We studied 12 adult patients with ARDS, defined according to Bernard 14, and 7 subjects with normal lungs on mechanical ventilation or breathing spontaneously through a tracheostomy tube due to neuromuscular diseases. Patients were admitted to the Intensive Care or Respiratory Units of the University of Padova, Italy. The study was approved by the Ethics Committee, and written, informed consent was obtained. After intubation with a cuffed tube, all patients received into the trachea 20 ml of normal saline containing 7.5 mg of ¹³C-dipalmitoyl-phosphatidylcholine and 40 mg of surfactant extract (Curosurf^®, Chiesi, Parma, Italy) as spreading agent. Both palmitates were uniformly labeled with carbon 13 ([U-¹³C-PA]-DPPC, Martek-Biosciences, Columbia, MD). The suspension was instilled close to the carina with a 4.5 mm bronchoscope (Olympus BF-40 OD 6.0 mm Olympus-Europe, Italy). Patients with ARDS were studied within 72 h from the onset of the acute respiratory failure and ventilator parameters were adjusted to maintain an oxygen saturation > 85% and pH > 7.25. Ventilator and gas exchange parameters were recorded at time 0 and subsequently every 6 h in ARDS patients and at least once in controls.

Tracheal aspirates, collected by suction below the tip of the endotracheal tube after instilling 5 ml of normal saline, were obtained at baseline, every 6 h until 72 h and then every 12 h for 7 days or until extubation. Aspirates were filtered on gauze, centrifuged at 150-g for 10 minutes and supernatants were stored at -20°C.

Lipids from tracheal aspirates and from the administered tracer were extracted according to Bligh and Dyer after addition of the internal standard heptadecanoylphosphatidylcholine 15. One third of the extract was oxidized with osmium tetroxide. Disaturated-phosphatidilcholine was isolated from the lipid extract by thin layer chromatography 16, the fatty acids were derivatized as pentafluorobenzyl derivatives 17, extracted with hexane and stored at -20°C. Tracheal aspirates with visible blood were discarded. The enrichments of ¹³C -disaturated-phosphatidylcholine-palmitate were measured by gas chromatography-mass spectrometry (GC-MS, Voyager, Thermoquest, Rodano, Milano, Italy), as previously described 18.

Data were analyzed with the two compartment model shown in figure 1 under the following assumptions: a) surfactant is distributed between two compartments (alveoli and lung parenchyma); b) disaturated-phosphatidylcholine is synthesized by lung parenchyma, secreted in the alveoli and recycled before being degraded by alveolar macrophages or lung tissue; c) the system is at steady state and is not perturbed by the administration of tracer. These assumptions have been validated in adult and newborn animals by several authors, and have been used in numerous studies on surfactant turnover in experimental animals 7192021.

Tracer model equations are:

m˙1 MathType@MTEF@5@5@+=feaafiart1ev1aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacH8akY=wiFfYdH8Gipec8Eeeu0xXdbba9frFj0=OqFfea0dXdd9vqai=hGuQ8kuc9pgc9s8qqaq=dirpe0xb9q8qiLsFr0=vr0=vr0dc8meaabaqaciaacaGaaeqabaqabeGadaaakeaacuqGTbqBgaGaamaaBaaaleaacqaIXaqmaeqaaaaa@2F32@ (t) = -(k₀₁ + k₂₁)m₁ (t) + k₁₂m₂ (t) + u(t)

m˙1 MathType@MTEF@5@5@+=feaafiart1ev1aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacH8akY=wiFfYdH8Gipec8Eeeu0xXdbba9frFj0=OqFfea0dXdd9vqai=hGuQ8kuc9pgc9s8qqaq=dirpe0xb9q8qiLsFr0=vr0=vr0dc8meaabaqaciaacaGaaeqabaqabeGadaaakeaacuqGTbqBgaGaamaaBaaaleaacqaIXaqmaeqaaaaa@2F32@ (t) = k₂₁m₁ (t) - (k₀₁ + k₁₂)m₂ (t)     (1)

where m₁ and m₂ are the amount (in mg) of disaturated-phosphatidylcholine-palmitate tracer in compartment 1 and 2 respectively, m˙1 MathType@MTEF@5@5@+=feaafiart1ev1aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacH8akY=wiFfYdH8Gipec8Eeeu0xXdbba9frFj0=OqFfea0dXdd9vqai=hGuQ8kuc9pgc9s8qqaq=dirpe0xb9q8qiLsFr0=vr0=vr0dc8meaabaqaciaacaGaaeqabaqabeGadaaakeaacuqGTbqBgaGaamaaBaaaleaacqaIXaqmaeqaaaaa@2F32@ and m˙2 MathType@MTEF@5@5@+=feaafiart1ev1aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacH8akY=wiFfYdH8Gipec8Eeeu0xXdbba9frFj0=OqFfea0dXdd9vqai=hGuQ8kuc9pgc9s8qqaq=dirpe0xb9q8qiLsFr0=vr0=vr0dc8meaabaqaciaacaGaaeqabaqabeGadaaakeaacuqGTbqBgaGaamaaBaaaleaacqaIYaGmaeqaaaaa@2F34@ (mg/h) represent their rate of change, k₂₁ and k₁₂ (h^-1) are inter-conversion rate parameters, k₀₁ and k₀₂ (h^-1) are irreversible losses, and u is the labeled disaturated-phosphatidylcholine-palmitate injection into the accessible compartment.

Tracee steady state equations are:

0 = -(K₀₁ + K₂₁)M₁ + K₁₂M₂ = -F₀₁ - F₂₁ + F₁₂

0 = K₂₁M₁ - (K₀₁ + K₁₂)M₂ + P = F₂₁ - F₀₁ - F₁₂ + P     (2)

where M₁ and M₂ (mg) are the steady state tracee disaturated-phosphatidylcholine-palmitate masses in the two compartments, P (mg/h) is disaturated-phosphatidylcholine-palmitate de novo synthesis, F₂₁ = k₂₁M₁, F₁₂ = k₁₂M_2, F₀₁ = k₀₁M₁, F₀₂ = k₀₂M₂ (mg/h) are inter-conversion and irreversible loss fluxes.

Measured tracer to tracee ratio at time t is the ratio between tracer and tracee masses in the accessible compartment:

ttr 1 ( t ) = m 1 ( t ) M 1       ( 3 ) MathType@MTEF@5@5@+=feaafiart1ev1aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacH8akY=wiFfYdH8Gipec8Eeeu0xXdbba9frFj0=OqFfea0dXdd9vqai=hGuQ8kuc9pgc9s8qqaq=dirpe0xb9q8qiLsFr0=vr0=vr0dc8meaabaqaciaacaGaaeqabaqabeGadaaakeaacqqG0baDcqqG0baDcqqGYbGCdaWgaaWcbaGaeGymaedabeaakiabcIcaOiabbsha0jabcMcaPiabg2da9maalaaabaGaeeyBa02aaSbaaSqaaiabigdaXaqabaGccqGGOaakcqqG0baDcqGGPaqkaeaacqqGnbqtdaWgaaWcbaGaeGymaedabeaaaaGccaWLjaGaaCzcamaabmaabaGaeG4mamdacaGLOaGaayzkaaaaaa@4202@

The tracer model (equations 1 and 3) is not identifiable, since it is not possible to quantify from the input-output tracer experiment in the alveolar compartment unique values for the unknown parameters of the tracer model, namely M₁, k₀₁, k₀₂, k₁₂, k₂₁ 22. Only the mass in the alveolar compartment M₁ can be uniquely identified, together with some combinations of the original parameters, namely k₀₁+ k₂₁, k₀₂ + k₂₁ and k₂₁ k₁₂. To resolve model nonidentifiability, assumptions on the relative role of the two degradation pathways need to be incorporated into the model. Based on the results of studies in which rabbits or mice received non-degradable analogues of disaturated-phosphatidylcholine into the trachea 1011, we assumed that, in normal subjects, alveolar macrophages may degrade between 5 and 50% of surfactant disaturated-phosphatidylcholine, the remaining being degraded by lung parenchyma (i.e. F₀₁ varies between 5 and 50% of F₀₁+F₀₂). In ARDS, we assumed that the degradation of disaturated-phosphatidylcoline in the airways could vary between 5 and 100% due to the degradative activity of inflammatory cells, bacteria or enzymes released in the alveolar spaces (i.e. F₀₁ varies between 5 and 100% of F₀₁+F₀₂). Using this information, upper and lower bounds for parameters k₁₂, k₂₁, k₀₁and k₀₂ were estimated from tracer to tracee data in each individual 23. Using these values in equation 2, upper and lower bounds were derived for P, M₂ and tracee fluxes F₂₁ and F₀₂, while flux F₁₂ was uniquely solved 22. Additional kinetic parameters were used to characterize the system, namely the total mass in the system (M_tot = M₁ + M₂), the mean residence time of molecules entering the system from alveoli or lung tissue (MRT₁, MRT₂), defined as the sum of the elements in column 1 and 2 of the mean residence time matrix Θ:

Θ = [ − ( k 01 + k 21 ) k 12 k 21 − ( k 02 + k 12 ) ] − 1 = 1 k 21 k 02 + k 01 k 02 + k 01 k 12 [ k 02 + k 12 k 12 k 21 k 01 + k 21 ]       ( 4 ) MathType@MTEF@5@5@+=feaafiart1ev1aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacH8akY=wiFfYdH8Gipec8Eeeu0xXdbba9frFj0=OqFfea0dXdd9vqai=hGuQ8kuc9pgc9s8qqaq=dirpe0xb9q8qiLsFr0=vr0=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@83B6@

and the percentage R (%) of particles that recycle back after leaving the intracellular pool:

R = k 21 k 21 + k 01 ⋅ k 12 k 12 + k 02       ( 5 ) MathType@MTEF@5@5@+=feaafiart1ev1aaatCvAUfKttLearuWrP9MDH5MBPbIqV92AaeXatLxBI9gBaebbnrfifHhDYfgasaacH8akY=wiFfYdH8Gipec8Eeeu0xXdbba9frFj0=OqFfea0dXdd9vqai=hGuQ8kuc9pgc9s8qqaq=dirpe0xb9q8qiLsFr0=vr0=vr0dc8meaabaqaciaacaGaaeqabaqabeGadaaakeaacqqGsbGucqGH9aqpdaWcaaqaaiabbUgaRnaaBaaaleaacqaIYaGmcqaIXaqmaeqaaaGcbaGaee4AaS2aaSbaaSqaaiabikdaYiabigdaXaqabaGccqGHRaWkcqqGRbWAdaWgaaWcbaGaeGimaaJaeGymaedabeaaaaGccqGHflY1daWcaaqaaiabbUgaRnaaBaaaleaacqaIXaqmcqaIYaGmaeqaaaGcbaGaee4AaS2aaSbaaSqaaiabigdaXiabikdaYaqabaGccqGHRaWkcqqGRbWAdaWgaaWcbaGaeGimaaJaeGOmaidabeaaaaGccaWLjaGaaCzcamaabmaabaGaeGynaudacaGLOaGaayzkaaaaaa@4B88@

Upper and lower bound were calculated for M_tot, MRT₁ and MRT₂22, while unique values were calculated for R.

Parameters k₂₁, k₁₂, k₀₁, k₀₂, and M₁ of the model (figure 1) were fitted on disaturated-phosphatidylcholine-palmitate tracer to tracee ratio using SAAMII 24. Weights were chosen optimally, i.e. equal to the inverse of the measurement errors. They were assumed to be Gaussian, independent and zero mean with a constant coefficient of variation, which was estimated a posteriori.

Masses of palmitate residues were multiplied by 1.3025 to obtain disaturated-posphatidycholine masses. Rate of changes (k), fluxes (F) and synthesis (P) were multiplied by 24 to obtain the respective values per day.

Results are presented as mean ± SEM. Data in Table 1 are presented as mean ± SD. Differences were analysed using the Mann-Whitney test with a 2-tailed probability of <0.05 (SPSS 10.0, Windows 2000). Parameters, resolved as upper and lower bounds, were considered different when the interval of admissible values in ARDS was significantly different from the interval of admissible values in controls.

We studied 12 ARDS patients and 7 controls. No ARDS patient was treated with exogenous surfactant. Eight ARDS patients (67%) died before hospital discharge, 5 for multi-organ failure and 3 for the underlying disease. Patients died within 4 to 18 days of study completion and during the study respiratory and gas exchange parameters were stable. No death occurred in the control group. In the control group, five patients suffered from spinal muscular atrophy, two had polineuropathy and one had encephalopathy secondary to head injury. Clinical characteristics of the 12 ARDS and 7 controls are reported in Table 1. ARDS was induced by an indirect insult in all but one patient (patient 5, Table 2). Mean age was comparable in the two groups, mean weight was significantly lower in control groups (p = 0.05) and the male/female ratio was 8/4 in ARDS and 3/4 in controls (p = 0.26). Ventilator parameters were significantly different as expected from the study design. All ARDS patients were mechanically ventilated, whereas six controls were on intermittent ventilator support and one was breathing spontaneously via tracheostomy tube. Table 2 reports detailed clinical data for the 12 ARDS patients.

The average time courses of disaturated-phosphatidylcholine-palmitate tracer to tracee ratio in controls and ARDS are shown in figure 2. Although similar tracer doses were used in ARDS and controls, the tracer to tracee ratio of ARDS was markedly higher than in controls. In both cases, the tracer to tracee ratio declined to negligible values at 96 h. Therefore we used data up to 96 h.

Individual curves of the tracer to tracee ratio were fitted to the model presented in figure 1. All parameters were estimated with acceptable precision, on average less than 50%. Kinetic parameters are summarized in figure 3 and depicted in greater detail in figure 4. Three of them (M₁, F₁₂ and R) were uniquely identified, the others are presented as ranges of values included between two extremes, the upper and lower bounds.

In controls, the alveolar pool of disaturated-phosphatidylcholine was 1.31 ± 0.40 mg/kg, far smaller than the tissue pool, which, depending on assumptions about degradation of disaturated-phosphatidylcholine by alveolar macrophages, ranged from 9.64 ± 2.43 to 19.35 ± 3.74 mg/kg. De novo synthesis (P) of disaturated-phosphatidylcholine ranged from 4.25 ± 0.7 to 8.64 ± 1.44 mg/kg/day. The flux from alveoli to tissue (F₂₁) ranged from 3.12 ± 1.49 to 4.80 ± 1.78 mg/kg/day. The flux from tissue to alveoli (F₁₂) was 5.23 ± 1.78 mg/kg/day and recycling (R) was 31.9 ± 7.3%. According to the model, labelled disaturated-phosphatidylcholine is expected to accumulate into the lung parenchyma of control subjects, reaching a maximum concentration between 12 and 24 hours after instillation. Afterwards, tissue isotopic enrichment is expected to decrease, so that 96 hours after the start of the study around 20% of the tracer remains associated with lung tissue (data not shown).

In patients with ARDS, the alveolar pool of disaturated-phosphatidylcholine (M₁) was smaller than in controls: 0.16 ± 0.04 vs 1.31 ± 0.40 mg/kg (p < 0.05). Fluxes between tissue and alveoli (F₁₂ and F₂₁) and de novo synthesis (P) of disaturated-phosphatidylcholine were also smaller than in controls. Fractional rates of transfer between tissue and airways (k₂₁ and k₁₂) and alveolar mean resident time (MRT₁) were not different from controls. In ARDS, the tissue mean resident time of disaturated-phosphatidylcholine was significantly longer than in controls (figure 3 and 4). Recycling tended to be smaller in patients with ARDS, but the difference was not significant: 16.2% ± 3.5 in ARDS and 31.9% ± 7.3 in controls (p = 0.08, figure 4). Differences between ARDS and control patients appear to be robust, since, with the exception of the synthesis rate P, all differences remained significant even assuming that in controls 5–100% of disaturated-phosphatidycholine can be degraded in the alveolar spaces.

The model predicts that in ARDS instilled disaturated-phosphatidylcholine associates rapidly with lung tissue, reaching a maximum after 12–24 hours, and then decreases gradually, so that after 96 hours 10–30% of the dose remains tissue-associated (not shown).

The design of the study assumes that the tracer was administered as a pulse, that there was good mixing between tracer and endogenous surfactant, that the administered material did not perturb endogenous surfactant, that tracheal aspirates were representative of events happening in the most peripheral airways and that patients were at steady state.

While in neonatal respiratory disorders the lung parenchyma is relatively homogeneous, this is certainly not the case in patients with ARDS, where areas of atelectasis and over-distension coexist and the tracer might distribute preferentially to aerated sections of the lungs 3. In this study, to optimize distribution, we mixed the tracer with a surfactant extract used as a spreading agent. We could not document directly in our patients that the instilled material distributed uniformly throughout the aerated airways, but we relied on the following findings all indicating that the instilled material mixed well with resident surfactant: a) animals who receive surfactant through the airways with the technique we used, display a rather homogeneous distribution through the airways, 373839; b) our estimate of the alveolar pool of disaturated-phosphatidylcholine in control patients agrees very nicely with data obtained by Rebello et al on bronchoalveolar lavage fluid of human cadaver lungs 40; c) in preterm baboons we found that the disaturated-phosphatidylcholine pools calculated from the dilution of tracers administered through the trachea compare well with direct measurements done at autopsy 31; d) in the same experiment we found the disaturated-phosphatidylcholine tracer enrichments in tracheal aspirates were remarkably similar to the enrichments measured in the bronchoalveolar lavage fluid (data not shown).

The dose of disaturated-phosphatidycholine administered to control subjects (20 ± 2 mg) represented 1.1–2.1% of the estimated lung pool 5, an amount unlikely to perturb endogenous surfactant. In patients with ARDS, the dose (20 ± 2 mg) represented 5.0–13.1% of the estimated lung pool, an amount also unlikely to induce a pharmacologic effect, considering that the doses of surfactant used for the treatment of ARDS are at least two orders of magnitude greater 2930. Since the dose of surfactant administered was small and clinical conditions remained stable during the study, we assume that the system was at steady state, thus allowing the use of a linear time invariant compartmental model to describe disaturated-phosphatidylcholine kinetics.

Data were analysed according to the two compartment model reported in figure 1. This model is physiologically plausible, but too complex to be uniquely resolvable from the available data, since only the mass in the alveolar compartment (M₁), the flux from the lung tissue back to the alveolar space (F₁₂) and recycling (R) can be uniquely solved. Only a far more complex experiment, with tracer administered also in the lung tissue compartment, could permit to uniquely identify all kinetic parameters. Since this experiment could not be done, we used existing knowledge on the contribution of alveolar macrophages to surfactant degradation to derive bounds for parameters that could not be uniquely identified. Thus, on the basis of animal experiments done by Gurel and Rider 1011, we assumed that alveolar macrophages could normally degrade between 5 and 50% of surfactant disaturated-phosphatidylcholine, the remaining being degraded by the lung parenchyma. It should be noted however, that 50% degradation by alveolar macrophages probably represents a maximum, since this figure was derived on the assumption that alveolar macrophages do not re-enter lung parenchyma after the uptake of surfactant in the alveoli 10. In ARDS, we assumed that 5–100% of surfactant disaturated-phosphatidylcoline could be degraded in the airways, due to the degradative activity of inflammatory cells or bacteria. By incorporating these assumptions into the tracer-tracee model, upper and lower bounds were derived for all non identifiable kinetic parameters, following a strategy formalized in 23 and applied to study thyroid hormones 4142 and glucose 43 kinetics.

Our estimate of the alveolar and tissue pools of disaturated-phosphatidylcholine in controls agree quite well with measurements taken by Rebello et al. during autopsies of adults without lung disease 40. In fact, according to Rebello et al. the alveolar and tissue pools contain respectively 1.9 μmol/kg and 28.4 μmol/kg of disaturated-phosphatidylcholine. We found that in controls the alveolar pool of disaturated-phosphatidylcholine was 2.3 μmol/kg, while the tissue pool ranged between 17.1 and 34.3 μmol/kg. It is also of note that our results compare favorably with those of Martini et al. who studied surfactant turnover in adult pigs using stable isotopes 44. These authors reported that mean phosphatidylcholine synthesis was 4.7 mg/kg/day, while our estimate ranged between 4.3 and 8.6 mg/kg/day. Furthermore they reported that the phosphatidylcholine tissue pool was 10 times higher than the alveolar pool 44, in good agreement with our finding that in control subjects the tissue pool was 7.6–14.8 times greater the alveolar pool. Overall, these results support our approach and also indicate that tracheal aspirates can be as useful as bronchoalveolar lavage fluid for the study of surfactant turnover.

Using morphometric methods Young et al. estimated that the alveolar pool of disaturated-phosphatidylcholine is comparable to the lamellar body pool 45. Thus it is likely that the tissue pool of disaturated-phosphatidylcholine measured with the present technique includes both intracellular surfactant and non-surfactant membranes that, with time, incorporate a fraction of administered disaturated-phosphatidylcholine.

In patients with ARDS alveolar pool, fluxes between tissue and alveoli and de novo synthesis of disaturated-phosphatidylcholine were all smaller than in controls, while the mean residence time in lung tissue was greater than in controls. These differences appear to be robust, since, with the exception of de novo synthesis, they persist even assuming that in controls alveolar macrophages degrade between 5% and 100% of surfactant disaturated-phosphatidylcholine. Thus most of our conclusions remain valid independent of any assumption regarding the site of degradation of surfactant.

The present results agree with the view that, in ARDS, only a fraction of the lung is accessible to exogenous surfactant. In fact, the decrease of the alveolar pool of disaturated-phosphatidylcholine, the decrease of fluxes between tissue and alveoli and the decrease in the rate of synthesis can all be interpreted assuming that instilled surfactant reached only aerated lung sections. However, our data do not support the notion that these residual lung sections were normal, since the mean resident time of disaturated-phosphatidylcholine in lung parenchyma (MRT₂) was greater while the rate of recycling tended to be lower than in controls. The greater mean residence time of disaturated-phosphatidylcholine in lung tissue could be due to a number of factors, namely to a decreased ability to degrade surfactant components, to an increased reacylation of lysophosphatidylcholine (favored by the increased availability of palmitate residues generated by phospholipase A₂, released by inflammatory cells), to a proliferation of type II cells, to the distribution of tracer to lung structures not pertaining to the surfactant system (i.e. infiltrating inflammatory cells), or to a combination of these phenomena 46. The distribution of tracer to lung structures not pertaining to the surfactant system could explain the tendency towards a less efficient recycling of DSPC observed in patients with ARDS (figure 4).