Tracheal aspirate surface tension in babies with hyaline membrane disease: effects of synthetic surfactant replacement

RESPIRATORY CONSEQUENCES OF PRETERM BIRTH

Approximately 8% of Australia's 250,000 annual births occur preterm (before 37 weeks completed gestation). Preterm infants represent 75% of all neonatal deaths in Australia, with the vast majority of these deaths caused by pulmonary disease. 2. The respiratory consequences for survivors of preterm birth include the immediate challenges of breathing with underdeveloped lungs, usually manifest as respiratory distress syndrome (RDS), and, in the long term, with persisting pulmonary abnormalities. Therapies to prevent neonatal lung disease now permit survival of preterm infants born as early as 22 weeks gestational age, but not without consequences. 3. Preterm infants are at risk of developing chronic lung disease/bronchopulmonary dysplasia (BPD). The lungs of infants dying from BPD are inflamed and have fewer, larger alveoli than normal and exhibit abnormal pulmonary vascular development. There is now a growing appreciation of the contribution of intrauterine inflammation to the aetiology of BPD. 4. Impaired airway function is commonly reported in follow-up studies of children born preterm. Decreased expiratory flow rates have been associated with preterm birth per se, but airway function appears more affected in survivors of RDS and BPD. Observations in survivors of BPD suggest persisting abnormalities in the structure of the lung parenchyma and airways. 5. Follow-up studies of preterm infants into adulthood are lacking, as are experimental examinations of the long-term physiological and anatomical effects of preterm birth. Both are necessary to understand the causes of the long-term respiratory consequences of preterm birth.

Harvesting airway surface liquid: a comparison of two techniques

The quantity and composition of airway surface liquid (ASL) are essential to host defense. To date, attempts to harvest ASL and measure its composition have yielded conflicting results. We investigated the physical principles underlying two techniques that were proposed for harvesting ASL: filter paper pledgets and polyethylene catheters. We compared the force and pressure generation and the kinematics of capillarity-induced fluid uptake with both techniques. Both have significant limitations for harvesting ASL, generating physiologically significant pressures (filter paper, 60.4 Pa; polyethylene, 14.3 Pa) that could potentially compromise epithelial integrity. Furthermore, filter paper generates a force 85-fold higher than the polyethylene catheter, which is associated with a very high rate of uptake of liquid and a large total amount of liquid relative to ASL thickness. While the PE catheter harvests liquid more gently, it is only effective when ASL surface tension is below 31 mN/m. These limitations likely account for some of the variability in reported ASL composition, and highlight the need for improved methods for harvesting ASL.

Surfactant protein profile of pulmonary surfactant in premature infants

Although premature infants are known to be deficient in pulmonary surfactant, there is limited information regarding surfactant protein (SP) composition. To assess the postnatal profile of SPs, tracheal aspirate samples were collected from 35 intubated infants of 23-31 weeks of gestation between 8 and 80 days of age. In 71 large aggregate surfactant samples that had normal in vitro function (minimum surface tension of less than 1 mN/m by pulsating bubble surfactometry), mean +/- SEM contents of SP-A, SP-B, and SP-C (3.7 kD) were 7.1 +/- 1.4%, 1.8 +/- 0.2%, and 4.6 +/- 0.6%, respectively, of phospholipid. To assess SPs in the 1st week of life, we analyzed samples from additional infants receiving only synthetic replacement surfactant. On the 2nd day of life, contents of SP-A, SP-B, and SP-C were 13.4%, 8.4%, and 0.1%, respectively, of the mean levels for Day 8-80 samples. The major postnatal increases for SP-A, SP-B, and SP-C occurred during the 1st, 2nd, and 3rd weeks, respectively. We conclude that surfactant of newborn premature infants is markedly deficient in SPs, in particular SP-C. Despite continuing lung disease, some infants who are more than 1 week of age have surfactant with normal in vitro function that contains SPs at levels comparable to adult surfactant.

Relationship between surface tension of upper airway lining liquid and upper airway collapsibility during sleep in obstructive sleep apnea hypopnea syndrome

Lowering surface tension (gamma) of upper airway lining liquid (UAL) reduces upper airway opening (anesthetized humans) and closing (anesthetized rabbits) pressures. We now hypothesize that in sleeping obstructive sleep apnea hypopnea syndrome (OSAHS) patients lowering gamma of UAL will enhance upper airway stability and decrease the severity of sleep-disordered breathing. Nine OSAHS patients [respiratory disturbance index (RDI): 49 +/- 8 (SE) events/h, diagnostic night] participated in a two-part, one-night, polysomnography study. In the first part, upper airway closing pressures (during non-rapid eye movement sleep, Pcrit) were measured and samples of UAL (awake) were obtained before and after 2.5 ml of surfactant (Exosurf, Glaxo Smith Kline) was instilled into the posterior pharynx. The gamma of UAL was determined with the use of the "pull-off" force technique. In the second part, subjects received a second application of 2.5 ml of surfactant and then slept the remainder of the night (205 +/- 30 min). Instillation of surfactant decreased the gamma of UAL from 60.9 +/- 3.1 mN/m (control) to 45.2 +/- 2.5 mN/m (surfactant group) (n = 9, P < 0.001). Pcrit decreased from 1.19 +/- 1.14 cmH2O (control) to -0.56 +/- 1.15 cmH2O (surfactant group) (n = 7, P < 0.02). Compared with the second half of diagnostic night, surfactant decreased RDI from 51 +/- 8 to 35 +/- 8 events/h (n = 9, P < 0.03). The fall in RDI (deltaRDI) correlated with the fall in gamma of UAL (deltagamma) (deltaRDI = 1.8 x deltagamma, r = 0.68, P = 0.04). Hypopneas decreased approximately 50% from 42 +/- 8 to 20 +/- 5 events/h (n = 9, P < 0.03, paired t-test). The gamma of UAL measured the next morning remained low at 49.5 +/- 2.7 mN/m (n = 9, P < 0.001, ANOVA, compared with control). In conclusion, instillation of surfactant reduced the gamma of UAL in OSAHS patients and decreased Pcrit and the occurrence of hypopneas. Therapeutic manipulation of gamma of UAL may be beneficial in reducing the severity of sleep-disordered breathing in OSAHS patients.

Commercial versus native surfactants. Surface activity, molecular components, and the effect of calcium

Despite their broad clinical use, there is no standardized comparative study on the functional, biochemical, and morphologic differences of the various commercial surfactants in relation to native surfactant. We investigated these parameters in Alveofact, Curosurf, Exosurf, and Survanta, and compared them with native bovine (NBS) and porcine (NPS) surfactant. For Curosurf and Alveofact the concentrations necessary for minimal surface tensions < 5 mN/m were six to 12 times higher (1.5 and 3 mg/ml, respectively) than with NPS and NBS. Exosurf and Survanta only reached 22 and 8 mN/m, respectively. Increasing calcium to nonphysiologic concentrations artificially improved the function of Alveofact and Curosurf, but it had little effect on Exosurf and Survanta. Impaired surface activity of commercial versus native surfactants corresponded with their lack in surfactant protein SP-A and decreased SP-B/C. The higher surface activity of Curosurf compared with Alveofact corresponded with its higher concentration of dipalmitoylphosphatidylcholine (DPPC). Despite their enrichment in DPPC Survanta and Exosurf exhibited poor surface activity because of low or absent SP-B/C. Ultrastructurally, Curosurf and Alveofact consisted mainly of lamellar and vesicular structures, which were also present in NPS and NBS. Exosurf contained crystalline structures only, whereas the DPPC-enriched Survanta contained separate lamellar/vesicular and crystalline structures. We conclude that in vitro surface activity of commercial surfactants is impaired compared with native surfactants at physiologic calcium concentrations. In the presence of SP-B/C, surface activity corresponds to the concentration of DPPC. Our data underscore the importance of a standardized protocol at physiologic calcium concentrations for the in vitro assessment of commercial surfactants.