rewarming rate was analyzed as both a dichotomous (≥ 0.5°C/h rapid group; < 0.5°C/h slow group) and a continuous variable. Multivariable analysis was performed to explore the relation between rewarming rate and several outcomes, adjusting for clinically relevant confounders.

RESULTS

Hypothermia on NICU admission was present in 182 out of 744 ELBWIs (24.5%). The rewarming rate was slow in 109 subjects (59.9%) and rapid in 73 subjects (40.1%), with a median rewarming rate of 0.29°C/h (IQR 0.2-0.35) and 0.76°C/h (IQR 0.61-1.09), respectively (P < .0001). The median rewarming time was 340 minutes (IQR 250-480) and 170 minutes (IQR 110-230), respectively (P < .0001). After adjusting for clinically relevant confounders, we did not find significant associations between rewarming rate group (≥ 0.5°C/h vs < 0.5°C/h) and neonatal outcomes. When we considered the rewarming rate as continuous variable, a higher rewarming rate was identified as a protective factor for respiratory distress syndrome (OR 0.39, 95% CI 0.17-0.87; P = .02).

CONCLUSIONS

In ELBWIs with hypothermia upon NICU admission, there were no significant differences between rapid or slow rewarming rate and major neonatal outcomes. A higher rewarming rate was associated with a reduced incidence of respiratory distress syndrome.

Physiological variables affecting surface film formation by native lamellar body-like pulmonary surfactant particles

Pulmonary surfactant (PS) is a surface active complex of lipids and proteins that prevents the alveolar structures from collapsing and reduces the work of breathing by lowering the surface tension at the alveolar air-liquid interface (ALI). Surfactant is synthesized by the alveolar type II (AT II) cells, and it is stored in specialized organelles, the lamellar bodies (LBs), as tightly packed lipid bilayers. Upon secretion into the alveolar lining fluid, a large fraction of these particles retain most of their packed lamellar structure, giving rise to the term lamellar body like-particles (LBPs). Due to their stability in aqueous media, freshly secreted LBPs can be harvested from AT II cell preparations. However, when LBPs get in contact with an ALI, they quickly and spontaneously adsorb into a highly organized surface film. In the present study we investigated the adsorptive capacity of LBPs at an ALI under relevant physiological parameters that characterize the alveolar environment in homeostatic or in pathological conditions. Adsorption of LBPs at an ALI is highly sensitive to pH, temperature and albumin concentration and to a relatively lesser extent to changes in osmolarity or Ca(2+) concentrations in the physiological range. Furthermore, proteolysis of LBPs significantly decreases their adsorptive capacity confirming the important role of surfactant proteins in the formation of surface active films.

The Efficacy of Surfactant Replacement Therapy in the Growth-Restricted Preterm Infant: What is the Evidence?

BACKGROUND

Surfactant replacement therapy (SRT) is an integral part of management of preterm surfactant deficiency respiratory distress syndrome (RDS). Its role in the management of RDS has been extensively studied. However, its efficacy in the management of lung disease in preterm infants born with intrauterine growth restriction (IUGR) has not been systematically studied.

OBJECTIVE

To evaluate the efficacy of exogenous SRT in the management of preterm IUGR lung disease.

METHODS

A systematic search of all available randomized clinical trials (RCT) of SRT in preterm IUGR infants was done according to the standard Cochrane collaboration search strategy. Neonatal respiratory outcomes were compared between the preterm IUGR and appropriately grown for gestational age (AGA) preterm infant populations in eligible studies.

RESULTS

No study was identified which evaluated the efficacy or responsiveness of exogenous SRT in preterm IUGR infants as compared to preterm AGA-infants. The only study identified through the search strategy used small for gestational age (SGA; defined as less than tenth centile for birth weight) as a proxy for IUGR. The RCT evaluated the efficacy or responsiveness of SRT in preterm SGA group as compared to AGA-infants. The rate of intubation, severity of RDS, rate of surfactant administration, pulmonary air leaks, and days on the ventilator did not differ between both groups. However, the requirement for prolonged nasal continuous positive airway pressure (p < 0.001), supplemental oxygen therapy (p < 0.01), and the incidence of bronchopulmonary dysplasia at 28 days and 36 weeks (both p < 0.01) was greater in SGA-infants.

DISCUSSION

There is currently insufficient data available to evaluate the efficacy of SRT in preterm IUGR lung disease. A variety of research strategies will be needed to enhance our understanding of the role and rationale for use of SRT in preterm IUGR lung disease.

The effect of body cooling on respiratory system mechanics and hysteresis in rats

Literature reports and theoretical considerations suggest that body cooling may affect respiratory mechanics in vivo. To examine this hypothesis, healthy rats were studied using the end-inflation occlusion method under control conditions and after total body cooling. Respiratory mechanics parameters, hysteresis areas, the inspiratory work of breathing, and its elastic and resistive components, were calculated. After body cooling (mean rectal temperature from 36.6 ± 0.25 to 32.1 ± 0.26 °C), the ohmic and the additional visco-elastic respiratory system resistances, the hysteresis, the total inspiratory work of breathing, and its resistive components, were all increased. No significant changes were detected for the static and dynamic respiratory system elastance mean values, and the related elastic component of the work of breathing. These data indicate that body cooling increases the mechanical inspiratory work of breathing by increasing the resistive pressures dissipation. This effect is evident even for limited temperature variations, and it is suggested that it may occur in the event of accidental or therapeutic hypothermia.

PROTEIN INHIBITION OF SURFACTANT DURING MECHANICAL VENTILATION OF ISOLATED RAT LUNGS

This study tested the hypothesis that material leaking into the airspace from the vasculature during ventilation interferes with surfactant function and contributes to decreases in lung compliance. Rats were euthanized and the lungs were isolated either with or without flushing of the vasculature, followed by mechanical ventilation and analysis of lung compliance and lung lavage analysis. Flushed lungs had higher lung compliance compared to the non-flushed lungs. This was associated with lower protein concentrations and improved surfactant activity. It is concluded that during mechanical ventilation, leakage of proteins results in surfactant inhibition and thereby contribute to decreased lung compliance.

Continuous pulmonary infusion of L-arginine during deep hypothermia and circulatory arrest improves pulmonary surfactant integrity in piglets

BACKGROUND

The integrity of pulmonary surfactant (PS) is impaired during deep hypothermia and circulatory arrest (DHCA), a preferred bypass strategy for infants undergoing complex cardiac operations, due mainly to bypass-induced systemic inflammation. The requirement of L-arginine, a precursor of nitric oxide, is elevated during acute pulmonary inflammation. We hypothesized that continuous intrapulmonary supplementation of L-arginine during DHCA can maintain the integrity of PS metabolism and thus protect the pulmonary function.

METHODS

Sixteen piglets underwent 90-minute circulatory arrest at 18 degrees C before rewarming. During circulatory arrest, antegrade infusion of Ringer's lactate solution alone (n = 8) or containing L-arginine (1 mg/kg/min, n = 8) was initiated into the pulmonary circulation. Disaturated phosphatidylcholine, total phospholipids, and total proteins from tracheal aspirates were measured serially until the experiment ended (4 hours after rewarming). Various variables of pulmonary function were also monitored.

RESULTS

L-arginine led to less decrement of disaturated phosphatidylcholine/total phospholipids and disaturated phosphatidylcholine/total proteins after DHCA. At 4 hours after rewarming, L-arginine had significantly mitigated the deterioration of pulmonary static compliance (3.6 +/- 0.5 vs 3.3 +/- 0.3 mL/cm H2O) and partial pressure of arterial oxygen/fraction of inspired oxygen (330 +/- 48 vs 296 +/- 32 mm Hg). Pulmonary retention of water (6.2 +/- 1.0 vs 5.5 +/- 1.2) was significantly reduced. The L-arginine-treated group showed an increase in NO metabolites (NO2-/NO3-) from the pulmonary circulation, the extent of which is correlated to PS content.

CONCLUSIONS

Continuous L-arginine supplementation during DHCA attenuated PS depletion and, therefore, ameliorated postoperative pulmonary dysfunction.

Atomic force microscopy studies of functional and dysfunctional pulmonary surfactant films, II: albumin-inhibited pulmonary surfactant films and the effect of SP-A

Pulmonary surfactant (PS) dysfunction because of the leakage of serum proteins into the alveolar space could be an operative pathogenesis in acute respiratory distress syndrome. Albumin-inhibited PS is a commonly used in vitro model for studying surfactant abnormality in acute respiratory distress syndrome. However, the mechanism by which PS is inhibited by albumin remains controversial. This study investigated the film organization of albumin-inhibited bovine lipid extract surfactant (BLES) with and without surfactant protein A (SP-A), using atomic force microscopy. The BLES and albumin (1:4 w/w) were cospread at an air-water interface from aqueous media. Cospreading minimized the adsorption barrier for phospholipid vesicles imposed by preadsorbed albumin molecules, i.e., inhibition because of competitive adsorption. Atomic force microscopy revealed distinct variations in film organization, persisting up to 40 mN/m, compared with pure BLES monolayers. Fluorescence confocal microscopy confirmed that albumin remained within the liquid-expanded phase of the monolayer at surface pressures higher than the equilibrium surface pressure of albumin. The remaining albumin mixed with the BLES monolayer so as to increase film compressibility. Such an inhibitory effect could not be relieved by repeated compression-expansion cycles or by adding surfactant protein A. These experimental data indicate a new mechanism of surfactant inhibition by serum proteins, complementing the traditional competitive adsorption mechanism.

Inactivation of pulmonary surfactant due to serum-inhibited adsorption and reversal by hydrophilic polymers: experimental

The rate of change of surface pressure, pi, in a Langmuir trough following the deposition of surfactant suspensions on subphases containing serum, with or without polymers, is used to model a likely cause of surfactant inactivation in vivo: inhibition of surfactant adsorption due to competitive adsorption of surface active serum proteins. Aqueous suspensions of native porcine surfactant, organic extracts of native surfactant, and the clinical surfactants Curosurf, Infasurf, and Survanta spread on buffered subphases increase the surface pressure, pi, to approximately 40 mN/m within 2 min. The variation with concentration, temperature, and mode of spreading confirmed Brewster angle microscopy observations that subphase to surface adsorption of surfactant is the dominant form of surfactant transport to the interface. However (with the exception of native porcine surfactant), similar rapid increases in pi did not occur when surfactants were applied to subphases containing serum. Components of serum are surface active and adsorb reversibly to the interface increasing pi up to a concentration-dependent saturation value, pi(max). When surfactants were applied to subphases containing serum, the increase in pi was significantly slowed or eliminated. Therefore, serum at the interface presents a barrier to surfactant adsorption. Addition of either hyaluronan (normally found in alveolar fluid) or polyethylene glycol to subphases containing serum reversed inhibition by restoring the rate of surfactant adsorption to that of the clean interface, thereby allowing surfactant to overcome the serum-induced barrier to adsorption.

Surfactant Therapy for Meconium Aspiration Syndrome

Meconium aspiration syndrome (MAS) is an important cause of respiratory distress in the term infant. Therapy for the disease remains problematic, and newer treatments such as high-frequency ventilation and inhaled nitric oxide are being applied with increasing frequency. There is a significant disturbance of the pulmonary surfactant system in MAS, with a wealth of experimental data indicating that inhibition of surfactant function in the alveolar space is an important element of the pathophysiology of the disease. This inhibition may be mediated by meconium, plasma proteins, haemoglobin and oedema fluid, and, at least in vitro, can be overcome by increasing surfactant phospholipid concentration. These observations have served as the rationale for administration of exogenous surfactant preparations in MAS, initially as standard bolus therapy and, more recently, in association with therapeutic lung lavage. Bolus surfactant therapy in ventilated infants with MAS has been found to improve oxygenation in most studies, although there are a significant proportion of nonresponders and in many cases the effect is transient. Pooled data from randomised controlled trials of surfactant therapy suggest a benefit in terms of a reduction in the requirement for extracorporeal membrane oxygenation (relative risk 0.48 in surfactant-treated infants) but no diminution of air leak or ventilator days. Current evidence would support the use of bolus surfactant therapy on a case by case basis in nurseries with a relatively high mortality associated with MAS, or the lack of availability of other forms of respiratory support such as high-frequency ventilation or nitric oxide. If used, bolus surfactant should be administered as early as practicable to infants who exhibit significant parenchymal disease, at a phospholipid dose of at least 100 mg/kg, rapidly instilled into the trachea. Natural surfactant or a third-generation synthetic surfactant should be used and the dosage repeated every 6 hours until oxygenation has improved. Lung lavage with dilute surfactant has recently emerged as an alternative to bolus therapy in MAS, which has the advantage of removing surfactant inhibitors from the alveolar space in addition to augmenting surfactant phospholipid concentration. Combined animal and human data suggest that lung lavage can remove significant amounts of meconium and alveolar debris, and thereby improve oxygenation and pulmonary mechanics. Arterial oxygen saturation inevitably falls during lavage but has been noted to recover relatively rapidly, even in infants with severe disease. Several randomised controlled trials of surfactant lavage in MAS are underway, and until the results are known, lavage must be considered an unproven and experimental therapy.

Alveolar fibrosis and changes in equine lung morphometry in response to intrapulmonary blood

Necropsy studies of horses suffering exercise-induced pulmonary haemorrhage (EIPH) have identified mild inflammatory lesions with evidence of alveolar fibrosis and bronchiolitis. These lesions were thought to be the result of viral infections that predisposed the affected regions of the lung to EIPH. We have shown previously that during erythrophagocytosis in the alveolar space, there is a prolonged period of macrophage influx and activation. This present study used morphometric analysis to quantify the effects of macrophage activity during erythrophagocytosis, on the alveolar cell population and physical structure of the alveolar walls. Segments of the bronchial tree were inoculated with either autologous whole blood or serum, at 15, 8, 3 days, 24 h and 30 min prior to euthanasia. Blood inoculation produced many significant changes in the alveolar morphometry including, increased numbers of alveolar macrophages, increased septal thickness, and a markedly increased percentage of collagen in the alveolar walls. Signs of chronic inflammation including increased macrophage activity and erythrophagocytosis coincided with increased alveolar macrophage numbers (10,688 +/- 1708 cells/mm3 to 30,957 +/- 6831 cells/mm3), septal thickness (4.1 +/- 0.4 microm to 6.1 +/- 0.5 microm) and alveolar septal collagen content (6.6 +/- 0.5% to 27.5 +/- 3.3%). The results suggest that intrapulmonary blood induces a macrophage dominated inflammatory response, septal thickening and the development of alveolar fibrosis. These changes are the probable cause of the observed alveolar fibrosis and bronchiolitis that was once suspected to be the originating cause of EIPH.

Intratracheal administration of perfluorochemical-gentamicin suspension: a comparison to intravenous administration in normal and injured lungs

Respiratory infections can lead to acute lung injury and perfusion abnormalities. We hypothesized that intratracheal (IT) administration of a perfluorochemical (PFC) gentamicin (G) suspension as compared to intravenous (IV) administration of gentamicin will result in higher lung tissue levels of gentamicin, while maintaining safe serum levels. To test this hypothesis, 21 lambs with normal and acid injured lungs were studied for 4 hr, using 2 different drug delivery methods, IT and IV. Lungs were injured with warm HCl acid in saline lavage, followed by partial liquid ventilation with perflubron (bolus FRC = 20 mL/kg). G at a dose of 5 mg/kg was delivered either IT (G-PFC; 20 mL/kg) or IV (aqueous injection with IT 20 mL/kg PFC alone). Throughout the study, serum G levels, arterial blood gases, respiratory system compliance, and mean arterial blood pressure were measured. Lung tissue G levels were measured at 4 hr and averaged across lobes. Physiologic gas exchange and pulmonary function were maintained throughout the protocol for both the normal and injured lungs. Intravenously administered G resulted in an initial 5-min serum concentration of 43 +/- 2.5 mcg/mL, followed by an exponential decline over the 4-hr protocol to a level of 2.1 +/- 0.23 mcg/mL at hr 4. The intratracheally administered G suspension resulted in a 5-min serum concentration of 1.8 +/- 0.98 mcg/mL and remained relatively constant throughout the protocol, with a 4-hr level of 1.6 +/- 0.29 mcg/mL. With respect to lung tissue G levels, IT administration was significantly more effective in delivering the drug to the normal lungs than IV (31.4 +/- 3.3 mcg/g vs. 4.0 +/- 0.7 mcg/g) 4 hr after administration. In the lung injury group, there was a small but significant difference in lung tissue G levels, with the IT-administered perfluorochemical-G suspension achieving greater levels than the IV-administered G (11.9 +/- 0.52 mcg/g vs. 10.1 +/- 0.8 mcg/g). Additionally, the drug delivered IV and IT in both the normal and injured lung models was homogeneously distributed throughout the lung. These data show that G lung tissue levels in both normal and injured lungs were higher in the IT group when compared to IV administration. The results of this study demonstrate that in normal and injured lungs, homogeneous G lung tissue levels can be more effectively achieved at lower serum levels when delivered IT in a G-PFC suspension as compared to IV administration.

Determinants of surfactant function in acute lung injury and early recovery

Relationships between lung function and surfactant function and composition were examined during the evolution of acute lung injury in guinea pigs. Lung mechanics and gas exchange were assessed 12, 24, or 48 h after exposure to nebulized lipopolysaccharide (LPS). Bronchoalveolar lavage (BAL) fluid was processed for phospholipid and protein contents and surfactant protein (SP) A and SP-B levels; surfactant function was measured by pulsating bubble surfactometry. Lung elastance, tissue resistance, and arterial-alveolar gradient were moderately elevated by 12 h after LPS exposure and continued to increase over the first 24 h but began to recover between 24 and 48 h. Similarly, the absolute amount of 30,000 g pelleted SP-A and SP-B, the phospholipid content of BAL fluid, and surfactant function declined over the first 24 h after exposure, with recovery between 24 and 48 h. BAL fluid total protein content increased steadily over the first 48 h after LPS nebulization. In this model of acute lung injury, the intra-alveolar repletion of surfactant components in early recovery led to improved surfactant function despite the presence of potentially inhibitory plasma proteins.

Normal surfactant pool sizes and inhibition-resistant surfactant from mice that overexpress surfactant protein A

Pulmonary surfactant protein-A (SP-A) has been reported to regulate the uptake and secretion of surfactant by alveolar type II cells, to stabilize large surfactant aggregates including tubular myelin, and to protect the surface activity of surfactant from protein inhibitors. In this study we investigated the consequences of overexpression of SP-A on pulmonary homeostasis and surfactant function in transgenic mice. The human SP-C promoter was used to direct synthesis of rat surfactant protein A (rSP-A) in alveolar type II cells and nonciliated bronchiolar cells of the distal respiratory epithelium. Levels of SP-A measured through enzyme-linked immunosorbent assay were 7- to 8-fold higher in lung homogenates and alveolar lavage fluid of the rSP-A mice than in those of transgene-negative littermates. The swimming exercise tolerance and lung compliance of mice bearing the transgene were unchanged. Mean air space sizes seen in randomly selected light-microscopic fields were not significantly different in the transgene-positive and -negative mice by morphometric analysis, but 15% of transgenic animals had scattered foci containing dilated alveoli and alveolar ducts without evidence of inflammation or fibrosis. Some alveolar macrophages contained bar-shaped osmophilic inclusions that had a highly ordered ultrastructure. There were no differences between the transgene-positive and -negative mice in the tissue or alveolar pool sizes of saturated phosphatidylcholine or in the large-aggregate composition of alveolar surfactant. The surface activity of surfactant isolated from the rSP-A mice was similar to that of the controls, but in the presence of protein inhibitors, the surface tension-reducing properties of the rSP-A surfactant were better preserved (P < 0.05). We conclude that overexpression of SP-A does not affect resting surfactant phospholipid levels, but that it enhances the resistance of surfactant to protein inhibition.

Nonionic polymers reverse inactivation of surfactant by meconium and other substances

A variety of substances including human meconium have been found to affect adversely the surface tension-lowering activity of pulmonary surfactants, and this effect may be important in the pathogenesis of a number of human diseases. To find whether inactivation of surfactant could be prevented or reduced by nonionic polymers, we added dextrans, polyethylene glycols (PEGs), or polyvinylpyrrolidones (PVPs) of various molecular weights to pulmonary surfactants. One to 3% human meconium or other inactivating substances were then added to the mixtures, which were tested in a modified pulsating bubble surfactometer. Polymers (3.3-500 kD) in 1-10% concentrations enhanced the ability of a commercial surfactant replacement (Survanta) to lower the minimum surface tension in the presence of meconium, serum, or lysophosphatidylcholine. Similar effects were seen when polymers were added after mixing of surfactant and meconium or other inhibitors, indicating that polymers are capable of reversing the inactivation. Results from rat experiments indicate that total lung capacity is increased when PEG is first added to the Survanta, then mixed with meconium and instilled into the lungs. We postulate that polymers separate meconium-surfactant complexes, permitting surfactant components better access to the air-liquid interface. Taeusch HW, Lu KW, Goerke J, Clements JA. Nonionic polymers reverse inactivation of surfactant by meconium and other substances.

Synthetic mimics of surfactant proteins B and C: in vitro surface activity and effects on lung compliance in two animal models of surfactant deficiency

Synthetic surfactant peptides SP-B1-78 and SP-C1-31 in a standard phospholipid mixture have been employed to examine the correlation between in vitro surface activity and in vivo function of synthetic surfactant preparations in the isolated rat lung and premature rabbit models of respiratory distress syndrome. Monolayer techniques showed that SP-B peptides have a high propensity for association with a phospholipid structure. By dynamic respreading, synthetic SP-B and SP-C showed rapid spreading and attained low surface tensions. Used as replacement surfactants in two animal models, these synthetic surfactant preparations partially restored lung compliance in lavaged rats and premature rabbits better than a pure phospholipid preparation and to a degree comparable to clinical surfactant, measured by pressure/volume curves. Our data confirm that in vitro functional determinations of synthetic surfactant peptides are instrumental in the preparation of replacement surfactants, and that dispersions thus selected represent viable therapeutic alternatives to current treatments for respiratory distress syndrome.

Surfactant inhibition by plasma: gestational age and surfactant treatment effects in preterm lambs

The preterm infant with respiratory distress syndrome has edematous lungs and small amounts of surfactant that do not function normally. We reported that surfactant recovered from preterm lambs after surfactant treatment can have decreased sensitivity to inhibition of surface tension by plasma. We asked whether this augmented resistance to inhibition was dependent on lung development (gestational age) by testing sensitivity to plasma inhibition of 1) endogenous surfactant from preterm lambs and 2) surfactant from preterm lambs after treatment with an organic solvent-extracted natural sheep surfactant. Surfactant recovered after surfactant treatment of 121- or 128-days-gestation lambs had the same sensitivity to plasma inhibition as did the surfactant used to treat the lambs. Surfactant recovered from 134-days-gestation lambs had decreased sensitivity to inhibition. Lung maturation is a variable influencing surfactant inhibition by plasma.