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Abstract
The acute respiratory distress syndrome (ARDS) is a complex disorder of heterogeneous etiologies characterized by a consistent, recognizable pattern of lung injury. Extensive epidemiologic studies and clinical intervention trials have been conducted to address the high mortality of this disorder and have provided significant insight into the complexity of studying new therapies for this condition. The existing clinical investigations in ARDS will be highlighted in this review. The limitations to current definitions, patient selection, and outcome assessment will be considered. While significant attention has been focused on the parenchymal injury that characterizes this disorder and the clinical support of gas exchange function, relatively limited focus has been directed to hemodynamic and pulmonary vascular dysfunction equally prominent in the disease. The limited available clinical information in this area will also be reviewed. The current standards for cardiopulmonary management of the condition will be outlined. Current gaps in our understanding of the clinical condition will be highlighted with the expectation that continued progress will contribute to a decline in disease mortality.
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Affiliation(s)
- Michael Donahoe
- Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Kim JW, Rhee CK, Kim TJ, Kim YH, Lee SH, Yoon HK, Kim SC, Lee SY, Kwon SS, Kim KH, Kim YK. Effect of pravastatin on bleomycin-induced acute lung injury and pulmonary fibrosis. Clin Exp Pharmacol Physiol 2011; 37:1055-63. [PMID: 20659133 DOI: 10.1111/j.1440-1681.2010.05431.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
1. Pravastatin is best known for its antilipidemic action. Recent studies have shown that statins have immunomodulatory and anti-inflammatory effects. The present study aimed to determine whether or not pravastatin can attenuate acute lung injury and fibrosis in a mouse model. 2. Bleomycin was given to C57BL6 mice through intratracheal instillation. Pravastatin was given through intraperitoneal injection. To study the effect of pravastatin on the early inflammatory phase and the late fibrotic phase, mice were killed on days 3, 7, 14 and 21. 3. Pravastatin attenuated the histopathological change of bleomycin-induced lung injury and fibrosis. The accumulation of neutrophils and increased production of tumor necrosis factor-α in bronchoalveolar lavage fluid were inhibited in the early inflammatory phase. Pravastatin effectively inhibited the increase of lung hydroxyproline content induced by bleomycin. Furthermore, pravastatin reduced the increased expression of transforming growth factor (TGF)-β1, connective tissue growth factor (CTGF), RhoA and cyclin D1. The increased levels of TGF-β1 and CTGF mRNA expression were also significantly inhibited by pravastatin. 4. Pravastatin effectively attenuated bleomycin-induced lung injury and pulmonary fibrosis in mice. Our results provide evidence for the therapeutic potential of pravastatin in the treatment of acute lung injury and pulmonary fibrosis.
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Affiliation(s)
- Jin Woo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Catholic University of Korea, Seoul, Korea
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Scanziani M, Amigoni M, Bellani G, Zambelli V, Masson S, Radaelli E, Pesenti A, Latini R. The effect of a single bolus of exogenous surfactant on lung compliance persists until two weeks after treatment in a model of acid aspiration pneumonitis. Pulm Pharmacol Ther 2011; 24:141-6. [DOI: 10.1016/j.pupt.2010.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2010] [Revised: 07/14/2010] [Accepted: 07/22/2010] [Indexed: 10/19/2022]
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Liu CJ, Ha XQ, Jiang JJ, Lv TD, Wu C. Keratinocyte growth factor (KGF) gene therapy mediated by an attenuated form of Salmonella typhimurium ameliorates radiation induced pulmonary injury in rats. JOURNAL OF RADIATION RESEARCH 2011; 52:176-184. [PMID: 21436609 DOI: 10.1269/jrr.10148] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
The aim of this study is to investigate the effect of KGF (Keratinocyte growth factor) gene therapy mediated by the attenuated Salmonella typhimurium Ty21a on radiation-induced pulmonary injury in rats model. Sprague-Dawley rats were divided into three groups: TPK group (treated with TPK strain, attenuated Salmonella typhimurium Ty21a-recombined human KGF gene); TP group (treated with TP strain, attenuated Salmonella typhimurium Ty21a-recombined blank plasmid); and Saline group (treated with saline). After intraperitoneal administration for 48 h, the thoraxes of the rats were exposed to X-ray (20 Gy), and the rats were administered again two weeks after radiation. On the 3rd, 5th, 7th, 14th and 28th day after radiation, the rats were sacrificed and lung tissues were harvested. Histological analysis was performed, MDA contents and SOD activity were detected, mRNA levels of KGF, TGF-β, SP-A and SP-C were measured by Real-time RT-PCR, and their concentrations in the BALF were quantified with ELISA. Administration of TPK strain improved the pathological changes of the lung on the 28th day. In the TPK group, KGF effectively expressed since the 3rd day, MDA contents decreased and SOD activity increased significantly, on the 7th day and 14th day respectively. SP-A and SP-C expression elevated, whereas TGF-β expression was inhibited in the TPK group. These results suggest that this novel gene therapy of KGF could ameliorate radiation-induced pulmonary injury in rats, and may be a promising therapy for the treatment of radiative pulmonary injury.
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Affiliation(s)
- Chun-Jie Liu
- Department of Pharmaceutical Engineering, School of Chemical Engineering and Technology, Tianjin University, Tianjin, China
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Spragg RG, Taut FJH, Lewis JF, Schenk P, Ruppert C, Dean N, Krell K, Karabinis A, Günther A. Recombinant surfactant protein C-based surfactant for patients with severe direct lung injury. Am J Respir Crit Care Med 2010; 183:1055-61. [PMID: 21148720 DOI: 10.1164/rccm.201009-1424oc] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
RATIONALE Patients with acute lung injury have impaired function of the lung surfactant system. Prior clinical trials have shown that treatment with exogenous recombinant surfactant protein C (rSP-C)-based surfactant results in improvement in blood oxygenation and have suggested that treatment of patients with severe direct lung injury may decrease mortality. OBJECTIVES Determine the clinical benefit of administering an rSP-C-based synthetic surfactant to patients with severe direct lung injury due to pneumonia or aspiration. METHODS A prospective randomized blinded study was performed at 161 centers in 22 countries. Patients were randomly allocated to receive usual care plus up to eight doses of rSP-C surfactant administered over 96 hours (n = 419) or only usual care (n = 424). MEASUREMENTS AND MAIN RESULTS Mortality to 28 days after treatment, the requirement for mechanical ventilation, and the number of nonpulmonary organ failure-free days were not different between study groups. In contrast to prior studies, there was no improvement in oxygenation in patients receiving surfactant compared with the usual care group. Investigation of the possible reasons underlying the lack of efficacy suggested a partial inactivation of rSP-C surfactant caused by a step of the resuspension process that was introduced with this study. CONCLUSIONS In this study, rSP-C-based surfactant was of no clinical benefit to patients with severe direct lung injury. The unexpected lack of improvement in oxygenation, coupled with the results of in vitro tests, suggest that the administered suspension may have had insufficient surface activity to achieve clinical benefit.
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Affiliation(s)
- Roger G Spragg
- Veterans Affairs Medical Center, 3350 La Jolla Village Drive, San Diego, CA 92161, USA.
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Lu Q, Zhang M, Girardi C, Bouhemad B, Kesecioglu J, Rouby JJ. Computed tomography assessment of exogenous surfactant-induced lung reaeration in patients with acute lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2010; 14:R135. [PMID: 20633284 PMCID: PMC2945105 DOI: 10.1186/cc9186] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2010] [Revised: 04/27/2010] [Accepted: 07/15/2010] [Indexed: 12/02/2022]
Abstract
Introduction Previous randomized trials failed to demonstrate a decrease in mortality of patients with acute lung injury treated by exogenous surfactant. The aim of this prospective randomized study was to evaluate the effects of exogenous porcine-derived surfactant on pulmonary reaeration and lung tissue in patients with acute lung injury and acute respiratory distress syndrome (ALI/ARDS). Methods Twenty patients with ALI/ARDS were studied (10 treated by surfactant and 10 controls) in whom a spiral thoracic computed tomography scan was acquired before (baseline), 39 hours and 7 days after the first surfactant administration. In the surfactant group, 3 doses of porcine-derived lung surfactant (200 mg/kg/dose) were instilled in both lungs at 0, 12 and 36 hours. Each instillation was followed by recruitment maneuvers. Gas and tissue volumes were measured separately in poorly/nonaerated and normally aerated lung areas before and seven days after the first surfactant administration. Surfactant-induced lung reaeration was defined as an increase in gas volume in poorly/non-aerated lung areas between day seven and baseline compared to the control group. Results At day seven, surfactant induced a significant increase in volume of gas in poorly/non-aerated lung areas (320 ± 125 ml versus 135 ± 161 ml in controls, P = 0.01) and a significant increase in volume of tissue in normally aerated lung areas (189 ± 179 ml versus -15 ± 105 ml in controls, P < 0.01). PaO2/FiO2 ratio was not different between the surfactant treated group and control group after surfactant replacement. Conclusions Intratracheal surfactant replacement induces a significant and prolonged lung reaeration. It also induces a significant increase in lung tissue in normally aerated lung areas, whose mechanisms remain to be elucidated. Trial registration NCT00742482.
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Affiliation(s)
- Qin Lu
- Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care Medicine, Assistance Publique-Hôpitaux de Paris, La Pitié-Salpêtrière Hospital, UPMC Univ Paris 06, 47-83 boulevard de l'hôpital, 75013 Paris, France.
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Farewell to exogenous surfactant therapy in acute lung injury/acute respiratory distress syndrome! Or, must we start all over again?*. Crit Care Med 2010; 38:1606-7. [DOI: 10.1097/ccm.0b013e3181e08fde] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dry powder aerosolization of a recombinant surfactant protein-C–based surfactant for inhalative treatment of the acutely inflamed lung*. Crit Care Med 2010; 38:1584-91. [DOI: 10.1097/ccm.0b013e3181dfcb3b] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Nonventilatory strategies for patients with life-threatening 2009 H1N1 influenza and severe respiratory failure. Crit Care Med 2010; 38:e74-90. [PMID: 20035216 DOI: 10.1097/ccm.0b013e3181cc5373] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Severe respiratory failure (including acute lung injury and acute respiratory distress syndrome) caused by 2009 H1N1 influenza infection has been reported worldwide. Refractory hypoxemia is a common finding in these patients and can be challenging to manage. This review focuses on nonventilatory strategies in the advanced treatment of severe respiratory failure and refractory hypoxemia such as that seen in patients with severe acute respiratory distress syndrome attributable to 2009 H1N1 influenza. Specific modalities covered include conservative fluid management, prone positioning, inhaled nitric oxide, inhaled vasodilatory prostaglandins, and extracorporeal membrane oxygenation and life support. Pharmacologic strategies (including steroids) investigated for the treatment of severe respiratory failure are also reviewed.
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Song J, Palmer K, Sun B. Effects of inhaled nitric oxide and surfactant with extracorporeal life support in recovery phase of septic acute lung injury in piglets. Pulm Pharmacol Ther 2010; 23:78-87. [DOI: 10.1016/j.pupt.2009.10.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2009] [Revised: 08/15/2009] [Accepted: 10/21/2009] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW Studies of the pharmacologic management of acute respiratory distress syndrome (ARDS) have yielded conflicting results. The purpose of this review is to discuss recent pharmacologic trials in ARDS, using the conceptual framework of ARDS as a heterogeneous disease. RECENT FINDINGS Whereas most drug trials in ARDS have been negative, some studies suggest that targeting therapies at subgroups of patients may be successful. Proposed subgroups include early versus late-phase ARDS, direct versus indirect lung injury, and patients with altered coagulation. Corticosteroids have beneficial short-term effects when given at low or moderate doses sooner than 2 weeks but appear to be harmful if initiated later and are of unclear benefit if lung protective ventilation is also used. Surfactant may be helpful in patients with direct lung injury. Anticoagulants and vasodilators may have a greater chance for success in the subset of patients with vascular disease and a high dead-space fraction may identify such a population. SUMMARY ARDS is a heterogeneous syndrome. Failure to target subgroups more likely to benefit from specific therapies may be one explanation for largely disappointing trial results so far.
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Predictive modeling and inflammatory biomarkers in rats with lung contusion and gastric aspiration. ACTA ACUST UNITED AC 2010; 67:1182-90. [PMID: 20009665 DOI: 10.1097/ta.0b013e318187a2bf] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND This study uses statistical predictive modeling and hierarchical cluster analyses to examine inflammatory mediators and cells in bronchoalveolar lavage (BAL) as putative biomarkers in rats with blunt trauma lung contusion (LC), gastric aspiration (combined acid and small gastric food particles, CASP), or a combination of the two. METHODS Specific parameters assessed in the innate pulmonary inflammatory response were leukocytes, macrophages, and polymorphonuclear neutrophils (PMNs) in BAL; whole lung myeloperoxidase activity; and a series of cytokines or chemokines present in BAL at 5 or 24 hours after injury: tumor necrosis factor-alpha, interleukin (IL)-1beta, IL-6, interferon-gamma, IL-10, macrophage inflammatory protein-2, cytokine-induced neutrophil chemoattractant-1, and monocyte chemoattractant protein-1. RESULTS Rats with LC, CASP, LC + CASP all had severe lung injury compared with uninjured controls based on decreased arterial oxygenation or increased BAL albumin at 5 or 24 hours postinsult. However, the injury groups had distinct overall patterns of inflammation that allowed them to be discriminated accurately by hierarchical cluster analysis (29 of 30 and 35 of 37 rats were correctly classified in hierarchical clusters at 5 and 24 hours, respectively). Moreover, predictive analyses based on an extension of standard receiver-operator characteristic methodology discriminated individual animals and groups with similar high accuracy based on a maximum of two inflammatory parameters per group (29 of 30 and 36 of 37 rats were correctly classified at 5 hours and 24 hours, respectively). CONCLUSIONS These results support the possibility that inflammatory biomarker profiles could be developed in the future to improve the diagnosis and management of trauma patients with unwitnessed (occult) gastric aspiration who have an increased risk of clinical acute lung injury or the acute respiratory distress syndrome.
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Do Nonventilatory Strategies for Acute Lung Injury and ARDS Work? EVIDENCE-BASED PRACTICE OF CRITICAL CARE 2010. [PMCID: PMC7151787 DOI: 10.1016/b978-1-4160-5476-4.00012-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Marraro GA, Denaro C, Spada C, Luchetti M, Giansiracusa C. Selective medicated (saline + natural surfactant) bronchoalveolar lavage in unilateral lung contusion. A clinical randomized controlled trial. J Clin Monit Comput 2009; 24:73-81. [PMID: 20012912 DOI: 10.1007/s10877-009-9213-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Accepted: 11/25/2009] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Open lung and low tidal volume ventilation appear to be a promising ventilation for chest trauma as it can reduce ARDS and improve outcome. Local therapy (e.g. BAL) can be synergic to remove from the lung the debris, mitigate inflammatory cascade and avoid damage spreading to not compromised lung areas. MATERIALS AND METHODS 44 pulmonary contused patients were randomized to receive broncho-suction and volume controlled low tidal volume ventilation-VCLTVV (Control Group) or the same ventilation plus medicated (saline + surfactant) BAL (Treatment Group). Tidal volume <10 ml/kg, PEEP of 10-12 cm H(2)O and PaO(2) 60-100 mm Hg and PaCO(2) 35-45 mm Hg were used in both groups. BAL was performed using a fiberscope. 4 boluses of 25 ml saline with 2.4 mg/ml of surfactant were introduced into each contused lobe in which, subsequently, 240 mg of surfactant was instilled. RESULTS All patients survived. In the Control Group 18 patients developed pneumonia, 5 ARDS and days of intubation were 11.50 (3.83) compared to 5.05 (1.21) of Treatment Group in which OI and PaO(2)/FiO(2) significantly improved from 36 h. CONCLUSIONS VCLTVV alone was not able to prevent ARDS and infection in the Control Group as the reduction of intubation. In the Treatment Group, VCLTVV and medicated BAL facilitated the removal of degradated lung material and recruited the contused lung regions, enabling the healing of the lung pathology.
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Affiliation(s)
- Giuseppe A Marraro
- Anesthesia and Intensive Care Department, A.O. Fatebenefratelli and Ophthalmiatric Hospital, Milan, Italy.
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Jian MY, Koizumi T, Tsushima K, Yokoyama T, Kubo K, Baba A. Exogenous surfactant instillation attenuates inflammatory response to acid-induced lung injury in rat. Pulm Pharmacol Ther 2009; 23:43-7. [PMID: 19835974 DOI: 10.1016/j.pupt.2009.10.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2009] [Revised: 08/11/2009] [Accepted: 10/08/2009] [Indexed: 11/28/2022]
Abstract
The present study was performed to investigate the role of exogenous surfactant on hydrochloric acid (HCL) - induced lung injury in rats. Six-week-old male Sprague-Dawley rats were anesthetized by intraperitoneal injection of pentobarbital sodium (40mg/kg) and HCL (0.1N, 2mL/kg) or normal saline (NS, 2mL/kg) was instilled into the trachea. Thirty minutes after HCL instillation, surfactant at a dose of 60mg (=2mL)/body or NS (2mL) was instilled into the rat lungs. Animals in another experimental group were also treated with the same dose of surfactant supplement 2hours after the first administration. Bronchoalveolar lavage fluid (BALF) was obtained 5hours after HCL instillation. In BALF, increases in total nuclear cell counts, neutrophil counts, optical density at 412nm as an indicator of pulmonary hemorrhage, neutrophil elastase activity, concentrations of albumin and cytokine-induced neutrophil chemoattractant (CINC) induced by HCL instillation were significantly attenuated by surfactant treatment. The wet-to-dry weight (W/D) ratio in the lung and partial oxygen tension (P(O2)) were also estimated; surfactant treatment significantly attenuated the W/D ratio and improved deteriorated P(O2) induced by HCL. Additional surfactant supplementation did not show further beneficial effects on HCL-induced lung injury compared with a single treatment. These results suggest that surfactant shows an anti-inflammatory effect on acid lung injury in rats but the beneficial effects may be dose limited.
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Affiliation(s)
- Ming-Yuan Jian
- First Department of Internal Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto 390-8621, Japan
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Martínez Ó, Nin N, Esteban A. Prone Position for the Treatment of Acute Respiratory Distress Syndrome: A Review of Current Literature. ACTA ACUST UNITED AC 2009. [DOI: 10.1016/s1579-2129(09)72420-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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[Prone position for the treatment of acute respiratory distress syndrome: a review of current literature]. Arch Bronconeumol 2009; 45:291-6. [PMID: 19403223 DOI: 10.1016/j.arbres.2008.05.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2008] [Accepted: 05/29/2008] [Indexed: 11/21/2022]
Abstract
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) have high incidence and mortality rates. Most of the recently introduced treatments have failed to improve the prognosis of patients with ALI or ARDS or to reduce mortality. Several studies have shown improved oxygenation in the prone position during mechanical ventilation in patients with ARDS. However, current evidence strongly suggests that placing ARDS patients in prone position does not improve survival or reduce the duration of mechanical ventilation. Therefore, though in clinical practice this position may improve refractory hypoxemia in patients with ARDS, there is no evidence to support its systematic use.
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Sun Y, Yang R, Zhong JG, Fang F, Jiang JJ, Liu MY, Lu J. Aerosolised surfactant generated by a novel noninvasive apparatus reduced acute lung injury in rats. Crit Care 2009; 13:R31. [PMID: 19257907 PMCID: PMC2689462 DOI: 10.1186/cc7737] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2008] [Revised: 02/23/2009] [Accepted: 03/04/2009] [Indexed: 11/18/2022] Open
Abstract
Introduction Exogenous surfactant has been explored as a potential therapy for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). In the present study, a nebuliser driven by oxygen lines found in the hospital was developed to deliver aerosolised porcine pulmonary surfactant (PPS). We hypothesised that aerosolised surfactant inhaled through spontaneous breathing may effectively reduce severe lung injury. Methods Rats were intravenously injected with oleic acid (OA) to induce ALI and 30 minutes later they were divided into five groups: model (injury only), PPS aerosol (PPS-aer), saline aerosol (saline-aer), PPS instillation (PPS-inst), and saline instillation (Saline-Inst). Blood gases, lung histology, and protein and TNF-α concentrations in the bronchoalveolar lavage fluid (BALF) were examined. Results The PPS aerosol particles were less than 2.0 μm in size as determined by a laser aerosol particle counter. Treatment of animals with a PPS aerosol significantly increased the phospholipid content in the BALF, improved lung function, reduced pulmonary oedema, decreased total protein and TNF-α concentrations in BALF, ameliorated lung injury and improved animal survival. These therapeutic effects are similar to those seen in the PPS-inst group. Conclusions This new method of PPS aerosolisation combines the therapeutic effects of a surfactant with partial oxygen inhalation under spontaneous breathing. It is an effective, simple and safe method of administering an exogenous surfactant.
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Affiliation(s)
- Yu Sun
- Department of Pathophysiology, College of Basic Medical Sciences, Second Military Medical University, 800 Xiangyin Road, Shanghai, 200433, China
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Pulmonary Surfactant: Biology and Therapy. THE RESPIRATORY TRACT IN PEDIATRIC CRITICAL ILLNESS AND INJURY 2009. [PMCID: PMC7124042 DOI: 10.1007/978-1-84800-925-7_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
OBJECTIVE Acute respiratory distress syndrome is a common disorder associated with significant mortality and morbidity. The aim of this article is to critically evaluate the definition of acute respiratory distress syndrome and examine the impact the definition has on clinical practice and research. DATA SOURCES Articles from a MEDLINE search (1950 to August 2007) using the Medical Subject Heading respiratory distress syndrome, adult, diagnosis, limited to the English language and human subjects, their relevant bibliographies, and personal collections, were reviewed. DATA SYNTHESIS The definition of acute respiratory distress syndrome is important to researchers, clinicians, and administrators alike. It has evolved significantly over the last 40 years, culminating in the American-European Consensus Conference definition, which was published in 1994. Although the American-European Consensus Conference definition is widely used, it has some important limitations that may impact on the conduct of clinical research, on resource allocation, and ultimately on the bedside management of such patients. These limitations stem partially from the fact that as defined, acute respiratory distress syndrome is a heterogeneous entity and also involve the reliability and validity of the criteria used in the definition. This article critically evaluates the American-European Consensus Conference definition and its limitations. Importantly, it highlights how these limitations may contribute to clinical trials that have failed to detect a potential true treatment effect. Finally, recommendations are made that could be considered in future definition modifications with an emphasis on the significance of accurately identifying the target population in future trials and subsequently in clinical care. CONCLUSION How acute respiratory distress syndrome is defined has a significant impact on the results of randomized, controlled trials and epidemiologic studies. Changes to the current American-European Consensus Conference definition are likely to have an important role in advancing the understanding and management of acute respiratory distress syndrome.
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Taut FJ, Rippin G, Schenk P, Findlay G, Wurst W, Häfner D, Lewis JF, Seeger W, Günther A, Spragg RG. A Search for Subgroups of Patients With ARDS Who May Benefit From Surfactant Replacement Therapy. Chest 2008; 134:724-732. [DOI: 10.1378/chest.08-0362] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
This article reviews exogenous surfactant therapy and its use in mitigating acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) in infants, children, and adults. Biophysical and animal research documenting surfactant dysfunction in ALI/ARDS is described, and the scientific rationale for treatment with exogenous surfactant is discussed. Major emphasis is placed on reviewing clinical studies of surfactant therapy in pediatric and adult patients who have ALI/ARDS. Particular advantages from surfactant therapy in direct pulmonary forms of these syndromes are described. Also discussed are additional factors affecting the efficacy of exogenous surfactants in ALI/ARDS.
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Affiliation(s)
- Douglas F Willson
- Pediatric ICU and Division of Pediatric Critical Care, University of Virginia Children's Medical Center, UVA Health Sciences System, Box 800386, Charlottesville, VA 22908-0386, USA.
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Schuster KM, Alouidor R, Barquist ES. Nonventilatory interventions in the acute respiratory distress syndrome. J Intensive Care Med 2008; 23:19-32. [PMID: 18230633 DOI: 10.1177/0885066607310166] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute respiratory distress syndrome was first described in 1967. Acute respiratory distress syndrome and acute lung injury are diseases the busy intensivist treats almost daily. The etiologies of acute respiratory distress syndrome are many. A significant distinction is based on whether the insult to the lung was direct, such as in pneumonia, or indirect, such as trauma or sepsis. Strategies for managing patients with acute respiratory distress syndrome/acute lung injury can be subdivided into 2 large groups, those based in manipulation of mechanical ventilation and those based in nonventilatory modalities. This review focuses on the nonventlilatory strategies and includes fluid restriction, exogenous surfactant, inhaled nitric oxide, manipulation of production, or administration of eicosanoids, neuromuscular blocking agents, prone position ventilation, glucocorticoids, extracorporeal membrane oxygenation, and administration of beta-agonists. Most of these therapies either have not been studied in large trials or have failed to show a benefit in terms of long-term patient mortality. Many of these therapies have shown promise in terms of improved oxygenation and may therefore be beneficial as rescue therapy for severely hypoxic patients. Recommendations regarding the use of each of these strategies are made, and an algorithm for implementing these strategies is suggested.
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Affiliation(s)
- Kevin M Schuster
- Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, Connecticut, USA
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Zuo YY, Veldhuizen RAW, Neumann AW, Petersen NO, Possmayer F. Current perspectives in pulmonary surfactant--inhibition, enhancement and evaluation. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2008; 1778:1947-77. [PMID: 18433715 DOI: 10.1016/j.bbamem.2008.03.021] [Citation(s) in RCA: 361] [Impact Index Per Article: 22.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 12/06/2007] [Revised: 03/26/2008] [Accepted: 03/26/2008] [Indexed: 02/06/2023]
Abstract
Pulmonary surfactant (PS) is a complicated mixture of approximately 90% lipids and 10% proteins. It plays an important role in maintaining normal respiratory mechanics by reducing alveolar surface tension to near-zero values. Supplementing exogenous surfactant to newborns suffering from respiratory distress syndrome (RDS), a leading cause of perinatal mortality, has completely altered neonatal care in industrialized countries. Surfactant therapy has also been applied to the acute respiratory distress syndrome (ARDS) but with only limited success. Biophysical studies suggest that surfactant inhibition is partially responsible for this unsatisfactory performance. This paper reviews the biophysical properties of functional and dysfunctional PS. The biophysical properties of PS are further limited to surface activity, i.e., properties related to highly dynamic and very low surface tensions. Three main perspectives are reviewed. (1) How does PS permit both rapid adsorption and the ability to reach very low surface tensions? (2) How is PS inactivated by different inhibitory substances and how can this inhibition be counteracted? A recent research focus of using water-soluble polymers as additives to enhance the surface activity of clinical PS and to overcome inhibition is extensively discussed. (3) Which in vivo, in situ, and in vitro methods are available for evaluating the surface activity of PS and what are their relative merits? A better understanding of the biophysical properties of functional and dysfunctional PS is important for the further development of surfactant therapy, especially for its potential application in ARDS.
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Affiliation(s)
- Yi Y Zuo
- Department of Biochemistry, University of Western Ontario, London, Ontario, Canada
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76
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Yamashita C, Forbes A, Tessolini JM, Yao LJ, Lewis JF, Veldhuizen RAW. Protective effects of elevated endogenous surfactant pools to injurious mechanical ventilation. Am J Physiol Lung Cell Mol Physiol 2008; 294:L724-32. [DOI: 10.1152/ajplung.00389.2007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Depletion of alveolar macrophages (AM) leads to an increase in endogenous surfactant that lasts several days beyond the repletion of AM. Furthermore, impairment to the endogenous pulmonary surfactant system contributes to ventilation-induced lung injury. The objective of the current study was to determine whether increased endogenous surfactant pools induced via AM depletion was protective against ventilation-induced lung injury. Adult rats were intratracheally instilled with either control or dichloromethylene diphosphonic acid (DMDP) containing liposomes to deplete AMs and thereby increase endogenous surfactant pools. Either 3 or 7 days following instillation, rats were exposed to 2 h of injurious ventilation using either an ex vivo or in vivo ventilation protocol and were compared with nonventilated controls. The measured outcomes were oxygenation, lung compliance, lavage protein, and inflammatory cytokine concentrations. Compared with controls, the DMDP-treated animals had significantly reduced AM numbers and increased surfactant pools 3 days after instillation. Seven days after instillation, AM numbers had returned to normal, but surfactant pools were still elevated. DMDP-treated animals at both time points exhibited protection against ventilation-induced lung injury, which included superior physiological parameters, lower protein leakage, and lower inflammatory mediator release into the air space, compared with animals not receiving DMDP. It is concluded that DMDP-liposome administration protects against ventilation-induced lung injury. This effect appears to be due to the presence of elevated endogenous surfactant pools.
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77
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Duffett M, Choong K, Ng V, Randolph A, Cook DJ. Surfactant therapy for acute respiratory failure in children: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 11:R66. [PMID: 17573963 PMCID: PMC2206432 DOI: 10.1186/cc5944] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/16/2007] [Revised: 05/11/2007] [Accepted: 06/15/2007] [Indexed: 11/10/2022]
Abstract
Introduction Exogenous surfactant is used to treat acute respiratory failure in children, although the benefits and harms in this setting are not clear. The objective of the present systematic review is to assess the effect of exogenous pulmonary surfactant on all-cause mortality in children mechanically ventilated for acute respiratory failure. Methods We searched the MEDLINE, EMBASE, CINAHL and Ovid Healthstar databases, the bibliographies of included trials and review articles, conference proceedings and trial registries. We included prospective, randomized, controlled trials of pulmonary surfactant that enrolled intubated and mechanically ventilated children with acute respiratory failure. We excluded trials that exclusively enrolled neonates or patients with asthma. Two reviewers independently rated trials for inclusion, extracted data and assessed the methodologic quality. We quantitatively pooled the results of trials, where suitable, using a random effects model. Results Six trials randomizing 314 patients were included. Surfactant use reduced mortality (relative risk = 0.7, 95% confidence interval = 0.4 to 0.97, P = 0.04), was associated with increased ventilator-free days (weighted mean difference = 2.5 days, 95% confidence interval = 0.3 to 4.6 days, P = 0.02) and reduced the duration of ventilation (weighted mean difference = 2.3 days, 95% confidence interval = 0.1 to 4.4 days, P = 0.04). Conclusion Surfactant use decreased mortality, was associated with more ventilator-free days and reduced the duration of ventilation. No serious adverse events were reported.
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Affiliation(s)
- Mark Duffett
- Department of Critical Care, McMaster Children's Hospital, 1200 Main St. W., Hamilton, Ontario L8S 4J9, Canada
| | - Karen Choong
- Department of Critical Care, McMaster Children's Hospital, 1200 Main St. W., Hamilton, Ontario L8S 4J9, Canada
| | - Vivian Ng
- Grand River Hospital, 835 King St. West, Kitchener, Ontario N2G 1G3, Canada
| | - Adrienne Randolph
- Children's Hospital Boston, 300 Longwood Avenue, MSICU, FA-108, Boston, MA 02115, USA
| | - Deborah J Cook
- Department of Clinical Epidemiology and Statistics, McMaster University, 1200 Main St. W., Hamilton, Ontario L8N 3Z5, Canada
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Acute Lung Injury: Acute Respiratory Distress Syndrome. MECHANICAL VENTILATION 2008. [PMCID: PMC7149661 DOI: 10.1016/b978-0-7216-0186-1.50008-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Ikegami M, Scoville EA, Grant S, Korfhagen T, Brondyk W, Scheule RK, Whitsett JA. Surfactant Protein-D and Surfactant Inhibit Endotoxin-Induced Pulmonary Inflammation. Chest 2007; 132:1447-54. [DOI: 10.1378/chest.07-0864] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Schmidt R, Markart P, Ruppert C, Wygrecka M, Kuchenbuch T, Walmrath D, Seeger W, Guenther A. Time-dependent changes in pulmonary surfactant function and composition in acute respiratory distress syndrome due to pneumonia or aspiration. Respir Res 2007; 8:55. [PMID: 17662121 PMCID: PMC1950506 DOI: 10.1186/1465-9921-8-55] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2007] [Accepted: 07/27/2007] [Indexed: 01/11/2023] Open
Abstract
Background Alterations to pulmonary surfactant composition have been encountered in the Acute Respiratory Distress Syndrome (ARDS). However, only few data are available regarding the time-course and duration of surfactant changes in ARDS patients, although this information may largely influence the optimum design of clinical trials addressing surfactant replacement therapy. We therefore examined the time-course of surfactant changes in 15 patients with direct ARDS (pneumonia, aspiration) over the first 8 days after onset of mechanical ventilation. Methods Three consecutive bronchoalveolar lavages (BAL) were performed shortly after intubation (T0), and four days (T1) and eight days (T2) after intubation. Fifteen healthy volunteers served as controls. Phospholipid-to-protein ratio in BAL fluids, phospholipid class profiles, phosphatidylcholine (PC) molecular species, surfactant proteins (SP)-A, -B, -C, -D, and relative content and surface tension properties of large surfactant aggregates (LA) were assessed. Results At T0, a severe and highly significant reduction in SP-A, SP-B and SP-C, the LA fraction, PC and phosphatidylglycerol (PG) percentages, and dipalmitoylation of PC (DPPC) was encountered. Surface activity of the LA fraction was greatly impaired. Over time, significant improvements were encountered especially in view of LA content, DPPC, PG and SP-A, but minimum surface tension of LA was not fully restored (15 mN/m at T2). A highly significant correlation was observed between PaO2/FiO2 and minimum surface tension (r = -0.83; p < 0.001), SP-C (r = 0.64; p < 0.001), and DPPC (r = 0.59; p = 0.003). Outcome analysis revealed that non-survivors had even more unfavourable surfactant properties as compared to survivors. Conclusion We concluded that a profound impairment of pulmonary surfactant composition and function occurs in the very early stage of the disease and only gradually resolves over time. These observations may explain why former surfactant replacement studies with a short treatment duration failed to improve outcome and may help to establish optimal composition and duration of surfactant administration in future surfactant replacement studies in acute lung injury.
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Affiliation(s)
- Reinhold Schmidt
- University of Giessen Lung Center (UGLC), Medical Clinic II, Giessen, Germany
| | - Philipp Markart
- University of Giessen Lung Center (UGLC), Medical Clinic II, Giessen, Germany
| | - Clemens Ruppert
- University of Giessen Lung Center (UGLC), Medical Clinic II, Giessen, Germany
| | - Malgorzata Wygrecka
- University of Giessen Lung Center (UGLC), Medical Clinic II, Giessen, Germany
| | - Tim Kuchenbuch
- University of Giessen Lung Center (UGLC), Medical Clinic II, Giessen, Germany
| | - Dieter Walmrath
- University of Giessen Lung Center (UGLC), Medical Clinic II, Giessen, Germany
| | - Werner Seeger
- University of Giessen Lung Center (UGLC), Medical Clinic II, Giessen, Germany
| | - Andreas Guenther
- University of Giessen Lung Center (UGLC), Medical Clinic II, Giessen, Germany
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81
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Abstract
PURPOSE OF REVIEW The aim of this article is to discuss the various factors that influence aerosol delivery in mechanically ventilated patients and clarify optimal techniques for aerosol administration in this patient population. Clinical use of various inhaled therapies in patients receiving invasive and noninvasive mechanical ventilation is also discussed. RECENT FINDINGS With optimal techniques for using pressurized metered-dose inhalers and nebulizers in ventilator circuits, the efficiency of inhaled drug delivery in mechanically ventilated patients is comparable to that in ambulatory patients. Techniques for enhancing inhaled drug delivery during noninvasive positive pressure ventilation are also being investigated. SUMMARY Pressurized metered-dose inhalers of bronchodilator and corticosteroid aerosols are more efficient and convenient to use than nebulizers for routine therapy in ventilated patients. Nebulizers are, however, more versatile and are employed to generate aerosols of bronchodilators, corticosteroids, antibiotics, prostaglandins, surfactant, and mucolytic agents. Factors influencing drug delivery during noninvasive positive pressure ventilation are not fully understood as yet, and further work is needed to enhance drug delivery in this setting. Improvements in drug formulations and the design and efficiency of aerosol generating devices have led to increasing application of inhaled therapies in mechanically ventilated patients.
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Affiliation(s)
- Rajiv Dhand
- Division of Pulmonary, Critical Care and Environmental Medicine, Department of Internal Medicine, University of Missouri, Columbia, Missouri 65212, USA.
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82
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Abstract
Acute respiratory distress syndrome and acute lung injury are well defined and readily recognised clinical disorders caused by many clinical insults to the lung or because of predispositions to lung injury. That this process is common in intensive care is well established. The mainstay of treatment for this disorder is provision of excellent supportive care since these patients are critically ill and frequently have coexisting conditions including sepsis and multiple organ failure. Refinements in ventilator and fluid management supported by data from prospective randomised trials have increased the methods available to effectively manage this disorder.
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Affiliation(s)
- Arthur P Wheeler
- Medical Intensive Care Unit, Vanderbilt University Medical Center, Nashville, TN 37232-2650, USA
| | - Gordon R Bernard
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-2650, USA.
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83
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Abstract
Over the past decade, advances in the ventilatory management of acute lung injury (ALI) and ARDS have improved outcomes; however, until recently the search for other therapies has been less fruitful. Recently, the Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment Trial reported that a conservative fluid management strategy, compared with a fluid liberal strategy, increased the mean (+/- SE) number of ventilator-free days in patients with ALI (14.6 +/- 0.5 vs 12.1 +/- 0.5 days, respectively; p < 0.001). In addition to this beneficial effect on outcomes, the study found that the conservative fluid strategy did not increase the incidence of renal failure or the development of shock. Other studies have demonstrated that albumin and furosemide therapy may be beneficial in hypoproteinemic patients with lung injury, though data on outcomes is still lacking. Although several pharmacologic therapies, such as corticosteroids, surfactant, and nitric oxide, have been demonstrated to be ineffective in improving outcomes, several promising new treatments are being investigated in ongoing or upcoming clinical trials. This article reviews these developments and other recent research on the optimal nonventilatory management of patients with ALI.
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Affiliation(s)
- Carolyn S Calfee
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California at San Francisco, San Francisco, CA..
| | - Michael A Matthay
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of California at San Francisco, San Francisco, CA
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84
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Blanco O, Pérez-Gil J. Biochemical and pharmacological differences between preparations of exogenous natural surfactant used to treat Respiratory Distress Syndrome: role of the different components in an efficient pulmonary surfactant. Eur J Pharmacol 2007; 568:1-15. [PMID: 17543939 DOI: 10.1016/j.ejphar.2007.04.035] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2006] [Revised: 04/10/2007] [Accepted: 04/17/2007] [Indexed: 12/01/2022]
Abstract
The pharmaceutical application of exogenous natural pulmonary surfactant preparations has shown its efficiency in the therapeutical treatment of infants with Respiratory Distress Syndrome. At the same time, the use of these preparations in patients with Acute Respiratory Distress Syndrome, although not still an effective therapy, shows promising results. The analysis of composition, structure and surface activity of some of the different natural surfactant preparations available today for clinical use reveals important differences, a fact that opens horizons in the optimization of new effective formulations in the treatment of the Acute Respiratory Distress Syndrome. The purpose of this review is to carry out an updating of the current models interpreting the role of the main components of pulmonary surfactant as a reference to evaluate the biochemical composition of the preparations of exogenous natural pulmonary surfactant currently in use and their apparent pharmacological effect.
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Affiliation(s)
- Odalys Blanco
- Chemical-Pharmacology-Toxicology Group, Direction of Health and Animal Production, National Center of Agropecuary Sanity, Havana, Cuba
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85
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Markart P, Ruppert C, Wygrecka M, Colaris T, Dahal B, Walmrath D, Harbach H, Wilhelm J, Seeger W, Schmidt R, Guenther A. Patients with ARDS show improvement but not normalisation of alveolar surface activity with surfactant treatment: putative role of neutral lipids. Thorax 2007; 62:588-94. [PMID: 17287298 PMCID: PMC2117258 DOI: 10.1136/thx.2006.062398] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Extensive biochemical and biophysical changes of the pulmonary surfactant system occur in the acute respiratory distress syndrome (ARDS). METHODS The effect of intrabronchial administration of a recombinant surfactant protein C-based surfactant preparation (Venticute) on gas exchange, surfactant composition and function was investigated in 31 patients with ARDS in a randomised controlled phase I/II clinical pilot trial. Bronchoalveolar lavage fluids for surfactant analysis were obtained 3 h before and 48 and 120 h after the first surfactant application. Potentially deleterious effects of surfactant neutral lipids in patients with ARDS were also identified. RESULTS Before treatment all patients had marked abnormalities in the surfactant phospholipid and protein composition. In response to surfactant treatment, gas exchange improved and surfactant phospholipid and protein content were almost normalised. Alveolar surface activity was dramatically impaired before treatment and only partially improved after surfactant administration. Further analysis of the bronchoalveolar lavage fluids revealed a twofold increase in neutral lipid content and altered neutral lipid profile in patients with ARDS compared with healthy controls. These differences persisted even after administration of large amounts of Venticute. Supplementation of Venticute or natural surfactant with a synthetic neutral lipid preparation, mimicking the profile in ARDS, caused a dose-dependent deterioration of surface activity in vitro. CONCLUSION Intrabronchial surfactant treatment improves gas exchange in ARDS, but the efficacy may be limited by increased concentration and altered neutral lipid profile in surfactant under these conditions.
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Affiliation(s)
- Philipp Markart
- Department of Internal Medicine, Faculty of Medicine, University of Giessen Lung Center, Klinikstrasse 36, 35392 Giessen, Germany
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Anzueto A, Guntapalli K. Adjunctive therapy to mechanical ventilation: surfactant therapy, liquid ventilation, and prone position. Clin Chest Med 2007; 27:637-54; abstract ix. [PMID: 17085252 DOI: 10.1016/j.ccm.2006.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute lung injury and acute respiratory distress syndrome are associated with significant morbidity and mortality in critically ill patients. Although lung protective mechanical ventilation is the only therapy shown to reduce mortality and development of organ failure, several biologic pathways have been identified and provided an opportunity for therapeutic interventions. No pharmacologic or adjunctive treatments are available. Clinical studies demonstrated that prone position results in significant and clinically relevant improvement in oxygenation and ventilation, which persist when patients are returned to supine position; the beneficial response is not limited to patients turned early in disease course. Few complications are associated with prone ventilation. Clinical experience suggests that prone ventilation may protect the lung from potential detrimental effects of mechanical ventilation. Further studies are needed.
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Affiliation(s)
- Antonio Anzueto
- University of Texas Health Science Center, San Antonio, TX 78229, USA.
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87
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Dhand R, Mercier E. Effective inhaled drug administration to mechanically ventilated patients. Expert Opin Drug Deliv 2006. [DOI: 10.1517/17425247.4.1.47] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Davidson WJ, Dorscheid D, Spragg R, Schulzer M, Mak E, Ayas NT. Exogenous pulmonary surfactant for the treatment of adult patients with acute respiratory distress syndrome: results of a meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2006; 10:R41. [PMID: 16542488 PMCID: PMC1550886 DOI: 10.1186/cc4851] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2005] [Revised: 02/09/2006] [Accepted: 02/13/2006] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The purpose of this study was to perform a systematic review and meta-analysis of exogenous surfactant administration to assess whether this therapy may be useful in adult patients with acute respiratory distress syndrome. METHODS We performed a computerized literature search from 1966 to December 2005 to identify randomized clinical trials. The primary outcome measure was mortality 28-30 days after randomization. Secondary outcome measures included a change in oxygenation (PaO2:FiO2 ratio), the number of ventilation-free days, and the mean duration of ventilation. Meta-analysis was performed using the inverse variance method. RESULTS Two hundred and fifty-one articles were identified. Five studies met our inclusion criteria. Treatment with pulmonary surfactant was not associated with reduced mortality compared with the control group (odds ratio 0.97; 95% confidence interval (CI) 0.73, 1.30). Subgroup analysis revealed no difference between surfactant containing surface protein or not - the pooled odds ratio for mortality was 0.87 (95% CI 0.48, 1.58) for trials using surface protein and the odds ratio was 1.08 (95% CI 0.72, 1.64) for trials without surface protein. The mean difference in change in the PaO2:FiO2 ratio was not significant (P = 0.11). There was a trend for improved oxygenation in the surfactant group (pooled mean change 13.18 mmHg, standard error 8.23 mmHg; 95% CI -2.95, 29.32). The number of ventilation-free days and the mean duration of ventilation could not undergo pooled analysis due to a lack of sufficient data. CONCLUSION Exogenous surfactant may improve oxygenation but has not been shown to improve mortality. Currently, exogenous surfactant cannot be considered an effective adjunctive therapy in acute respiratory distress syndrome.
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Affiliation(s)
- Warren J Davidson
- Department of Medicine University of British Columbia, Vancouver, British Columbia, Canada.
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89
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Abstract
Regardless of the cause, a common pathophysiological feature of patients with acute respiratory distress syndrome is a dysfunction of the endogenous surfactant system. Although exogenous surfactant therapy has proven to be an effective treatment for neonatal respiratory distress syndrome, no similar current effective therapy exists for patients with acute respiratory distress syndrome. This is mainly due to the complexity of the lung injury that is involved with this disorder. Results from clinical trials, to date, have failed to show an improvement in patient survival after administration of exogenous surfactant; however, ongoing and future research efforts suggest that this therapy may eventually be feasible.
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Affiliation(s)
- Adam Maruscak
- St. Joseph's Health Centre, London, ON, N6A 4V2, Canada
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Cepkova M, Matthay MA. Pharmacotherapy of acute lung injury and the acute respiratory distress syndrome. J Intensive Care Med 2006; 21:119-43. [PMID: 16672636 PMCID: PMC2765330 DOI: 10.1177/0885066606287045] [Citation(s) in RCA: 140] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Acute lung injury and the acute respiratory distress syndrome are common syndromes with a high mortality rate that affect both medical and surgical patients. Better understanding of the pathophysiology of acute lung injury and the acute respiratory distress syndrome and advances in supportive care and mechanical ventilation have led to improved clinical outcomes since the syndrome was first described in 1967. Although several promising pharmacological therapies, including surfactant, nitric oxide, glucocorticoids and lysofylline, have been studied in patients with acute lung injury and the acute respiratory distress syndrome, none of these pharmacological treatments reduced mortality. This article provides an overview of pharmacological therapies of acute lung injury and the acute respiratory distress syndrome tested in clinical trials and current recommendations for their use as well as a discussion of potential future pharmacological therapies including beta(2)-adrenergic agonist therapy, keratinocyte growth factor, and activated protein C.
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Affiliation(s)
- Magda Cepkova
- Cardiovascular Research Institute, University of California San Francisco, CA 94143-0130, USA.
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91
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Vreugdenhil HA, Lachmann B, Haitsma JJ, Zijlstra J, Heijnen CJ, Jansen NJ, van Vught AJ. Exogenous surfactant restores lung function but not peripheral immunosuppression in ventilated surfactant-deficient rats. Exp Lung Res 2006; 32:1-14. [PMID: 16809217 DOI: 10.1080/01902140600575006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The authors have previously shown that mechanical ventilation can result in increased pulmonary inflammation and suppressed peripheral leukocyte function. In the present study the effect of surfactant therapy on pulmonary inflammation and peripheral immune function in ventilated surfactant-deficient rats was assessed. Surfactant deficiency was induced by repeated lung lavage, treated rats with surfactant or left them untreated, and ventilated the rats during 2 hours. Nonventilated rats served as healthy control group. Expression of macrophage inflammatory protein (MIP)-2 was measured in bronchoalveolar lavage (BAL), interleukin (IL)-1beta, and heat shock protein 70 (HSP70) were measured in total lung homogenates. Outside the lung phytohemagglutinin (PHA)-induced lymphocyte proliferation, interferon (IFN)-gamma and IL-10 production, and natural killer activity were measured in splenocytes. After 2 hours of mechanical ventilation, expression of MIP-2, IL-1beta, and HSP70 increased significantly in the lungs of surfactant-deficient rats. Outside the lung, mitogen-induced proliferation and production of IFN-gamma and IL-10 reduced significantly. Only natural killer cell activity remained unaffected. Surfactant treatment significantly improved lung function, but could not prevent increased pulmonary expression of MIP-2, IL-1beta, and HSP70 and decreased peripheral mitogen-induced lymphocyte proliferation and IFN-gamma and IL-10 production in vitro. In conclusion, 2 hours of mechanical ventilation resulted in increased lung inflammation and partial peripheral leukocyte suppression in surfactant-deficient rats. Surfactant therapy ameliorated lung function but could not prevent or restore peripheral immunosuppression. The authors postulate that peripheral immunosuppression may occur in ventilated surfactant deficient patients, which may enhance susceptibility for infections.
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Affiliation(s)
- Harriet A Vreugdenhil
- Pediatric Intensive Care Unit, and Laboratory for Psycho-Neuroimmunology, University Medical Center Utrecht, Utrecht, The Netherlands
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Kesecioglu J, Haitsma JJ. Surfactant therapy in adults with acute lung injury/acute respiratory distress syndrome. Curr Opin Crit Care 2006; 12:55-60. [PMID: 16394785 DOI: 10.1097/01.ccx.0000199000.19393.a7] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Several phase II and phase III studies have been performed to investigate safety, efficacy and the improvement of survival due to exogenous surfactant instillation in patients with acute lung injury or acute respiratory distress syndrome. In this review we will discuss the most recent of these studies, paying particular attention to differences in the composition of the exogenous surfactant used, the diverse modes of delivery and dose of therapy and the influence of mechanical ventilation. RECENT FINDINGS Several phase II studies performed on patients with acute lung injury or acute respiratory distress syndrome and a phase III study performed on a pediatric population have shown beneficial effects of surfactant on oxygenation and survival. No effect of exogenous surfactant has been shown on survival in phase III studies in adult patients. SUMMARY The changes in the surfactant system of patients with acute lung injury and acute respiratory distress syndrome form the rationale for the instillation of exogenous surfactant. There is enough evidence to use surfactant instillation for pediatric patients with acute lung injury. Due to the results of the randomized controlled trials performed so far, however, exogenous surfactant is not recommended for routine use in patients with acute lung injury or acute respiratory distress syndrome. In the future, other surfactants with different compositions may show beneficial effects.
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Affiliation(s)
- Jozef Kesecioglu
- Department of Intensive Care Medicine, University Medical Center, Utrecht, The Netherlands.
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93
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Abstract
Animal-derived surfactant preparations are very effective in the treatment of premature infants with respiratory distress syndrome but they are expensive to produce and supplies are limited. In order to widen the indications for surfactant treatment there is a need for synthetic preparations, which can be produced in large quantities and at a reasonable cost. However, development of clinically active synthetic surfactants has turned out to be more complicated than initially anticipated. The hydrophobic surfactant proteins, SP-B and SP-C, which are involved in the adsorption of surface-active lipids to the air-liquid interface of the alveoli and increase alveolar stability, are either too big to synthesize, structurally complex or unstable in pure form. A new generation of synthetic surfactants containing simplified phospholipid mixtures and small amounts of peptides replacing the hydrophobic proteins is currently under development and will in the near future be introduced into the market. However, more trials need to be performed before any conclusions can be drawn about the effectiveness of these synthetic surfactants in relation to natural animal-derived preparations.
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Affiliation(s)
- Tore Curstedt
- Department of Clinical Chemistry, Karolinska University Hospital, Stockholm, Sweden.
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Lukovic D, Plasencia I, Taberner FJ, Salgado J, Calvete JJ, Pérez-Gil J, Mingarro I. Production and characterisation of recombinant forms of human pulmonary surfactant protein C (SP-C): Structure and surface activity. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2006; 1758:509-18. [PMID: 16631109 DOI: 10.1016/j.bbamem.2006.03.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Revised: 03/03/2006] [Accepted: 03/06/2006] [Indexed: 11/26/2022]
Abstract
Surfactant protein C (SP-C) is an essential component for the surface tension-lowering activity of the pulmonary surfactant system. It contains a valine-rich alpha helix that spans the lipid bilayer, and is one of the most hydrophobic proteins known so far. SP-C is also an essential component of various surfactant preparations of animal origin currently used to treat neonatal respiratory distress syndrome (NRDS) in preterm infants. The limited supply of this material and the risk of transmission of infectious agents and immunological reactions have prompted the development of synthetic SP-C-derived peptides or recombinant humanized SP-C for inclusion in new preparations for therapeutic use. We describe herein the recombinant production in bacterial cultures of SP-C variants containing phenylalanines instead of the palmitoylated cysteines of the native protein, as fusions to the hydrophilic nuclease A (SN) from Staphylococcus aureus. The resulting chimerae were partially purified by affinity chromatography and subsequently subjected to protease digestion. The SP-C forms were recovered from the digestion mixtures by organic extraction and further purified by size exclusion chromatography. The two recombinant SP-C variants so obtained retained more than 50% alpha-helical content and showed surface activity comparable to the native protein, as measured by surface spreading of lipid/protein suspensions and from compression pi-A isotherms of lipid/protein films. Compared to the protein purified from porcine lungs, the recombinant SP-C forms improved movement of phospholipid molecules into the interface (during adsorption), or out from the interfacial film (during compression), suggesting new possibilities to develop improved therapeutic preparations.
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Affiliation(s)
- Dunja Lukovic
- Departament de Bioquímica i Biologia Molecular, Universitat de València, E-46 100 Burjassot (Valencia), Spain
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95
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Zhou J, Wu Y, Henderson F, McCoy DM, Salome RG, McGowan SE, Mallampalli RK. Adenoviral gene transfer of a mutant surfactant enzyme ameliorates pseudomonas-induced lung injury. Gene Ther 2006; 13:974-85. [PMID: 16511521 DOI: 10.1038/sj.gt.3302746] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Surfactant deficiency is an important contributor to the acute respiratory distress syndrome, a disorder that commonly occurs after bacterial sepsis. CTP:phosphocholine cytidylyltransferase (CCTalpha) is the rate-limiting enzyme required for the biosynthesis of dipalmitoylphosphatidylcholine (DPPC), the major phospholipid of surfactant. In this study, a cDNA encoding a novel, calpain-resistant mutant CCTalpha enzyme was delivered intratracheally in mice using a replication-deficient adenovirus 5 CTP:phosphocholine cytidylyltransferase construct (Ad5-CCT(Penta)) in models of bacterial sepsis. Ad5-CCT(Penta) gene transfer produced high-level CCTalpha gene expression, increased alveolar surfactant (DPPC) levels and improved lung surface tension and pressure-volume relationships relative to control mice. Pseudomonas aeruginosa (PA103) decreased DPPC synthesis, in part, via calpain-mediated degradation of CCTalpha. Deleterious effects of Pseudomonas on surfactant were lessened after infection with a mutant strain lacking the type III exotoxin, Exo U. Replication-deficient adenovirus 5 CTP:phosphocholine cytidylyltransferase gene delivery improved lung biophysical properties by optimizing surface activity in this Pseudomonas model of proteinase-mediated lung injury. The studies are the first demonstration of in vivo gene transfer of a lipogenic enzyme resulting in improved lung mechanics. The studies suggest that augmentation of DPPC synthesis via gene delivery of CCTalpha can attenuate impaired lung function in surfactant-deficient states such as bacterial sepsis.
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Affiliation(s)
- J Zhou
- Department of Internal Medicine, Pulmonary and Critical Care Division, Roy J and Lucille A Carver College of Medicine, The University of Iowa, Iowa City, IA 52242, USA
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96
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Abstract
Acute respiratory distress syndrome (ARDS) is an Inflammatory process caused by a variety of direct and indirect injuries to the lungs. Despite improvements in supportive care and advances in ventilator management, mortality in patients with ARDS remains high. Multiple pharmacological interventions have been investigated but have not shown improved survival. Clinical trials using corticosterolds, prostaglandins, nitric oxide, prostacyclin, surfactant, lisofylline, ketoconazole, N-acetylcystelne, and fish oil have been unable to show a statistically significant Improvement in patient mortality. As more is understood about the pathophyslology of ARDS, treatment strategies such as increasing alveolar fluid clearance through activation of sodium channels, enhancing repair of alveolar epithelium with growth factors, inhibiting fibrin deposition, blocking proinflammatory transcription factors, preventing the effect of potent vasocontrictors such as endothelin, and using antibodies against key inflammatory cytokines are being explored. This review focuses on the pharmacological treatments studied clinically, proposed reasons for their lack of success, and new concepts emerging in ARDS therapy.
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Affiliation(s)
- Raksha Jain
- Department of Internal Medicine, Pulmonary and Critical Care Division, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX 75390-9034, USA
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97
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Parmigiani S, Solari E, Bevilacqua G. Current concepts on the pulmonary surfactant in infants. J Matern Fetal Neonatal Med 2006; 18:369-80. [PMID: 16390802 DOI: 10.1080/14767050500244552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Surfactant has been a main topic of neonatology in the last 20 years. Many studies have been conducted since the discovery of its role in the pathogenesis of respiratory distress syndrome and the knowledge on its composition and metabolism has become complex. In this article we review the current concepts of its metabolism, ways of acting, properties of its proteins and activities other than the ability of reducing surface tension within the lung as a basis to understand the development of disease in case of its deficiency.
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Affiliation(s)
- S Parmigiani
- Department of Gynecologic, Obstetric and Neonatologic Sciences, Section of Child Health and Neonatology, University of Parma, Parma, Italy.
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98
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99
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Wüstneck R, Perez-Gil J, Wüstneck N, Cruz A, Fainerman VB, Pison U. Interfacial properties of pulmonary surfactant layers. Adv Colloid Interface Sci 2005; 117:33-58. [PMID: 16120435 DOI: 10.1016/j.cis.2005.05.001] [Citation(s) in RCA: 145] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2004] [Revised: 02/16/2005] [Accepted: 05/20/2005] [Indexed: 11/25/2022]
Abstract
The composition of the pulmonary surfactant and the border conditions of normal human breathing are relevant to characterize the interfacial behavior of pulmonary layers. Based on experimental data methods are reviewed to investigate interfacial properties of artificial pulmonary layers and to explain the behavior and interfacial structures of the main components during compression and expansion of the layers observed by epifluorescence and scanning force microscopy. Terms like over-compression, collapse, and formation of the surfactant reservoir are discussed. Consequences for the viscoelastic surface rheological behavior of such layers are elucidated by surface pressure relaxation and harmonic oscillation experiments. Based on a generalized Volmer isotherm the interfacial phase transition is discussed for the hydrophobic surfactant proteins, SP-B and SP-C, as well as for the mixtures of dipalmitoylphosphatidylcholine (DPPC) with these proteins. The behavior of the layers depends on both the oligomerisation state and the secondary structure of the hydrophobic surfactant proteins, which are controlled by the preparation of the proteins. An example for the surface properties of bronchoalveolar porcine lung washings of uninjured, injured, and Curosurf treated lavage is discussed in the light of surface behavior. An outlook summarizes the present knowledge and the main future development in this field of surface science.
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Affiliation(s)
- R Wüstneck
- Charité, Campus Virchow-Klinikum, Universitätsmedizin Berlin, Klinik für Anästhesiologie und operative Intensivmedizin, Spandauer Damm 130, 14050 Berlin, Germany.
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100
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Bernard GR. Acute respiratory distress syndrome: a historical perspective. Am J Respir Crit Care Med 2005; 172:798-806. [PMID: 16020801 PMCID: PMC2718401 DOI: 10.1164/rccm.200504-663oe] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2005] [Accepted: 07/14/2005] [Indexed: 12/28/2022] Open
Abstract
Though well described even in ancient writings, the acute respiratory distress syndrome (ARDS) gained major medical attention with the availability of mechanical ventilation and establishment of intensive care units. In the 50 years since this beginning there have been remarkable advances in the understanding of the etiology, physiology, histology, and epidemiology of this often lethal complication of common human maladies. Until recently, improvements in outcome have mainly followed improvements in intensive care unit operation and their associated life support systems, and have not come through discoveries made in the course of prospective randomized trials. In spite of the remarkable increase in research focused on ARDS, there remain a large number of unanswered clinical questions that are potentially extremely important with regard to short-term morbidity as well as long-term outcome. The ARDS Clinical Trials Network study of tidal volume has proven that randomized trials in ARDS with positive results are possible even when using difficult primary outcome measures such as mortality or ventilator-free days. Therefore, the rich combination of new trial strategies, potential treatments, experienced investigators, and increasingly standardized routine care set the stage for rapid advances to be made in the short- and long-term outcomes of this devastating syndrome.
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Affiliation(s)
- Gordon R Bernard
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, 1161 21st Avenue South, Room T1218 MCN, Nashville, TN 37232-2650, USA.
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