Surface-active phospholipid: a Pandora's box of clinical applications. Part I. The lung and air spaces

Almost everywhere in the body there are phospholipids, not only comprising the lipid bilayer of membranes, but also in the free state. What is seldom appreciated, except in respirology, is that these 'free' phospholipids are unusual in that many are highly surface active. Surface activity is a property of certain substances (surfactants), conferred by their molecular constitution and configuration, which predisposes them to locate at interfaces because, in doing so, they reduce interfacial energy. When adsorbed (reversibly bound) to solid surfaces, surfactants can impart many highly desirable properties that have been widely studied and long accepted in the physical sciences, while their commercial applications have withstood the test of time. These desirable properties include lubricity (boundary lubrication), release (antistick) and dewatering, while providing a barrier to corrosion, abrasion, solute transmission and to biological microorganisms. Many of these offer obvious roles for surface-active phospholipid (SAPL), ranging from a corrosion inhibitor in the stomach to a load-bearing lubricant in the joints. This opens a veritable 'Pandora's box' of potential clinical applications. Part I of this review challenges traditional beliefs in respirology that 'surfactant' is unique to the lung and, moreover, that its actions are confined to the liquid-air interface. Evidence is discussed that, by binding to alveolar epithelium, SAPL imparts semi-permeability needed before channels pumping ions can also pump water vital for maintaining fluid balance. Evidence is also reviewed for a lining to upper airways, sinuses and Eustachian tube where it can act like a standard release agent.