Current perspectives in assessment of fetal pulmonary surfactant status with amniotic fluid

Prediction of Neonatal Respiratory Distress Biomarker Concentration by Application of Machine Learning to Mid-Infrared Spectra

The authors of this study developed the use of attenuated total reflectance Fourier transform infrared spectroscopy (ATR–FTIR) combined with machine learning as a point-of-care (POC) diagnostic platform, considering neonatal respiratory distress syndrome (nRDS), for which no POC currently exists, as an example. nRDS can be diagnosed by a ratio of less than 2.2 of two nRDS biomarkers, lecithin and sphingomyelin (L/S ratio), and in this study, ATR–FTIR spectra were recorded from L/S ratios of between 1.0 and 3.4, which were generated using purified reagents. The calibration of principal component (PCR) and partial least squares (PLSR) regression models was performed using 155 raw baselined and second derivative spectra prior to predicting the concentration of a further 104 spectra. A three-factor PLSR model of second derivative spectra best predicted L/S ratios across the full range (R²: 0.967; MSE: 0.014). The L/S ratios from 1.0 to 3.4 were predicted with a prediction interval of +0.29, −0.37 when using a second derivative spectra PLSR model and had a mean prediction interval of +0.26, −0.34 around the L/S 2.2 region. These results support the validity of combining ATR–FTIR with machine learning to develop a point-of-care device for detecting and quantifying any biomarker with an interpretable mid-infrared spectrum.

Rapid test for lung maturity, based on spectroscopy of gastric aspirate, predicted respiratory distress syndrome with high sensitivity

AIM

Respiratory distress syndrome (RDS) is a major cause of mortality and morbidity in premature infants. By the time symptoms appear, it may already be too late to prevent a severe course, with bronchopulmonary dysplasia or mortality. We aimed to develop a rapid test of lung maturity for targeting surfactant supplementation.

METHODS

Concentrations of the most surface-active lung phospholipid dipalmitoylphosphatidylcholine and sphingomyelin in gastric aspirates from premature infants were measured by mass spectrometry and expressed as the lecithin/sphingomyelin ratio (L/S). The same aspirates were analysed with mid-infrared spectroscopy. Subsequently, L/S was measured in gastric aspirates and oropharyngeal secretions from another group of premature infants using spectroscopy and the results were compared with RDS development. The 10-minute analysis required 10 μL of aspirate.

RESULTS

An L/S algorithm was developed based on 89 aspirates. Subsequently, gastric aspirates were sampled in 136 infants of 24-31 weeks of gestation and 61 (45%) developed RDS. The cut-off value of L/S was 2.2, sensitivity was 92%, and specificity was 73%. In 59 cases, the oropharyngeal secretions had less valid L/S than gastric aspirate results.

CONCLUSION

Our rapid test for lung maturity, based on spectroscopy of gastric aspirate, predicted RDS with high sensitivity.

Comparison of infrared spectroscopic and fluorescence depolarization assays for fetal lung maturity

OBJECTIVE

Infrared spectroscopic analysis of amniotic fluid was recently shown to be a potential useful method for the determination of fetal lung maturity. Those studies used thin-layer chromatography as a reference method for the calibration of the infrared-based technique. However, thin-layer chromatography is compromised by large intra-assay and interlaboratory coefficients of variation. Therefore in this study we have used a reference method that is based on fluorescence depolarization, the TDx FLM II assay, to verify the sensitivity and precision of infrared spectroscopy for assessment of fetal lung maturity status.

STUDY DESIGN

Samples of amniotic fluid were obtained by amniocentesis from 101 patients between the 24th and 40th weeks of pregnancy. Small volumes (35 microL) of amniotic fluid specimens were dried, and the infrared spectra were measured with a commercial infrared spectrometer. The fetal lung surfactant/albumin ratio was determined separately for each specimen with the TDx FLM II assay. The proposed infrared method was then calibrated and tested with a partial least-squares regression analysis to quantitatively correlate the infrared spectra with the surfactant/albumin ratios provided by the TDx FLM II assays.

RESULTS

A total of 144 training spectra were used to build the partial least-squares calibration model. The correlation coefficient for the training set was excellent (r = 0.92), with an SE between infrared-predicted and reference surfactant/albumin ratios of 17 mg/g. The model was then validated on a set of 69 test spectra and yielded an SE of 14 mg/g (r = 0.86). The final partial least-squares model included the 900- to 1500-cm(-1) and 2800- to 3200-cm(-1) spectral ranges and 6 partial least-squares factors.

CONCLUSION

Because the infrared-based fetal lung maturity measurements correlated well with assays from both of the current standard clinical techniques (thin-layer chromatography and fluorescence depolarization) and the procedure is less labor and training intensive, we concluded that infrared spectroscopy has the potential to emerge as the method of choice for prediction of fetal lung maturity from amniotic fluid analysis.

Prediction of RDS from amniotic fluid analysis: a comparison of the prognostic value of TLC and infra-red spectroscopy

Infra-red (IR) spectroscopy was recently shown to be a sensitive method for the determination of fetal lung maturity (Liu et al., 1998). The present study was undertaken to validate the newly developed method for prediction of RDS (Respiratory Distress Syndrome). Samples of amniotic fluid were obtained by amniocentesis from 86 patients between the 28th and 41st week of pregnancy. A small volume, 35 microliters, of amniotic fluid was used to acquire infra-red spectra with a commercial spectrometer. The lecithin/sphingomyelin (L/S) ratio was determined separately by TLC (thin layer chromatography). A calibration model was established using a partial least squares regression analysis which quantitatively correlated 145 IR spectra with the TLC-based L/S ratios; the correlation coefficient was 0.95. The model was then validated using a total of 111 spectra which also showed a high correlation coefficient (r = 0.91). Based upon the clinical data associated with these samples, the prediction accuracy for the presence of RDS was 67 per cent for TLC and 83.3 per cent for IR. The accuracy for predicting the absence of RDS was 93.4 per cent for TLC and 96.8 per cent for IR. We conclude that IR spectroscopy has the potential to become the clinical method of choice for predicting RDS from amniotic fluid analysis.

Primary importance of zwitterionic over anionic phospholipids in the surface-active function of calf lung surfactant extract

The relative contributions of zwitterionic and anionic phospholipids to the surface-active function of calf lung surfactant extract (CLSE) were assessed by measurements of surface properties in vitro and pressure-volume (P-V) mechanics in excised rat lungs in situ. Surface activity and mechanical effects were compared for chromatographically purified CLSE subfractions containing the complete mix of phospholipids (PPL) or modified phospholipids depleted in anionic components (mPPL), alone or combined with 1.3% (by weight) of hydrophobic surfactant proteins (SP-B and SP-C). Surface pressure-time (pi-t) adsorption isotherms at 37 degrees C were very similar for dispersions of PPL and mPPL in a Teflon dish with a stirred subphase to minimize diffusion resistance. Combination of either PPL or mPPL with hydrophobic SP substantially improved adsorption, but mixtures of PPL:SP and mPPL:SP had only small differences in pi-t isotherms and reached the same final equilibrium pi of approximately 47 mN/m achieved by CLSE. Surface pressure-area (pi-A) isotherms and maximum surface pressures were also very similar for spread films of PPL versus mPPL and PPL:SP versus mPPL:SP on the Wilhelmy balance (23 degrees C and 37 degrees C). Respreading based on pi-A isotherm area calculations was slightly better in surface-excess films of PPL versus mPPL and PPL:SP versus mPPL:SP, but differences were minor and were smaller at 37 degrees C than at 23 degrees C. Overall dynamic surface activity in oscillating bubble studies was not significantly different for PPL versus mPPL or for PPL:SP versus mPPL:SP, and the latter two mixtures both reached minimum surface tensions < 1 mN/m (37 degrees C, 20 cycles/min, 0.5 mM phospholipid). Dispersions of PPL:SP, mPPL:SP, and CLSE were also not significantly different in improving P-V mechanics almost to normal when instilled in lavaged, excised rat lungs at 37 degrees C (30 mg/2.5 ml saline). These data suggest that zwitterionic phospholipids have a major role over anionic phospholipids in interacting with hydrophobic SP in the adsorption, dynamic surface tension lowering, film respreading, and pulmonary mechanical activity of the hydrophobic components of calf lung surfactant in CLSE.

Use of low-frequency electrical impedance measurements to determine phospholipid content in amniotic fluid

In this report we propose a new method for an in vitro test of the foetal lung maturity based on the measurement of the electrical conductivity of the overall amniotic fluid obtained from transabdominal amniocentesis, since this quantity can be linked to a first approximation in a very simple way to the phospholipid content. We have carried out measurements of 85 different samples of amniotic fluid as a function of gestation weeks and we have observed a pronounced change of the electrical conductivity that reflects the increase in the phospholipid concentration occurring at the end of normal pregnancies. The method could be further developed to obtain similar information on in vivo experiments by means of bioelectric impedance tomography, taking advantage of the frequency dependence of the tissue electrical impedance.

Analysis of saturated phosphatidylcholine in amniotic fluid by 31P NMR

A technique using solubilization with sodium cholate to resolve 31P NMR resonances of phospholipid molecular species was applied to amniotic fluid samples from 16 subjects. Gestational ages from 25 to 40 weeks were represented, and two subjects were sampled sequentially. Fitting of the partially resolved 31P NMR signal of phosphatidylcholine (PC) generated an estimate of percent disaturated acyl PC (%dsPC) which correlated more highly with gestational age than did several other potential indices of fetal lung maturation, such as the ratio of PC to inorganic phosphate from the solubilized spectra, or PC to sphingomyelin from extract spectra. In a few cases, enzyme-catalyzed PC hydrolysis limited the precision, but did not appear to affect the accuracy, of the %dsPC estimates. Resolution of palmitoyl and oleoyl lyso-PC species was observed for both the 1- and 2-acyl isomers. Upfield shifts due to the presence of cis double bonds in the lone acyl chain of the lyso-PCs were analogous to those observed for the diacyl PCs.

Prediction of respiratory distress syndrome by a new colorimetric assay

OBJECTIVE

The purpose of this study was to evaluate the clinical performance of a new, simple, and rapid colorimetric assay for predicting respiratory distress syndrome.

STUDY DESIGN

Ninety-four specimens obtained within 3 days of delivery were assayed with the new test. For 78 of these specimens, the lecithin/sphingomyelin ratio was also determined. Significant differences were calculated with chi 2 analysis. Cutoff points were selected by maximizing the corresponding sums of sensitivity and specificity and from receiver-operator-characteristic curves.

RESULTS

The specificity of the new colorimetric test was better than 89%, and it yielded more than 86% correct diagnoses. Furthermore, the test had a significantly (p less than 0.05) lower percentage of false-immature results than that obtained with the lecithin/sphingomyelin ratio. Moreover, the new test performed relatively well in analyses of patients between 27 weeks and 36 weeks' gestation.

CONCLUSION

We concluded that the new assay is reliable and that it can serve as a useful alternative to current methods for predicting respiratory distress syndrome.

Analysis of phospholipids in human amniotic fluid by 31P NMR

A recently described solvent-reagent system for obtaining narrow linewidths in 31P NMR spectra of phospholipid extracts was applied to human amniotic fluid. Resolution of the major components was achieved by manipulating the solvent composition, and assignments were made by spiking samples with standard compounds. Spin-lattice relaxation times were determined and used to optimize data acquisition. NMR estimates of the phosphatidylcholine to sphingomyelin ratio for 33 patients were compared to those obtained by TLC densitometry, a common clinical assay for fetal pulmonary maturity. Estimates of the levels of phosphatidylglycerol and phosphatidylinositol could also be obtained from 31P NMR. High-resolution 31P NMR in this solvent-reagent system provides a relatively straightforward and reliable alternative method for assessing fetal pulmonary status by phospholipid quantitation in human amniotic fluid. The 31P NMR method has the advantage that it is sensitive to total, and not just unsaturated, phosphatidylcholine.