Development of the concept of a liquid pulmonary alveolar lining layer

Pulmonary surfactant and COVID-19: A new synthesis

Chapter 1

COVID-19 pathogenesis poses paradoxes difficult to explain with traditional physiology. For instance, since type II pneumocytes are considered the primary cellular target of SARS-CoV-2; as these produce pulmonary surfactant (PS), the possibility that insufficient PS plays a role in COVID-19 pathogenesis has been raised. However, the opposite of predicted high alveolar surface tension is found in many early COVID-19 patients: paradoxically normal lung volumes and high compliance occur, with profound hypoxemia. That 'COVID anomaly' was quickly rationalised by invoking traditional vascular mechanisms-mainly because of surprisingly preserved alveolar surface in early hypoxemic cases. However, that quick rejection of alveolar damage only occurred because the actual mechanism of gas exchange has long been presumed to be non-problematic, due to diffusion through the alveolar surface. On the contrary, we provide physical chemical evidence that gas exchange occurs by an process of expansion and contraction of the three-dimensional structures of PS and its associated proteins. This view explains anomalous observations from the level of cryo-TEM to whole individuals. It encompasses results from premature infants to the deepest diving seals. Once understood, the COVID anomaly dissolves and is straightforwardly explained as covert viral damage to the 3D structure of PS, with direct treatment implications. As a natural experiment, the SARS-CoV-2 virus itself has helped us to simplify and clarify not only the nature of dyspnea and its relationship to pulmonary compliance, but also the fine detail of the PS including such features as water channels which had heretofore been entirely unexpected.

Chapter 2

For a long time, physical, colloid and surface chemistry have not intersected with physiology and cell biology as much as we might have hoped. The reasons are starting to become clear. The discipline of physical chemistry suffered from serious unrecognised omissions that rendered it ineffective. These foundational defects included omission of specific ion molecular forces and hydration effects. The discipline lacked a predictive theory of self-assembly of lipids and proteins. Worse, theory omitted any role for dissolved gases, O2, N2, CO2, and their existence as stable nanobubbles above physiological salt concentration. Recent developments have gone some way to explaining the foam-like lung surfactant structures and function. It delivers O2/N2 as nanobubbles, and efflux of CO2, and H2O nanobubbles at the alveolar surface. Knowledge of pulmonary surfactant structure allows an explanation of the mechanism of corona virus entry, and differences in infectivity of different variants. CO2 nanobubbles, resulting from metabolism passing through the molecular frit provided by the glycocalyx of venous tissue, forms the previously unexplained foam which is the endothelial surface layer. CO2 nanobubbles turn out to be lethal to viruses, providing a plausible explanation for the origin of 'Long COVID'. Circulating nanobubbles, stable above physiological 0.17 M salt drive various enzyme-like activities and chemical reactions. Awareness of the microstructure of Pulmonary Surfactant and that nanobubbles of (O2/N2) and CO2 are integral to respiratory and circulatory physiology provides new insights to the COVID-19 and other pathogen activity.

Effect of neutral lipids on coexisting phases in monolayers of pulmonary surfactant

We previously established that compression of monolayers containing the lipids in pulmonary surfactant, with or without the surfactant proteins, initially leads to phase separation. On further compression, however, phase coexistence terminates at a critical point that requires the presence of cholesterol. The studies reported here address the changes in the phospholipid phase diagram produced by cholesterol. We used the two systems of the lipids from calf surfactant with and without the surfactant proteins. For both systems, we began with the postulate that cholesterol had no effect on the composition of other constituents in the two phases, and then used the known behavior of interfacial tension at a critical point to test the two extreme cases in which the cholesterol partitions exclusively into condensed domains or into the surrounding film. Measurements of surface potential along with the fraction of the nonfluorescent area and the radius of the domains, both obtained by fluorescence microscopy, for films with and without cholesterol allowed calculation of the interfacial tension between the two phases. Only the model that assumes the presence of cholesterol within the domains accurately predicts a decreasing line tension during film compression toward the critical point. That model, however, also predicts an unlikely decrease during compression of the dipole moment density for the condensed phase. Our results are best explained in terms of cholesterol partitioning predominantly into the condensed domains, with a resulting partial redistribution of the phospholipids between the two phases.

Pulmonary surfactant: phase behavior and function

Pulmonary surfactant functions by first flowing rapidly into the alveolar air/water interface, but then resisting collapse from the surface when the adsorbed interfacial film is compressed during exhalation. Widely accepted models emphasize the importance of phase behavior in both processes. Recent studies show, however, that fluidity is a relatively minor determinant of adsorption and that solid films, which resist collapse, can form by kinetic processes unrelated to equilibrium phase behavior.

Inhibition of active sodium absorption leads to a net liquid secretion into in vivo rabbit lung at two levels of alveolar hypoxia

Active sodium transport across alveolar epithelium is known to contribute to the resolution of pulmonary oedema. We have attempted to assess whether sodium transport is essential to prevent liquid accumulation in healthy pulmonary alveoli exposed to mild hypoxia, and whether its contribution to liquid absorption differs between mild and moderate levels of hypoxia. In twenty-four anaesthetized adult rabbits we used direct bronchial cannulation to measure liquid movement from the liquid-filled left lung over 3.5 h. Half of the rabbits were studied at a level of mixed venous (and alveolar) oxygen partial pressure, PVO2, of 6.5 kPa and half at 4.5 kPa. PVO2 was altered by changing the inspired oxygen fraction in the ventilated right lung. Alveolar hydrostatic pressure was 0.3 kPa. In each group of 12, six animals with inhibitors of sodium transport in the isosmotic instillate were compared with six controls. We have shown an alveolar liquid secretion (approximately 0.6 microl min(-1) (kg body weight)(-1)) in the presence of inhibitors of active transport and an absorption (approximately 4 microl min(-1) (kg body weight)(-1)) in controls. Changing PVO2 had no influence on these movements. We conclude that, in this model of pulmonary oedema, active sodium transport appears to be essential for prevention of alveolar liquid accumulation via secretion. Furthermore, the contribution of active sodium transport to liquid absorption remains constant at oxygen tensions between 4.5 and 6.5 kPa.