PAEDIATRIC RESPIRATORY REVIEWS (2015) 6, 35–43

SERIES: PULMONARY VASCULAR DISEASE

Developmental biology of the pulmonary

circulation
Alison Hislop*

Institute of Child Health, 30 Guilford Street, London WC1N 1EH, UK

KEYWORDS Summary From the earliest stage of lung development, there is an accompanying lung growth; blood
circulation. In the adult lung, the pulmonary arteries are closely associated with the pulmonary arteries; airways.
During early fetal development, the airways act as a template for pulmonary pulmonary veins; blood vessel
development in that the vessels form by vasculogenesis around the pulmonary arterial branching airways. In later
lung development, as the alveoli multiply, new capillaries hypertension; form by angiogenesis. As blood vessels
increase in size, they develop a muscle wall that is growth factors relatively thick during fetal life and shows a rapid
reduction after birth. The control of development by growth factors and the physiological changes immediately
after birth are described in this review. Abnormal pulmonary vascular development leading to pulmonary arterial
hypertension and strategies for treatment are also discussed. 2005 Elsevier Ltd. All rights reserved.
In 2000, a mini-symposium in Paediatric Respiratory Embryonic stage (up to 7 weeks’ gestation)
Reviews on growth of the lung included a review on During this stage, the lung primordium derives from
the growth of the pulmonary circulation. 1 In this, we the foregut and lobar airways lined with endoderm are
described the development of the arteries and veins, established within the surrounding mesenchyme.
their branching pattern and structure and also changes
that occur at birth to lead to the drop in vascular
resistance and increase in flow to the lung. This review * Tel.: +44 207 813 8459; fax: +44 207 905 2321. E-mail
address: a.hislop@ich.ucl.ac.uk.
will be an update on the information available and is
mainly concerned with the factors that control both 1526-0542/$ – see front matter 2005 Elsevier Ltd. All rights reserved.
normal and abnormal growth. It will draw on both doi:10.1016/j.prrv.2004.11.009
human and experimental studies. Pseudoglandular stage (7–17 weeks’ gestation)
During this stage, all pre-acinar airways develop by
SUMMARY OF AIRWAY AND BLOOD VESSEL progressive branching of epithelium-lined airways
DEVELOPMENT into the expanding mesenchyme.

Traditionally, development of the lung has been divided

Canalicular stage (17–27 weeks’ gestation)
into stages based on its histological appearance (Fig. 1).
During this stage, peripheral airways enlarge and have
a thinned epithelium that eventually forms Type I and
II pneumonocytes.
 36
Saccular stage (28–36 weeks’ gestation)
During this stage, the sac-shaped distal airways
develop crests with elastin and muscle that cause
shallow indentations. These extend to form cup-
shaped alveoli.
Alveolar stage (36 weeks’ gestation onwards)
Alveoli multiply and, at birth, one-third to one-half of
the adult number is present. Alveoli continue to
increase in
number until 2–4 years of age. They increase in size until
somatic growth is complete.
Figure 1 The stages of lung development showing the development of arteries and airways. Pre-acinar arteries start as a
capillary plexus around growing lung buds (vasculogenesis). Intra-acinar arteries grow by angiogenesis.
In the adult lung, the pulmonary arteries run
alongside the branching airways distributing blood to
the alveolar capillary bed. The pulmonary veins have a
similar number of branches (tributaries) and return
blood from the capillary bed to the heart. They are
separated from the airways by the alveolar region. The
A. HISLOP
close proximity of the circulation to the airway system
suggests that there is an interaction between them both
during development and later.
The single lung bud leading from the embryonic
foregut in the fourth week of gestation is surrounded
by mesenchyme which contains a number of cells
staining positively for CD34, a marker for endothelial
cells.2 By 34 days’ gestation, a capillary network
around each prospective main bronchus connects
cranially with the aortic sac and caudally with the left
atrium and there is evidence of circulating blood cells 3
[Fig. 2(a)]. A similar appearance of a completed
circulation has been described in the mouse at 10.5
days.4 It seems that the earliest pulmonary vessels
form de novo in the mesenchyme by a process of
vasculogenesis; differentiation of cells to form single
endothelial cells and then capillary
DEVELOPMENTAL BIOLOGY OF THE PULMONARY CIRCULATION 37
Figure 2 (a) Reconstruction of human embryonic lung at 34 days’ gestation with completed circulation between the aortic sac
(AS), through a capillary bed surrounding the single left and right lung buds and returning to the sinus venosus (SV).
Reconstruction by Dr Sue Hall. (b) Photomicrograph of lung from an 8-week fetus stained for CD31 (endothelial cells stain
brown). (c, d) Photomicrograph of lung from an 8-week fetus stained for smooth muscle myosin. A capillary plexus is seen
around the terminal buds that coalesce to form small pulmonary arteries with the endothelial cells staining positively for CD31.
The penultimate airways have a layer of smooth muscle cells around the epithelium. The small pulmonary arteries accompanying
these have a muscular wall. In (d), the connection between bronchial smooth muscle and arterial smooth muscle can be seen at
a higher magnification.*
Table 1 Landmarks of pulmonary vascular development.
1. Pulmonary circulation present by 5 weeks’ gestation
2. Pre-acinar arteries and veins form by vasculogenesis using the airways as a template and all are present by 17 weeks’
gestation
3. Intra-acinar arteries and veins form by angiogenesis as long as alveoli increase in number and size
4. Resistance is high during fetal life due to thick arterial walls
5. Decrease in resistance rapidly after birth by vasodilatation and decrease in relative wall thickness
tubes [Fig. 2(b)]. These capillaries coalesce to form Development of the vessel wall
small blood vessels alongside the airways. As each new Once the newly formed vessels are present, they
airway buds into the mesenchyme, a new plexus forms acquire a muscle wall. Muscle is first seen in human
as a halo and adds to the peripheral circulation so fetal intrapulmonary arteries at 38 days. Initially, these
extending the arteries and veins. Thus there is are derived from the bronchial smooth muscle of
sustained addition of the newly formed tubules to the adjacent airways.2 The cells appear to migrate from the
existing vessels and the airways act as a template for bronchial smooth muscle and to line up around the
the development of blood vessels. This formation of arteries [Fig. 2(c,d)]. This occurs in the region proximal
vessels occurs until the 17th week of gestation (end of to the terminal bud. These smooth muscle cells make
the pseudoglandular stage) when all pre-acinar airways up the innermost layers of the mature vessel and
and their accompanying arteries and veins have formed experimental studies in piglets suggest that their
and there is little undifferentiated mesenchyme left phenotype may be different even after birth. 5 We do
between the structures (Fig. 1, Table 1). In addition to not know what stimulates the migration of smooth
the conventional (pulmonary) arteries alongside each muscle cells from the bronchial smooth muscle.
airway, there are a large number of small However, tenascin, versican and fibronectin, which are
supernumerary arteries that supply the alveolar region all involved in cell locomotion, colocate only in this
in the adult. Their presence at this early stage in area. Once smooth muscle cells are present, the lumen
development suggests a genetic control of branching. becomes relatively smaller, suggesting vasoconstriction.
In the canalicular stage (Fig. 1), further division of A second derivation of smooth muscle cells is from the
airways to form respiratory bronchioli and sac-shaped mesenchyme. From 8 weeks’ gestation, fibroblasts
alveolar ducts is accompanied by thinning of the from the mesenchyme line up around the outer part of
epithelium due to capillaries coming to lie immediately the arterial wall in the proximal arteries, become
beneath the epithelium. The capillaries at this stage elongated and develop a smooth-muscle-cell
seem to form by angiogenesis (the sprouting of blood phenotype expressing smooth muscle actin and myosin.
vessels from pre-existing vessels) as dividing cells are As the arteries increase in size, the number of layers of
found in the existing capillary tubules rather than in the these cells increases and this wall structure is found
general mesenchyme.3 By 24 weeks’ gestation, the closer to the periphery of the lung. Elastic laminae form
blood gas barrier is the same thickness as in the adult between the muscle layers, leading to the typical elastic
and the area for gas exchange is sufficient to support arterial appearance. A third source of arterial smooth
extremely premature infants. As alveoli appear, their muscle cells, the endothelial cell, is seen later in
walls are lined initially by a double capillary network, development for a short period of time. The capillary
which coalesces to form a single sheet. New capillaries endothelial cells stain positively for a actin and may
form by a process of angiogenesis that enlarges the give rise to smooth muscle cells by division.
network as new alveoli form and then increase in size. The veins do not derive any muscle cells from the
Throughout this time, the proximal arteries and veins bronchial smooth muscle. However, fibroblasts from
increase in size to accommodate the blood flow to the the surrounding mesenchyme line up around the
increased capillary bed volume. venous endothelium and express smooth-muscle-
specific protein that first appears at 8 weeks’
gestation. There is also evidence that some muscle
derives from the endothelial cells. 3 The veins
 38
maintain a relatively large lumen as the muscle
surrounds them and the walls are never as thick as in
the pulmonary arteries.
The smooth muscle cells of the airways, arteries
and veins show progressive and gradual maturation
of their cytoskeletal structure. During fetal life, the
bronchial smooth muscle is always the most mature
at any age. From 8 weeks’ gestation, desmin is
expressed. In the arteries and veins, there is no
desmin even at birth; it appears by 3 years of age.
Postnatal adaptation
During fetal life, resistance to flow is high with less
than 10% of the flow from the right ventricle passing
through the lung. This is partly due to the thick wall
and relatively small lumen of the pulmonary arteries.
Pulmonary vascular resistance falls and blood flow
increases immediately after birth. The pulmonary
arterial wall thickness decreases and lumen diameter
increases. This entails re-organisation of the
cytoskeleton of both endothelial and smooth muscle
cells so that the cells become thinner and spread
around a larger lumen.6 There is no loss of muscle
cells. This process may be facilitated by the paucity of
fixed connective tissue in the vessel walls at birth.
The actin filaments of the smooth muscle cell
undergo abrupt but transient disassembly to their
monomeric form, reducing the number of contractile
myofilaments during the first 1–2 weeks of life. 7
Later, there is an increase in myofilaments as the
muscle cells mature.
Development of the bronchial circulation
In the human lung, there is a second circulatory
system, the bronchial circulation, that carries
systemic blood to the walls of the airways and the
large pulmonary vessels. The bronchial arteries are
found in adult airways as far to the periphery as the
alveolar ducts. They form later than the pulmonary
circulation and are first identified in the lungs around
8 weeks’ gestation.8 At this time, one or two small
vessels extend from the dorsal aorta and run into the
lung alongside the cartilage plates of the main
bronchus. They extend to the periphery as the
airways increase in size and the walls differentiate.
They eventually form a network throughout the
airway wall both below the epithelium and in the
outer wall. They remain small relative to the adjacent
pulmonary arteries and only increase in size in cases
where there is a failure of development of the
pulmonary circulation, as in pulmonary atresia. Many
of the small bronchial veins within the airway wall
drain into the pulmonary veins. Bronchial veins are
A. HISLOP
only seen close to the hilum and these drain into the
cardinal veins and the right atrium.
CONTROL OF BLOOD VESSEL DEVELOPMENT
Early development
Control of airway development is by a panel of hox
genes, transcription factors and growth factors.
These are succinctly summarised in recent review
articles.9–11 The control of the development of the
pulmonary circulation has been studied less
extensively but it is apparent that there are
interactions between the epithelium, the
mesenchyme and the blood vessels.
The formation of new capillaries by
vasculogenesis occurs at a similar distance from the
epithelial buds at all ages. This suggests some control
by the epithelial cells. Vascular endothelial growth
factor (VEGF) is known to be involved in angiogenesis
and vasculogenesis and has been demonstrated in
the epithelial cells of human fetuses.12,13 In cultured
mouse lungs, most VEGF is found at the branching
points of the peripheral airways 14 and grafting of
VEGFcoated beads into cultured mouse lung leads to
the production of an increased capillary bed. The
VEGF receptors Flt-1 and Flk-1 are expressed in the
endothelium from 38 days’ gestation in man. Mice
deficient in Flk-1 have no blood vessel
development.15 VEGF-deficient mice do not survive to
term even in the presence of one allele and have
defects in their vessel formation. 16 Recent studies
have shown that there is reciprocal control between
blood vessels and airways in that overexpression of
VEGF leads to disrupted vascular net assembly and
arrested airway branching.17 Another tyrosine kinase
receptor, Tie-2, is expressed on the endothelial cells
in the mesenchyme and its ligand is angiopoietin.
Null mice for Tie-2 and Ang-1 have abnormal vascular
network formation. These factors are more involved
in vessel assembly and stabilisation of the network
than its initial appearance.18 mRNA for epidermal
growth factor (EGF) and transforming growth factor
alpha (TGFa) has been located in the mesenchyme in
human fetal lungs ranging from 12 to 33 weeks’
gestation. The receptors for these growth factors
were, however, demonstrated mainly in the airways
and were involved in differentiation. 19 A study on
human lung explants showed the presence of insulin-
like growth factor (IGF) and its receptor from 4
weeks’ gestation onwards.20 Both colocalised with
endothelial markers during the embryonic and
pseudoglandular stage but not in a fetus of 19 weeks’
gestation. IGF receptors were also found on
epithelial cells and blockade of the receptor led to a
reduction in production of endothelial tubules. This
DEVELOPMENTAL BIOLOGY OF THE PULMONARY CIRCULATION
in turn led to abnormal growth of the lung buds,
suggesting that IGF receptors are involved in both
airway and endothelium development.
Endothelial nitric oxide synthase (eNOS) is expressed
on the endothelium of arteries, capillaries and veins
throughout development. Nitric oxide (NO) is known to
stimulate endothelial proliferation, migration and tube
formation and inhibit apoptosis.
The differentiation of arteries from veins
The capillary bed with its connection to arteries and
veins originally forms at a similar distance from the
epithelial bud. However, the arteries coalesce and run
closely associated with the airway wall while the veins
separate from the airways and eventually run
equidistant between them. They seem to be further
separated from the influence of the airways as they
become surrounded by lymphatic channels within the
connective tissue septa.3 We do not know the stimulus
that differentiates the arteries from the veins initially canalicular phase and the mRNA for both VEGF and Flk-
but their endothelial cells do have a different
phenotype. In the systemic vessels of mice, the
capillaries can be divided early in development by
discriminatory expression of the tyrosine kinase
receptor EphB4 and its ligand ephrinB2 which are
thought to have a repulsive interaction.21 However, this secondary crests developing from primary septa initially
was not the case in human lungs where ephrinB2 was
only found in arteries and EphB4 was found in arteries,
veins3 and throughout the capillary bed. Since a
circulation is present from the single lung bud stage,
there may be influence on the endothelium by humoral
factors affecting the arterial side, which is under
greater sheer stress because of the thicker artery wall. been shown to increase in perinatal mice. 32 In a study
The veins do not have smooth muscle cells derived
from the bronchial smooth muscle, which may be an
important differentiator.
Control of muscle cell differentiation
Folkman and D’Amore22 suggested that angiopoietin
produced by undifferentiated mesenchymal cells binds
to and activates the Tie-2 receptor on the endothelial
cells resulting in a chemo-attractant signal (platelet-
derived growth factor or EGF) for the fibroblasts. These
are then attracted to the vessel wall and they become
committed to becoming smooth muscle cells as a result
of further growth factors from the endothelial cells.
Overexpression of angiopoietin in rats led to muscle
hypertrophy and hyperplasia in pulmonary arteries, 23
while knockout mice die in utero with no muscle cell
encasement around their endothelial tubes. 24 Once the
cells have been attracted, they become differentiated.
This may be controlled by TGFb which inhibits
endothelial and smooth muscle proliferation and
39
migration and induces differentiation of mesenchymal
cells into smooth muscle cells.25
Control of peripheral blood vessel development
During the canalicular stage, capillaries come to lie
much closer to the epithelium. We do not know what
attracts the capillaries to underlie the epithelium but
once there, they seem to influence the epithelium to
thin and differentiate into Type I and II pneumonocytes.
In-vitro studies have demonstrated that cell matrix
produced by rat pulmonary vascular endothelial cells
leads to differentiation of Type II to Type I cells in rats. 26
There is evidence that stretch upregulates myogenic
differentiation and leads to an increase in VEGF mRNA
in vascular smooth muscle cells, allowing endothelial
cell motility and an increase in capillary number by
angiogenesis.27 Transgenic mice with an excess of TGFb1
fail to differentiate peripheral epithelial cells in the
1 is decreased associated with a decrease in the
number of alveolar
28
capillaries.
The interaction of the arteries with the airways
continues into alveolar development. Alveoli form by
with a capillary loop, which then coalesces to form a
single capillary sheet. In man, this appearance is
present in the alveolar region until 18 months of age. 29
In mice and rabbits, as alveoli form, the Type II
pneumonocytes in the alveolar wall show evidence of
VEGF mRNA.30,31 VEGF and its receptor Flk-1 have both
on rat alveolar development, the inhibitor of Flk-1
(Su5416) reduced the number of arteries and alveoli as
did antiangiogenic factors such as fumagillin and
thalidomide.33 Loss of vessels can be associated with
right ventricular hypertrophy (RVH) but inhaled NO
helped prevent the RVH and abnormal growth of
alveoli.34
Adaptation to extra-uterine life
The mechanisms responsible for the postnatal fall in
pulmonary vascular resistance are uncertain but the
initial rapid dilatation of the pulmonary vasculature is
stimulated by mechanical ventilation, an increase in
oxygen tension and an increase in sheer stress. The
sudden increase in flow and sheer stress leads to the
production of potent vasodilators such as NO and
prostacyclin (PGI2) (Fig. 3). NO helps to modulate
pulmonary vascular resistance in utero and
experimental studies using NOS inhibitors have
shown that endothelial cells produce NO from early
 40
in gestation. The NO formed by the endothelium
diffuses into the underlying smooth muscle cells and
causes vasodilatation by the action of soluble
guanylate cyclase (sGC) to produce cGMP. cGMP-
mediated vasodilation is limited by
phosphodiesterase type V (PDE5). All of these are
present in fetal life with apparently little purpose
because of the high resistance in the fetal circulation.
However, they are important in contributing to the
postnatal fall in resistance. NOS is present in utero
and there is a surge in both protein and
enzyme activity at birth.35,36 In-vitro studies in piglets
have
shown that endothelium-dependent and -independent
relaxation in response to a variety of agonists is absent
or poor immediately after birth6 but increases rapidly in
the first 3 days of life. This is associated with an
increase in NOS, sGC and PDE5. The NO/cGMP pathway
is not the only one involved in adaptation since mice in
which the eNOS gene has been knocked out still reduce
their arterial wall thickness after birth. Of less
importance is PGI2 which is released by increased sheer
stress and increased oxygen tension. It does not appear
to play a major role in fetal life since the addition of a
cyclo-oxygenase inhibitor only modestly increases
pulmonary vascular resistance. Maternal ingestion of
non-steroidal anti-inflammatory drugs is, however,
associated with infants developing pulmonary
hypertension of the newborn (PPHN). 37 PGI2 production
Figure 3 Normal vascular equilibrium in the pulmonary arteries between relaxant and contractile agonists and current therapies
used in treatment for pulmonary arterial hypertension.
in lambs decreases within hours after birth; however,
hypoxia increases its production and gene expression. 38
PGI2 causes relaxation via adenylate cyclase which
decreases towards term; therefore, PGI 2 may be more
important in preterm babies.
Maintenance of the low-pressure system in the
lung is a balance between vasodilators and
A. HISLOP
vasoconstrictors. Endothelin (ET-1) is a potent
vasoconstrictor and growth factor produced by
endothelium. In experimental studies, ET-1 was
found to constrict fetal lamb arteries and veins and
increase the pulmonary artery pressure in newborn
lambs.38 It is probably an important player in
maintaining the high pulmonary vascular resistance
in fetal life since inhibition of the ET A receptor leads
to a decrease in basal pulmonary vascular resistance
in sheep. ET-1 has two receptors. ET A receptors are
found on smooth muscle cells and their stimulation
leads to vasoconstriction. ET B receptors are found on
both smooth muscle cells (stimulation leads to
vasoconstriction) and endothelial cells (stimulation
leads to release of NO or PGI 2 and thus
vasodilatation). An ETB blocker attenuated the drop in
vascular resistance on ventilation in lambs,
suggesting that stimulation of the ET B receptor
contributes to vasodilatation at birth. 39 In a study on
piglet lungs, the ETB receptors appeared on the
endothelium 1–3 days after birth but did not appear
in piglets with pulmonary hypertension. 40 Plasma ET
is high in infants and in animals at birth and in those
with pulmonary hypertension. In the sheep model of
clamping the ductus arteriosus in utero, an ET A
blocker attenuated the hypertensive structural
changes in the pulmonary artery and enhanced
vasodilation at birth. The number of ET A contractile
receptors also increased in hypertensive piglets. A
large number of experimental studies have been
performed on the use of ET receptor antagonists to
prevent the development of pulmonary hypertension
or to induce a recovery. These suggested that they
had varying effectiveness depending upon the
species and the model of hypertension. However, the
overall encouraging results have led to the use of
DEVELOPMENTAL BIOLOGY OF THE PULMONARY CIRCULATION 41
bosentan (a combined ETA/ETB antagonist) and pulmonary hypertension is well reviewed in a paper by
sitaxsentan (an ETA antagonist) in the treatment of Rosenzweig et al.49
patients with pulmonary hypertension. PPHN is a syndrome in term babies that have
ABNORMAL BLOOD VESSEL GROWTH increased pulmonary vascular resistance and right-to-
left shunt with severe hypoxaemia. It is frequently
Abnormalities in fetal lung development affect both
associated with meconium aspiration, pneumonia,
airways and blood vessels. In congenital diaphragmatic
sepsis or when the lung is hypoplastic. In addition, it
hernia (CDH), there is an equal reduction in arteries and
may be as a result of an idiopathic failure of thinning of
airway number along the main pathway and there is
41 the smooth muscle cells after birth. PPHN is almost
consequently a reduction in alveolar number. Such
always transient and most cases recover and
babies also get pulmonary hypertension with an
increase in arterial wall thickness that is probably
related to the decreased vascular bed increasing the
pulmonary vascular resistance. A similar decrease in
vascular bed is seen in cases with renal agenesis,
thoracic dystrophy and idiopathic pulmonary
hypoplasia. Postnatally, other factors that lead to
pulmonary hypertension include chronic lung disease
(CLD) or bronchopulmonary dysplasia (BPD) after
premature delivery and artificial ventilation where
there is also a reduction in alveolar formation with
abnormal structure.42,43 These babies frequently
develop pulmonary hypertension.44 This may be due to
the failure of capillary development or hypoxia. One
study on CLD45 described abnormal capillaries with a
decrease in VEGF mRNA and protein, while Lassus et
al.46 showed reduced circulating VEGF. This was
confirmed in a baboon model by Maniscalco et al. 47
VEGF not only induces the formation of microvessels
but upregulates eNOS and PGI2; thus, reduction in VEGF
may add to vasoconstriction.48

Pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is defined as
pulmonary artery pressure equal to or greater than 25
mmHg. This is associated with an increase in pulmonary
arterial smooth muscle (Fig. 4). Until recently, prognosis
for children with PAH was poor with a mean survival of
less than 1 year. Pulmonary hypertension can be
primary, now termed ‘idiopathic’, or secondary to other
factors. In the latest World Health Organisation
classification (2003), there has been a separation of
PAH – including idiopathic PAH (IPAH), PPHN, that
related to congenital heart disease (CHD) and
connective tissue disease – from pulmonary
hypertension associated with venous hypertension and
associated with disorders of the respiratory system
such as BPD, CDH, cystic fibrosis etc. 49 In all these, there
is an increase in the amount of muscle in the wall of the
pulmonary arteries; in some, there is development of
intimal hyperplasia and plexiform lesions. Younger
children and infants have less intimal damage. The
natural history, pathogenesis and treatment of
Figure 4 Photomicrograph of the pulmonary artery from an
infant with idiopathic pulmonary artery hypertension stained
with elastic van Gieson stain. There is an increase in collagen
(red) and smooth muscle in the wall (brown).
do not need further treatment. However, infants with
idiopathic failure of adaptation usually need treatment
indefinitely. IPAH may develop at birth but it may not
appear clinically until later in childhood and is often
misdiagnosed as a respiratory problem. IPAH may also
appear spontaneously at any time in childhood. IPAH
may be familial (6% in adults) and is more prevalent in
females (1.8:1). In many cases, even those not familial,
the abnormality is related to mutations in the gene for
the bone morphogenetic protein receptor II (BMPR2). 50
This is part of the TGFb pathway which is known to
control excessive multiplication of cells. Cells from
patients with the mutation show excessive
multiplication in response to TGFb or bone
morphogenetic protein.51 Not all people carrying the
mutated gene develop pulmonary hypertension. These
 42
diseases are discussed in more detail in other articles in
this series.
Therapies present and future
Current treatment in children with PAH, both idiopathic
and secondary, is based on adult experience and is
discussed in other articles in this series. Circulating ET is
high in pulmonary hypertension; thus, receptor
antagonists should reduce constriction (Fig. 3). In
addition, there will be an antiproliferative effect that
may reduce smooth muscle cells or prevent further
increase. Bosentan is successful in improving
haemodynamics and has been found to be well
tolerated by children aged 8 years and older. 52
Sitaxsentan, an ETA-only antagonist, may be a better
therapy because the ETB receptors on the endothelium
may aid vasodilation and also remove ET from the
circulation. This has been used successfully in small
studies in adults53 but has not been used in children.
Nebulised sildenafil decreased pulmonary artery
pressure in hypertensive sheep.54 Also, in a piglet
model of meconium aspiration, intravenous dosing
lowered pulmonary vascular resistance.55 In rats, it
attenuated the increase in muscle during hypoxic
exposure or monocrotaline ingestion and improved
the rate of recovery.56,57
We need novel therapies not only to cure or
attenuate pulmonary hypertension but also to
prevent reduction of arterial development in cases
such as BPD and/or enhance growth of new vessels
where there is a reduced vascular bed. VEGF gene
transfer administered by adenovirus to lambs after
intra-uterine banding of the pulmonary artery
leading to lung hypoplasia caused induction of
angiogenesis and some recovery of the alveolar
region.58 However, although intra-amniotic VEGF
protein given to mice improved surfactant and
thinned alveolar walls in prematurely delivered
animals, the walls did not increase blood vessel
development.59 Angiopoietin-1 transfected cells
injected into rats exposed to monocrotaline (a
hypertensive agent) reduced pulmonary
hypertension by prevention of microvasculature
apoptosis and the decrease in NOS.60
An adenoviral vector containing the eNOS gene
administered intratracheally in eNOS-deficient mice
led to an increase in eNOS protein and activity and a
decrease in pulmonary vascular resistance.61 Mice
with overexpression of PGI synthase were protected
from developing hypoxiainduced pulmonary
hypertension.62 Intratracheal instillation of PGI
synthase in hypertensive rats led to reduced
pulmonary vascular resistance.63
A. HISLOP
In future, it may be possible to tailor-make
therapies to produce a normal pulmonary vascular
bed using the accumulating knowledge on growth
factor control of arterial growth and differentiation.
ACKNOWLEDGEMENTS
Supported by The British Heart Foundation.
PRACTICE POINTS
Blood vessels follow airway development.
Abnormalities in growth of airways or alveoli will
also affect blood vessel number and structure.
PAH may be as a result of abnormal growth of blood
vessels.
IPAH may begin in infancy and childhood.
RESEARCH DIRECTIONS
Investigate the use of growth factors to stimulate
pulmonary vascular growth.
Investigate the use of transfection of genes
that might lead to reduction in pulmonary
artery smooth muscle cell hypertrophy or
hypoplasia.
REFERENCES
1. Hislop AA, Pierce CM. Growth of the vascular tree. Paediat Respir
Rev 2000; 1: 321–327.
2. Hall SM, Hislop AA, Pierce CM, Haworth SG. Prenatal origins
ofhuman intrapulmonary arteries: formation and smooth muscle
maturation. Am J Respir Cell Mol Biol 2000; 23: 194–203.
3. Hall SM, Hislop AA, Haworth SG. Origin, differentiation, and
maturation of human pulmonary veins. Am J Respir Cell Mol Biol
2002; 26: 333–340.
4. Schachtner SK, Wang Y, Scott BH. Qualitative and quantitative
analysisof embryonic pulmonary vessel formation. Am J Respir
Cell Mol Biol 2000; 22: 157–165.
5. Bailly K, Ridley AJ, Hall SM, Haworth SG. RhoA activation by
hypoxia inpulmonary arterial smooth muscle cells is age and site
specific. Circ Res 2004; 94: 1383–1391.
6. Haworth SG. Pulmonary hypertension in the young. Heart 2002;
88: 658–664.
7. Hall SM, Gorenflo M, Reader J, Lawson D, Haworth SG. Neonatal
pulmonary hypertension prevents reorganisation of the
pulmonary arterial smooth muscle cytoskeleton after birth. J Anat
2000; 196: 391– 403.
8. Hislop AA. Airway and blood vessel interaction during lung
development. J Anat 2002; 201: 325–334.
9. Minoo P. Transcriptional regulation of lung development:
emergenceof specificity. Respir Res 2000; 1: 109–115.
10. Roth-Kleiner M, Post M. Genetic control of lung development.
Biol Neonate 2003; 84: 83–88.
11. Jones PL. Homeobox genes in pulmonary vascular development
anddisease. Trends Cardiovasc Med 2003; 13: 336–345.
DEVELOPMENTAL BIOLOGY OF THE PULMONARY CIRCULATION
12. Acarregui MJ, Penisten ST, Goss KL, Ramirez K, Snyder JM.
Vascularendothelial growth factor gene expression in human fetal
lung in vitro. Am J Respir Cell Mol Biol 1999; 20: 14–23.
13. Shifren JL, Doldi N, Ferrara N, Mesiano S, Jaffe RB. In the human
fetus,vascular endothelial growth factor is expressed in epithelial
cells and myocytes, but not vascular endothelium: implications
for mode of action. J Clin Endocrinol Metab 1994; 79: 316–322.
14. Healy AM, Morgenthau L, Zhu X, Farber HW, Cardoso WV. VEGF
isdeposited in the subepithelial matrix at the leading edge of
branching airways and stimulates neovascularization in the
murine embryonic lung. Dev Dyn 2000; 219: 341–352.
15. Shalaby F, Rossant J, Yamaguchi TP et al. Failure of blood-island
formation and vasculogenesis in Flk-1-deficient mice. Nature
1995; 376: 62–66.
16. Carmeliet P, Ferreira V, Breier G et al. Abnormal blood vessel
development and lethality in embryos lacking a single VEGF allele.
Nature 1996; 380: 435–439.
17. Akeson AL, Greenberg JM, Cameron JE et al. Temporal and spatial
regulation of VEGF-A controls vascular patterning in the
embryonic lung. Dev Biol 2003; 264: 443–455.
18. Sato TN, Tozawa Y, Deutsch U et al. Distinct roles of the receptor
tyrosine kinases tie-1 and tie-2 in blood vessel formation. Nature
1995; 376: 70–74.
19. Ruocco S, Lallemand A, Tournier JM, Gaillard D. Expression and
localization of epidermal growth factor, transforming growth
factor-alpha, and localization of their common receptor in fetal
human lung development. Pediatr Res 1996; 39: 448–455.
20. Han RN, Post M, Tanswell AK, Lye SJ. Insulin-like growth factor-
Ireceptor-mediated vasculogenesis/angiogenesis in human lung
development. Am J Respir Cell Mol Biol 2003; 28: 159–169.
21. Gale NW, Yancopoulos GD. Growth factors acting via
endothelialcell-specific receptor tyrosine kinases: VEGFs,
angiopoietins, and ephrins in vascular development. Genes Dev
1999; 13: 1055–1066.
22. Folkman J, D’Amore PA. Blood vessel formation: what is its
molecular basis? Cell 1996; 87: 1153–1155.
23. Chu D, Sullivan CC, Du L et al. A new animal model for pulmonary
hypertension based on the overexpression of a single gene,
angiopoietin-1. Ann Thorac Surg 2004; 77: 449–456.
24. Suri C, Jones PF, Patan S et al. Requisite role of angiopoietin-1, a
ligand for the TIE2 receptor, during embryonic angiogenesis. Cell
1996; 87: 1171–1180.
25. Frid MG, Kale VA, Stenmark KR. Mature vascular endothelium can
giverise to smooth muscle cells via endothelial-mesenchymal
transdifferentiation: in vitro analysis. Circ Res 2002; 90: 1189–
1196.
26. Adamson IY, Young L. Alveolar type II cell growth on a
pulmonaryendothelial extracellular matrix. Am J Physiol 1996;
270: L1017–L1022.
27. Smith JD, Davies N, Willis AI, Sumpio BE, Zilla P. Cyclic stretch
inducesthe expression of vascular endothelial growth factor in
vascular smooth muscle cells. Endothelium 2001; 8: 41–48.
28. Zeng X, Gray M, Stahlman MT, Whitsett JA. TGF-beta1
perturbsvascular development and inhibits epithelial
differentiation in fetal lung in vivo. Dev Dyn 2001; 221: 289–301.
29. Zeltner TB, Burri PH. The postnatal development and growth of
thehuman lung. II. Morphology. Respir Physiol 1987; 67: 269–282.
30. Ng YS, Rohan R, Sunday ME, deMello DE, D’Amore PA. Differential
expression of VEGF isoforms in mouse during development and in
the adult. Dev Dyn 2001; 220: 112–121.
31. Maniscalco WM, Watkins RH, D’Angio CT, Ryan RM. Hyperoxic
injury decreases alveolar epithelial cell expression of vascular
43
endothelial growth factor (VEGF) in neonatal rabbit lung. Am J
Respir Cell Mol Biol 1997; 16: 557–567.
32. Bhatt AJ, Amin SB, Chess PR,
Watkins RH, Maniscalco WM.
Expression of vascular endothelial growth factor and Flk-1 in
developing and glucocorticoid-treated mouse lung. Pediatr Res
2000; 47: 606–613.
33. Jakkula M, Le Cras TD, Gebb S et al. Inhibition of angiogenesis
decreases alveolarization in the developing rat lung. Am J Physiol
Lung Cell Mol Physiol 2000; 279: L600–L607.
34. Tang JR, Markham NE, Lin YJ et al. Inhaled nitric oxide attenuates
pulmonary hypertension and improves lung growth in infant rats
after neonatal treatment with a VEGF receptor inhibitor. Am J
Physiol Lung Cell Mol Physiol 2004; 287: L344–L351.
35. Hislop AA, Springall DR, Buttery LD, Pollock JS, Haworth SG.
Abundance of endothelial nitric oxide synthase in newborn
intrapulmonary arteries. Arch Dis Child Fetal Neonatal Ed 1995;
73: F17–F21.
36. Arrigoni FI, Hislop AA, Pollock JS, Haworth SG, Mitchell JA.
Birthupregulates nitric oxide synthase activity in the porcine lung.
Life Sci 2002; 70: 1609–1620.
37. Alano MA, Ngougmna E, Ostrea EM Jr, Konduri GG. Analysis
ofnonsteroidal antiinflammatory drugs in meconium and its
relation to persistent pulmonary hypertension of the newborn.
Pediatrics 2001; 107: 519–523.
38. Abman SH, Kinsella JP, Mercier J. Nitric oxide and endothelin in
thedeveloping pulmonary circulation: physiologic and clinical
implications. In: Gaultier C, Bourbon JR, Post M, eds: Lung
Development.. New York: Oxford University Press, 1999; pp. 196–
220.
39. Ivy DD, Lee DS, Rairigh RL, Parker TA, Abman SH. Endothelin
Breceptor blockade attenuates pulmonary vasodilation in oxygen-
ventilated fetal lambs. Biol Neonate 2004; 86: 155–159.
40. Noguchi Y, Hislop AA, Haworth SG. Influence of hypoxia on
endothelin-1 binding sites in neonatal porcine pulmonary
vasculature. Am J Physiol 1997; 272: H669–H678.
41. IJsselstijn H, Tibboel D. The lungs in congenital diaphragmatic
hernia: do we understand? Pediatr Pulmonol 1998; 26: 204–218.
42. Hislop AA, Wigglesworth JS, Desai R, Aber V. The effects of
pretermdelivery and mechanical ventilation on human lung
growth. Early Hum Dev 1987; 15: 147–164.
43. Jobe AJ. The new BPD: an arrest of lung development. Pediatr Res
1999; 46: 641–643.
44. Hislop AA, Haworth SG. Pulmonary vascular damage and the
development of cor pulmonale following hyaline membrane
disease. Pediatr Pulmonol 1990; 9: 152–161.
45. Bhatt AJ, Pryhuber GS, Huyck H, Watkins RH, Metlay LA,
ManiscalcoWM. Disrupted pulmonary vasculature and decreased
vascular endothelial growth factor, Flt-1, and TIE-2 in human
infants dying with bronchopulmonary dysplasia. Am J Respir Crit
Care Med 2001; 164: 1971–1980.
46. Lassus P, Turanlahti M, Heikkila P et al. Pulmonary vascular
endothelial growth factor and Flt-1 in fetuses, in acute and
chronic lung disease, and in persistent pulmonary hypertension of
the newborn. Am J Respir Crit Care Med 2001; 164: 1981–1987.
47. Maniscalco WM, Watkins RH, Pryhuber GS, Bhatt A, Shea C,
Huyck H.Angiogenic factors and alveolar vasculature:
development and alterations by injury in very premature
baboons. Am J Physiol Lung Cell Mol Physiol 2002; 282: L811–
L823.
48. Murohara T, Horowitz JR, Silver M et al. Vascular endothelial
growth factor/vascular permeability factor enhances vascular
 44 A. HISLOP
permeability via nitric oxide and prostacyclin. Circulation 1998;
97: 99–107.
49. Rosenzweig EB, Widlitz AC, Barst RJ. Pulmonary arterial
hypertensionin children. Pediatr Pulmonol 2004; 38: 2–22.
50. Newman JH, Trembath RC, Morse JA et al. Genetic basis of
pulmonary arterial hypertension: current understanding and
future directions. J Am Coll Cardiol 2004; 43: 33S–39S.
51. Morrell NW, Yang X, Upton PD et al. Growth responses of
pulmonary artery smooth muscle cells from patients with primary
pulmonary hypertension to transforming growth factor-beta(1)
and bone morphogenetic proteins. Circulation 2001; 104: 790–
795.
52. Barst RJ, Ivy D, Dingemanse J, Widlitz A et al. Pharmacokinetics,
safety, and efficacy of bosentan in pediatric patients with
pulmonary arterial hypertension. Clin Pharmacol Ther 2003; 73:
372–382.

53. Channick RN, Sitbon O, Barst RJ, Manes A, Rubin LJ.

Endothelinreceptor antagonists in pulmonary arterial
hypertension. J Am Coll Cardiol 2004; 43: 62S–67S.
54. Ichinose F, Hataishi R, Wu JC et al. A selective inducible NOS
dimerization inhibitor prevents systemic, cardiac, and pulmonary
hemodynamic dysfunction in endotoxemic mice. Am J Physiol
Heart Circ Physiol 2003; 285: H2524–H2530.
55. Shekerdemian LS, Ravn HB, Penny DJ. Interaction between
inhalednitric oxide and intravenous sildenafil in a porcine model
of meconium aspiration syndrome. Pediatr Res 2004; 55: 413–
418.
56. Sebkhi A, Strange JW, Phillips SC, Wharton J, Wilkins MR.
Phosphodiesterase type 5 as a target for the treatment of
hypoxia-induced pulmonary hypertension. Circulation 2003; 107:
3230–3235.
57. Itoh T, Nagaya N, Fujii T et al. A combination of oral sildenafil and
beraprost ameliorates pulmonary hypertension in rats. Am J
Respir Crit Care Med 2004; 169: 34–38.
58. Lambert V, Michel R, Mazmanian GM et al. Induction of
pulmonary angiogenesis by adenoviral-mediated gene transfer of
vascular endothelial growth factor. Ann Thorac Surg 2004; 77:
458–463.
59. Compernolle V, Brusselmans K, Acker T et al. Loss of HIF-2alpha
and inhibition of VEGF impair fetal lung maturation, whereas
treatment with VEGF prevents fatal respiratory distress in
premature mice. Nat Med 2002; 8: 702–710.
60. Zhao YD, Campbell AI, Robb M, Ng D, Stewart DJ. Protective role
ofangiopoietin-1 in experimental pulmonary hypertension. Circ
Res 2003; 92: 984–991.
61. Champion HC, Bivalacqua TJ, Greenberg SS, Giles TD, Hyman
AL,Kadowitz PJ. Adenoviral gene transfer of endothelial nitric-
oxide synthase (eNOS) partially restores normal pulmonary
arterial pressure in eNOS-deficient mice. Proc Natl Acad Sci USA
2002; 99: 13248– 13253.
62. Geraci MW, Gao B, Shepherd DC et al. Pulmonary prostacyclin
synthase overexpression in transgenic mice protects against
development of hypoxic pulmonary hypertension. J Clin Invest
1999; 103: 1509–1515.
63. Nagaya N, Yokoyama C, Kyotani S et al. Gene transfer of human
prostacyclin synthase ameliorates monocrotaline-induced
pulmonary hypertension in rats. Circulation 2000; 102: 2005–
2010.