Growth of the small airways and alveoli from childhood to the adult lung measured by aerosol-derived airway morphometry

Quantifying abnormal alveolar microstructure in cystic fibrosis lung disease via hyperpolarized 129Xe diffusion MRI

RATIONALE

Cystic Fibrosis (CF) progresses through recurrent infection and inflammation, causing permanent lung function loss and airway remodeling. CT scans reveal abnormally low-density lung parenchyma in CF, but its microstructural nature remains insufficiently explored due to clinical CT limitations. To this end, diffusion-weighted 129Xe MRI is a non-invasive and validated measure of lung microstructure. In this work, we investigate microstructural changes in people with CF (pwCF) relative to age-matched, healthy subjects using comprehensive imaging and analysis involving pulmonary-function tests (PFTs), and 129Xe MRI.

METHODS

38 healthy subjects (age 6-40; 17.2 ± 9.5 years) and 39 pwCF (age 6-40; 15.6 ± 8.0 years) underwent 129Xe-diffusion MRI and PFTs. The distribution of diffusion measurements (i.e., apparent diffusion coefficients (ADC) and morphometric parameters) was assessed via linear binning (LB). The resulting volume percentages of bins were compared between controls and pwCF. Mean ADC and morphometric parameters were also correlated with PFTs.

RESULTS

Mean whole-lung ADC correlated significantly with age (P < 0.001) for both controls and CF, and with PFTs (P < 0.05) specifically for pwCF. Although there was no significant difference in mean ADC between controls and pwCF (P = 0.334), age-adjusted LB indicated significant voxel-level diffusion (i.e., ADC and morphometric parameters) differences in pwCF compared to controls (P < 0.05).

CONCLUSIONS

129Xe diffusion MRI revealed microstructural abnormalities in CF lung disease. Smaller microstructural size may reflect compression from overall higher lung density due to interstitial inflammation, fibrosis, or other pathological changes. While elevated microstructural size may indicate emphysema-like remodeling due to chronic inflammation and infection.

Exploring the acoustic and prosodic features of a lung-function-sensitive repeated-word speech articulation test

Introduction

Speech breathing is a term usually used to refer to the manner in which expired air and lung mechanics are utilized for the production of the airflow necessary for phonation. Neurologically, speech breathing overrides the normal rhythms of alveolar ventilation. Speech breathing is generated using the diaphragm, glottis, and tongue. The glottis is the opening between the vocal folds in the larynx; it is the primary valve between the lungs and the mouth, and by varying its degree of opening, the sound can be varied. The use of voice as an indicator of health has been widely reported. Chronic obstructive pulmonary disease (COPD) is the most common long-term respiratory disease. The main symptoms of COPD are increasing breathlessness, a persistent chesty cough with phlegm, frequent chest infections, and persistent wheezing. There is no cure for COPD, and it is one of the leading causes of death worldwide. The principal cause of COPD is tobacco smoking, and estimates indicate that COPD will become the third leading cause of death worldwide by 2030. The long-term aim of this research program is to understand how speech generation, breathing, and lung function are linked in people with chronic respiratory diseases such as COPD.

Methods

This pilot study was designed to test an articulatory speech task that uses a single word ("helicopter"), repeated multiple times, to challenge speech-generated breathing and breathlessness. Specifically, a single-word articulation task was used to challenge respiratory system endurance in people with healthy lungs by asking participants to rapidly repeat the word "helicopter" for three 20-s runs interspersed with two 20-s rest periods of silent relaxed breathing. Acoustic and prosodic features were then extracted from the audio recordings of each adult participant.

Results and discussion

The pause ratio increased from the first run to the third, representing an increasing demand for breath. These data show that the repeated articulation task challenges speech articulation in a quantifiable manner, which may prove useful in defining respiratory ill-health.

Overhead AC powerlines and rain can alter the electric charge distribution on airborne particles - Implications for aerosol dispersion and lung deposition

Corona ions from high voltage power lines (HVPL) can increase electrostatic charge on airborne pollutant particulates, possibly increasing received dose upon inhalation. To investigate the potential increased risk of childhood leukemia associated with residence near alternating current (AC) HVPL, we measured the particle charge state and atmospheric electricity parameters upwind, downwind and away from HVPL. Although we observed noticeable charge state alteration from background levels, most HVPL do not significantly increase charge magnitude. Particular HVPL types are shown to have most effect, increasing net charge to 15 times that at background. However, the magnitude of charge alteration during rainfall is comparable with the most extreme HVPL measurement. On current evidence, based on the current adult lung model, we suggest that although charge is sometimes enhanced to levels which may alter atmospheric particle dynamics, increased lung deposition is unlikely.

Childhood to adulthood: Accounting for age dependence in healthy-reference distributions in 129 Xe gas-exchange MRI

PURPOSE

Xenon-129 (129 Xe) gas-exchange MRI is a pulmonary-imaging technique that provides quantitative metrics for lung structure and function and is often compared to pulmonary-function tests. Unlike such tests, it does not normalize to predictive values based on demographic variables such as age. Many sites have alluded to an age dependence in gas-exchange metrics; however, a procedure for normalizing metrics has not yet been introduced.

THEORY

We model healthy reference values for 129 Xe gas-exchange MRI against age using generalized additive models for location, scale, and shape (GAMLSS). GAMLSS takes signal data from an aggregated heathy-reference cohort and fits a distribution with flexible median, variation, skewness, and kurtosis to predict age-dependent centiles. This approach mirrors methods by the Global Lung Function Initiative for modeling pulmonary-function test data and applies it to binning methods widely used by the 129 Xe MRI community to interpret and quantify gas-exchange data.

METHODS

Ventilation, membrane-uptake, red blood cell transfer, and red blood cell:membrane gas-exchange metrics were collected on 30 healthy subjects over an age range of 5 to 68 years. A GAMLSS model was fit against age and compared against widely used linear and generalized-linear binning 129 Xe MRI analysis schemes.

RESULTS

All 4 gas-exchange metrics had significant skewness, and membrane-uptake had significant kurtosis compared to a normal distribution. Age has significant impact on distribution parameters. GAMLSS-binning produced narrower bins compared to the linear and generalized-linear binning schemes and distributed signal data closer to a normal distribution.

CONCLUSION

The proposed "proof-of-concept" GAMLSS-binning approach can improve diagnostic accuracy of 129 Xe gas-exchange MRI by providing a means of modeling voxel distribution data against age.

Lung mechanics and respiratory morbidities in school-age children born moderate-to-late preterm

BACKGROUND

Late and moderate prematurity may have an impact on pulmonary function during childhood. The present study aimed to investigate lung mechanics in school-age children born moderate-to-late preterm (MLPT).

METHODS

Children aged 5-10 years were enrolled in this case-control study. Lung function and bronchodilator response were assessed by impulse oscillometry (IOS) at two hospital-based specialized clinics. A structured questionnaire was employed to assess respiratory morbidities.

RESULTS

A total of 123 children was divided into two groups: case (MLPT) n = 52 and control (children born at term) n = 71. The results showed no difference between groups in mean baseline IOS variables: R5 0.80 ± 0.20 vs 0.82 ± 0.22 kPa/L/s, p = 0.594, R20 0.54 ± 0.13 vs 0.55 ± 0.13 kPa/L/s, p = 0.732, R5-R20 0.26 ± 0.12 vs 0.27 ± 0.15 kPa/L/s, p = 0.615, X5 -0.29 ± 0.01 vs -0.29 ± 0.1 kPa/L/s, p = 0.990, Fres 21.1 ± 3.3 vs 21.7 ± 3.1 L/s, p = 0.380, and AX 2.7 ± 3.36 vs 2.5 ± 1.31 kPa/L/s, p = 0.626. Bronchodilator response and the occurrence of respiratory morbidities after birth were also similar between groups.

CONCLUSIONS

This study found lung mechanics parameters to be similar in school-age children born MLPT and those born at term, suggesting that pulmonary plasticity continues to occur in children up to school age.

IMPACT

Late and moderate prematurity is associated with an increased risk of reduced pulmonary function during childhood. Follow-up reports in adolescents and adults born MLPT are scarce but have indicated pulmonary plasticity with normalization of airway function. Our results show that the lung function in school-age children born MLPT is similar to that of children born at term.

Improving hyperpolarized 129 Xe ADC mapping in pediatric and adult lungs with uncertainty propagation

RATIONALE

Hyperpolarized (HP) ¹²⁹ Xe-MRI provides non-invasive methods to quantify lung function and structure, with the ¹²⁹ Xe apparent diffusion coefficient (ADC) being a well validated measure of alveolar airspace size. However, the experimental factors that impact the precision and accuracy of HP ¹²⁹ Xe ADC measurements have not been rigorously investigated. Here, we introduce an analytical model to predict the experimental uncertainty of ¹²⁹ Xe ADC estimates. Additionally, we report ADC dependence on age in healthy pediatric volunteers.

METHODS

An analytical expression for ADC uncertainty was derived from the Stejskal-Tanner equation and simplified Bloch equations appropriate for HP media. Parameters in the model were maximum b-value (b_max ), number of b-values (N_b ), number of phase encoding lines (N_ph ), flip angle and the ADC itself. This model was validated by simulations and phantom experiments, and five fitting methods for calculating ADC were investigated. To examine the lower range for ¹²⁹ Xe ADC, 32 healthy subjects (age 6-40 years) underwent diffusion-weighted ¹²⁹ Xe MRI.

RESULTS

The analytical model provides a lower bound on ADC uncertainty and predicts that decreased signal-to-noise ratio yields increases in relative uncertainty (ϵADC) . As such, experimental parameters that impact non-equilibrium ¹²⁹ Xe magnetization necessarily impact the resulting ϵADC . The values of diffusion encoding parameters (N_b and b_max ) that minimize ϵADC strongly depend on the underlying ADC value, resulting in a global minimum for ϵADC . Bayesian fitting outperformed other methods (error < 5%) for estimating ADC. The whole-lung mean ¹²⁹ Xe ADC of healthy subjects increased with age at a rate of 1.75 × 10^-4  cm² /s/yr (p = 0.001).

CONCLUSIONS

HP ¹²⁹ Xe diffusion MRI can be improved by minimizing the uncertainty of ADC measurements via uncertainty propagation. Doing so will improve experimental accuracy when measuring lung microstructure in vivo and should allow improved monitoring of regional disease progression and assessment of therapy response in a range of lung diseases.

Development of lung diffusion to adulthood following extremely preterm birth

Background

Gas exchange in extremely preterm (EP) infants must take place in fetal lungs. Childhood lung diffusing capacity of the lung for carbon monoxide (D_LCO) is reduced; however, longitudinal development has not been investigated. We describe the growth of D_LCO and its subcomponents to adulthood in EP compared with term-born subjects.

Methods

Two area-based cohorts born at gestational age ≤28 weeks or birthweight ≤1000 g in 1982–1985 (n=48) and 1991–1992 (n=35) were examined twice, at ages 18 and 25 years and 10 and 18 years, respectively, and compared with matched term-born controls. Single-breath D_LCO was measured at two oxygen pressures, with subcomponents (membrane diffusion (D_M) and pulmonary capillary blood volume (V_C)) calculated using the Roughton–Forster equation.

Results

Age-, sex- and height-standardised transfer coefficients for carbon monoxide (K_CO) and D_LCO were reduced in EP compared with term-born subjects, and remained so during puberty and early adulthood (p-values for all time-points and both cohorts ≤0.04), whereas alveolar volume (V_A) was similar. Development occurred in parallel to term-born controls, with no signs of pubertal catch-up growth nor decline at age 25 years (p-values for lack of parallelism within cohorts 0.99, 0.65, 0.71, 0.94 and 0.44 for z-D_LCO, z-V_A, z-K_CO, D_M and V_C, respectively). Split by membrane and blood volume components, findings were less clear; however, membrane diffusion seemed most affected.

Conclusions

Pulmonary diffusing capacity was reduced in EP compared with term-born subjects, and development from childhood to adulthood tracked in parallel to term-born subjects, with no signs of catch-up growth nor decline at age 25 years.

Pulmonary diffusing capacity following extremely preterm (EP) birth was reduced compared with term-born subjects. From mid-childhood to adulthood, development tracked in parallel in the EP and term-born groups, with preterms following lower trajectories.https://bit.ly/3ARPD7D

A comparison of airway pressures for inflation fixation of developing mouse lungs for stereological analyses

The morphometric analysis of lung structure using the principles of stereology has emerged as a powerful tool to describe the structural changes in lung architecture that accompany the development of lung disease that is experimentally modelled in adult mice. These stereological principles are now being applied to the study of the evolution of the lung architecture over the course of prenatal and postnatal lung development in mouse neonates and adolescents. The immature lung is structurally and functionally distinct from the adult lung, and has a smaller volume than does the adult lung. These differences have raised concerns about whether the inflation fixation of neonatal mouse lungs with the airway pressure (P_aw) used for the inflation fixation of adult mouse lungs may cause distortion of the neonatal mouse lung structure, leading to the generation of artefacts in subsequent analyses. The objective of this study was to examine the impact of a P_aw of 10, 20 and 30 cmH₂O on the estimation of lung volumes and stereologically assessed parameters that describe the lung structure in developing mouse lungs. The data presented demonstrate that low P_aw (10 cmH₂O) leads to heterogeneity in the unfolding of alveolar structures within the lungs, and that high P_aw (30 cmH₂O) leads to an overestimation of the lung volume, and thus, affects the estimation of volume-dependent parameters, such as total alveoli number and gas-exchange surface area. Thus, these data support the use of a P_aw of 20 cmH₂O for inflation fixation in morphometric studies on neonatal mouse lungs.

Low lung function in the developing world is analogous to stunting: a review of the evidence

Background: Low vital capacity, one of the consequences of restricted lung growth, is a strong predictor of cardiovascular mortality. Vital capacity is lower in the developing world than the developed world, even after adjusting for height, weight and gender. This difference is typically dismissed as ethnic variation, adjusted for by redefining normal. Whether this is a consequence of stunted lung growth, rather than just genetically smaller lungs, has not been investigated in detail. Therefore, we sought to compare factors implicated in both stunting and lung development, particularly in the developing world.

Methods: We conducted a manual screen of articles identified through Google Scholar and assessed risk of bias. No language restrictions were applied, so long as there was an associated English abstract. We queried VizHub (Global Burden of Disease Visualization Tool) and Google Dataset search engines for disease burden and genome wide association studies.  The scope of the article and the heterogeneity of the outcome measures reported required a narrative review of available evidence. To the extent possible, the review follows PRISMA reporting guidelines.

Results: Early life influences operate in synergism with genetic, environmental and nutritional factors to influence lung growth and development in children.  Low lung function and stunting have common anthropometric, environmental and nutritional correlates originating during early development. Similar anthropometric correlates shared chronic inflammatory pathways, indicated that the two conditions were analogous.

Conclusion: The analogy between poor lung function and stunting is conspicuous in the developing world, with malnutrition at the center of non -achievement of growth potential, susceptibility to infectious diseases and intrauterine programming for metabolic syndrome. This counter the idea of redefining the normal for lung function measurements, since observed inter-ethnic variations are likely a mix of natural genetic differences as well as differences in nurture such that reduced lung function reflects early life adversities.

Image-based scaling laws for somatic growth and pulmonary artery morphometry from infancy to adulthood

Pulmonary artery (PA) morphometry has been extensively explored in adults, with particular focus on intra-acinar arteries. However, scaling law relationships for length and diameter of extensive preacinar PAs by age have not been previously reported for in vivo human data. To understand preacinar PA growth spanning children to adults, we performed morphometric analyses of all PAs visible in the computed tomography (CT) and magnetic resonance (MR) images from a healthy subject cohort [n = 16; age: 1-51 yr; body surface area (BSA): 0.49-2.01 m²]. Subject-specific anatomic PA models were constructed from CT and MR images, and morphometric information-diameter, length, tortuosity, bifurcation angle, and connectivity-was extracted and sorted into diameter-defined Strahler orders. Validation of Murray's law, describing optimal scaling exponents of radii for branching vessels, was performed to determine how closely PAs conform to this classical relationship. Using regression analyses of vessel diameters and lengths against orders and patient metrics (BSA, age, height), we found that diameters increased exponentially with order and allometrically with patient metrics. Length increased allometrically with patient metrics, albeit weakly. The average tortuosity index of all vessels was 0.026 ± 0.024, average bifurcation angle was 28.2 ± 15.1°, and average Murray's law exponent was 2.92 ± 1.07. We report a set of scaling laws for vessel diameter and length, along with other morphometric information. These provide an initial understanding of healthy structural preacinar PA development with age, which can be used for computational modeling studies and comparison with diseased PA anatomy.NEW & NOTEWORTHY Pulmonary artery (PA) morphometry studies to date have focused primarily on large arteries and intra-acinar arteries in either adults or children, neglecting preacinar arteries in both populations. Our study is the first to quantify in vivo preacinar PA morphometry changes spanning infants to adults. For preacinar arteries > 1 mm in diameter, we identify scaling laws for vessel diameters and lengths with patient metrics of growth and establish a healthy PA morphometry baseline for most preacinar PAs.

Low lung function in the developing world is analogous to stunting: a review of the evidence

Background: Low vital capacity, one of the consequences of restricted lung growth, is a strong predictor of cardiovascular mortality. Vital capacity is lower in the developing world than the developed world, even after adjusting for height, weight and gender. This difference is typically dismissed as ethnic variation, adjusted for by redefining normal. Whether this is a consequence of stunted lung growth, rather than genetically smaller lungs, has not been investigated in detail. Therefore, we sought to compare factors implicated in both stunting and lung development, particularly in the developing world. Methods: We conducted a manual screen of articles identified through Google Scholar and assessed risk of bias. No language restrictions were applied, so long as there was an associated English abstract. We queried VizHub (Global Burden of Disease Visualization Tool) and Google Dataset search engines for disease burden and genome wide association studies.  The scope of the article and the heterogeneity of the outcome measures reported required a narrative review of available evidence. To the extent possible, the review follows PRISMA reporting guidelines. Results: Early life influences operate in synergism with environmental and nutritional factors to influence lung growth and development in children.  Low lung function and stunting have common anthropometric, environmental and nutritional correlates originating during early development. Similar anthropometric correlates and shared chronic inflammatory pathways indicated that the two conditions were analogous. Conclusion: The analogy between poor lung function and stunting is conspicuous in the developing world, where malnutrition lies at the center of non -achievement of growth potential, susceptibility to infectious diseases and intrauterine programming for metabolic syndrome. The common pathological mechanisms governing stunting and lung function deficits counter the idea of redefining the normal for lung function measurements.

Modeling Airflow and Particle Deposition in a Human Acinar Region

The alveolar region, encompassing millions of alveoli, is the most vital part of the lung. However, airflow behavior and particle deposition in that region are not fully understood because of the complex geometrical structure and intricate wall movement. Although recent investigations using 3D computer simulations have provided some valuable information, a realistic analysis of the air-particle dynamics in the acinar region is still lacking. So, to gain better physical insight, a physiologically inspired whole acinar model has been developed. Specifically, air sacs (i.e., alveoli) were attached as partial spheroids to the bifurcating airway ducts, while breathing-related wall deformation was included to simulate actual alveolar expansion and contraction. Current model predictions confirm previous notions that the location of the alveoli greatly influences the alveolar flow pattern, with recirculating flow dominant in the proximal lung region. In the midalveolar lung generations, the intensity of the recirculating flow inside alveoli decreases while radial flow increases. In the distal alveolar region, the flow pattern is completely radial. The micron/submicron particle simulation results, employing the Euler–Lagrange modeling approach, indicate that deposition depends on the inhalation conditions and particle size. Specifically, the particle deposition rate in the alveolar region increases with higher inhalation tidal volume and particle diameter. Compared to previous acinar models, the present system takes into account the entire acinar region, including both partially alveolated respiratory bronchioles as well the fully alveolated distal airways and alveolar sacs. In addition, the alveolar expansion and contraction have been calculated based on physiological breathing conditions which make it easy to compare and validate model results with in vivo lung deposition measurements. Thus, the current work can be readily incorporated into human whole-lung airway models to simulate/predict the flow dynamics of toxic or therapeutic aerosols.

Charting the human respiratory tract with airborne nanoparticles: evaluation of the Airspace Dimension Assessment technique

Airspace Dimension Assessment (AiDA) is a technique to assess lung morphology by measuring lung deposition of inhaled nanoparticles. Nanoparticles deposit in the lungs predominately by diffusion, and average diffusion distances, corresponding to effective airspace radii ( rAiDA), can be inferred from measurements of particle recovery after varied breath holds. Also, particle recovery after a 0-s breath hold ( R0) may hold information about the small conducting airways. This study investigates rAiDA at different volumetric sample depths in the lungs of healthy subjects. Measurements were performed with 50-nm polystyrene nanospheres on 19 healthy subjects aged 17–67 yr. Volumetric sample depths ranged from 200 to 5,000 ml and breath-hold times from 5 to 20 s. At the examined volumetric sample depths, rAiDA values ranged from ~200–600 μm, which correspond to dimensions of the bronchiolar and the gas-exchanging regions of the lungs. R0 decreased with volumetric sample depth and showed more intersubject variation than rAiDA. Correlations were found between the AiDA parameters, anthropometry, and lung function tests, but not between rAiDA and R0. For repeated measurements on 3 subjects over an 18-mo period, rAiDA varied on average within ± 7 μm (± 2.4%). The results indicate that AiDA has potential as an efficient new in vivo technique to assess individual lung properties. The information obtained by such measurements may be of value for lung diagnostics, especially for the distal lungs, which are challenging to examine directly by other means.

NEW & NOTEWORTHY This is the first study to measure effective airspace radii ( rAiDA) at volumetric sample depths 200–5,000 ml in healthy subjects by Airspace Dimension Assessment (AiDA). Observed rAiDA were 200–600 μm, which corresponds to airspaces for the bronchiolar and the gas-exchanging regions around airway generation 14–17. rAiDA correlated with lung function tests and anthropometry. Measurements of rAiDA on 3 subjects over 11–18 mo were within ± 7 μm.

Pre- and Postnatal Lung Development: An Updated Species Comparison

The purpose of this review is to give an outline of respiratory tract morphological and functional development with an emphasis on perinatal and postnatal maturational processes. In view of the rising need for qualitative and quantitative data for the development of pediatric pharmaceuticals, a comparison of the human situation to experimental animal models is made, and functional data as well as suitable models for human airway diseases and functional testing are presented. Birth Defects Research 109:1519-1539, 2017. © 2017 Wiley Periodicals, Inc.

Electronic cigarettes: age-specific generation-resolved pulmonary doses

Particle size-number distributions of aerosol from e-cigarettes (0 and 14 mg mL^-1 nicotine) were compared with conventional cigarettes. Results were used to provide age-specific (9-21 years) dosimetry estimates applying the MMPD model. After a 2-s puff, total number doses (D _Tot ) were highest for 9 years of age (6.01 × 10¹⁰-1.31 × 10¹¹ particles) and lowest for 18 years of age (4.69 × 10¹⁰-1.06 × 10¹¹ particles). Such doses represented about 19-45 and 25-100% of the relevant daily doses of not smoking individuals, respectively, in tracheobronchial (TB) and alveolar (A) regions. D _Tot for the e-cigarettes were about double that for conventional cigarette. Deposition densities and daily volume of e-cigarette liquid deposited per unit surface area were maximum at lobar bronchi, highest for 9 years and lowest for 21 years age.

Do nanoparticles provide a new opportunity for diagnosis of distal airspace disease?

There is a need for efficient techniques to assess abnormalities in the peripheral regions of the lungs, for example, for diagnosis of pulmonary emphysema. Considerable scientific efforts have been directed toward measuring lung morphology by studying recovery of inhaled micron-sized aerosol particles (0.4-1.5 µm). In contrast, it is suggested that the recovery of inhaled airborne nanoparticles may be more useful for diagnosis. The objective of this work is to provide a theoretical background for the use of nanoparticles in measuring lung morphology and to assess their applicability based on a review of the literature. Using nanoparticles for studying distal airspace dimensions is shown to have several advantages over other aerosol-based methods. 1) Nanoparticles deposit almost exclusively by diffusion, which allows a simpler breathing maneuver with minor artifacts from particle losses in the oropharyngeal and upper airways. 2) A higher breathing flow rate can be utilized, making it possible to rapidly inhale from residual volume to total lung capacity (TLC), thereby eliminating the need to determine the TLC before measurement. 3) Recent studies indicate better penetration of nanoparticles than micron-sized particles into poorly ventilated and diseased regions of the lungs; thus, a stronger signal from the abnormal parts is expected. 4) Changes in airspace dimensions have a larger impact on the recovery of nanoparticles. Compared to current diagnostic techniques with high specificity for morphometric changes of the lungs, computed tomography and magnetic resonance imaging with hyperpolarized gases, an aerosol-based method is likely to be less time consuming, considerably cheaper, simpler to use, and easier to interpret (providing a single value rather than an image that has to be analyzed). Compared to diagnosis by carbon monoxide (DL,CO), the uptake of nanoparticles in the lung is not affected by blood flow, hemoglobin concentration or alterations of the alveolar membranes, but relies only on lung morphology.

The Natural History of Bronchopulmonary Dysplasia: The Case for Primary Prevention

Brochopulmonary dysplasia (BPD) is the most common form of chronic lung disease in infancy. At present, BPD primarily occurs in extremely premature infants (23-28 weeks of gestation) born during the late canalicular/early saccular stage of lung development. This article summarizes the current knowledge of the life course of BPD by emphasizing recent or key articles notating its natural history from the newborn period through adulthood and building the case for a continued focus on its primary prevention.

Stunting and the Prediction of Lung Volumes Among Tibetan Children and Adolescents at High Altitude

This study examines the extent to which stunting (height-for-age Z-scores ≤ -2) compromises the use of low altitude prediction equations to gauge the general increase in lung volumes during growth among high altitude populations. The forced vital capacity (FVC) and forced expiratory volume (FEV1) of 208 stunted and 365 non-stunted high-altitude Tibetan children and adolescents between the ages of 6 and 20 years are predicted using the Third National Health and Nutrition Examination Survey (NHANESIII) and the Global Lung Function Initiative (GLF) equations, and compared to observed lung volumes. Stunted Tibetan children show smaller positive deviations from both NHANESIII and GLF prediction equations at most ages than non-stunted children. Deviations from predictions do not correspond to differences in body proportions (sitting heights and chest circumferences relative to stature) between stunted and non-stunted children; but appear compatible with the effects of retarded growth and lung maturation that are likely to exist among stunted children. These results indicate that, before low altitude standards can be used to evaluate the effects of hypoxia, or before high altitude populations can be compared to any other group, it is necessary to assess the relative proportion of stunted children in the samples. If the proportion of stunted children in a high altitude population differs significantly from the proportion in the comparison group, lung function comparisons are unlikely to yield an accurate assessment of the hypoxia effect. The best solution to this problem is to (1) use stature and lung function standards based on the same low altitude population; and (2) assess the hypoxic effect by comparing observed and predicted values among high altitude children whose statures are most like those of children on whom the low altitude spirometric standard is based-preferably high altitude children with HAZ-scores ≥ -1.

Developmental functional adaptation to high altitude: review

Various approaches have been used to understand the origins of the functional traits that characterize the Andean high-altitude native. Based on the conceptual framework of developmental functional adaptation which postulates that environmental influences during the period of growth and development have long lasting effects that may be expressed during adulthood, we initiated a series of studies addressed at determining the pattern of physical growth and the contribution of growth and development to the attainment of full functional adaptation to high-altitude of low and high altitude natives living under rural and urban conditions. Current research indicate that: (a) the pattern of growth at high altitude due to limited nutritional resources, physical growth in body size is delayed but growth in lung volumes is accelerated because of hypoxic stress); (b) low-altitude male and female urban natives can attain a full functional adaptation to high altitude by exposure to high-altitude hypoxia during the period of growth and development; (c) both experimental studies on animals and comparative human studies indicate that exposure to high altitude during the period of growth and development results in the attainment of a large residual lung volume; (d) this developmentally acquired enlarged residual lung volume and its associated increase in alveolar area when combined with the increased tissue capillarization and moderate increase in red blood cells and hemoglobin concentration contributes to the successful functional adaptation of the Andean high-altitude native to hypoxia; and (e) any specific genetic traits that are related to the successful functional adaptation of Andean high-altitude natives have yet to be identified.

Does lung development differ in male and female fetuses?

Preterm male infants have a higher incidence of morbidity and mortality due to respiratory insufficiency than females of the same gestational age. This male disadvantage could be due to differences in lung architecture; however, few studies have compared lung architecture in male and female fetuses during late gestation. Our principal objectives were to compare the morphology of the fetal lung and the maturity of the surfactant system in preterm male and female fetuses. Lungs from male (n = 9) and female (n = 11) fetal sheep were collected at 0.9 of term (131 days of the 145-day gestation) for morphological and molecular analyses. In separate groups, tracheal liquid was obtained from male (n = 9) and female (n = 9) fetuses at 0.9 of term for determination of surfactant phospholipid composition. We found no sex-related differences in body weight, lung weight, right lung volume, lung tissue and airspace fractions, mean linear intercept, septal crest density, septal thickness, the proportion of proliferating and apoptotic cells, and the percentages of collagen or elastin. The gene expression of surfactant protein -A, -B, -C, and -D and tropoelastin was similar between sexes. There were no differences in the proportion of the major phospholipid classes in the tracheal liquid between sexes; however there was a significantly higher percentage of the phospholipid species phosphatidylinositol 38:5 in males. The greater morbidity and mortality in preterm male lambs do not appear to be related to differences in lung structure or surfactant phospholipid synthesis before birth, but may relate to physiological adaptation to air-breathing at birth.

Particle transport and deposition: basic physics of particle kinetics

The human body interacts with the environment in many different ways. The lungs interact with the external environment through breathing. The enormously large surface area of the lung with its extremely thin air-blood barrier is exposed to particles suspended in the inhaled air. The particle-lung interaction may cause deleterious effects on health if the inhaled pollutant aerosols are toxic. Conversely, this interaction can be beneficial for disease treatment if the inhaled particles are therapeutic aerosolized drugs. In either case, an accurate estimation of dose and sites of deposition in the respiratory tract is fundamental to understanding subsequent biological response, and the basic physics of particle motion and engineering knowledge needed to understand these subjects is the topic of this article. A large portion of this article deals with three fundamental areas necessary to the understanding of particle transport and deposition in the respiratory tract. These are: (i) the physical characteristics of particles, (ii) particle behavior in gas flow, and (iii) gas-flow patterns in the respiratory tract. Other areas, such as particle transport in the developing lung and in the diseased lung are also considered. The article concludes with a summary and a brief discussion of areas of future research.

Long-term pulmonary outcomes of patients with bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD) is the commonest cause of chronic lung disease in infancy. The incidence of BPD has remained unchanged despite many advances in neonatal care. BPD starts in the neonatal period but its effects can persist long term. Premature infants with BPD have a greater incidence of hospitalization, and continue to have a greater respiratory morbidity and need for respiratory medications, compared to those without BPD. Lung function abnormalites, especially small airway abnormalities, often persist. Even in the absence of clinical symptoms, BPD survivors have persistent radiological abnormalities and presence of emphysema has been reported on chest computed tomography scans. Concern regarding their exercise tolerance remains. Long-term effects of BPD are still unknown, but given reports of a more rapid decline in lung function and their suspectibility to develop chronic obstructive pulmonary disease phenotype with aging, it is imperative that lung function of survivors of BPD be closely monitored.

Physiological measurement of the small airways

Noninvasive physiological measurements are reviewed that have been reported in the literature with the specific aim being to study the small airways in lung disease. This has mostly involved at-the-mouth noninvasive measurement of flow, pressure or inert gas concentration, with the intent of deriving one or more indices that are representative of small airway structure and function. While these measurements have remained relatively low-tech, the effort and sophistication increasingly reside with the interpretation of such indices. When aspiring to derive information at the mouth about structural and mechanical processes occurring several airway generations away in a complex cyclically changing cul-de-sac structure, conceptual or semi-quantitative lung models can be valuable. Two assumptions that are central to small airway structure-function measurement are that of an average airway change at a given peripheral lung generation and of a parallel heterogeneity in airway changes. While these are complementary pieces of information, they can affect certain small airways tests in confounding ways. We critically analyzed the various small airway tests under review, while contending that negative outcomes of these tests are probably a true reflection of the fact that no change occurred in the small airways. Utmost care has been taken to not favor one technique over another, given that most current small airways tests still have room for improvement in terms of rendering their content more specific to the small airways. One way to achieve this could consist of the coupling of signals collected at the mouth to spatial information gathered from imaging in the same patient.

Pediatric Sepsis - Part I: "Children are not small adults!"

The recognition, diagnosis, and management of sepsis remain among the greatest challenges in pediatric critical care medicine. Sepsis remains among the leading causes of death in both developed and underdeveloped countries and has an incidence that is predicted to increase each year. Unfortunately, promising therapies derived from preclinical models have universally failed to significantly reduce the substantial mortality and morbidity associated with sepsis. There are several key developmental differences in the host response to infection and therapy that clearly delineate pediatric sepsis as a separate, albeit related, entity from adult sepsis. Thus, there remains a critical need for well-designed epidemiologic and mechanistic studies of pediatric sepsis in order to gain a better understanding of these unique developmental differences so that we may provide the appropriate treatment. Herein, we will review the important differences in the pediatric host response to sepsis, highlighting key differences at the whole-organism level, organ system level, and cellular and molecular level.

Analysis of impulse oscillometric measures of lung function and respiratory system model parameters in small airway-impaired and healthy children over a 2-year period

BACKGROUND

Is Impulse Oscillometry System (IOS) a valuable tool to measure respiratory system function in Children? Asthma (A) is the most prevalent chronic respiratory disease in children. Therefore, early and accurate assessment of respiratory function is of tremendous clinical interest in diagnosis, monitoring and treatment of respiratory conditions in this subpopulation. IOS has been successfully used to measure lung function in children with a high degree of sensitivity and specificity to small airway impairments (SAI) and asthma. IOS measures of airway function and equivalent electrical circuit models of the human respiratory system have been developed to quantify the severity of these conditions. Previously, we have evaluated several known respiratory models based on the Mead's model and more parsimonious versions based on fitting IOS data known as extended RIC (eRIC) and augmented RIC (aRIC) models have emerged, which offer advantages over earlier models.

METHODS

IOS data from twenty-six children were collected and compared during pre-bronchodilation (pre-B) and post- bronchodilation (post-B) conditions over a period of 2 years.

RESULTS AND DISCUSSION

Are the IOS and model parameters capable of differentiating between healthy children and children with respiratory system distress? Children were classified into two main categories: Healthy (H) and Small Airway-Impaired (SAI). The IOS measures and respiratory model parameters analyzed differed consistently between H and SAI children. SAI children showed smaller trend of "growth" and larger trend of bronchodilator responses than H children.The two model parameters: peripheral compliance (Cp) and peripheral resistance (Rp) tracked IOS indices of small airway function well. Cp was a more sensitive index than Rp. Both eRIC and aRIC Cps and the IOS Reactance Area, AX, (also known as the "Goldman Triangle") showed good correlations.

CONCLUSIONS

What are the most useful IOS and model parameters? In this work we demonstrate that IOS parameters such as resistance at 5 Hz (R5), frequency-dependence of resistance (fdR: R5-R20), reactance area (AX), and parameter estimates of respiratory system such as Cp and Rp provide sensitive indicators of lung function and have the capacity to differentiate between obstructed and non-obstructed airway conditions. They are also capable of demonstrating airway growth-related changes over a two-year period. We conclude that the IOS parameters AX and the eRIC model derived parameter Cp are the most reliable parameters to track lung function in children before and after bronchodilator and over a time period (2 years). Which model is more suitable for interpreting IOS data? IOS data are equally well-modelled by eRIC and aRIC models, based on the close correlations of their corresponding parameters - excluding upper airway shunt compliance. The eRIC model is a more parsimonious and equally powerful model in capturing the differences in IOS indices between SAI and H children. Therefore, it may be considered a clinically-preferred model of lung function.

Developmental adaptation: where we go from here

The concept of developmental adaptation is a powerful framework that can be used for understanding the origin of population differences in phenotypic and genotypic biological traits. There is great deal of information describing how developmental responses can shape adult biological outcomes. Specifically, current research suggest that individuals developing in stressful environments such as high altitude will attain an adult enlarged residual lung volume that contribute to the successful cardiovascular adaptation of the high-altitude Andean native. Likewise, studies on the etiology of the metabolic syndrome indicate that development under poor nutritional environments elicit efficient physiological and metabolic responses for the utilization of nutrients and energy, which become disadvantageous when the adult environmental conditions provide abundant access to food and low energy expenditure. Epigenetic research in experimental animals and retrospective research in humans confirm that environmental influences during developmental period have profound consequences on the phenotypic expression of biological and behavioral traits during adulthood. Research on epigenetics is a productive direction for human biologists concerned with understanding the origins of human biological variability.

[Lung function testing and assessment of distal airways in asthma]

INTRODUCTION

Small airways are defined (in humans) as those<2mm in diameter.

BACKGROUND

They were originally described as the "quiet zone" of the lungs contributing less than 10% of the total resistance to airflow. Pulmonary function tests remain the most used method to assess distal airway flow limitation.

VIEWPOINTS

However, these tests are limited in adults and also in children because MEF25-75% and FEF50% are highly variable spirometric indices and they depend on vital capacity, which increases with expiratory time in obstructed subjects. There is a need for promising non invasive new tools like the forced oscillation technique to measure resistance. The increased availability of the exhaled fraction of nitric oxide (FeNO) measurement means that this method is accessible and attractive.

CONCLUSION

The production of nitric oxide (NO) can be assessed by measuring the fraction of NO during a prolonged expiration (FENO) or by estimating other parameters of NO exchange including the alveolar NO concentration (CalvNO) and may provide information about small airway inflammation and assist the optimal control of the disease.

Impaired lung homeostasis in neonatal mice exposed to cigarette smoke

In infants, smoke exposure is associated with more respiratory illnesses and decreased lung function. We hypothesized that perinatal lung is particularly susceptible to the damaging effects of cigarette smoke (CS) and that exposure to CS during this period may alter expression of immune response genes and adversely affect lung growth. To test this, we exposed neonatal mice to 14 days of CS. Immediately after exposure to CS, pulmonary gene expression profiling was performed on 2-week-old CS-exposed lung and age-matched control lung. Nitrotyrosine, TUNEL, MAC3, and phospho-SMAD-2 (p-SMAD2) staining was also performed. At 8 weeks of age, lung volume measurements were determined and mean linear intercept measurements were calculated. Pulmonary gene expression profiling revealed that CS exposure significantly inhibited type 1 and type 2 interferon pathway genes in neonatal lung, compared with age-matched control lung. Neonatal CS-exposed lung also had a significant increase in n-tyrosine, TUNEL, and p-SMAD2 staining when compared with adult CS-exposed lung and age-matched control lung. Lung volumes at 8 weeks of age were modestly but significantly decreased in mice exposed to CS in the neonatal period compared with age-matched controls, consistent with impaired lung growth. The results of this study indicate that exposure to CS during the neonatal period inhibits expression of genes involved in innate immunity and mildly impairs postnatal lung growth. These findings may in part explain the increased incidence of respiratory symptoms in infants and children exposed to CS.

Focusing on children's inhalation dosimetry and health effects for risk assessment: an introduction

Substantial effort has been invested in improving children's health risk assessment in recent years. However, the body of scientific evidence in support of children's health assessment is constantly advancing, indicating the need for continual updating of risk assessment methods. Children's inhalation dosimetry and child-specific adverse health effects are of particular concern for risk assessment. When focusing on this topic within children's health, key issues for consideration include (1) epidemiological evidence of adverse effects following children's exposure to air pollution, (2) ontogeny of the lungs and effects on dosimetry, (3) estimation and variability of children's inhalation rates, and (4) current risk assessment methodologies for addressing children. In this article, existing and emerging information relating to these key issues are introduced and discussed in an effort to better understand children's inhalation dosimetry and adverse health effects for risk assessment. While much useful evidence is currently available, additional research and methods are warranted for improved children's health risk assessment.

Lung growth and development

Human lung growth starts as a primitive lung bud in early embryonic life and undergoes several morphological stages which continue into postnatal life. Each stage of lung growth is a result of complex and tightly regulated events governed by physical, environmental, hormonal and genetic factors. Fetal lung liquid and fetal breathing movements are by far the most important determinants of lung growth. Although timing of the stages of lung growth in animals do not mimic that of human, numerous animal studies, mainly on sheep and rat, have given us a better understanding of the regulators of lung growth. Insight into the genetic basis of lung growth has helped us understand and improve management of complex life threatening congenital abnormalities such as congenital diaphragmatic hernia and pulmonary hypoplasia. Although advances in perinatal medicine have improved survival of preterm infants, premature birth is perhaps still the most important factor for adverse lung growth.

Challenges for Future Research in Exercise Physiology as Applied to the Respiratory System

Some of the major unresolved questions in the respiratory physiology and pathophysiology of exercise are addressed. To solve many of these difficult basic problems and to understand how systems operate alone and in combination in an integrated fashion, truly experimental integrative physiological approaches are required in both humans and animals.