From bench to bedside: in vitro and in vivo evaluation of a neonate-focused nebulized surfactant delivery strategy

F Bianco, F Ricci, C Catozzi, X Murgia, M Schlun, A Bucholski, U Hetzer, S Bonelli, M Lombardini, E Pasini, M Nutini, M Pertile, S Minocchieri, M Simonato, B Rosa, G Pieraccini, G Moneti, L Lorenzini, S Catinella, G Villetti, M Civelli, B Pioselli, P Cogo, V Carnielli, C Dani, F Salomone, F Bianco, F Ricci, C Catozzi, X Murgia, M Schlun, A Bucholski, U Hetzer, S Bonelli, M Lombardini, E Pasini, M Nutini, M Pertile, S Minocchieri, M Simonato, B Rosa, G Pieraccini, G Moneti, L Lorenzini, S Catinella, G Villetti, M Civelli, B Pioselli, P Cogo, V Carnielli, C Dani, F Salomone

Abstract

Background: Non-invasive delivery of nebulized surfactant has been a neonatology long-pursued goal. Nevertheless, the clinical efficacy of nebulized surfactant remains inconclusive, in part, due to the great technical challenges of depositing nebulized drugs in the lungs of preterm infants. The aim of this study was to investigate the feasibility of delivering nebulized surfactant (poractant alfa) in vitro and in vivo with an adapted, neonate-tailored aerosol delivery strategy.

Methods: Particle size distribution of undiluted poractant alfa aerosols generated by a customized eFlow-Neos nebulizer system was determined by laser diffraction. The theoretical nebulized surfactant lung dose was estimated in vitro in a clinical setting replica including a neonatal continuous positive airway pressure (CPAP) circuit, a cast of the upper airways of a preterm neonate, and a breath simulator programmed with the tidal breathing pattern of an infant with mild respiratory distress syndrome (RDS). A dose-response study with nebulized surfactant covering the 100-600 mg/kg nominal dose-range was conducted in RDS-modelling, lung-lavaged spontaneously-breathing rabbits managed with nasal CPAP. The effects of nebulized poractant alfa on arterial gas exchange and lung mechanics were assessed. Exogenous alveolar disaturated-phosphatidylcholine (DSPC) in the lungs was measured as a proxy of surfactant deposition efficacy.

Results: Laser diffraction studies demonstrated suitable aerosol characteristics for inhalation (mass median diameter, MMD = 3 μm). The mean surfactant lung dose determined in vitro was 13.7% ± 4.0 of the 200 mg/kg nominal dose. Nebulized surfactant delivered to spontaneously-breathing rabbits during nasal CPAP significantly improved arterial oxygenation compared to animals receiving CPAP only. Particularly, the groups of animals treated with 200 mg/kg and 400 mg/kg of nebulized poractant alfa achieved an equivalent pulmonary response in terms of oxygenation and lung mechanics as the group of animals treated with instilled surfactant (200 mg/kg).

Conclusions: The customized eFlow-Neos vibrating-membrane nebulizer system efficiently generated respirable aerosols of undiluted poractant alfa. Nebulized surfactant delivered at doses of 200 mg/kg and 400 mg/kg elicited a pulmonary response equivalent to that observed after treatment with an intratracheal surfactant bolus of 200 mg/kg. This bench-characterized nebulized surfactant delivery strategy is now under evaluation in Phase II clinical trial (EUDRACT No.:2016-004547-36).

Keywords: CPAP; Nebulized surfactant; Nebulizer; Neonatal ventilation; Poractant alfa; Respiratory distress syndrome; eFlow-Neos.

Conflict of interest statement

MS, AB, and UH are employees of Pari Pharma GmbH. ML, EP, MN, GV, FR, FB, FS, CC, SC, BP, SB,MP, are employees of Chiesi Pharmaceutici S.p.A. XM, CD, and LL served as consultants for this study.

Figures

Fig. 1
Fig. 1
(a) Scheme of the experimental setup. (b) Mass median diameter (MMD) of nebulized surfactant measured by laser diffraction under different relative humidity (RH) conditions. (c) Fine particle fraction (FPF) of nebulized surfactant under different RH conditions. (d) Mean cumulative percentage of deposited surfactant within the different setup compartments (n = 5) and cumulative percentage of deposited surfactant for individual experiments, each of them conducted with independent nebulizer units. * P vs. RH 30% < 0.01
Fig. 2
Fig. 2
Mean PaO2 (a), PaCO2 (b), and pH (c) values over time in surfactant-depleted adult rabbits treated with nasal continuous positive pressure ventilation (nCPAP, black squares), with intratracheal surfactant (Inst-SURF, white squares), or with different doses of nebulized surfactant (Neb-SURF100, up-pointing triangles; Neb-SURF200, down-pointing triangles; Neb-SURF400, right-pointing triangles; and Neb-SURF600, left-pointing triangles). Values are shown as the mean ± SD. * P vs. nCPAP < 0.01; #P vs. Inst-SURF < 0.05
Fig. 3
Fig. 3
Box-plots showing (a) the oxygenation index (OI) and (b) ventilation efficacy index (VEI) at baseline (from all animals), after inducing a respiratory distress (Post BALs, from all animals) and 180 min after treatment with just nasal continuous positive pressure ventilation (nCPAP), with different doses of nebulized surfactant (Neb-SURF100, Neb-SURF200, Neb-SURF400, Neb-SURF600) or with intratracheal surfactant (Inst-SURF). The boxes encompass the 25–75 percentiles. The horizontal line within the boxes represents the median. The whiskers indicate the maximum and minimum values observed for each group. * P vs. nCPA P < 0.01; #P vs. Inst-SURF < 0.05
Fig. 4
Fig. 4
Box-plots showing dynamic compliance (Cdyn) at baseline (from all animals), after inducing a respiratory distress (Post BALs, from all animals) and 180 min after treatment with just nasal continuous positive pressure ventilation (nCPAP), with different doses of nebulized surfactant (Neb-SURF100, Neb-SURF200, Neb-SURF400, and Neb-SURF600) or with intratracheal surfactant (Inst-SURF). The boxes encompass the 25–75 percentiles. The horizontal line within the boxes represents the median. The whiskers indicate the maximum and minimum values observed for each group. The whiskers indicate the maximum and minimum values observed for each group. * P vs. nCPAP < 0.05

References

    1. Gizzi C, Montecchia F, Panetta V, Castellano C, Mariani C, Campelli M, et al. Is synchronised NIPPV more effective than NIPPV and NCPAP in treating apnoea of prematurity (AOP)? A randomised cross-over trial. Arch Dis Child - Fetal Neonatal Ed. 2015;100:F17 LP–F17F23. doi: 10.1136/archdischild-2013-305892.
    1. Morley CJ, Davis PG, Doyle LW, Brion LP, Hascoet J-M, Carlin JB. Nasal CPAP or intubation at birth for very preterm infants. N Engl J Med. 2008;358:700–708. doi: 10.1056/NEJMoa072788.
    1. Vento Máximo. Tailoring Oxygen Needs of Extremely Low Birth Weight Infants in the Delivery Room. Neonatology. 2011;99(4):342–348. doi: 10.1159/000326626.
    1. Göpel W, Kribs A, Ziegler A, Laux R, Hoehn T, Wieg C, et al. Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomised, controlled trial. Lancet. 2011;378:1627–1634. doi: 10.1016/S0140-6736(11)60986-0.
    1. Rojas-Reyes MX, Morley CJ, Soll R. Prophylactic versus selective use of surfactant in preventing morbidity and mortality in preterm infants. Cochrane Database Syst Rev. 2012;3:CD000510.
    1. Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med. 2001;163:1723–1729. doi: 10.1164/ajrccm.163.7.2011060.
    1. Vento M, Moro M, Escrig R, Arruza L, Villar G, Izquierdo I, et al. Preterm resuscitation with low oxygen causes less oxidative stress, inflammation, and chronic lung disease. Pediatrics. 2009;124:e439–e449. doi: 10.1542/peds.2009-0434.
    1. Owen LS, Manley BJ. Nasal intermittent positive pressure ventilation in preterm infants: equipment, evidence, and synchronization. Semin Fetal Neonatal Med. 2017;21:146–153. doi: 10.1016/j.siny.2016.01.003.
    1. Dargaville PA, Aiyappan A, Cornelius A, Williams C, De Paoli AG. Preliminary evaluation of a new technique of minimally invasive surfactant therapy. Arch Dis Child - Fetal Neonatal Ed. 2011;96:F243 LP–F24F248. doi: 10.1136/adc.2010.192518.
    1. Moretti Corrado, Gizzi Camilla, Montecchia Francesco, Barbàra Caterina Silvia, Midulla Fabio, Sanchez-Luna Manuel, Papoff Paola. Synchronized Nasal Intermittent Positive Pressure Ventilation of the Newborn: Technical Issues and Clinical Results. Neonatology. 2016;109(4):359–365. doi: 10.1159/000444898.
    1. Dunn MS, Kaempf J, de Klerk A, de Klerk R, Reilly M, Howard D, et al. Randomized trial comparing 3 approaches to the initial respiratory Management of Preterm Neonates. Pediatrics. 2011;128:e1069 LP–e10e1076. doi: 10.1542/peds.2010-3848.
    1. Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Plavka R, et al. European consensus guidelines on the Management of Respiratory Distress Syndrome - 2016 update. Neonatology. 2017;111:107–125. doi: 10.1159/000448985.
    1. Lemyre B, Davis PG, De Paoli AG, Kirpalani H. Nasal intermittent positive pressure ventilation (NIPPV) versus nasal continuous positive airway pressure (NCPAP) for preterm neonates after extubation. Cochrane Database Syst Rev. 2017.
    1. Niemarkt HJ, Hütten MC, Kramer BW. Surfactant for respiratory distress syndrome: new ideas on a familiar drug with innovative applications. Neonatology. 2017;111:408–414. doi: 10.1159/000458466.
    1. Pillow J, Minocchieri S. Innovation in surfactant therapy II: surfactant administration by Aerosolization. Neonatology. 2012;101:337–344. doi: 10.1159/000337354.
    1. Mazela J, Merritt TA, Finer NN. Aerosolized surfactants. Curr Opin Pediatr. 2007;19:155–162. doi: 10.1097/MOP.0b013e32807fb013.
    1. Dijk PH, Heikamp A, Bambang Oetomo S. Surfactant nebulisation: lung function, surfactant distribution and pulmonary blood flow distribution in lung lavaged rabbits. Intensive Care Med. 1997;23:1070–1076. doi: 10.1007/s001340050458.
    1. Tashiro K, Yamada K, Li WZ, Matsumoto Y, Kobayashi T. Aerosolized and instilled surfactant therapies for acute lung injury caused by intratracheal endotoxin in rats. Crit Care Med. 1996;24:488–494. doi: 10.1097/00003246-199603000-00020.
    1. Dijk PH, Heikamp A, Oetomo SB. Surfactant nebulisation prevents the adverse effects of surfactant therapy on blood pressure and cerebral blood flow in rabbits with severe respiratory failure. Intensive Care Med. 1997;23:1077–1081. doi: 10.1007/s001340050459.
    1. Rey-Santano C, Mielgo VE, López-De-Heredia-Y-Goya J, Murgia X, Valls-I-Soler A. Cerebral effect of Intratracheal aerosolized surfactant versus bolus therapy in preterm lambs. Crit Care Med. 2016;44:e218–e226.
    1. Henry MD, Rebello CM, Ikegami M, Jobe AH, Langenback EG, Davis JM. Ultrasonic nebulized in comparison with instilled surfactant treatment of preterm lambs. Am J Respir Crit Care Med. 1996;154:366–375. doi: 10.1164/ajrccm.154.2.8756808.
    1. Lewis JF, Ikegami M, Jobe a H, Tabor B. Aerosolized surfactant treatment of preterm lambs. J Appl Physiol. 1991;70:869–876. doi: 10.1152/jappl.1991.70.2.869.
    1. Bahlmann H, Sun B, Nilsson G, Curstedt T, Robertson B. Aerosolized surfactant in lung-lavaged adult rats: factors influencing the therapeutic response. Acta Anaesthesiol Scand. 2000;44:612–622. doi: 10.1034/j.1399-6576.2000.00521.x.
    1. Dijk PH, Heikamp A, Oetomo SB. Surfactant nebulization versus instillation during high frequency ventilation in surfactant-deficient rabbits. Pediatr Res. 1998;44:699–704. doi: 10.1203/00006450-199811000-00012.
    1. Ruppert C, Kuchenbuch T, Boensch M, Schmidt S, Mathes U, Hillebrand V, et al. Dry powder aerosolization of a recombinant surfactant protein-C-based surfactant for inhalative treatment of the acutely inflamed lung. Crit Care Med. 2010;38:1584–1591. doi: 10.1097/CCM.0b013e3181dfcb3b.
    1. Schermuly R, Schmehl T, Günther A, Grimminger F, Seeger W, Walmrath D. Ultrasonic nebulization for efficient delivery of surfactant in a model of acute lung injury: impact on gas exchange. Am J Respir Crit Care Med. 1997;156:445–453. doi: 10.1164/ajrccm.156.2.9609092.
    1. Rey-Santano C, Mielgo VE, Andres L, Ruiz-del-Yerro E, Valls-i-Soler A, Murgia X. Acute and sustained effects of aerosolized vs. bolus surfactant therapy in premature lambs with respiratory distress syndrome. Pediatr Res Springer Nature. 2013;73:639–646. doi: 10.1038/pr.2013.24.
    1. Rahmel DK, Pohlmann G, Iwatschenko P, Volland J, Liebisch S, Kock H, et al. The non-intubated, spontaneously breathing, continuous positive airway pressure (CPAP) ventilated pre-term lamb: a unique animal model. Reprod Toxicol. 2012;34:204–215. doi: 10.1016/j.reprotox.2012.05.089.
    1. Hütten MC, Kuypers E, Ophelders DR, Nikiforou M, Jellema RK, Niemarkt HJ, et al. Nebulization of Poractant alfa via a vibrating membrane nebulizer in spontaneously breathing preterm lambs with binasal continuous positive pressure ventilation. Pediatr Res. 2015;78:664–669. doi: 10.1038/pr.2015.165.
    1. Walther FJ, Hernández-Juviel JM, Waring AJ. Aerosol delivery of synthetic lung surfactant. Longo M, editor. PeerJ. 2014;2:e403.
    1. Jorch Gerhard, Hartl Heike, Roth Bernhard, Kribs Angela, Gortner Ludwig, Schaible Thomas, Hennecke Karl Heinz, Poets Christian. To the editor: Surfactant aerosol treatment of respiratory distress syndrome in spontaneously breathing premature infants. Pediatric Pulmonology. 1997;24(3):222–224. doi: 10.1002/(SICI)1099-0496(199709)24:3<222::AID-PPUL9>;2-O.
    1. Arroe M, Pedersen-Bjergaard L, Albertsen P, Bode S, Greison G, Jonsbo F. Inhalation of aerosolized surfactant exosurf to neonates treated with nasal continuous positive airway pressure. Prenat Neonatal Med. 1998;3:346–352.
    1. Berggren E, Liljedahl M, Winbladh B, Andreasson B, Curstedt T, Robertson B, et al. Pilot study of nebulized surfactant therapy for neonatal respiratory distress syndrome. Acta Paediatr. 2000;89:460–464. doi: 10.1111/j.1651-2227.2000.tb00084.x.
    1. Finer NN, Merritt TA, Bernstein G, Job L, Mazela J, Segal R. An open label, pilot study of Aerosurf® combined with nCPAP to prevent RDS in preterm neonates. J Aerosol Med Pulm Drug Deliv. 2010;23:303–309. doi: 10.1089/jamp.2009.0758.
    1. Minocchieri S, Berry CA, Pillow JJ. Nebulised surfactant to reduce severity of respiratory distress: a blinded, parallel, randomised controlled trial. Arch Dis Child - Fetal Neonatal Ed. 2018.
    1. Fok TF, Monkman S, Dolovich M, Gray S, Coates G, Paes B, et al. Efficiency of aerosol medication delivery from a metered dose inhaler versus jet nebulizer in infants with bronchopulmonary dysplasia. Pediatr Pulmonol. 1996;21:301–309. doi: 10.1002/(SICI)1099-0496(199605)21:5<301::AID-PPUL5>;2-P.
    1. Köhler E, Jilg G, Avenarius S, Jorch G. Lung deposition after inhalation with various nebulisers in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2008:93.
    1. Mazela Jan, Polin Richard A. Aerosol delivery to ventilated newborn infants: historical challenges and new directions. European Journal of Pediatrics. 2010;170(4):433–444. doi: 10.1007/s00431-010-1292-6.
    1. Goikoetxea E, Murgia X, Serna-Grande P, Valls-i-Soler A, Rey-Santano C, Rivas A, et al. In vitro surfactant and perfluorocarbon aerosol deposition in a neonatal physical model of the upper conducting airways. PLoS One. 2014;9:e106835. doi: 10.1371/journal.pone.0106835.
    1. Goikoetxea E, Rivas A, Murgia X, Antón R. Mathematical modeling and numerical simulation of surfactant delivery within a physical model of the neonatal trachea for different aerosol characteristics. Aerosol Sci Technol. 2017;51:168–177. doi: 10.1080/02786826.2016.1255714.
    1. Minocchieri S, Burren JM, Bachmann MA, Stern G, Wildhaber J, Buob S, et al. Development of the premature infant nose throat-model (PrINT-model)-an upper airway replica of a premature neonate for the study of aerosol delivery. Pediatr Res. 2008;64:141–146. doi: 10.1203/PDR.0b013e318175dcfa.
    1. Milesi I, Tingay DG, Zannin E, Bianco F, Tagliabue P, Mosca F, et al. Intratracheal atomized surfactant provides similar outcomes as bolus surfactant in preterm lambs with respiratory distress syndrome. Pediatr Res. 2016;80:92–100. doi: 10.1038/pr.2016.39.
    1. Murgia X, Gastiasoro E, Mielgo V, Alvarez-Diaz F, Lafuente H, Valls-i-Soler A, et al. Surfactant and perfluorocarbon Aerosolization by means of inhalation catheters for the treatment of respiratory distress syndrome: an In Vitro study. J Aerosol Med Pulm Drug Deliv. 2011;24:81–87. doi: 10.1089/jamp.2010.0831.
    1. Pohlmann G, Iwatschenko P, Koch W, Windt H, Rast M, de Abreu MG, et al. A novel continuous powder Aerosolizer (CPA) for Inhalative Administration of Highly Concentrated Recombinant Surfactant Protein-C (rSP-C) surfactant to preterm neonates. J Aerosol Med Pulm Drug Deliv. 2013;26:370–379. doi: 10.1089/jamp.2012.0996.
    1. Syedain ZH, Naqwi AA, Dolovich M, Somani A. In vitro evaluation of a device for intra-pulmonary aerosol generation and delivery. Aerosol Sci Technol. 2015;49:747–752. doi: 10.1080/02786826.2015.1067670.
    1. Awad S, Williams DK, Berlinski A. Longitudinal evaluation of compressor/nebulizer performance. Respir Care. 2014;59:1053 LP–1051061. doi: 10.4187/respcare.02776.
    1. Berg EB, Picard RJ. In vitro delivery of budesonide from 30 jet nebulizer/compressor combinations using infant and child breathing patterns. Respir Care. 2009;54:1671–1678.
    1. Ricci F, Catozzi C, Murgia X, Rosa B, Amidani D, Lorenzini L, et al. Physiological, biochemical, and biophysical characterization of the lung-Lavaged spontaneously-breathing rabbit as a model for respiratory distress syndrome. PLoS One. 2017;12:e0169190. doi: 10.1371/journal.pone.0169190.
    1. Ricci F, Casiraghi C, Storti M, D'Alò F, Catozzi C, Ciccimarra R, et al. Surfactant replacement therapy in combination with different non-invasive ventilation techniques in spontaneously-breathing, surfactant-depleted adult rabbits. PLoS One. 2018;13:e0200542. doi: 10.1371/journal.pone.0200542.
    1. Cochrane CG, Revak SD, Merritt TA, Heldt GP, Hallman M, Cunningham MD, et al. The efficacy and safety of KL4-surfactant in preterm infants with respiratory distress syndrome. Am J Respir Crit Care Med. 1996;153:404–410. doi: 10.1164/ajrccm.153.1.8542150.
    1. Bligh EG. Dier WJ. A rapid method of total lipid extraction and purification. Can J Biochem Physiol. 1959;37:911–917. doi: 10.1139/y59-099.
    1. Verlato G, Cogo PE, Balzani M, Gucciardi A, Burattini I, De Benedictis F, et al. Surfactant status in preterm neonates recovering from respiratory distress syndrome. Pediatrics. 2008;122:102 LP–102108. doi: 10.1542/peds.2007-1021.
    1. Cogo PE, Facco M, Simonato M, Verlato G, Rondina C, Baritussio A, et al. Dosing of porcine surfactant: effect on kinetics and gas exchange in respiratory distress syndrome. Pediatrics. 2009;124:e950–e957. doi: 10.1542/peds.2009-0126.
    1. Robillard E, Alarie Y, Dagenais-Perusse P, Baril E, Guilbeault A. Microaerosol Administration of Synthetic β-γ-Dipalmitoyl-L-α-lecithin in the respiratory distress syndrome: a preliminary report. Can Med Assoc J. 1964;90:55–57.
    1. Chu J, Clements JA, Cotton EK, Klaus MH, Sweet AY, Tooley WH. Neonatal Pulmonary Ischemia Pediatrics. 1967;40:709 LP–709782.
    1. Speer CP, Gefeller O, Groneck P, Laufkötter E, Roll C, Hanssler L, et al. Randomised clinical trial of two treatment regimens of natural surfactant preparations in neonatal respiratory distress syndrome. Arch Dis Child Fetal Neonatal Ed. 1995;72:F8–13. doi: 10.1136/fn.72.1.F8.
    1. Speer CP, Robertson B, Curstedt T, Halliday HL, Compagnone D, Gefeller O, et al. Randomized European multicenter trial of surfactant replacement therapy for severe neonatal respiratory distress syndrome: single versus multiple doses of Curosurf. Pediatrics. 1992;89:13–20.
    1. Verder H, Robertson B, Greisen G, Ebbesen F, Albertsen P, Lundstrom K, et al. Surfactant therapy and nasal continuous positive airway pressure for newborns with respiratory distress syndrome. N Engl J Med. 1994;331:1051–1055. doi: 10.1056/NEJM199410203311603.
    1. Aldana-Aguirre JC, Pinto M, Featherstone RM, Kumar M. Less invasive surfactant administration versus intubation for surfactant delivery in preterm infants with respiratory distress syndrome: a systematic review and meta-analysis. Arch Dis Child - Fetal Neonatal Ed. 2017;102:F17 LP–F17F23. doi: 10.1136/archdischild-2015-310299.
    1. Linner R, Perez-de-Sa V, Cunha-Goncalves D. Lung deposition of nebulized surfactant in newborn piglets. Neonatology. 2015;107:277–282. doi: 10.1159/000369955.
    1. Sun Y, Wang YQ, Yang R, Zhu JJ, Le YY, Zhong JG, et al. Exogenous porcine surfactants increase the infiltration of leukocytes in the lung of rats. Pulm Pharmacol Ther. 2009;22:253–259. doi: 10.1016/j.pupt.2009.01.001.
    1. Schrod L, Hornemann F, Von Stockhausen HB. Chemiluminescence activity of phagocytes from tracheal aspirates of premature infants after surfactant therapy. Acta Paediatr Int J Paediatr. 1996;85:719–723. doi: 10.1111/j.1651-2227.1996.tb14133.x.

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