Effects of hydrogen sulfide exposure on surface properties of lung surfactant

Comparison of Inflation and Ventilation with Hydrogen Sulfide during the Warm Ischemia Phase on Ischemia-Reperfusion Injury in a Rat Model of Non-Heart-Beating Donor Lung Transplantation

Donor lung ventilation and inflation during the warm ischemia could attenuate ischemia-reperfusion injury (IRI) after lung transplantation. Hydrogen sulfide (H₂S), as a kind of protective gas, has demonstrated the antilung IRI effect. This study is aimed at observing the different methods of administering H₂S in the setting of warm ischemia, ventilation, and inflation on the lung graft from a rat non-heart-beating donor. After 1 h of cardiac arrest, donor lungs in situ were inflated with 80 ppm H₂S (FS group), ventilated with 80 ppm H₂S (VS group), or deflated (control group) for 2 h. Then, the lung transplantation was performed after 3 h cold ischemia. The rats without ischemia and reperfusion were in the sham group. Pulmonary surfactant in the bronchoalveolar lavage fluid was measured in donor lung. The inflammatory response, cell apoptosis, and lung graft function were assessed at 3 h after reperfusion. The lung injury was exacerbated in the control group, which was attenuated significantly after the H₂S treatment. Compared with the FS group, the pulmonary surfactant in the donor was deteriorated, the lung oxygenation function was decreased, and the inflammatory response and cell apoptosis were increased in the graft in the VS group (P < 0.05). In conclusion, H₂S inflation during the warm ischemia phase improved the function of lung graft via regulating pulmonary surfactant stability and decreased the lung graft IRI via decreasing the inflammatory response and cell apoptosis.

Physiological roles of hydrogen sulfide in mammalian cells, tissues and organs

H2S belongs to the class of molecules known as gasotransmitters, which also includes nitric oxide (NO) and carbon monoxide (CO). Three enzymes are recognized as endogenous sources of H2S in various cells and tissues: cystathionine g-lyase (CSE), cystathionine β-synthase (CBS) and 3-mercaptopyruvate sulfurtransferase (3-MST). The current article reviews the regulation of these enzymes as well as the pathways of their enzymatic and non-enzymatic degradation and elimination. The multiple interactions of H2S with other labile endogenous molecules (e.g. NO) and reactive oxygen species are also outlined. The various biological targets and signaling pathways are discussed, with special reference to H2S and oxidative posttranscriptional modification of proteins, the effect of H2S on channels and intracellular second messenger pathways, the regulation of gene transcription and translation and the regulation of cellular bioenergetics and metabolism. The pharmacological and molecular tools currently available to study H2S physiology are also reviewed, including their utility and limitations. In subsequent sections, the role of H2S in the regulation of various physiological and cellular functions is reviewed. The physiological role of H2S in various cell types and organ systems are overviewed. Finally, the role of H2S in the regulation of various organ functions is discussed as well as the characteristic bell-shaped biphasic effects of H2S. In addition, key pathophysiological aspects, debated areas, and future research and translational areas are identified A wide array of significant roles of H2S in the physiological regulation of all organ functions emerges from this review.

Application of adverse outcome pathway networks to integrate mechanistic data informing the choice of a point of departure for hydrogen sulfide exposure limits

Acute exposure to hydrogen sulfide initiates a series of hallmark biological effects that occur progressively at increasing exposure levels: odor perception, conjunctivitis, olfactory paralysis, "knockdown," pulmonary edema, and apnea. Although effects of exposure to high concentrations of hydrogen sulfide are clear, effects associated with chronic, low-level exposure in humans is under debate, leading to uncertainty in the critical effect used in regulatory risk assessments addressing low dose exposures. This study integrates experimental animal, observational epidemiology, and occupational exposure evidence by applying a pathway-based approach. A hypothesized adverse outcome pathway (AOP) network was developed from 34 studies, composed of 4 AOPs sharing 1 molecular initiating events (MIE) and culminating in 4 adverse outcomes. A comparative assessment of effect levels and weight of evidence identified an AOP leading to a biologically-plausible, low-dose outcome relative to the other outcomes (nasal lesions, 30 ppm versus olfactory paralysis, >100 ppm; neurological effects, >80 ppm; pulmonary edema, >80 ppm). This AOP (i.e. AOP1) consists of the following key events: cytochrome oxidase inhibition (>10 ppm), neuronal cell loss (>30 ppm), and olfactory nasal lesions (defined as both neuronal cell loss and basal cell hyperplasia; >30 ppm) in rodents. The key event relationships in this pathway were supported by moderate empirical evidence and have high biological plausibility due to known mechanistic understanding and consistency in observations for diverse chemicals.

Hyperbaric oxygen therapy in the management of two cases of hydrogen sulfide toxicity from liquid manure

Hydrogen sulfide is a potent lethal gas. Supportive care, nitrite therapy and hyperbaric oxygen are the treatment modalities reported in the literature in cases of hydrogen sulfide exposure. We describe an industrial exposure in which 6 workers inhaled high concentrations of hydrogen sulfide when they entered a closed spreader tank partially filled with liquid swine manure. Five of the 6 lost consciousness, and 2 were agitated and poorly responsive on arrival to the emergency department despite having already received high-flow oxygen for nearly 1 hour. These 2 patients received nitrite therapy followed by orotracheal intubation and hyperbaric oxygen. All patients were discharged home without sequelae after short stays in hospital. The emergency management of hydrogen sulfide exposure is briefly reviewed.

Selective recognition of hydrogen sulfide using template and catalyst free grown ZnO nanorods

A single step spray pyrolysis technique was used to grow ZnO nanorods on glass substrates without any template or catalyst and the nanorods were successfully employed to detect hydrogen sulfide at room temperature.

ECG alteration due to prolong exposure to natural gas leakage containing sulfur compounds in polluted areas of Masjid-I-Sulaiman (south of Iran)

This study was performed on 89 female healthy students with mean age 17 years who have lived in sulfur compounds contaminated areas of Masjid-I-Sulaiman (MIS). In order to determine the effects of sour gas containing sulfur compounds on some electrical activity of the heart, electrocardiogram was recorded. QT(c) interval, PR interval, QRS complex and total sum of bipolar limb leads amplitude of R waves were analyzed and compared to standard values by using one sample t-test at P<0.05 as the significant level. The results showed that PR interval and R amplitude were less than those of standard values. However, QT(c) interval and QRS complex were not significantly different from their normal values. It can be concluded that chronic exposure to sour gas containing hydrogen sulfide contaminated air may provoke alterations of electrical activity of the heart.

Pulmonary toxicity and environmental contamination: radicals, electron transfer, and protection by antioxidants

The atmosphere is replete with a mixture of toxic substances, both natural and man-made. Inhalation of toxic substances produces a variety of insults to the pulmonary system. Lung poisons include industrial materials, particulates from mining and combustion, agricultural chemicals, cigarette smoke, ozone, and nitrogen oxides, among a large number of other chemicals and environmental contaminants. Many proposals have been advanced to explain the mode of action of pulmonary toxicants. In this review we focus on mechanisms of pulmonary toxicity that involve ET, ROS, and OS. The vast majority of toxicants or their metabolites possess chemical ET functionalities that can undergo redox cycling. Such recycling may generate ROS that can injure various cellular constituents in the lung and in other tissues. ET agents include quinones, metal complexes, aromatic nitro compounds, and conjugated iminium ions. Often, these agents are formed metabolically from parent toxicants. Such metabolic reactions are often catalytic and require only small amounts of the offending material. Oxidative attack is commonly associated with lipid peroxidation and oxidation of DNA, and it may result in strand cleavage and 8-OH-DG production. Toxicity is often accompanied by depletion of natural AOs, which further exacerbates the toxic effect. It is not surprising that the use of AOs, both natural in fruits and vegetables, as well as synthetic, may provide protection from the adverse effects of toxicant exposure. The mechanistic framework described earlier is also applicable to some of the more prominent pulmonary illnesses, such as asthma, COPD, and cancer.

Proceedings of the Hydrogen Sulfide Health Research and Risk Assessment Symposium October 31-November 2, 2000

The Hydrogen Sulfide Health Research and Risk Assessment Symposium came about for several reasons: (1) increased interest by the U.S. Environmental Protection Agency (EPA) and several state agencies in regulating hydrogen sulfide (H2S); (2) uncertainty about ambient exposure to H2S; (3) confusion and disagreement in the literature about possible health effects at low-level exposures; and (4) presentation of results of a series of recent animal bioassays. The American Petroleum Institute (API) proposed this symposium and the EPA became an early co-sponsor, with the Chemical Industry Institute of Toxicology (CIIT) and the American Forest & Paper Association (AF&PA) contributing expertise and funding assistance. The topics covered in this symposium included Animal Research, Human Research, Mode-of-Action and Dosimetry Issues, Environmental Exposure and Monitoring, Assessment and Regulatory Issues, and closed with a panel discussion. The overall goals of the symposium were to: gather together experts in H2S health effects research and individuals from governmental agencies charged with protecting the public health, provide a venue for reporting of recent research findings, identify gaps in the current information, and outline new research directions and promote research collaboration. During the course of the symposium, presenters provided comprehensive reviews of the state of knowledge for each topic. Several new research proposals discussed at the symposium have subsequently been initiated. This report provides a summary of the talks, poster presentations, and panel discussions that occurred at the Hydrogen Sulfide Health and Risk Assessment Symposium.

Concentration-time-response modeling for acute and short-term exposures

Risk of health effects from acute and short-term exposure depends on exposure time as well as exposure concentration. A general approach to extending a concentration-response model to include time as a variable is described using mortality of rats exposed to hydrogen sulfide (H(2)S) as an example. This particular example resulted in a logit model with concentration-time (c-t) relationship linear in time and log-concentration. It provided an improved statistical fit, based on the Akaike information criterion in the observed time range, 30 m-360 m, over implementing the c-t relationship of [ten Berge, W.F., Zwart, A., Appelman, L.M., 1986. Concentration-time mortality response relationship of irritant and systemically acting vapours and gases. J. Hazard. Mater. 13, 301--309] as a default in the logit model. This approach also indicated that there might be a fundamental difference in the relationship between concentration, time, and response at short exposure times, somewhere less than 30 m, a hypothesis for further consideration from a biological perspective. In general, the proposed approach provides flexibility to develop a concentration-time-response model, and the associated concentration-time relationship, from the data. Interpretation and potential implications, however, need to be considered within the context of biological plausibility as well. Implementation of the proposed approach requires adequate data for separate concentration-response modeling at each of several exposure durations.

Respiratory tract toxicity of inhaled hydrogen sulfide in Fischer-344 rats, Sprague–Dawley rats, and B6C3F1 mice following subchronic (90-day) exposure

The goal of this study was to characterize the toxicity of hydrogen sulfide (H2S), including nasal and pulmonary effects, in adult male and female Fischer-344 and Sprague-Dawley rats and B6C3F1 mice. Animals underwent whole-body exposure to 0, 10, 30, or 80 ppm H2S for 6 h/day for at least 90 days. Exposure to 80 ppm H2S was associated with reduced feed consumption during either the first exposure week (rats) or throughout the 90-day exposure (mice). Male Fischer-344 rats, female Sprague-Dawley rats, and female B6C3F1 mice exposed to 80 ppm H2S had depressed terminal body weights when compared with air-exposed controls. Subchronic H2S inhalation did not result in toxicologically relevant alterations in hematological indices, serum chemistries, or gross pathology. Histologic evaluation of the nose showed an exposure-related increased incidence of olfactory neuronal loss (ONL) and rhinitis. ONL occurred following exposure to > or =30 ppm H2S in both sexes of all experimental groups, with one exception, male Sprague-Dawley rats demonstrated ONL following exposure to 80 ppm H2S only. A 100% incidence of rhinitis was found in the male and female B6C3F1 mice exposed to 80 ppm H2S. In the lung, exposure to H2S was associated with bronchiolar epithelial hypertrophy and hyperplasia in male and female Sprague-Dawley rats following exposure to > or =30 ppm H2S and in male Fischer-344 rats exposed to 80 ppm H2S. Our results confirm that the rodent nose, and less so the lung, are highly sensitive to H2S-induced toxicity, with 10 ppm representing the NOAEL for ONL following subchronic inhalation.

Utilizing data from multiple studies (meta-analysis) to determine effective dose-duration levels. Example: rats and mice exposed to hydrogen sulfide

The objective of this exercise was to incorporate as much data as possible from multiple studies, that may differ in exposure durations, to derive a chemical-specific dose-duration response curve from which to identify toxicity markers (e.g., ED01, benchmark dose, and LD50). This has the advantage of incorporating more information than single-study assessments to improve estimates and reduce confidence intervals, and determining toxicity markers as functions of exposure duration as well as dose. The example used mortality for rats and mice, analyzed separately, from acute exposure to hydrogen sulfide (dose refers to airborne concentration of H(2)S). Statistical methods were applied to determine when data from different studies could be pooled. EC01, EC10, and EC50 (doses with response rates of 1, 10, and 50%) were estimated, with 95% confidence intervals, at durations of 5, 10, and 30 min, and 1, 2, 4, and 6 h. A single dose-duration response curve for mortality was fit to the rat data for exposures of 5 min, 10 min, 30 min, and 1h, using a logistic curve additive in log(dose) and log(duration). Separate fits of that model were required, however, at 2, 4, and 6h, due to an increasing impact of duration relative to concentration as duration increased. The curves for rats fit the data exceedingly well and exhibited a threshold-like response followed by a steep incline as concentration increased. There were fewer data for mice but the response pattern for mortality clearly differed from rats. This example demonstrates the feasibility of extending the concept of single-study benchmark doses to multiple-study dose-duration benchmarks, using U.S. EPA's program CatReg. Similar applications to long-term animal studies could be considered.

US EPA's acute reference exposure methodology for acute inhalation exposures

The US Environmental Protection Agency (EPA) National Center for Environmental Assessment is engaged in the development of a methodology for Agency use to perform risk assessments for non-cancer effects due to acute inhalation exposures. The methodology will provide general guidance for deriving chemical-specific acute exposure benchmarks called acute reference exposures (AREs). Chemical-specific AREs are analogous to reference concentra tions (RfCs) for chronic non-cancer effects and will be incorporated in chemical-specific files in the US EPA's Integrated Risk Information System (IRIS) as they are developed and reviewed. AREs will have wide applicability in assessing the potential health risks of accidental and routine acute releases of chemicals to the environment. The proposed methodology for ARE development provides a framework for choosing an optimal derivation approach, depending on the type of data available, from the no-observed-adverse-effect level (NOAEL), benchmark concentration (BMC), or categorical regression approaches. Uncertainty factors are applied to the point of departure, determined by one of the recommended approaches, to derive the ARE. Due to the capability to use more exposure-response information than the NOAEL approach allows, exposure-response analyses such as BMC and categorical regression are favored as methods to develop the point of departure when the available database will support such analyses. The NOAEL approach is suitable when the data are insufficient to support exposure-response modeling. Applications of the proposed ARE methodology are illustrated by the derivation of example AREs for hydrogen sulfide and hexachlorocyclopentadiene, which showcase the categorical regression and NOAEL approaches, respectively. In addition, a recent review of the proposed ARE methodology by the US EPA Risk Assessment Forum is discussed.

Is a reduction in residual volume a sub-clinical manifestation of hydrogen sulfide intoxication?

BACKGROUND

A number of employees at an aircraft factory were accidentally exposed to hydrogen sulfide. Because of concern that this may have resulted in lung injury, forty-seven workers were referred for clinical and physiological evaluation.

METHODS

Comprehensive pulmonary function tests were performed including spirometry, flow volume curves, static lung volumes, and diffusion capacity for carbon monoxide.

RESULTS

The results obtained indicated that ten people (23%) had an isolated reduction in residual volume. This was an unexpected finding as other physiological indices of lung function were within normal limits. Clinical examination was also normal, therefore, radiological investigations were considered inappropriate.

CONCLUSIONS

It is suggested that the decrement in residual volume, in the presence of other normal indices of lung function, could represent a sub-acute manifestation of hydrogen sulfide intoxication.

Surfactant effects in model airway closure experiments

The capillary instability that occurs on an annular film lining a tube is studied as a model of airway closure. Small waves in the film can amplify and form a plug across the tube. This dynamical behavior is studied using theoretical models and bench-top experiments. Our model predicts the initial growth rate of the instability and its dependence on surfactant effects. In experiments, an annular film is formed by infusion of water into an initially oil-filled glass capillary tube. The thickness of the oil film varies with the infusion flow rate. The instability growth rate and closure time are measured for a range of film thicknesses. Our theory predicts that a thinner film and higher surfactant activity enhance stability; surfactant can decrease the growth rate to 25% of its surfactant-free value. In experiments, we find that surfactant can decrease the growth rate to 20% and increase the closure time by a factor of 3.8. Functional values of a critical film thickness for closure support the theory that it increases in the presence of surfactant.

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

Our objective was to determine changes in surface tension of tracheal aspirate over the first 4-5 days of life in babies with hyaline membrane disease, with and without synthetic surfactant replacement. Tracheal aspirates were collected prior to and for 96-108 hr after initiation of a randomized double-blind trial of synthetic surfactant (EXOSURF Neonatal) or air-treated control patients. Using the captive bubble technique, we measured minimum surface tension (initial adsorption, first quasi-static compression, dynamic cycling at 30 cpm, second quasi-static compression and 5 min after quasi-static compressions) in 39 surfactant-treated and 44 control babies. We also compared minimum surface tension with the respiratory support provided. Twelve hours after one dose of synthetic surfactant, minimum surface tension on first quasistatic compression decreased significantly from 20.9+/-1.4 to 17.6+/-1.3 mN/m compared to air-treated babies, who did not show any change. Reduction in minimum tracheal aspirate surface tension on first quasi-static compression and during dynamic cycling over 48-60 hr occurred more rapidly in surfactant-treated babies. Ventilator support did not correlate with minimum tracheal aspirate surface tension. We conclude that treatment of babies with synthetic surfactant improved tracheal aspirate minimum surface tension within 12 hr of the first dose and for the next 48-60 hr.

Mechanisms of surfactant dysfunction in early acute lung injury

Surfactant dysfunction that occurs during acute lung injury is associated with alterations in phospholipid, total protein, and surfactant apoprotein content. The functional importance of these changes was examined by characterizing the biophysical properties and biochemical composition of lung surfactant from endotoxin-treated guinea pigs (LPS) with acute lung injury. Static and dynamic lung compliance significantly decreased following endotoxin exposure. Lavage fluid demonstrated a neutrophil predominance, and tissue histopathology revealed inflammation consistent with acute lung injury. LPS surfactant isolated by ultracentrifugation had minimum surface tensions of 21 dynes/cm compared to 2 dynes/cm among control samples. Biochemical abnormalities in LPS surfactant included increased total protein, decreased phosphatidylcholine, and increased sphingomyelin, phosphatidylethanolamine, and lysophosphatidylcholine. The addition to normal guinea pig surfactant of butanol extracts precipitated from lavage fluid of LPS animals and containing known amounts of protein caused elevations in minimum surface tensions to > or = 20 dynes/cm at protein to phospholipid ratios equivalent to those observed in LPS surfactant pellets. Addition of equal amounts of precipitate isolated from control animals had no effect on interfacial properties. Furthermore, addition of lysophosphatidylcholine and sphingomyelin to normal surfactant to simulate composition changes observed in LPS surfactant had minimal effect on surface film behavior. The results support the hypothesis that aqueous soluble inhibitors of surfactant are generated within the alveolar compartment during acute inflammation, and that surfactant dysfunction cannot be accounted for on the basis of phospholipid composition changes.

Influence of bilirubin on surface tension properties of lung surfactant

AIM

To investigate the influence of bilirubin on the surface tension activity of a porcine derived (Curosurf) and synthetic (Exosurf) surfactant.

METHODS

The captive bubble surfactometer at phospholipid doses of 0.5 mg/ml (low dose) and 1 mg/ml (high dose) in solutions of increasing bilirubin concentrations (0.25, 0.5, and 1.0 mg/ml) was used.

RESULTS

Curosurf (without bilirubin) showed a higher surface f1p4ion activity than Exosurf, as shown by area compression of 30 (SD 0.6)% compared with 76(1.4)% at low surfactant dose and 25 (0.9)% compared with 85 (0.5)% at high dose (P < 0.01). Bilirubin showed negligible surface activity at the concentrations studied. At low phospholipid dose (0.5 mg/ml Curosurf), bilirubin increased film area compression of lipid extract surfactant from 30 (0.6)% to 55 (1.6)%, 59 (0.1)%, and 68 (0.5)% at the three studied bilirubin concentrations, respectively (P < 0.01). At high phospholipid dose (1 mg/ml Curosurf), bilirubin had the same adverse, although less pronounced, effect on film area compression of porcine lipid extract surfactant (25 (0.9)% vs 26 (0.9)%, 39 (1.3)%, and 44 (1.1)%, respectively) (P < 0.01). Using synthetic surfactant (Exosurf), with a much lower original surface activity, bilirubin did not further inhibit its surface tension properties at any of the phospholipid doses studied.

CONCLUSION

These results indicate that in vitro bilirubin impairs the surface tension activity of porcine lipid extract surfactant, but does not affect synthetic surfactant activity.

Effects of acid aerosol exposure on the surface properties of airway mucus

It was hypothesized that the mucous layer lining the tracheas of rats and guinea pigs contains surfactant material capable of lowering the air/mucus surface tension, gamma, and that exposure to an irritant aerosol would raise the gamma. The gamma of the surface film was measured directly by a spreading droplet technique and indirectly by displacement of polymethyl methacrylate particles into the aqueous layer. The morphology of the mucous film was examined by electron microscopy after nonaqueous fixation. gamma was 33.3 +/- 0.70 (SE) mN/m and 32.3 +/- 0.68 (SE) mN/m for the normal rat and guinea pig trachea, respectively. Exposure for 4 h to aerosols of sulfuric acid (94.1 +/- 18.68 (SD) and 43.3 +/- 4.57 (SD) mg/m3) caused a several-fold increase in thickness of the mucous layer with exudation of protein-like material. The osmiophilic surfactant film at the air/mucus interface became irregularly thickened and multilayered. Despite these morphological changes gamma remained low, 33.2 +/- 0.43 (SE) mN/m and 32.6 +/- 0.60 (SE) mN/m for rats and guinea pigs, respectively, and displacement of particles into the subphase was not compromised. The results indicate that rodent tracheas are able to maintain a low surface tension in the presence of injury.

Properties of lavage material from excised lungs ventilated at different temperatures

We studied the phospholipid (PL) and protein contents, the PL composition, and some of the surface properties of lavage materials obtained from freshly excised rat lungs and excised lungs which had been ventilated at different temperatures (22, 37, and 42 degrees C). Ventilation (60 breaths/min) was carried out at constant tidal volume with periodic sighs for one hour. Although there is slightly more lavageable PL and protein in lungs ventilated at 22 degrees C than in freshly excised lungs, there is no difference in the PL composition or surface properties of lavage materials from these lungs. However, as the temperature at which lungs are ventilated is increased to 37 degrees and 42 degrees C, there is(are): 1) a reduction in lavage fluid PL, 2) a reduction in the relative amounts of total phosphatidylcholines (PC) and disaturated PC (DSPC), the major surface active component of pulmonary surfactant, 3) an increase in unsaturated PC, and 4) increases in total protein and nonsedimentable protein (100,000 g; 2 hr) in the lavage materials. There are also differences in the surface properties of the lavage materials from lungs ventilated at higher temperatures when compared with freshly excised lungs or lungs ventilated at 22 degrees C, probably as a result of the changes in composition. Maximal surface tension is greater for lavage materials from lungs ventilated at 37 degrees C. For lungs ventilated at 42 degrees C, maximal and minimal surface tension values are increased. These results demonstrate that there are differences in the composition and surface properties of alveolar lavage materials from excised lungs ventilated at different temperatures.

Experimental hydrostatic pulmonary edema in rabbit lungs. Morphology

To study the accumulation and distribution of edema fluid and the associated changes in alveolar microarchitecture, edema was induced in excised rabbit lungs perfused with 6% albumin solution. The lungs, including the edema fluid, were then fixed by vascular perfusion with glutaraldehyde, osmium tetroxide, and uranyl acetate. Tissue samples were analyzed by light microscopy and transmission and scanning electron microscopy. We found (1) fixation was successful in that the albumin in the edema fluid formed coherent webs indicating the location and arrangement of the extravascular fluid accumulations; (2) regardless of the filtration pressure (about 29 mm Hg in one set of experiments and about 14 mm Hg in the other), an apical to basal gradient of fluid accumulation was found. This gradient was absent in lungs held in the inverse position, suggesting that the regional distribution of pulmonary edema is not simply gravity dependent. At the same lung height, there was a remarkable inhomogeneity of interstitial and alveolar edema. (3) Both the inhomogeneous distribution of fluid and the resulting changes in surface tension affected the entire alveolar architecture. (4) Within interstitial and alveolar spaces, there were striking inequalities in the density of the proteinaceous fluid pools that suggest local differences in the sieving properties of the barriers, that is, in the reflection coefficients for albumin. In conclusion, our findings suggest that the formation of pulmonary edema cannot be explained solely by uniform membrane models for fluid exchange.

The surfactant system of the adult lung: physiology and clinical perspectives

Pulmonary surfactant is synthesized and secreted by alveolar type II cells and constitutes an important component of the alveolar lining fluid. It comprises a unique mixture of phospholipids and surfactant-specific proteins. More than 30 years after its first biochemical characterization, knowledge of the composition and functions of the surfactant complex has grown considerably. Its classically known role is to decrease surface tension in alveolar air spaces to a degree that facilitates adequate ventilation of the peripheral lung. More recently, other important surfactant functions have come into view. Probably most notable among these, surfactant has been demonstrated to enhance local pulmonary defense mechanisms and to modulate immune responses in the alveolar milieu. These findings have prompted interest in the role and the possible alterations of the surfactant system in a variety of lung diseases and in environmental impacts on the lung. However, only a limited number of studies investigating surfactant changes in human lung disease have hitherto been published. Preliminary results suggest that surfactant analyses, e.g., from bronchoalveolar lavage fluids, may reveal quantitative and qualitative abnormalities of the surfactant system in human lung disorders. It is hypothesized that in the future, surfactant studies may become one of our clinical tools to evaluate the activity and severity of peripheral lung diseases. In certain disorders they may also gain diagnostic significance. Further clinical studies will be necessary to investigate the potential therapeutic benefits of surfactant substitution and the usefulness of pharmacologic manipulation of the secretory activity of alveolar type II cells in pulmonary medicine.