New insights into exogenous surfactant as a carrier of pulmonary therapeutics

Reflections on the introduction of surfactant therapy for neonates with respiratory distress

When pulmonary surfactant was first detected in the 1950s by Pattle and Clements, many thousands of infants perished each year due to a respiratory illness termed hyaline membrane disease. Hyaline membranes are formed by plasma leaking through damaged endothelial barriers into the terminal bronchiolar: alveolar spaces. Since the leaking plasma lacks erythrocytes, these clots are opaque. Insightful research by Avery and Mead soon led to the suggestion that the neonatal respiratory distress syndrome (RDS) did not arise because of the presence of hyaline membranes, but rather was related to the lack of sufficient pulmonary surfactant, mainly as a result of immaturity. Unfortunately, initial attempts at treating RDS with aerosolized dipalmitoyl-phosphatidylcholine, the major single molecular component, proved unsuccessful. Almost 20 years later, it was demonstrated by Enhorning and Robertson that treating prematurely delivered rabbit pups with natural surfactant prevents respiratory failure. Initially, it appeared unlikely that animal surfactants could be used for therapy with human infants. However, in 1980, Fujiwara demonstrated that a modified bovine surfactant extract promoted gaseous exchange with infants suffering from RDS. Soon a number of bovine and porcine-modified surfactants and two wholly synthetic formulations were shown to alleviate RDS. The present review relates some of the key scientific findings and significant clinical contributions responsible for reducing the neonatal morbidity and mortality associated with RDS. It further describes some of the more recent findings on the biological, biophysical, and physiological significance of pulmonary surfactant in health and disease.

In vitro and in silico studies of the interaction between glucocorticoid drug mometasone furoate and model lung surfactant monolayer

In an effort to treat preterm neonates who are already suffering or are at high risk for chronic pulmonary illness, the comprehensive investigation has recently been focused on the intratracheal administration of corticosteroid drugs employing an innate lung surfactant as a drug carrier. A novel approach to utilize exogenous surfactant preparation as a drug delivery vehicle for corticosteroids, which are the inflammation-reducing agents for lung diseases has not been comprehensively investigated. The direct corticosteroid drugs administered through pulmonary surfactants would impair their surface activity and exacerbate normal breathing cycles. This study was conducted to characterize the physiological interaction between frequently used inhaled corticosteroid, mometasone furoate, and relevant composition of lung surfactants by using the in vitro and in silico methods. The major objective of this work is to elucidate the effects of glucocorticoids on the structural and dynamical characteristics of the lung surfactant as well as the effects of the drug on the ability of the surfactant monolayer to reduce surface tension during mechanical breathing. Our results from the Langmuir experiment and atomic force microscopy imply that mometasone furoate concentrations less than 4.18% w/w might not strongly influence the physicochemical characteristics of the surfactant molecules representing the feasible concentration for pulmonary drug delivery. Beyond this range, mometasone furoate concentrations cause intensified film fluidization that leads the surfactant film to collapse at lower surface pressure, which is also verified by the in silico study. The failure of the drug to permeate into the lipid bilayer is most likely what causes this collapse. On the other hand, for inhalation breathing, the monolayer forms pores induced by the high drug concentrations. Our investigation also reveals that mometasone furoate exhibits different spreading behaviors because of their affinities to the surfactant molecules. This work may have implications for the use of inhaled steroids in the treatment of asthma in addition to its translational significance in the management of chronic lung disease.

Exogenous-Endogenous Surfactant Interaction Yields Heterogeneous Spreading in Complex Branching Networks

Experiments have shown that surfactant introduced to a liquid-filled maze can find the solution path. We reveal how the maze-solving dynamics arise from interactions between the added surfactant and endogenous surfactant present at the liquid surface. We simulate the dynamics using a nonlinear model solved with a discrete mimetic scheme on a graph. Endogenous surfactant transforms local spreading into a nonlocal problem with an omniscient view of the maze geometry, key to the maze-solving dynamics. Our results offer insight into surfactant-driven transport in complex networks such as lung airways.

Studying the interfacial activity and structure of pulmonary surfactant complexes

Pulmonary surfactant (PS) is a membranous complex that coats the respiratory air-liquid interface in air-breathing animal lungs. Its main function is to minimize the surface tension at the end of expiration, what is needed for preventing alveolar collapse. Although the tension reduction capabilities of surfactant depend on the formation of air-exposed phospholipid-enriched monolayers, the interfacial surfactant films are far from simple monolayers. Surfactant surface films are dynamically interconnected to continuously secreted newly synthetized material thanks to the action of a pair of very hydrophobic proteins, termed SP-B and SP-C, which are responsible to modulate the biophysical behavior of the complex. Other proteins in the system, such as the hydrophilic SP-A and SP-D, are integrated into different surfactant structures but participate primarily in the immune defense of the lung. In spite of countless studies on the structure and chemico-physical properties of surfactant membranes, the full complexity of surfactant three-dimensional structure is far from being completely understood. Here we review some of the most useful techniques that have allowed the characterization of the PS system along the years to develop the current models interpreting surfactant structure-function relationships.

Validation of a high-performance liquid chromatography method for determining lysophosphatidylcholine content in bovine pulmonary surfactant medication

Pulmonary surfactant replacement therapy is a promising improvement in neonatal care for infants with respiratory distress syndrome. Lysophosphatidylcholine (LPC) is an undesirable component that can hinder surfactant proteins from enhancing the adsorption of surfactant lipids to balance surface tensions by creating a saturated coating on the interior of the lungs. A novel normal-phase liquid chromatography method utilizing UV detection and non-toxic solvents was developed and validated for the first time to analyze LPC in the complex matrix of pulmonary surfactant medication. The analytical method validation included evaluation of system suitability, repeatability, intermediate precision, linearity, accuracy, limit of detection (LOD), limit of quantification (LOQ), stability and robustness. The method yielded detection and quantification limits of 4.4 and 14.5 μg/ml, respectively. The calibration curve was modified linearly within the LOQ to 1.44 mg/ml range, with a determination coefficient of 0.9999 for standards and 0.9997 for sample solutions. Given the lack of reliable published data on LPC analysis in pulmonary surfactant medications, this newly developed method demonstrates promising results and offers advantages of HPLC methodology, including simplicity, accuracy, specificity, sensitivity and an exceptionally low LOD and LOQ. These attributes contribute to considering this achievement as an innovative method.

Polymyxin B-Enriched Exogenous Lung Surfactant: Thermodynamics and Structure

The use of an exogenous pulmonary surfactant (EPS) to deliver other relevant drugs to the lungs is a promising strategy for combined therapy. We evaluated the interaction of polymyxin B (PxB) with a clinically used EPS, the poractant alfa Curosurf (PSUR). The effect of PxB on the protein-free model system (MS) composed of four phospholipids (diC16:0PC/16:0-18:1PC/16:0-18:2PC/16:0-18:1PG) was examined in parallel to distinguish the specificity of the composition of PSUR. We used several experimental techniques (differential scanning calorimetry, small- and wide-angle X-ray scattering, small-angle neutron scattering, fluorescence spectroscopy, and electrophoretic light scattering) to characterize the binding of PxB to both EPS. Electrostatic interactions PxB-EPS are dominant. The results obtained support the concept of cationic PxB molecules lying on the surface of the PSUR bilayer, strengthening the multilamellar structure of PSUR as derived from SAXS and SANS. A protein-free MS mimics a natural EPS well but was found to be less resistant to penetration of PxB into the lipid bilayer. PxB does not affect the gel-to-fluid phase transition temperature, Tm, of PSUR, while Tm increased by ∼+ 2 °C in MS. The decrease of the thickness of the lipid bilayer (dL) of PSUR upon PxB binding is negligible. The hydrophobic tail of the PxB molecule does not penetrate the bilayer as derived from SANS data analysis and changes in lateral pressure monitored by excimer fluorescence at two depths of the hydrophobic region of the bilayer. Changes in dL of protein-free MS show a biphasic dependence on the adsorbed amount of PxB with a minimum close to the point of electroneutrality of the mixture. Our results do not discourage the concept of a combined treatment with PxB-enriched Curosurf. However, the amount of PxB must be carefully assessed (less than 5 wt % relative to the mass of the surfactant) to avoid inversion of the surface charge of the membrane.

Pulmonary Surfactant: A Mighty Thin Film

Pulmonary surfactant is a critical component of lung function in healthy individuals. It functions in part by lowering surface tension in the alveoli, thereby allowing for breathing with minimal effort. The prevailing thinking is that low surface tension is attained by a compression-driven squeeze-out of unsaturated phospholipids during exhalation, forming a film enriched in saturated phospholipids that achieves surface tensions close to zero. A thorough review of past and recent literature suggests that the compression-driven squeeze-out mechanism may be erroneous. Here, we posit that a surfactant film enriched in saturated lipids is formed shortly after birth by an adsorption-driven sorting process and that its composition does not change during normal breathing. We provide biophysical evidence for the rapid formation of an enriched film at high surfactant concentrations, facilitated by adsorption structures containing hydrophobic surfactant proteins. We examine biophysical evidence for and against the compression-driven squeeze-out mechanism and propose a new model for surfactant function. The proposed model is tested against existing physiological and pathophysiological evidence in neonatal and adult lungs, leading to ideas for biophysical research, that should be addressed to establish the physiological relevance of this new perspective on the function of the mighty thin film that surfactant provides.

Unveiling the Role of Nonionic Surfactants in Enhancing Cefotaxime Drug Solubility: A UV-Visible Spectroscopic Investigation in Single and Mixed Micellar Formulations

This study reports the interfacial phenomenon of cefotaxime in combination with nonionic surfactants, Triton X-100 (TX-100) and Tween-80 (TW-80), and their mixed micellar formulations. Cefotaxime was enclosed in a micellar system to improve its solubility and effectiveness. TX-100 and TW-80 were used in an amphiphilic self-assembly process to create the micellar formulation. The effect of the addition of TX-100, a nonionic surfactant, on the ability of TW-80 to solubilize the drug was examined. The values of the critical micelle concentration (CMC) were determined via UV-Visible spectroscopy. Gibbs free energies (ΔGp and ΔGb), the partition coefficient (Kx), and the binding constant (Kb) were also computed. In a single micellar system, the partition coefficient (Kx) was found to be 33.78 × 106 and 2.78 × 106 in the presence of TX-100 and TW-80, respectively. In a mixed micellar system, the value of the partition coefficient for the CEF/TW-80 system is maximum (5.48 × 106) in the presence of 0.0019 mM of TX-100, which shows that TX-100 significantly enhances the solubilizing power of micelles. It has been demonstrated that these surfactants are effective in enhancing the solubility and bioavailability of therapeutic compounds. This study elaborates on the physicochemical characteristics and solubilization of reactive drugs in single and mixed micellar media. This investigation, conducted in the presence of surfactants, shows a large contribution to the binding process via both hydrogen bonding and hydrophobic interactions.

A recent overview of surfactant-drug interactions and their importance

This review focuses on the self-aggregation properties of different drugs, as well as on their interaction with anionic, cationic, and gemini surfactants. The interaction of drugs with surfactants has been reviewed concerning conductivity, surface tension, viscosity, density, and UV-Vis spectrophotometric measurements, and their relation with critical micelle concentration (CMC), cloud point, and binding constant. The conductivity measurement technique is used for the micellization of ionic surfactants. Cloud point studies can be used for the non-ionic, and also for certain ionic surfactants. Usually, surface tension studies are mostly employed for non-ionic surfactants. The degree of dissociation that is determined is used to evaluate thermodynamic parameters of micellization at various temperatures. The effect of external parameters like temperature, salt, solvent, pH, etc., is discussed for thermodynamics parameters using recent experimental works on drug-surfactant interactions. Consequences of drug-surfactant interaction, condition of drugs during interaction with surfactants, and applications of drug-surfactant interaction are being generalized which reflects current and future potential uses of drug-surfactant interactions.

The reconciliation between the experimental and calculated octanol-water partition coefficient of 1,2-dipalmitoyl-sn-glycero-3-phosphatidylcholine using atomistic molecular dynamics: an open question

The octanol-water partition coefficient of 1,2-dipalmitoyl-sn-glycero-3-phosphatidylcholine (DPPC) was investigated using atomistic molecular dynamics simulations via thermodynamic integration and multistate Bennett acceptance ratio methods. The GAFF and CHARMM36 force fields were used with six water models widely used in molecular dynamics simulations. The OPC4 water model provided the best agreement with the experimental octanol-water partition coefficient of DPPC using the two force fields. However, there is still plenty of room for improvement in water models with correct estimation of surface tension that uses better and suitable non-bonded interaction parameters between water-water and water-DPPC. The Gibbs free energy of transferring DPPC from octanol to water phase was calculated to be 19.8 ± 0.3 and 20.2 ± 0.3 kcal mol-1, giving a partition coefficient of 14.5 ± 0.4 and 14.8 ± 0.3 for the GAFF and CHARMM36 force fields, respectively. This study reinforces the importance of developing new water models that reproduce experimental surface tensions to reconcile the water-water and water-DPPC non-bonded interactions and the existing discrepancy between experimental measurements of amphiphilic molecules that are important in many areas of scientific applications and industry such as biophysics, surfactant, colloids, membranes, medicine, nanotechnology, and food and pharmaceutical industries, and so on. It raises two important open questions: Is the experimental octanol-water partition coefficient of DPPC reliable? Or is its calculation accurate using the OPC4 water model? With respect to the experimental measurements, there may be non-treated aspects such as the formation of aggregates in aqueous phase and limit of detection of the applied method. And, in the calculation, some effects are not possible to be considered in a correct way or viable time such as calculating quantum effects, sampling all conformations, considering phase transitions, and correctly evaluating the intermolecular forces to estimate an accurate surface tension.Communicated by Ramaswamy H. Sarma.

Interfacial Dynamics of Adsorption Layers as Supports for Biomedical Research and Diagnostics

The input of chemical and physical sciences to life sciences is increasingly important. Surface science as a complex multidisciplinary research area provides many relevant practical tools to support research in medicine. The tensiometry and surface rheology of human biological liquids as diagnostic tools have been very successfully applied. Additionally, for the characterization of pulmonary surfactants, this methodology is essential to deepen the insights into the functionality of the lungs and for the most efficient administration of certain drugs. Problems in ophthalmology can be addressed using surface science methods, such as the stability of the wetting films and the development of artificial tears. The serious problem of obesity is fast-developing in many industrial countries and must be better understood, while therapies for its treatment must also be developed. Finally, the application of fullerenes as a suitable system for detecting cancer in humans is discussed.

Impact of Polymer Nanoparticles on DPPC Monolayer Properties

The application of surface rheology and Brewster angle microscopy on mixed monolayers of DPPC and polymeric nanoparticles (cationic and anionic) showed that the sign of the particle charge affects the dynamic properties of the monolayers less than the nanoparticles’ ability to aggregate. Under almost physiological conditions, the effect of nanoparticles on the elasticity of DPPC monolayer is insignificant. However, the particles prevent the surface tension from decreasing to extremely low values. This effect could affect the functionality of pulmonary surfactants.

A recipe for a good clinical pulmonary surfactant

The lives of thousands premature babies have been saved along the last thirty years thanks to the establishment and consolidation of pulmonary surfactant replacement therapies (SRT). It took some time to close the gap between the identification of the biophysical and molecular causes of the high mortality associated with respiratory distress syndrome in very premature babies and the development of a proper therapy. Closing the gap required the elucidation of some key questions defining the structure–function relationships in surfactant as well as the particular role of the different molecular components assembled into the surfactant system. On the other hand, the application of SRT as part of treatments targeting other devastating respiratory pathologies, in babies and adults, is depending on further extensive research still required before enough amounts of good humanized clinical surfactants will be available. This review summarizes our current concepts on the compositional and structural determinants defining pulmonary surfactant activity, the principles behind the development of efficient natural animal-derived or recombinant or synthetic therapeutic surfactants, as well as a the most promising lines of research that are already opening new perspectives in the application of tailored surfactant therapies to treat important yet unresolved respiratory pathologies.

Pulmonary surfactant: a unique biomaterial with life-saving therapeutic applications

Pulmonary surfactant is a complex lipoprotein mixture secreted into the alveolar lumen by type 2 pneumocytes, which is composed by tens of different lipids (approximately 90% of its entire mass) and surfactant proteins (approximately 10% of the mass). It is crucially involved in maintaining lung homeostasis by reducing the values of alveolar liquid surface tension close to zero at end-expiration, thereby avoiding the alveolar collapse, and assembling a chemical and physical barrier against inhaled pathogens. A deficient amount of surfactant or its functional inactivation is directly linked to a wide range of lung pathologies, including the neonatal respiratory distress syndrome. This paper reviews the main biophysical concepts of surfactant activity and its inactivation mechanisms, and describes the past, present and future roles of surfactant replacement therapy, focusing on the exogenous surfactant preparations marketed worldwide and new formulations under development. The closing section describes the pulmonary surfactant in the context of drug delivery. Thanks to its peculiar composition, biocompatibility, and alveolar spreading capability, the surfactant may work not only as a shuttle to the branched anatomy of the lung for other drugs but also as a modulator for their release, opening to innovative therapeutic avenues for the treatment of several respiratory diseases.

Pulmonary surfactants affinity Pluronic-hybridized liposomes enhance the treatment of drug-resistant lung cancer

For a long time, the incidence and mortality of lung cancer have ranked first among all kinds of cancers, of which the major type is non-small cell lung cancer (NSCLC). Until now, chemotherapy and radiotherapy are still the first choice for patients with advanced or metastatic NSCLC. However, the emergence of multi-drug resistance (MDR) always leads to the failure of chemotherapy and increases cancer-related mortality. In this study, we prepared a Pluronic-hybridized paclitaxel-loaded liposome (PPL), which was used in combination with ambroxol (Ax) to not only resensitize drug-resistant tumor cells, but also increase the preparation retention in the lung. On the one hand, Ax induced the production of pulmonary surfactants (PS) and responsively improved the accumulation of pulmonary surfactants affinity liposomes whose skeleton was exogenous pulmonary surfactant phospholipids DPPC, because of the specific affinity of phospholipids related to pulmonary surfactant proteins. On the other hand, drug-resistant tumor cells were resensitized due to the inhibition of autophagy by Ax and the reduced expression of the drug-resistant protein P-glycoprotein (P-gp) by Pluronic P105. Therefore, we concluded that the combination of PPL and Ax achieved excellent killing tumor effects through multi-path and multi-strategy, having great application prospects in the future.

PepBiotics, novel cathelicidin-inspired antimicrobials to fight pulmonary bacterial infections

BACKGROUND

Antimicrobial peptides are considered potential alternatives to antibiotics. Here we describe the antibacterial properties of a family of novel cathelicidin-related (CR-) peptides, which we named PepBiotics, against bacteria typically present in cystic fibrosis (CF) patients.

METHODS

Broth dilution assays were used to determine antibacterial activity of PepBiotics under physiological conditions, as well as development of bacterial resistance against these peptides. Toxicity was tested in mice and cell cultures while molecular interactions of PepBiotics with bacterial membrane components was determined using CD, ITC and LPS/LTA induced macrophage studies.

RESULTS

A relatively small number of PepBiotics remained highly antibacterial against CF-related respiratory pathogens Pseudomonas aeruginosa and Staphylococcus aureus, at high ionic strength and low pH. Interestingly, these PepBiotics also prevented LPS/LTA induced activation of macrophages and was shown to be non-toxic to primary human nasal epithelial cells. Furthermore, both P. aeruginosa and S. aureus were unable to induce resistance against CR-163 and CR-172, two PepBiotics selected for their excellent antimicrobial and immunomodulatory properties. Toxicity studies in mice indicated that intratracheal administration of CR-163 was well tolerated in vivo. Finally, interaction of CR-163 with bacterial-type anionic membranes but not with mammalian-type (zwitterionic lipid) membranes was confirmed using ITC and ³¹P solid state NMR.

CONCLUSIONS

PepBiotics are a promising novel class of highly active antimicrobial peptides, of which CR-163 showed the most potential for treatment of clinically relevant (CF-) pathogens in physiological conditions.

GENERAL SIGNIFICANCE

These observations emphasize the therapeutic potential of PepBiotics against CF-related bacterial respiratory infections.

Nutritional approach for increasing public health during pandemic of COVID-19: A comprehensive review of antiviral nutrients and nutraceuticals

Background: The novel coronavirus (COVID-19) is considered as the most life-threatening pandemic disease during the last decade. The individual nutritional status, though usually ignored in the management of COVID-19, plays a critical role in the immune function and pathogenesis of infection. Accordingly, the present review article aimed to report the effects of nutrients and nutraceuticals on respiratory viral infections including COVID-19, with a focus on their mechanisms of action. Methods: Studies were identified via systematic searches of the databases including PubMed/ MEDLINE, ScienceDirect, Scopus, and Google Scholar from 2000 until April 2020, using keywords. All relevant clinical and experimental studies published in English were included. Results: Protein-energy malnutrition (PEM) is common in severe respiratory infections and should be considered in the management of COVID-19 patients. On the other hand, obesity can be accompanied by decreasing the host immunity. Therefore, increasing physical activity at home and a slight caloric restriction with adequate intake of micronutrients and nutraceuticals are simple aids to boost host immunity and decrease the clinical manifestations of COVID-19. Conclusion: The most important nutrients which can be considered for COVID-19 management are vitamin D, vitamin C, vitamin A, folate, zinc, and probiotics. Their adequacy should be provided through dietary intake or appropriate supplementation. Moreover, adequate intake of some other dietary agents including vitamin E, magnesium, selenium, alpha linolenic acid and phytochemicals are required to maintain the host immunity.

Aerosol drug delivery to spontaneously-breathing preterm neonates: lessons learned

Delivery of medications to preterm neonates receiving non-invasive ventilation (NIV) represents one of the most challenging scenarios for aerosol medicine. This challenge is highlighted by the undersized anatomy and the complex (patho)physiological characteristics of the lungs in such infants. Key physiological restraints include low lung volumes, low compliance, and irregular respiratory rates, which significantly reduce lung deposition. Such factors are inherent to premature birth and thus can be regarded to as the intrinsic factors that affect lung deposition. However, there are a number of extrinsic factors that also impact lung deposition: such factors include the choice of aerosol generator and its configuration within the ventilation circuit, the drug formulation, the aerosol particle size distribution, the choice of NIV type, and the patient interface between the delivery system and the patient. Together, these extrinsic factors provide an opportunity to optimize the lung deposition of therapeutic aerosols and, ultimately, the efficacy of the therapy.In this review, we first provide a comprehensive characterization of both the intrinsic and extrinsic factors affecting lung deposition in premature infants, followed by a revision of the clinical attempts to deliver therapeutic aerosols to premature neonates during NIV, which are almost exclusively related to the non-invasive delivery of surfactant aerosols. In this review, we provide clues to the interpretation of existing experimental and clinical data on neonatal aerosol delivery and we also describe a frame of measurable variables and available tools, including in vitro and in vivo models, that should be considered when developing a drug for inhalation in this important but under-served patient population.

In vivo Pharmacokinetics and in vitro Release of Imatinib Mesylate-Loaded Liposomes for Pulmonary Delivery

BACKGROUND

Pulmonary arterial hypertension (PAH) is characterized by abnormal proliferation of vascular endothelial and smooth muscle cells and causes occlusion of pulmonary arterioles that eventually results in right heart failure and death. The platelet-derived growth factor (PDGF) plays a prominent role in abnormal remodeling of pulmonary resistance vessels. Imatinib mesylate (IM), a PDGF-receptor tyrosine kinase inhibitor, was able to ameliorate PAH by reversing pulmonary vascular remodeling.

METHODS

In the present study, IM-loaded liposomes (IM-LPs) were developed and administered via the pulmonary route to delay the drug release and improve patient compliance for the treatment of PAH. The IM-LPs were prepared by the transmembrane gradient method with the spherical vesicles. The compatibility of the IM-LPs was studied by determining the viability of pulmonary arterial smooth muscle cells (PASMCs). Particle uptake by rat PASMCs was evaluated by incubating the particles with rat PASMCs. Pharmacokinetic studies were performed in male SD rats.

RESULTS

The IM-LPs showed an average size of 101.6 ± 50.80 nm with a zeta potential value of 19.66 ± 0.55 mV, a PDI of 0.250 and 81.96% ± 0.98% drug entrapment efficiency, meanwhile displayed a sustained release profile. Liposomes obviously increased intracellular accumulation of Rhodamine B by PASMCs using the fluorescence microscopic. Following intratracheal administration to rats, IM-LPs not only extended the half-life of IM, but also prolonged retention of IM compared with plain IM solution after intratracheal and intravenous administration.

CONCLUSION

The study show potential applications of the LPs for pulmonary delivery of IM and the method for the development of LPs in sustained release of IM for better therapeutic outcomes. Conclusively, the prepared IM-LPs were well designed in nanosized ranges and may be a promising formulation for pulmonary delivery of IM.

The COVID-19 pandemic: a target for surfactant therapy?

INTRODUCTION

The dramatic impact of COVID-19 on humans worldwide has initiated an extraordinary search for effective treatment approaches. One of these is the administration of exogenous surfactant, which is being tested in ongoing clinical trials.

AREAS COVERED

Exogenous surfactant is a life-saving treatment for premature infants with neonatal respiratory distress syndrome. This treatment has also been tested for acute respiratory distress syndrome (ARDS) with limited success possibly due to the complexity of that syndrome. The 60-year history of successes and failures associated with surfactant therapy distinguishes it from many other treatments currently being tested for COVID-19 and provides the opportunity to discuss the factors that may influence the success of this therapy.

EXPERT OPINION

Clinical data provide a strong rationale for using exogenous surfactant in COVID-19 patients. Success of this therapy may be influenced by the mechanical ventilation strategy, the timing of treatment, the doses delivered, the method of delivery and the preparations utilized. In addition, future development of enhanced preparations may improve this treatment approach. Overall, results from ongoing trials may not only provide data to indicate if this therapy is effective for COVID-19 patients, but also lead to further scientific understanding and improved treatment strategies.

Structure and Thermotropic Behavior of Bovine- and Porcine-Derived Exogenous Lung Surfactants

Two commercial exogenous pulmonary surfactants, Curosurf and Survanta, are investigated. Their thermotropic behavior and associated structural changes for the samples in bulk are characterized and described. For Survanta, the obtained results of differential scanning calorimetry showed a thermogram with three peaks on heating and only a single peak on cooling. Curosurf on the other hand, presents calorimetric thermograms with only one peak in both the heating and cooling scans. This distinct thermotropic behavior between the two pulmonary surfactants, a consequence of their particular compositions, is associated with structural changes that were evaluated by simultaneous small- and wide-angle X-ray scattering experiments with in situ temperature variation. Interestingly, for temperatures below ∼35 °C for Curosurf and ∼53 °C for Survanta, the scattering data indicated the coexistence of two lamellar phases with different carbon chain organizations. For temperatures above these limits, the coexistence of phases disappears, giving rise to a fluid phase in both pulmonary surfactants, with multilamelar vesicles for Curosurf and unilamellar vesicles for Survanta. This process is quasi-reversible under cooling, and advanced data analysis for the scattering data indicated differences in the structural and elastic properties of the pulmonary surfactants. The detailed and systematic investigation shown in this work expands on the knowledge of the structure and thermodynamic behavior of Curosurf and Survanta, being relevant from both physiological and biophysical perspectives and also providing a basis for further studies on other types of pulmonary surfactants.

Exogenous Surfactant as a Pulmonary Delivery Vehicle for Budesonide In Vivo

Background

Lung inflammation is associated with many respiratory conditions. Consequently, anti-inflammatory medications, like glucocorticoids, have become mainstay intrapulmonary therapeutics. However, their effectiveness for treating inflammation occurring in the alveolar regions of the lung is limited by suboptimal delivery. To improve the pulmonary distribution of glucocorticoids, such as budesonide to distal regions of the lung, exogenous surfactant has been proposed as an ideal delivery vehicle for such therapies. It was therefore hypothesized that fortifying an exogenous surfactant (BLES) with budesonide would enhance efficacy for treating pulmonary inflammation in vivo.

Methods

An intratracheal instillation of heat-killed bacteria was used to elicit an inflammatory response in the lungs of male and female rats. Thirty minutes after this initial instillation, either budesonide or BLES combined with budesonide was administered intratracheally. To evaluate the efficacy of surfactant delivery, various markers of inflammation were measured in the bronchoalveolar lavage and lung tissue.

Results

Although budesonide exhibited anti-inflammatory effects when administered alone, delivery with BLES enhanced those effects by lowering the lavage neutrophil counts and myeloperoxidase activity in lung tissue. Combining budesonide with BLES was also shown to reduce several other pro-inflammatory mediators. These results were shown across both sexes, with no observed sex differences.

Conclusion

Based on these findings, it was concluded that exogenous surfactant can enhance the delivery and efficacy of budesonide in vivo.

The Effect of Modified Porcine Surfactant Alone or in Combination with Polymyxin B on Lung Homeostasis in LPS-Challenged and Mechanically Ventilated Adult Rats

The study aimed to prove the hypothesis that exogenous surfactant and an antibiotic polymyxin B (PxB) can more effectively reduce lipopolysaccharide (LPS)-induced acute lung injury (ALI) than surfactant treatment alone, and to evaluate the effect of this treatment on the gene expression of surfactant proteins (SPs). Anesthetized rats were intratracheally instilled with different doses of LPS to induce ALI. Animals with LPS 500 μg/kg have been treated with exogenous surfactant (poractant alfa, Curosurf^®, 50 mg PL/kg b.w.) or surfactant with PxB 1% w.w. (PSUR + PxB) and mechanically ventilated for 5 hrs. LPS at 500 μg/kg increased lung edema, oxidative stress, and the levels of proinflammatory mediators in lung tissue and bronchoalveolar lavage fluid (BALF). PSUR reduced lung edema and oxidative stress in the lungs and IL-6 in BALF. This effect was further potentiated by PxB added to PSUR. Exogenous surfactant enhanced the gene expression of SP-A, SP-B, and SP-C, however, gene expression for all SPs was reduced after treatment with PSUR + PxB. In mechanically ventilated rats with LPS-induced ALI, the positive effect of exogenous surfactant on inflammation and oxidative stress was potentiated with PxB. Due to the tendency for reduced SPs gene expression after surfactant/PxB treatment topical use of PxB should be considered with caution.

Extrapulmonary Surfactant Therapy: Review of Available Data and Research/Development Issues

Since the discovery of surfactant, a large amount of knowledge has been accumulated about its biology and pharmacology. Surfactant is the cornerstone of neonatal respiratory critical care, but its proteins and phospholipids are produced in various tissues and organs, with possible roles only partially similar to that played in the alveoli. As surfactant research is focused mainly on its respiratory applications, knowledge about the possible role of surfactant in extrapulmonary disorders has never been summarized. Here we aim to comprehensively review the data about surfactant biology and pharmacology in organs other than the lung, especially focusing in the more promising surfactant extrapulmonary roles. We also review any preclinical or clinical data available about the therapeutic use of surfactant in these contexts. We offer a summary of knowledge and research/development milestones, as possible useful guidance for researchers of multidisciplinary background.

Optimizing Exogenous Surfactant as a Pulmonary Delivery Vehicle for Chicken Cathelicidin-2

The rising incidence of antibiotic-resistant lung infections has instigated a much-needed search for new therapeutic strategies. One proposed strategy is the use of exogenous surfactants to deliver antimicrobial peptides (AMPs), like CATH-2, to infected regions of the lung. CATH-2 can kill bacteria through a diverse range of antibacterial pathways and exogenous surfactant can improve pulmonary drug distribution. Unfortunately, mixing AMPs with commercially available exogenous surfactants has been shown to negatively impact their antimicrobial function. It was hypothesized that the phosphatidylglycerol component of surfactant was inhibiting AMP function and that an exogenous surfactant, with a reduced phosphatidylglycerol composition would increase peptide mediated killing at a distal site. To better understand how surfactant lipids interacted with CATH-2 and affected its function, isothermal titration calorimetry and solid-state nuclear magnetic resonance spectroscopy as well as bacterial killing curves against Pseudomonas aeruginosa were utilized. Additionally, the wet bridge transfer system was used to evaluate surfactant spreading and peptide transport. Phosphatidylglycerol was the only surfactant lipid to significantly inhibit CATH-2 function, showing a stronger electrostatic interaction with the peptide than other lipids. Although diluting the phosphatidylglycerol content in an existing surfactant, through the addition of other lipids, significantly improved peptide function and distal killing, it also reduced surfactant spreading. A synthetic phosphatidylglycerol-free surfactant however, was shown to further improve CATH-2 delivery and function at a remote site. Based on these in vitro experiments synthetic phosphatidylglycerol-free surfactants seem optimal for delivering AMPs to the lung.

Efficient delipidation of a recombinant lung surfactant lipopeptide analogue by liquid-gel chromatography

Pulmonary surfactant preparations extracted from natural sources have been used to treat millions of newborn babies with respiratory distress syndrome (RDS) and can possibly also be used to treat other lung diseases. Due to costly production and limited supply of animal-derived surfactants, synthetic alternatives are attractive. The water insolubility and aggregation-prone nature of the proteins present in animal-derived surfactant preparations have complicated development of artificial surfactant. A non-aggregating analog of lung surfactant protein C, SP-C33Leu is used in synthetic surfactant and we recently described an efficient method to produce rSP-C33Leu in bacteria. Here rSP-C33Leu obtained by salt precipitation of bacterial extracts was purified by two-step liquid gel chromatography and analyzed using mass spectrometry and RP-HPLC, showing that it is void of modifications and adducts. Premature New Zealand White rabbit fetuses instilled with 200mg/kg of 2% of rSP-C33Leu in phospholipids and ventilated with a positive end expiratory pressure showed increased tidal volumes and lung gas volumes compared to animals treated with phospholipids only. This shows that rSP-C33Leu can be purified from bacterial lipids and that rSP-C33Leu surfactant is active against experimental RDS.

Delivery of a thermo-enzymatically treated influenza vaccine using pulmonary surfactant in pigs

Swine influenza A virus (IAV-S) infections are a major cause of economic losses for the swine industry. The vast genetic and antigenic diversity often results in mismatch between the vaccine and field strains, necessitating frequent updates of vaccines. Inactivated IAV-S vaccines are of questionable efficacy. Intra-nasally administered live vaccines are more effective but are associated with safety concerns. The objective of this study was to develop a first-generation vaccine which combines the safety and efficacy advantages of inactivated and attenuated vaccines respectively. The approach targeted fragmentation of viral nucleic acids while preserving structure. Hence, cultures of influenza A/CA/04/09 H1N1 were exposed to 44 °C for 10 min. to reversibly denature the capsid, followed by RNase treatment to digest the genomic RNA and then refolded at lower temperatures. As targeted, treated virions retained an intact structure and were not detected in the first passage in infected cells. To improve intra-nasal delivery of the vaccine antigen, the vaccine antigen was delivered in porcine lung surfactant. Both the treated vaccine alone or vaccine in combination with the surfactant elicited strong anti-HA and virus neutralizing antibodies, protection against viral shedding and lung lesions in 3-week-old piglets. There were no significant differences between the groups. Vaccine viral replication was not detected in the vaccinated pigs. The described approach can advance current immunization practices against swine influenza viruses due to the relative simplicity, high efficacy and safety and ease of adaptation to newly emerging field strains.