Concentration-dependent, temperature-dependent non-Newtonian viscosity of lung surfactant dispersions

Reply to the 'Comment on "Bilayer aggregate microstructure determines viscoelasticity of lung surfactant suspensions"' by J.-F. Berret, DOI: 10.1039/d2sm00653g

In their comment, Berret suggests that Curosurf, one of three clinical lung surfactant aqueous suspensions examined in the Soft Matter, 2021, 17, 5170-51820 is a Newtonian liquid rather than a shear-thinning soft solid with a small, but measurable yield stress. We postulate that these discrepancies may be due to the size of the magnetic wire measurement probe used in their paper (Thai et al., Colloids Surf., B, 2019, 178, 337-345) the diameter of which is similar in size to the Curosurf bilayer agregates (1-10 μm). The cone and plate rheometer used by Ciutara and Zasadzinski measures averaged effects over the entire macroscopic sample. Our combined results point out that the local viscoelastic properties of a moderately dense suspension may be different than its bulk properties.

Comment on "Bilayer aggregate microstructure determines viscoelasticity of lung surfactant suspensions" by C. O. Ciutara and J. A. Zasadzinski, Soft Matter, 2021, , 5170-5182

For applications of pulmonary surfactant delivery to the lungs, the question of rheology of the existing clinical formulations is of upmost importance. Recently, Ciutara and Zasadsinky (C. O. Ciutara and J. A. Zasadzinski, Soft Matter, 2021, 17, 5170-5182.) measured the rheological properties of Infasurf®, Survanta® and Curosurf®, three of the most used pulmonary surfactant substitutes. This study revealed that these fluids are shear-thinning and characterized by a yield stress. The results obtained by Ciutara et al. on Curosurf® differ from our results published in L.-P.-A. Thai, F. Mousseau, E. Oikonomou, M. Radiom and J.-F. Berret, Colloids Surf., B, 2019, 178, 337-345. and in L.-P.-A. Thai, F. Mousseau, E. Oikonomou, M. Radiom and J.-F. Berret, ACS Nano, 2020, 14, 466-475. In contrast, we found that Curosurf® suspensions are viscous Newtonian or slightly shear-thinning fluids, with no evidence of yield stress. The purpose of this Comment is to discuss possible causes for the discrepancy between the two studies, and to suggest that for biological fluids such as surfactant substitutes, the microrheology technique of rotational magnetic spectroscopy (MRS) can provide valuable results.

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.

Potential effect of pulmonary fluid viscosity on positive end-expiratory pressure and regional distribution of lung ventilation in acute respiratory distress syndrome

BACKGROUND

Computational fluid dynamic simulations have showed that the elevated viscosity of pulmonary fluids may increase the likelihood of airway closure, thus exacerbating inhomogeneity of regional lung ventilation. Unfortunately, there have been few studies directed toward measurements of viscosity of pulmonary fluids and its effect on airway opening pressure and regional distribution of lung ventilation in acute respiratory distress syndrome.

METHODS

In this study, pulmonary fluids from 8 ARDS patients were measured using a cone and plate rheometer on days 1, 3, 7 and 14 in the treatment of the disorder. Ventilator settings were simultaneously recorded, including tidal volume, positive end-expiratory pressure, fraction of inspired oxygen (FiO₂), and so on. The regional distribution of lung ventilation was monitored by a bedside electrical impedance tomography system.

FINDINGS

The results showed that rheological properties of pulmonary fluids behaved as either Newtonian or non-Newtonian across all patients studied. Significant intersubject and intrasubject variations in measured viscosities were observed, spanning ranges from approximately 1 cP to 7 × 10⁴ cP at shear rates between 0.075-750 s^-1. The product of the positive end-expiratory airway pressure and fraction of inspired oxygen was well correlated with fluid viscosity in patients with high viscosity pulmonary fluids. Furthermore, lung ventilation in these patients was highly inhomogeneous and influenced by rheology of pulmonary fluids.

INTERPRETATION

The current findings provided the direct clinical data for theoretical models of airway reopening and may have important clinical implications in explaining inhomogeneity of lung ventilation and selecting initial levels of positive end-expiratory pressure in mechanically ventilated patients.

Bilayer aggregate microstructure determines viscoelasticity of lung surfactant suspensions

Neonatal respiratory distress syndrome (NRDS) is treated by intratracheal delivery of suspensions of animal-derived lung surfactant in saline. Lung surfactants are extracted via organic solvents from animal lung lavage, followed by solvent removal and surfactant re-hydration to form multi-bilayer particles suspended in saline. Following intra-tracheal administration, the surfactant suspension spreads throughout the lungs by surface tension gradient induced flow; the spreading rate is limited by suspension viscoelasticity. Here we examine the rheology of three clinical lung surfactant suspensions: Survanta (bovine lung), Curosurf (porcine lung), and Infasurf (calf lung). These surfactants have widely different rheological properties that depend on the lipid composition and bilayer organization. The steady shear viscosity is related to the bilayer particle volume fraction as for a suspension of hard spheres, but the lipid volume fraction is not simply related to the mass loading. Optical and electron microscopy and small angle X-ray scattering show that the viscosity variation is due to the temperature and composition dependent bilayer aggregate shapes and internal particle organization. Survanta forms crystalline bilayers at 37 °C, resulting in high aspect ratio asymmetric particles. Infasurf forms aggregates of unilamellar vesicles containing water pockets, while Curosurf forms onion-like multi-layered liposomes. While the mass loading of the three clinical surfactants is different, the different bilayer organization causes the particle volume fractions to be similar. Adding polyethylene glycol dehydrates and partially flocculates the bilayer aggregates in all suspensions, leading to smaller particle volume fractions and a reduced suspension viscosity even though the solvent viscosity increases almost six-fold.

Mitigation of Hydrochloric Acid (HCl)-Induced Lung Injury in Mice by Aerosol Therapy of Surface-Active Nanovesicles Containing Antioxidant and Anti-inflammatory Drugs

Acute lung injury leading to alveolar inflammation and surfactant dysfunction remains a medical challenge. Surface-active lipid nanovesicles of 200-250 nm size with antioxidant D-α-tocopheryl polyethylene glycol 1000 succinate (TPGS) and anti-inflammatory drug dexamethasone disodium phosphate (DXP) dual combination (Dual-NV) were developed for delivery as aerosols by nebulization in acid lung injury models. Drug deposition studies showed Dual-NV deposited ∼2.5 times more DXP compared to equivalent DXP solution. Nanovesicles are actively internalized by A549 cells through ATP- and clathrin-dependent pathways. The nanovesicles could be phagocytosed by RAW 264.7 macrophages and were nonimmunogenic and did not elicit overproduction of TNF-α, IL-1β, and IL-6. Dual-NV aerosol therapy at 200 mg/kg body weight, in HCl acid-induced lung injury in mice, markedly reduced pulmonary hemorrhage and protein leakage and improved capillary (airway) patency to ∼96%. Dual-NV aerosol therapy also significantly lowered production of inflammatory cytokine IL-1β, IL-6, and TNF-α and reduced oxidative stress by ∼95% in the injured group. Surface-active Dual-NV aerosol therapy is promising for replenishing the dysfunctional surfactant pool and mitigating inflammation and oxidative stress in lung injuries.

Determination of rheology and surface tension of airway surface liquid: a review of clinical relevance and measurement techniques

By airway surface liquid, we mean a thin fluid continuum consisting of the airway lining layer and the alveolar lining layer, which not only serves as a protective barrier against foreign particles but also contributes to maintaining normal respiratory mechanics. In recent years, measurements of the rheological properties of airway surface liquid have attracted considerable clinical attention due to new advances in microrheology instruments and methods. This article reviews the clinical relevance of measurements of airway surface liquid viscoelasticity and surface tension from four main aspects: maintaining the stability of the airways and alveoli, preventing ventilator-induced lung injury, optimizing surfactant replacement therapy for respiratory syndrome distress, and characterizing the barrier properties of airway mucus to improve drug and gene delivery. Primary measuring techniques and methods suitable for determining the viscoelasticity and surface tension of airway surface liquid are then introduced with respect to principles, advantages and limitations. Cone and plate viscometers and particle tracking microrheometers are the most commonly used instruments for measuring the bulk viscosity and microviscosity of airway surface liquid, respectively, and pendant drop methods are particularly suitable for the measurement of airway surface liquid surface tension in vitro. Currently, in vivo and in situ measurements of the viscoelasticity and surface tension of the airway surface liquid in humans still presents many challenges.

On the rheology of pulmonary surfactant: Effects of concentration and consequences for the surfactant replacement therapy

The role of pulmonary surfactant is to reduce the surface tension in the lungs and to facilitate breathing. Surfactant replacement therapy (SRT) aims at bringing a substitute by instillation into the airways, a technique that has proven to be efficient and lifesaving for preterm infants. Adapting this therapy to adults requires to scale the administered dose to the patient body weight and to increase the lipid concentration, whilst maintaining its surface and flow properties similar. Here, we exploit a magnetic wire-based microrheology technique to measure the viscosity of the exogenous pulmonary surfactant Curosurf® in various experimental conditions. The Curosurf® viscosity is found to increase exponentially with lipid concentration following the Krieger-Dougherty law of colloids. The Krieger-Dougherty behavior also predicts a divergence of the viscosity at the liquid-to-gel transition. For Curosurf® the transition concentration is found close to the concentration at which it is formulated (117 g L^-1versus 80 g L^-1). This outcome suggests that for SRT the surfactant rheological properties need to be monitored and kept within a certain range. The results found here could help in producing suspensions for respiratory distress syndrome adapted to adults. The present work also demonstrates the potential of the magnetic wire microrheology technique as an accurate tool to explore biological soft matter dynamics.

Skin mucus metabolites in response to physiological challenges: A valuable non-invasive method to study teleost marine species

Knowledge concerning the health and welfare of fish is important to conserve species diversity. Fish mucosal surfaces, and particularly the skin, are of utmost importance to protect the integrity and homeostasis of the body and to prevent skin infections by pathogens. We performed three trials simulating different environmental and anthropogenic challenges: fish capture (air exposure), bacterial infection and fasting, with the aim of evaluating epidermal mucus as a non-invasive target of studies in fish. In this initial approach, we selected three well-known marine species: meagre (Argyrosomus regius), European sea bass (Dicentrarchus labrax) and gilthead sea bream (Sparus aurata) for our study. Mucus viscosity was measured in order to determine its rheological properties, and mucus metabolite (glucose, lactate, protein and cortisol) levels were analysed to establish their suitability as potential biomarkers. Skin mucus appeared as a viscous fluid exhibiting clearly non-Newtonian behaviour, with its viscosity being dependent on shear rate. The highest viscosity (p < 0.05) was observed in sea bream. Mucus metabolites composition responded to the different challenges. In particular, glucose increased significantly due to the air exposure challenge in meagre; and it decreased during food deprivation in sea bream by a half (p < 0.05). In contrast, mucus protein only decreased significantly after pathogenic bacterial infection in sea bass. In addition, mucus lactate immediately reflected changes closely related to an anaerobic condition; whereas cortisol was only modified by air exposure, doubling its mucus concentration (p < 0.05). The data provided herein demonstrate that mucus metabolites can be considered as good non-invasive biomarkers for evaluating fish physiological responses; with the glucose/protein ratio being the most valuable and reliable parameter. Determining these skin mucus metabolites and ratios will be very useful when studying the condition of critically threatened species whose conservation status prohibits the killing of specimens.

Developing an exogenous pulmonary surfactant-glucocorticoids association: Effect of corticoid concentration on the biophysical properties of the surfactant

Glucocorticoids (GCs) are used to treat lung disease. GCs incorporated in an exogenous pulmonary surfactant (EPS) could be an alternative management to improve drug delivery avoiding side effects. In the development of these pharmaceutical products, it is important to know the maximum amount of GC that can be incorporated and if increasing quantities of GCs alter EPS biophysical properties. Formulations containing EPS and beclomethasone, budesonide or fluticasone were analyzed (PL 10mg/ml; GC 1-2mg/ml). The microstructure was evaluated by electron paramagnetic resonance spectroscopy, GCs incorporated were determined by UV absorption and polarized light microscopy and surfactant activity with pulsating bubble surfactometer. We found that GCs have a ceiling of incorporation of around 10wt%, and that the GC not incorporated remains as crystals in the aqueous phase without altering the biophysical properties of the surfactant. This fact is important, because the greater the proportion of GC that EPS can carry, the better the efficiency of this pulmonary GC system.

Synthetic lung surfactants containing SP-B and SP-C peptides plus novel phospholipase-resistant lipids or glycerophospholipids

Background

This study examines the biophysical and preclinical pulmonary activity of synthetic lung surfactants containing novel phospholipase-resistant phosphonolipids or synthetic glycerophospholipids combined with Super Mini-B (S-MB) DATK and/or SP-Css ion-lock 1 peptides that replicate the functional biophysics of surfactant proteins (SP)-B and SP-C. Phospholipase-resistant phosphonolipids used in synthetic surfactants are DEPN-8 and PG-1, molecular analogs of dipalmitoyl phosphatidylcholine (DPPC) and palmitoyl-oleoyl phosphatidylglycerol (POPG), while glycerophospholipids used are active lipid components of native surfactant (DPPC:POPC:POPG 5:3:2 by weight). The objective of the work is to test whether these novel lipid/peptide synthetic surfactants have favorable preclinical activity (biophysical, pulmonary) for therapeutic use in reversing surfactant deficiency or dysfunction in lung disease or injury.

Methods

Surface activity of synthetic lipid/peptide surfactants was assessed in vitro at 37 °C by measuring adsorption in a stirred subphase apparatus and dynamic surface tension lowering in pulsating and captive bubble surfactometers. Shear viscosity was measured as a function of shear rate on a Wells-Brookfield micro-viscometer. In vivo pulmonary activity was determined by measuring lung function (arterial oxygenation, dynamic lung compliance) in ventilated rats and rabbits with surfactant deficiency/dysfunction induced by saline lavage to lower arterial PO₂ to <100 mmHg, consistent with clinical acute respiratory distress syndrome (ARDS).

Results

Synthetic surfactants containing 5:3:2 DPPC:POPC:POPG or 9:1 DEPN-8:PG-1 combined with 3% (by wt) of S-MB DATK, 3% SP-Css ion-lock 1, or 1.5% each of both peptides all adsorbed rapidly to low equilibrium surface tensions and also reduced surface tension to ≤1 mN/m under dynamic compression at 37 °C. However, dual-peptide surfactants containing 1.5% S-MB DATK + 1.5% SP-Css ion-lock 1 combined with 9:1 DEPN-8:PG-1 or 5:3:2 DPPC:POPC:POPG had the greatest in vivo activity in improving arterial oxygenation and dynamic lung compliance in ventilated animals with ARDS. Saline dispersions of these dual-peptide synthetic surfactants were also found to have shear viscosities comparable to or below those of current animal-derived surfactant drugs, supporting their potential ease of deliverability by instillation in future clinical applications.

Discussion

Our findings support the potential of dual-peptide synthetic lipid/peptide surfactants containing S-MB DATK + SP-Css ion-lock 1 for treating diseases of surfactant deficiency or dysfunction. Moreover, phospholipase-resistant dual-peptide surfactants containing DEPN-8/PG-1 may have particular applications in treating direct forms of ARDS where endogenous phospholipases are present in the lungs.

Surfactant therapy for acute lung injury and acute respiratory distress syndrome

This article examines exogenous lung surfactant replacement therapy and its usefulness in mitigating clinical acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS). Surfactant therapy is beneficial in term infants with pneumonia and meconium aspiration lung injury, and in children up to age 21 years with direct pulmonary forms of ALI/ARDS. However, extension of exogenous surfactant therapy to adults with respiratory failure and clinical ALI/ARDS remains a challenge. This article reviews clinical studies of surfactant therapy in pediatric and adult patients with ALI/ARDS, focusing on its potential advantages in patients with direct pulmonary forms of these syndromes.

Influence of serum protein and albumin addition on the structure and activity of an exogenous pulmonary surfactant

The comparative analysis of the deleterious action of albumin and total serum proteins (SP) might help to understand the nature of the interaction surfactant--SP. This study evaluated the effects of serum proteins and albumin on bulk shear viscosity, surface tension, surface area reduction, and the ratio between the light and heavy subtypes of surfactant suspensions. Our results showed a correlation between the bulk viscosity and aggregation degree of surfactant suspensions. The addition of albumin or SP induced the transformation from the heavy to the light subtype, reducing the viscosity. SP caused disaggregation and inactivation, whereas albumin caused only disaggregation without loss of surface activity. When SP were removed, the heavy fraction obtained recovered its surface activity. We conclude that the disaggregation may not be the primary cause for the loss of surface activity. Surfactant inactivation by a serum component, different from albumin, would be probably due to a physical interaction, a phenomenon that is reversed when SP are removed.

Kinematic viscosity of therapeutic pulmonary surfactants with added polymers

The addition of various polymers to pulmonary surfactants improves surface activity in experiments both in vitro and in vivo. Although the viscosity of surfactants has been investigated, the viscosity of surfactant polymer mixtures has not. In this study, we have measured the viscosities of Survanta and Infasurf with and without the addition of polyethylene glycol, dextran or hyaluronan. The measurements were carried out over a range of surfactant concentrations using two concentrations of polymers at two temperatures. Our results indicate that at lower surfactant concentrations, the addition of any polymers increased the viscosity. However, the addition of polyethylene glycol and dextran to surfactants at clinically used concentrations can substantially lower viscosity. Addition of hyaluronan at clinical surfactant concentrations slightly increased Infasurf viscosity and produced little change in Survanta viscosity. Effects of polymers on viscosity correlate with changes in size and distribution of surfactant aggregates and the apparent free volume of liquid as estimated by light microscopy. Aggregation of surfactant vesicles caused by polymers may therefore not only improve surface activity as previously shown, but may also affect viscosity in ways that could improve surfactant distribution in vivo.

Surfactant for pediatric acute lung injury

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.

The viscosity and glycoprotein biochemistry of salmonid mucus varies with species, salinity and the presence of amoebic gill disease

Fish mucus has previously been reported to change in appearance and composition among species and in response to changes in salinity and disease status. This study reports on the mucus viscosity and glycoprotein biochemistry of Atlantic salmon (Salmo salar L.), brown trout (Salmo trutta L.) and rainbow trout (Oncorhynchus mykiss Walbaum) in freshwater and seawater, both naive to and affected by amoebic gill disease (AGD). Cutaneous mucus viscosity was measured over a range of shear rates (11.5, 23, 46 and 115 s(-1)), and non-Newtonian behaviour was demonstrated for all three species. Mucus viscosity was significantly greater in seawater than in freshwater for all species, and significantly lower in AGD-affected Atlantic salmon and brown trout. Mucus glucose, total protein and osmolality data indicated that differences in viscosity due to salinity were mostly attributed to changes in mucus hydration, while differences due to disease were mostly attributed to changes in mucus composition. Trends in gill mucus cell histochemistry included shifts in glycoproteins from neutral mucins in freshwater to acidic mucins in seawater, and shifts towards neutral mucins, with an increase in mucus cell numbers, in response to AGD. Results suggested that Atlantic salmon and brown trout are more similar to one another in their mucus profile than to rainbow trout. Atlantic salmon and brown trout both exhibited a whole-body mucus response to AGD, whereas rainbow trout exhibited only a local gill response. Findings hold implications for fish physiology and pathology, and indicate that future fish-disease management strategies should be species and condition specific.

Bulk shear viscosities of endogenous and exogenous lung surfactants

Bulk shear viscosities were measured with a cone and plate microviscometer as a function of concentration, shear rate, and temperature for lavaged calf lung surfactant (LS), Exosurf, Infasurf, Survanta, and synthetic lipid mixtures dispersed in normal saline. Viscosity increased with phospholipid concentration for all surfactants, but its magnitude and shear dependence varied widely among the different preparations. Saline dispersions of Exosurf and synthetic phospholipids had low viscosities of only a few centipoise (cp) and exhibited minimal shear dependence. LS, Infasurf, Survanta, and lipid mixtures containing palmitic acid and tripalmitin had larger non-Newtonian viscosities that increased as shear rate decreased. At 35 mg of phospholipid/ml and 37 degrees C, viscosity values were 52.3 cp (Survanta), 31.1 cp (LS), and 25 cp (Infasurf) at a shear rate of 77 s(-1) and 16.9 cp (Survanta), 10.1 cp (LS), and 6.6 cp (Infasurf) at 770 s(-1). At 25 mg of phospholipid/ml and 37 degrees C, viscosity values at 77 s(-1) were 28.8 cp (Survanta), 4.7 cp (LS), and 12.5 cp (Infasurf). At fixed shear rate, viscosity was substantially decreased at 23 degrees C compared with 37 degrees C for LS and Infasurf but was increased for Survanta. Calcium (5 mM) greatly reduced the viscosity of both Survanta and Infasurf at 37 degrees C. Studies on synthetic mixtures indicated that phospholipid/apoprotein interactions were important in the rheology of lung-derived surfactants and that palmitic acid and tripalmitin contributed to the increased viscosity of Survanta. The viscous behavior of clinical exogenous surfactants potentially influences their delivery and distribution in lungs and varies significantly with composition, concentration, temperature, ionic environment, and physical formulation.