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Lung recruitment before surfactant administration in extremely preterm neonates with respiratory distress syndrome (IN-REC-SUR-E): a randomised, unblinded, controlled trial. THE LANCET RESPIRATORY MEDICINE 2020; 9:159-166. [PMID: 32687801 DOI: 10.1016/s2213-2600(20)30179-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND The importance of lung recruitment before surfactant administration has been shown in animal studies. Well designed trials in preterm infants are absent. We aimed to examine whether the application of a recruitment manoeuvre just before surfactant administration, followed by rapid extubation (intubate-recruit-surfactant-extubate [IN-REC-SUR-E]), decreased the need for mechanical ventilation during the first 72 h of life compared with no recruitment manoeuvre (ie, intubate-surfactant-extubate [IN-SUR-E]). METHODS We did a randomised, unblinded, controlled trial in 35 tertiary neonatal intensive care units in Italy. Spontaneously breathing extremely preterm neonates (24 + 0 to 27 + 6 weeks' gestation) reaching failure criteria for continuous positive airway pressure within the first 24 h of life were randomly assigned (1:1) with a minimisation algorithm to IN-REC-SUR-E or IN-SUR-E using an interactive web-based electronic system, stratified by clinical site and gestational age. The primary outcome was the need for mechanical ventilation in the first 72 h of life. Analyses were done in intention-to-treat and per-protocol populations, with a log-binomial regression model correcting for stratification factors to estimate adjusted relative risk (RR). This study is registered with ClinicalTrials.gov, NCT02482766. FINDINGS Of 556 infants assessed for eligibility, 218 infants were recruited from Nov 12, 2015, to Sept 23, 2018, and included in the intention-to-treat analysis. The requirement for mechanical ventilation during the first 72 h of life was reduced in the IN-REC-SUR-E group (43 [40%] of 107) compared with the IN-SUR-E group (60 [54%] of 111; adjusted RR 0·75, 95% CI 0·57-0·98; p=0·037), with a number needed to treat of 7·2 (95% CI 3·7-135·0). The addition of the recruitment manoeuvre did not adversely affect the safety outcomes of in-hospital mortality (19 [19%] of 101 in the IN-REC-SUR-E group vs 37 [33%] of 111 in the IN-SUR-E group), pneumothorax (four [4%] of 101 vs seven [6%] of 111), or grade 3 or worse intraventricular haemorrhage (12 [12%] of 101 vs 17 [15%] of 111). INTERPRETATION A lung recruitment manoeuvre just before surfactant administration improved the efficacy of surfactant treatment in extremely preterm neonates compared with the standard IN-SUR-E technique, without increasing the risk of adverse neonatal outcomes. The reduced need for mechanical ventilation during the first 72 h of life might facilitate implementation of a non-invasive respiratory support strategy. FUNDING None.
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da Silva TD, Barnabé V, Ricci-Vitor AL, Papapostolou V, Tagle M, Henriquez A, Lawrence J, Ferguson S, Wolfson JM, Koutrakis P, Oyola P, Ferreira C, de Abreu LC, Monteiro CBDM, Godleski JJ. Secondary particles formed from the exhaust of vehicles using ethanol-gasoline blends increase the production of pulmonary and cardiac reactive oxygen species and induce pulmonary inflammation. ENVIRONMENTAL RESEARCH 2019; 177:108661. [PMID: 31442789 DOI: 10.1016/j.envres.2019.108661] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/08/2019] [Accepted: 08/12/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Ethanol vehicles release exhaust gases that contribute to the formation of secondary organic aerosols (SOA). OBJECTIVE To determine in vivo toxicity resulting from exposure to SOA derived from vehicles using different ethanol-gasoline blends (E0, E10, E22, E85W, E85S, E100). METHODS Exhaust emissions from vehicles using ethanol blends were delivered to a photochemical chamber and reacted to produce SOA. The aerosol samples were collected on filters, extracted, and dispersed in an aqueous solutions and intratracheally instilled into Sprague Dawley rats in doses of 700 μg/0.2 ml. After 45 min and 4 h pulmonary and cardiac chemiluminescence (CL) was measured to estimate the amount of reactive oxygen species (ROS) produced in the lungs and heart. Inflammation was measured by differential cell count in bronchoalveolar lavages (BAL). RESULTS Statistically and biologically significant differences in response to secondary particles from the different fuel formulations were detected. Compared to the control group, animals exposed to SOA from gasoline (E0) showed a significantly higher average CL in the lungs at 45 min. The highest CL averages in the heart were observed in the groups exposed to SOA from E10 and pure ethanol (E100) at 45 min. BAL of animals exposed to SOA from E0 and E85S had a significant increased number of macrophages at 45 min. BAL neutrophil count was increased in the groups exposed to E85S (45 min) and E0 (4 h). Animals exposed to E0 and E85W had increased BAL lymphocyte count compared to the control and the other exposed groups. DISCUSSION Our results suggest that SOA generated by gasoline (E0), followed by ethanol blends E85S and E85W, substantially induce oxidative stress measured by ROS generation and pulmonary inflammation measured by the recruitment of white blood cells in BAL.
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Affiliation(s)
- Talita Dias da Silva
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA; Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil.
| | - Viviani Barnabé
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA; Medical School, University City of São Paulo, São Paulo, SP, Brazil
| | - Ana Laura Ricci-Vitor
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA; Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil
| | | | - Matias Tagle
- Mario Molina Center for Strategic Studies in Energy and Environment, Santiago, Chile
| | - Andres Henriquez
- Oak Ridge Institute for Science and Education, Research Triangle Park, NC, United States
| | - Joy Lawrence
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Stephen Ferguson
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - J Mikhail Wolfson
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Petros Koutrakis
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Pedro Oyola
- Mario Molina Center for Strategic Studies in Energy and Environment, Santiago, Chile
| | - Celso Ferreira
- Paulista School of Medicine, Federal University of São Paulo, São Paulo, SP, Brazil
| | | | | | - John J Godleski
- Harvard T. H. Chan School of Public Health, Harvard University, Boston, MA, USA
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Zecchi R, Franceschi P, Tigli L, Ricci F, Boscaro F, Pioselli B, Mileo V, Murgia X, Bianco F, Salomone F, Schmidt AF, Hillman NH, Kemp MW, Jobe AH. Mass spectrometry imaging as a tool for evaluating the pulmonary distribution of exogenous surfactant in premature lambs. Respir Res 2019; 20:175. [PMID: 31382955 PMCID: PMC6683365 DOI: 10.1186/s12931-019-1144-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/24/2019] [Indexed: 01/29/2023] Open
Abstract
Background The amount of surfactant deposited in the lungs and its overall pulmonary distribution determine the therapeutic outcome of surfactant replacement therapy. Most of the currently available methods to determine the intrapulmonary distribution of surfactant are time-consuming and require surfactant labelling. Our aim was to assess the potential of Mass Spectrometry Imaging (MSI) as a label-free technique to qualitatively and quantitatively evaluate the distribution of surfactant to the premature lamb. Methods Twelve preterm lambs (gestational age 126-127d, term ~150d) were allocated in two experimental groups. Seven lambs were treated with an intratracheal bolus of the synthetic surfactant CHF5633 (200 mg/kg) and 5 lambs were managed with mechanical ventilation for 120 min, as controls. The right lung lobes of all lambs were gradually frozen while inflated to 20 cmH2O pressure for lung cryo-sections for MSI analysis. The intensity signals of SP-C analog and SP-B analog, the two synthetic peptides contained in the CHF5633 surfactant, were used to locate, map and quantify the intrapulmonary exogenous surfactant. Results Surfactant treatment was associated with a significant improvement of the mean arterial oxygenation and lung compliance (p < 0.05). Nevertheless, the physiological response to surfactant treatment was not uniform across all animals. SP-C analog and SP-B analog were successfully imaged and quantified by means of MSI in the peripheral lungs of all surfactant-treated animals. The intensity of the signal was remarkably low in untreated lambs, corresponding to background noise. The signal intensity of SP-B analog in each surfactant-treated animal, which represents the surfactant distributed to the peripheral right lung, correlated well with the physiologic response as assessed by the area under the curves of the individual arterial partial oxygen pressure and dynamic lung compliance curves of the lambs. Conclusions Applying MSI, we were able to detect, locate and quantify the amount of exogenous surfactant distributed to the lower right lung of surfactant-treated lambs. The distribution pattern of SP-B analog correlated well with the pulmonary physiological outcomes of the animals. MSI is a valuable label-free technique which is able to simultaneously evaluate qualitative and quantitative drug distribution in the lung. Electronic supplementary material The online version of this article (10.1186/s12931-019-1144-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Riccardo Zecchi
- Mass Spectrometry Service Center (CISM), University of Florence, Florence, Italy
| | - Pietro Franceschi
- Computational Biology, Research and Innovation Centre, Fondazione Edmund Mach, S. Michele all'Adige, TN, Italy
| | - Laura Tigli
- Preclinical R&D, Chiesi Farmaceutici, Largo Francesco Belloli, 11/A, 43122, Parma, Italy
| | - Francesca Ricci
- Preclinical R&D, Chiesi Farmaceutici, Largo Francesco Belloli, 11/A, 43122, Parma, Italy
| | - Francesca Boscaro
- Mass Spectrometry Service Center (CISM), University of Florence, Florence, Italy
| | - Barbara Pioselli
- Preclinical R&D, Chiesi Farmaceutici, Largo Francesco Belloli, 11/A, 43122, Parma, Italy
| | - Valentina Mileo
- Preclinical R&D, Chiesi Farmaceutici, Largo Francesco Belloli, 11/A, 43122, Parma, Italy
| | | | - Federico Bianco
- Preclinical R&D, Chiesi Farmaceutici, Largo Francesco Belloli, 11/A, 43122, Parma, Italy
| | - Fabrizio Salomone
- Preclinical R&D, Chiesi Farmaceutici, Largo Francesco Belloli, 11/A, 43122, Parma, Italy.
| | - Augusto F Schmidt
- Division of Neonatology and Pulmonary Biology, Cincinnati Children's Hospital, Cincinnati, USA
| | - Noah H Hillman
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, USA
| | - Matthew W Kemp
- Division of Obstetrics and Gynecology, University of Western Australia, Perth, WA, Australia
| | - Alan H Jobe
- Division of Neonatology, Cardinal Glennon Children's Hospital, Saint Louis University, Saint Louis, USA.,Division of Obstetrics and Gynecology, University of Western Australia, Perth, WA, Australia
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Krafft MP. Overcoming inactivation of the lung surfactant by serum proteins: a potential role for fluorocarbons? SOFT MATTER 2015; 11:5982-5994. [PMID: 26110877 DOI: 10.1039/c5sm00926j] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
In many pulmonary conditions serum proteins interfere with the normal adsorption of components of the lung surfactant to the surface of the alveoli, resulting in lung surfactant inactivation, with potentially serious untoward consequences. Here, we review the strategies that have recently been designed in order to counteract the biophysical mechanisms of inactivation of the surfactant. One approach includes protein analogues or peptides that mimic the native proteins responsible for innate resistance to inactivation. Another perspective uses water-soluble additives, such as electrolytes and hydrophilic polymers that are prone to enhance adsorption of phospholipids. An alternative, more recent approach consists of using fluorocarbons, that is, highly hydrophobic inert compounds that were investigated for partial liquid ventilation, that modify interfacial properties and can act as carriers of exogenous lung surfactant. The latter approach that allows fluidisation of phospholipid monolayers while maintaining capacity to reach near-zero surface tension definitely warrants further investigation.
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Affiliation(s)
- Marie Pierre Krafft
- Institut Charles Sadron (CNRS), University of Strasbourg, 23 rue du Loess, 67034 Strasbourg Cedex, France.
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5
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Composition, structure and mechanical properties define performance of pulmonary surfactant membranes and films. Chem Phys Lipids 2014; 185:153-75. [PMID: 25260665 DOI: 10.1016/j.chemphyslip.2014.09.002] [Citation(s) in RCA: 183] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 09/06/2014] [Accepted: 09/11/2014] [Indexed: 12/30/2022]
Abstract
The respiratory surface in the mammalian lung is stabilized by pulmonary surfactant, a membrane-based system composed of multiple lipids and specific proteins, the primary function of which is to minimize the surface tension at the alveolar air-liquid interface, optimizing the mechanics of breathing and avoiding alveolar collapse, especially at the end of expiration. The goal of the present review is to summarize current knowledge regarding the structure, lipid-protein interactions and mechanical features of surfactant membranes and films and how these properties correlate with surfactant biological function inside the lungs. Surfactant mechanical properties can be severely compromised by different agents, which lead to surfactant inhibition and ultimately contributes to the development of pulmonary disorders and pathologies in newborns, children and adults. A detailed comprehension of the unique mechanical and rheological properties of surfactant layers is crucial for the diagnostics and treatment of lung diseases, either by analyzing the contribution of surfactant impairment to the pathophysiology or by improving the formulations in surfactant replacement therapies. Finally, a short review is also included on the most relevant experimental techniques currently employed to evaluate lung surfactant mechanics, rheology, and inhibition and reactivation processes.
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Dushianthan A, Cusack R, Goss V, Postle AD, Grocott MPW. Clinical review: Exogenous surfactant therapy for acute lung injury/acute respiratory distress syndrome--where do we go from here? Crit Care 2012; 16:238. [PMID: 23171712 PMCID: PMC3672556 DOI: 10.1186/cc11512] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Acute lung injury and acute respiratory distress syndrome (ARDS) are characterised by severe hypoxemic respiratory failure and poor lung compliance. Despite advances in clinical management, morbidity and mortality remains high. Supportive measures including protective lung ventilation confer a survival advantage in patients with ARDS, but management is otherwise limited by the lack of effective pharmacological therapies. Surfactant dysfunction with quantitative and qualitative abnormalities of both phospholipids and proteins are characteristic of patients with ARDS. Exogenous surfactant replacement in animal models of ARDS and neonatal respiratory distress syndrome shows consistent improvements in gas exchange and survival. However, whilst some adult studies have shown improved oxygenation, no survival benefit has been demonstrated to date. This lack of clinical efficacy may be related to disease heterogeneity (where treatment responders may be obscured by nonresponders), limited understanding of surfactant biology in patients or an absence of therapeutic effect in this population. Crucially, the mechanism of lung injury in neonates is different from that in ARDS: surfactant inhibition by plasma constituents is a typical feature of ARDS, whereas the primary pathology in neonates is the deficiency of surfactant material due to reduced synthesis. Absence of phenotypic characterisation of patients, the lack of an ideal natural surfactant material with adequate surfactant proteins, coupled with uncertainty about optimal timing, dosing and delivery method are some of the limitations of published surfactant replacement clinical trials. Recent advances in stable isotope labelling of surfactant phospholipids coupled with analytical methods using electrospray ionisation mass spectrometry enable highly specific molecular assessment of phospholipid subclasses and synthetic rates that can be utilised for phenotypic characterisation and individualisation of exogenous surfactant replacement therapy. Exploring the clinical benefit of such an approach should be a priority for future ARDS research.
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Affiliation(s)
- Ahilanandan Dushianthan
- Anaesthesia and Critical Care Research Unit, CE 93, MP24, E-Level, Centre Block, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Integrative Physiology and Critical Illness, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Rebecca Cusack
- Anaesthesia and Critical Care Research Unit, CE 93, MP24, E-Level, Centre Block, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Victoria Goss
- Integrative Physiology and Critical Illness, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Anthony D Postle
- Integrative Physiology and Critical Illness, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Mike PW Grocott
- Anaesthesia and Critical Care Research Unit, CE 93, MP24, E-Level, Centre Block, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Integrative Physiology and Critical Illness, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
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7
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Burkhardt W, Kraft S, Ochs M, Proquitté H, Mense L, Rüdiger M. Persurf, a new method to improve surfactant delivery: a study in surfactant depleted rats. PLoS One 2012; 7:e47923. [PMID: 23082229 PMCID: PMC3474734 DOI: 10.1371/journal.pone.0047923] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Accepted: 09/19/2012] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Exogenous surfactant is not very effective in adults with ARDS, since surfactant does not reach atelectatic alveoli. Perfluorocarbons (PFC) can recruit atelectatic areas but do not replace impaired endogenous surfactant. A surfactant-PFC-mixture could combine benefits of both therapies. The aim of the proof-of-principal-study was to produce a PFC-in-surfactant emulsion (Persurf) and to test in surfactant depleted Wistar rats whether Persurf achieves I.) a more homogenous pulmonary distribution and II.) a more homogenous recruitment of alveoli when compared with surfactant or PFC alone. METHODS Three different PFC were mixed with surfactant and phospholipid concentration in the emulsion was measured. After surfactant depletion, animals either received 30 ml/kg of PF5080, 100 mg/kg of stained (green dye) Curosurf™ or 30 ml/kg of Persurf. Lungs were fixated after 1 hour of ventilation and alveolar aeration and surfactant distribution was estimated by a stereological approach. RESULTS Persurf contained 3 mg/ml phospholipids and was stable for more than 48 hours. Persurf-administration improved oxygenation. Histological evaluation revealed a more homogenous surfactant distribution and alveolar inflation when compared with surfactant treated animals. CONCLUSIONS In surfactant depleted rats administration of PFC-in-surfactant emulsion leads to a more homogenous distribution and aeration of the lung than surfactant alone.
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Affiliation(s)
- Wolfram Burkhardt
- Department for Neonatology and Pediatric Intensive Care Medicine, Klinik für Kinderheilkunde, Universitätsklinikum Carl Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden, Dresden, Germany
| | - Stephan Kraft
- Department for Pediatric Surgery, Klinikum Mutterhaus der Borromäerinnen, Trier, Germany
| | - Matthias Ochs
- Institute of Functional and Applied Anatomy, Hannover Medical School, Hannover, Germany
| | - Hans Proquitté
- Clinic for Neonatology, Charité, Universitätsmedizin Berlin, Campus Mitte, Berlin, Germany
| | - Lars Mense
- Department for Neonatology and Pediatric Intensive Care Medicine, Klinik für Kinderheilkunde, Universitätsklinikum Carl Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden, Dresden, Germany
| | - Mario Rüdiger
- Department for Neonatology and Pediatric Intensive Care Medicine, Klinik für Kinderheilkunde, Universitätsklinikum Carl Gustav Carus, Medizinische Fakultät der Technischen Universität Dresden, Dresden, Germany
- * E-mail:
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8
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Dani C, Corsini I, Poggi C. Risk factors for intubation-surfactant-extubation (INSURE) failure and multiple INSURE strategy in preterm infants. Early Hum Dev 2012; 88 Suppl 1:S3-4. [PMID: 22266202 DOI: 10.1016/j.earlhumdev.2011.12.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The INSURE method, which consists of an intubation-surfactant-extubation sequence, is effective in reducing the need for mechanical ventilation (MV), the duration of respiratory support, and the need for surfactant replacement in preterm infants with respiratory distress syndrome. Although beneficial, the INSURE method fails to avoid MV in selected patients. We demonstrated that body weight <750 g, pO(2)/FiO(2) <218, and a/ApO(2) <0.44 at the first blood gas analysis are independent risk factors for INSURE failure in infants with gestational age <30 weeks. Moreover, we demonstrated that the INSURE treatment can be safely repeated with the aim to avoid MV, since the respiratory outcome did not differ between infants treated with single or multiple INSURE procedures.
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Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, University of Florence, Viale Morgagni 85, Florence, Italy.
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9
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Quantitative computed tomography in porcine lung injury with variable versus conventional ventilation: Recruitment and surfactant replacement*. Crit Care Med 2011; 39:1721-30. [DOI: 10.1097/ccm.0b013e3182186d09] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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10
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Dani C, Corsini I, Bertini G, Pratesi S, Barp J, Rubaltelli FF. Effect of multiple INSURE procedures in extremely preterm infants. J Matern Fetal Neonatal Med 2011; 24:1427-31. [PMID: 21506654 DOI: 10.3109/14767058.2011.572203] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Our aim was to evaluate whether single and multiple intubation-surfactant-extubation (INSURE) procedures have similar effects on the need of mechanical ventilation (MV) and occurrence of bronchopulmonary dysplasia (BPD) in extremely preterm infants. METHODS We studied infants of <30 weeks of gestation with respiratory distress syndrome (RDS) who were treated with single (FiO(2)>0.30 without need of MV) or multiple (FiO(2)>0.40 without need of MV) INSURE procedures. RESULTS Seventy-five infants were studied: 53 (71%) received single INSURE and 22 (29%) received multiple INSURE procedures. Infants in the single and multiple groups had similar rates of need of MV (15 vs. 23%) and occurrence of BPD (9 vs. 9%), although the latter were more immature and affected by more severe RDS (higher FiO(2), lower a/ApO(2), and pO(2)/FiO(2)) than the former. CONCLUSIONS Single and multiple INSURE procedures were followed by similar respiratory outcome in a cohort of extremely preterm infants. Further studies are warranted to evaluate whether the multiple INSURE strategy enhances the success rate of INSURE in preventing the need of MV and the occurrence of BPD.
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Affiliation(s)
- Carlo Dani
- Department of Surgical and Medical Critical Care, Section of Neonatology, Careggi University Hospital of Florence, Viale Morgagni 85, Florence, Italy.
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Iwanicki JL, Lu KW, Taeusch HW. Reductions of phospholipase A2inhibition of pulmonary surfactant with hyaluronan. Exp Lung Res 2010; 36:167-74. [DOI: 10.3109/01902140903234186] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Fernsler JG, Zasadzinski JA. Competitive adsorption: a physical model for lung surfactant inactivation. LANGMUIR : THE ACS JOURNAL OF SURFACES AND COLLOIDS 2009; 25:8131-8143. [PMID: 19534502 PMCID: PMC2732715 DOI: 10.1021/la8039434] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
Charged, surface-active serum proteins can severely reduce or eliminate the adsorption of lung surfactant from the subphase to the alveolar air-liquid interface via a kinetically controlled competitive adsorption process. The decreased surfactant concentration at the interface leads to higher surface tensions during the compression of the interface during breathing. The correspondence between the factors governing colloid stability and competitive adsorption is validated via a new method of measuring surfactant and serum protein adsorption rates to the air-water interface, using quantitative Brewster angle microscopy (BAM). Competitive adsorption from a 10 mg/mL albumin subphase prevents the adsorption of lung surfactant from even high subphase concentrations due to the fast diffusion of the water-soluble proteins to the interface. The formation of an albumin film causes an electrostatic and steric barrier to subsequent surfactant adsorption, which can destroy the necessary properties of functional lung surfactant: low surface tension during compression and rapid respreading after film collapse. Surfactant inactivation is at least partially due to decreased surfactant adsorption; such decreased adsorption due to the presence of serum proteins may play a role in the development and severity of acute respiratory distress syndrome.
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Affiliation(s)
- Jonathan G Fernsler
- Department of Physics, California Polytechnic University, San Luis Obispo, CA 93407, USA.
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13
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Nold JL, Meyers PA, Worwa CT, Goertz RH, Huseby K, Schauer G, Mammel MC. Decreased lung injury after surfactant in piglets treated with continuous positive airway pressure or synchronized intermittent mandatory ventilation. Neonatology 2007; 92:19-25. [PMID: 17596733 DOI: 10.1159/000098444] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2006] [Accepted: 09/04/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Treatment with surfactant (S) decreases lung injury in paralyzed, mechanically ventilated animals. The use of nasal continuous positive airway pressure (CPAP) as an alternative to mechanical ventilation may further improve acute pulmonary outcomes. OBJECTIVES To evaluate the effect of surfactant (+S, -S) and synchronized intermittent mandatory ventilation (SIMV) on lung morphology and inflammatory markers in 24 spontaneously breathing piglets treated with CPAP or SIMV after saline lavage-induced lung injury. METHODS After induction of lung injury, animals were randomized to CPAP-S, CPAP+S or SIMV+S and treated for 4 h. Physiologic parameters were continuously monitored. After treatment, animals were euthanized and lungs fixed. Bronchoalveolar lavage (BAL) samples were collected for neutrophil count and H(2)O(2). RESULTS No physiologic differences were noted. BAL fluid from CPAP-S animals contained more neutrophils and more neutrophil H(2)O(2) than fluid from the SIMV+S or CPAP+S groups (p < 0.05 or greater). Pathologic injury scores were higher in dependent lung regions from CPAP groups (p < 0.05). Injury pattern scores showed greater dependent alveolar inflammation in all (p < 0.02), with more dependent atelectasis in the CPAP groups (p < 0.01). Morphometrics showed less total open alveolar air space in nondependent regions of the SIMV+S group compared to CPAP groups (p < 0.001). Dependent regions showed less total open alveolar air space compared to nondependent regions in the CPAP groups (p < 0.001). CONCLUSIONS Animals treated with surfactant prior to CPAP or SIMV had less acute lung injury. SIMV+S animals had less open air space in nondependent regions. This suggests, during early ventilatory support, surfactant administration may modulate pulmonary inflammation. CPAP alone without surfactant may not provide optimal pulmonary protection. The addition of mechanical breaths may alter and add to injury.
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Affiliation(s)
- Joan L Nold
- Infant Pulmonary Research Center, Children's Hospitals and Clinics of Minnesota, St. Paul, MN 55102, USA
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14
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Frerichs I, Dargaville PA, van Genderingen H, Morel DR, Rimensberger PC. Lung Volume Recruitment after Surfactant Administration Modifies Spatial Distribution of Ventilation. Am J Respir Crit Care Med 2006; 174:772-9. [PMID: 16840739 DOI: 10.1164/rccm.200512-1942oc] [Citation(s) in RCA: 139] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Although surfactant replacement therapy is an established treatment in infant respiratory distress syndrome, the optimum strategy for ventilatory management before, during, and after surfactant instillation remains to be elucidated. OBJECTIVES To determine the effects of surfactant and lung volume recruitment on the distribution of regional lung ventilation. METHODS Acute lung injury was induced in 16 newborn piglets by endotracheal lavage. Optimum positive end-expiratory pressure was identified after lung recruitment and surfactant was administered either at this pressure in the "open" lung or after disconnection of the endotracheal tube in the "closed" lung. An additional recruitment maneuver with subsequent optimum end-expiratory pressure finding was executed in eight animals; in the remaining eight animals, end-expiratory pressure was set at the same level as before surfactant without further recruitment. ("Open" and "closed" lung surfactant administration was evenly distributed in the groups.) Regional ventilation was assessed by electrical impedance tomography. MEASUREMENTS AND MAIN RESULTS Impedance tomography data, airway pressure, flow, and arterial blood gases were acquired during baseline conditions, after induction of lung injury, after the first lung recruitment, and before as well as 10 and 60 min after surfactant administration. Significant shift in ventilation toward the dependent lung regions and less asymmetry in the right-to-left lung ventilation distribution occurred in the postsurfactant period when an additional recruitment maneuver was performed. Surfactant instillation in an "open" versus "closed" lung did not influence ventilation distribution in a major way. CONCLUSIONS The spatial distribution of ventilation in the lavaged lung is modified by a recruitment maneuver performed after surfactant administration.
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Affiliation(s)
- Inéz Frerichs
- Department of Anesthesiological Research, University of Göttingen, Germany.
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Zasadzinski JA, Alig TF, Alonso C, Bernardino de la Serna J, Perez-Gil J, Taeusch HW. Inhibition of pulmonary surfactant adsorption by serum and the mechanisms of reversal by hydrophilic polymers: theory. Biophys J 2005; 89:1621-9. [PMID: 16006630 PMCID: PMC1366666 DOI: 10.1529/biophysj.105.062646] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
A theory based on the Smolukowski analysis of colloid stability shows that the presence of charged, surface-active serum proteins at the alveolar air-liquid interface can severely reduce or eliminate the adsorption of lung surfactant from the subphase to the interface, consistent with the observations reported in the companion article (pages 1769-1779). Adding nonadsorbing, hydrophilic polymers to the subphase provides a depletion attraction between the surfactant aggregates and the interface, which can overcome the steric and electrostatic resistance to adsorption induced by serum. The depletion force increases with polymer concentration as well as with polymer molecular weight. Increasing the surfactant concentration has a much smaller effect than adding polymer, as is observed. Natural hydrophilic polymers, like the SP-A present in native surfactant, or hyaluronan, normally present in the alveolar fluids, can enhance adsorption in the presence of serum to eliminate inactivation.
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Affiliation(s)
- Joseph A Zasadzinski
- Department of Chemical Engineering, University of California, Santa Barbara, California 93106, USA.
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Taeusch HW, Bernardino de la Serna J, Perez-Gil J, Alonso C, Zasadzinski JA. Inactivation of pulmonary surfactant due to serum-inhibited adsorption and reversal by hydrophilic polymers: experimental. Biophys J 2005; 89:1769-79. [PMID: 15923228 PMCID: PMC1366680 DOI: 10.1529/biophysj.105.062620] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The rate of change of surface pressure, pi, in a Langmuir trough following the deposition of surfactant suspensions on subphases containing serum, with or without polymers, is used to model a likely cause of surfactant inactivation in vivo: inhibition of surfactant adsorption due to competitive adsorption of surface active serum proteins. Aqueous suspensions of native porcine surfactant, organic extracts of native surfactant, and the clinical surfactants Curosurf, Infasurf, and Survanta spread on buffered subphases increase the surface pressure, pi, to approximately 40 mN/m within 2 min. The variation with concentration, temperature, and mode of spreading confirmed Brewster angle microscopy observations that subphase to surface adsorption of surfactant is the dominant form of surfactant transport to the interface. However (with the exception of native porcine surfactant), similar rapid increases in pi did not occur when surfactants were applied to subphases containing serum. Components of serum are surface active and adsorb reversibly to the interface increasing pi up to a concentration-dependent saturation value, pi(max). When surfactants were applied to subphases containing serum, the increase in pi was significantly slowed or eliminated. Therefore, serum at the interface presents a barrier to surfactant adsorption. Addition of either hyaluronan (normally found in alveolar fluid) or polyethylene glycol to subphases containing serum reversed inhibition by restoring the rate of surfactant adsorption to that of the clean interface, thereby allowing surfactant to overcome the serum-induced barrier to adsorption.
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Affiliation(s)
- H William Taeusch
- Pediatrics, University of California, San Francisco, California 94110, USA.
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