Stuart B. Hooper

FETAL LUNG LIQUID: A MAJOR DETERMINANT OF THE GROWTH AND FUNCTIONAL DEVELOPMENT OF THE FETAL LUNG

1. During fetal life the lung develops as a liquid‐filled organ. This liquid is produced by the fetal lung and leaves via the trachea from where it is either swallowed or enters the amniotic sac. Fetal lung liquid plays a crucial role in the growth and development of the lungs by maintaining them in a distended state. It is now recognized that the retention of liquid within the future airways is required to maintain the lungs at an appropriate level of expansion in order to stimulate their growth. Indeed, it is likely that most, if not all, of the conditions and malformations that lead to inadequate growth of the fetal lung do so by reducing the volume of lung liquid and hence the degree of lung expansion.

Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs

•  Delayed cord clamping improves circulatory stability in preterm infants at birth, but the underlying reason is not known. •  In a new preterm lamb study we investigated whether delayed cord clamping until ventilation had been initiated improved pulmonary, cardiovascular and cerebral haemodynamic stability. •  We demonstrated that ventilation prior to cord clamping markedly improves cardiovascular function by increasing pulmonary blood flow before the cord is clamped, thus further stabilising the cerebral haemodynamic transition. •  These results show that delaying cord clamping until after ventilation onset leads to a smoother transition to newborn life, and probably underlies previously demonstrated benefits of delayed cord clamping.

Imaging lung aeration and lung liquid clearance at birth

Aeration of the lung and the transition to air‐breathing at birth is fundamental to mammalian life and initiates major changes in cardiopulmonary physiology. However, the dynamics of this process and the factors involved are largely unknown, because it has not been possible to observe or measure lung aeration on a breath‐by‐breath basis. We have used the high contrast and spatial resolution of phase contrast X‐ray imaging to study lung aeration at birth in spontaneously breathing neonatal rabbits. As the liquid‐filled fetal lungs provide little absorption or phase contrast, they are not visible and only become visible as they aerate, allowing a detailed examination of this process. Pups were imaged live from birth to determine the timing and spatial pattern of lung aeration, and relative levels of lung aeration were measured from the images using a power spectral analysis. We report the first detailed observations and measurements of lung aeration, demonstrating its dependence on inspiratory activity and body position; dependent regions aerated at much slower rates. The air/liquid interface moved toward the distal airways only during inspiration, with little proximal movement during expiration, indicating that trans‐pulmonary pressures play an important role in airway liquid clearance at birth. Using these imaging techniques, the dynamics of lung aeration and the critical role it plays in regulating the physiological changes at birth can be fully explored.—Hooper S. B., Kitchen, M. J., Wallace, M. J., Yagi, N., Uesugi, K., Morgan M. J., Hall, C., Siu, K. K. W., Williams, I. M., Siew, M., Irvine, S. C., Pavlov, K., Lewis R. A. Imaging lung aeration and lung liquid clearance at birth. FASEB J. 21, 3329–3337 (2007)

Effect of Sustained Inflation Length on Establishing Functional Residual Capacity at Birth in Ventilated Premature Rabbits

The effect of inflation length on lung aeration pattern, tidal volumes, and functional residual capacity (FRC) immediately after birth was investigated. Preterm rabbits (28 d), randomized into four groups, received a 1-, 5-, 10-, or 20-s inflation (SI) followed by ventilation with 5 cm H2O end-expiratory pressure. Gas volumes were measured by plethysmography and uniformity of lung aeration by phase contrast x-ray imaging for 7 min. The first inspiratory volume significantly (p < 0.001) increased with inflation duration from a median (IQR) of 0.2 (0.1–3.1) mL/kg for 1-s inflation to 23.4 (19.3–30.4) mL/kg for 20-s SI. The lung was uniformly aerated, and the FRC and tidal volume fully recruited after 20-s SI. A 10-s SI caused a higher FRC (p < 0.05) at 7 min, and a 20-s SI caused a higher FRC (p < 0.05) at 20 s and 7 min than a 1- or 5-s SI. The mean (SD) time for 90% of the lung to aerate was 14.0 (4.1) s using 35 cm H2O peak inflation pressure. In these rabbits, 10- and 20-s SI increased the inspiratory volume and produced a greater FRC, and a 20-s SI uniformly aerated the lung before ventilation started.

From liquid to air: breathing after birth.

The first breaths after birth are characterized by a rapid transition from liquid- to air-filled lungs. Air is drawn into the lung during inspiration, and some remains at end expiration to establish an end-expiratory gas volume or functional residual capacity (FRC). This is usually marked by a cry, often misinterpreted as a protest from the baby. Some infants, especially those born preterm, require respiratory support during this transitional phase. To do this effectively, we need to understand the normal physiological processes occurring at this time. Sometimes it can be difficult to aerate the lungs of preterm infants with intermittent positive pressure ventilation with pressures recommended in international guidelines, particularly when the infant does not breathe and aeration is completely dependent on the inflation pressures. Studies have shown that intermittent positive pressure ventilation should be performed without high tidal volumes to avoid damaging the lung while establishing the FRC. 1,2 However, since the use of antenatal steroids, more very preterm infants breathe spontaneously at birth, only requiring support from nasal continuous positive airway pressure. Understanding the normal spontaneous breathing pattern after birth is essential for developing safe, efficient ventilatory strategies when breathing is inadequate. Numerous physiological studies immediately after birth of spontaneously breathing infants were published between 1960 and 1986. 3-10 However, little new data are currently available on this topic, reflecting the difficulties of performing these studies. This review will discuss what happens during the first breaths of air with the emphasis on where the liquid goes and the current knowledge about the spontaneous breathing pattern adopted by infants immediately after birth.

Positive end-expiratory pressure enhances development of a functional residual capacity in preterm rabbits ventilated from birth

The factors regulating lung aeration and the initiation of pulmonary gas exchange at birth are largely unknown, particularly in infants born very preterm. As hydrostatic pressure gradients may play a role, we have examined the effect of a positive end-expiratory pressure (PEEP) on the spatial and temporal pattern of lung aeration in preterm rabbit pups mechanically ventilated from birth using simultaneous phase-contrast X-ray imaging and plethysmography. Preterm rabbit pups were delivered by caesarean section at 28 days of gestational age, anesthetized, intubated, and placed within a water-filled plethysmograph (head out). Pups were imaged as they were mechanically ventilated from birth with a PEEP of either 0 cmH(2)O or 5 cmH(2)O. The peak inflation pressure was held constant at 35 cmH(2)O. Without PEEP, gas only entered into the distal airways during inflation. The distal airways collapsed during expiration, and, as a result, the functional residual capacity (FRC) did not increase above the lungs anatomic dead space volume (2.5 +/- 0.8 ml/kg). In contrast, ventilation with 5-cmH(2)O PEEP gradually increased aeration of the distal airways, which did not collapse at end expiration. The FRC achieved in pups ventilated with PEEP (19.9 +/- 3.2 ml/kg) was significantly greater than in pups ventilated without PEEP (-2.3 +/- 3.5 ml/kg). PEEP greatly facilitates aeration of the distal airways and the accumulation of FRC and prevents distal airway collapse at end expiration in very preterm rabbit pups mechanically ventilated from birth.

The vulnerability of the fetal sheep brain to hypoxemia at mid-gestation

Our aim was to test the hypothesis that a brief episode of hypoxemia near mid-gestation in fetal sheep will result in damage to the fetal brain with the extent and type of damage in any particular region being related to the developmental processes occurring at the time of the insult. Hypoxemia was induced, sufficient to reduce arterial O2 content by approximately 50%, by restricting utero-placental blood flow in 14 chronically catheterised fetuses for 6 h or 12 h at 84 days of gestation (term 145-8 days). Age-matched fetuses (n = 14; 4 operated and 10 unoperated) were used as controls. Fetuses were killed 7 days after being exposed to hypoxemia, and brains removed for histological analysis at the light and ultrastructural levels. Body weights of hypoxemic fetuses did not differ significantly from controls but brain weights were significantly reduced both in absolute terms and when expressed in relation to body weight (P < 0.05). Most fetuses exposed to hypoxemia sustained no gross brain damage. However, in one hypoxemic fetus from a multiple pregnancy there was extensive leucomalacia in the cortical white matter; mild focal damage was seen in another 8 hypoxemic fetuses. In the cerebral cortex (frontal lobe) the surface folding index was significantly reduced (P < 0.05) in hypoxemic fetuses compared to controls suggesting that gyral formation had been delayed. In these fetuses there were also degenerating neurons in the deeper cortical layers. In the hippocampus of hypoxemic fetuses there was a delay (P < 0.05), compared to controls, in the migration of cells from the germinal layer to the pyramidal layer in the CA1 region, and decreases (P < 0.05) in the density (area1) of neurons in the pyramidal layer and in the width of stratum oriens. In the cerebellum of hypoxemic fetuses there was a decrease (P < 0.05), compared to controls, in the density (area1) of mitotic bodies in the external granule cell layer. However, there were no significant differences in the number of pyknotic cells in this layer, in the density of Purkinje cells, in their somal area, or in the width of the external granule cell or molecular layers. There was an increase (P < 0.05) in the proportion of the brain parenchyma occupied by blood vessels in both the hippocampus and cortex of hypoxemic fetuses compared to controls. This study has shown that an hypoxemic insult near mid-gestation can result, one week later, in white matter damage and in neuronal death in the hippocampus and to a lesser extent in the cerebral cortex and cerebellum. It can also retard neuronal migration and the growth of neural processes in the hippocampus where development is well established at this age. Such brain damage could result in less than optimal neuronal connectivity and could affect function postnatally.

Stimulation of Lung Growth by Tracheal Obstruction in Fetal Sheep: Relation to Luminal Pressure and Lung Liquid Volume

Obstruction of the fetal trachea causes liquid to accumulate within the future airways, which is a potent stimulus for lung growth. Our aim was to determine the relationship between the increase in fetal lung growth after tracheal obstruction and the increases in lung liquid volume and tracheal pressure to better understand the mechanisms involved in the growth response. The effects of 4 and 10 d of tracheal obstruction on lung DNA and protein contents and DNA synthesis rates were determined; these data were combined with data collected previously after 2 and 7 d of tracheal obstruction. Fetal lung liquid volumes and secretion rates were measured before (d 0) and on d 1, 2, 4, 7, and 10 after tracheal obstruction; fetal tracheal pressures were monitored throughout this period. Tracheal pressures increased from 2.9± 0.8 mm Hg (control) to 4.3 ± 0.4 mm Hg within 1 d of tracheal obstruction and remained at this elevated level for the duration of the obstruction period. Lung liquid volume increased progressively from 24.7± 1.1 mL/kg on d 0 to 97.3 ± 15.2 mL/kg at d 7 of tracheal obstruction, but had not increased further by d 10. Tracheal obstruction significantly increased lung DNA and protein contents above control values; over the 10-d period the increase in lung DNA content was closely related(r = 0.99) to the increase in lung liquid volume, but not to the increase in tracheal pressure. DNA synthesis rates were increased at 4 d of tracheal obstruction (by 66%) but had returned to control levels by d 10. We conclude that: 1) the mechanisms responsible for the acceleration in lung growth induced by tracheal obstruction are most active on d 2, remain active at a reduced level on d 4 and 7, and have returned to control levels by d 10; and 2) the increase in lung DNA content during tracheal obstruction (d 2-7) is closely related to the increase in lung liquid volume, but not to the increase in intraluminal pressure. Thus, we suggest that an increase in lung expansion is one of the primary factors responsible for the acceleration in fetal lung growth induced by tracheal obstruction.

Positive End Expiratory Pressure during Resuscitation of Premature Lambs Rapidly Improves Blood Gases without Adversely Affecting Arterial Pressure

Positive end expiratory pressure (PEEP) is important for neonatal ventilation but is not considered in guidelines for resuscitation. Our aim was to investigate the effects of PEEP on cardiorespiratory parameters during resuscitation of very premature lambs delivered by hysterotomy at ∼125 d gestation (term ∼147 d). Before delivery, they were intubated and lung fluid was drained. Immediately after delivery, they were ventilated with a Dräger Babylog plus ventilator in volume guarantee mode with a tidal volume of 5 mL/kg. Lambs were randomized to receive 0, 4, 8, or 12 cm H2O of PEEP. They were ventilated for a 15-min resuscitation period followed by 2 h of stabilization at the same PEEP. Tidal volume, peak inspiratory pressure, PEEP, arterial pressure, oxygen saturation, and blood gases were measured regularly, and respiratory system compliance and alveolar/ arterial oxygen differences were calculated. Lambs that received 12 cm H2O of PEEP died from pneumothoraces; all others survived without pneumothoraces. Oxygenation was significantly improved by 8 and 12 cm H2O of PEEP compared with 0 and 4 cm H2O of PEEP. Lambs with 0 PEEP did not oxygenate adequately. The compliance of the respiratory system was significantly higher at 4 and 8 cm H2O of PEEP than at 0 PEEP. There were no significant differences in partial pressure of carbon dioxide in arterial blood between groups. Arterial pressure was highest with 8 cm H2O of PEEP, and there was no cardiorespiratory compromise at any level of PEEP. Applying PEEP during resuscitation of very premature infants might be advantageous and merits further investigation.

Dynamic imaging of the lungs using x-ray phase contrast

High quality real-time imaging of lungs in vivo presents considerable challenges. We demonstrate here that phase contrast x-ray imaging is capable of dynamically imaging the lungs. It retains many of the advantages of simple x-ray imaging, whilst also being able to map weakly absorbing soft tissues based on refractive index differences. Preliminary results reported herein show that this novel imaging technique can identify and locate airway liquid and allows lung aeration in newborn rabbit pups to be dynamically visualized.