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5 Immunological Defense Mechanisms oftheRespiratory System
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NF-kB from the cytoplasm to the nucleus and the transcription of chemokines and proinammatory cytokines (IL)-8, monocyte chemotactic protein-1, lym­phocyte chemoattractant factor (IL-16), IL-6, IL-8, and interferon (IFN)-β. Subsequently, adhesion molecules increase to attract neutrophils and macro­phages to the inammatory site.
7. Professional antigen-presenting cells (APC), such as DCs and alveolar mac- rophages in the lungs, are vital in directing adaptive immune responses to inammation, which infectious pathogens invade or tolerate after most envi­ronmental exposures and commensals [25]. They detect PAMPs through PRRs and release chemoattractant and inammatory cytokines, including tumor necrosis factor-alpha (TNF-α), IL-1β, IL-12, and IL-6, into the alveo­lar space. IL-12 augments NK cell activity microenvironmentally, and large amounts of IFN-γ secreted by NK cells enhance the antimicrobial function of the alveolar macrophages [26]. The microorganisms captured by APCs are subsequently transported to the draining hilar and mediastinal lymph nodes to commence an adaptive immune response. Dendritic cells and alveolar macrophages present epitopes of ingested pathogens through endocytosis or phagocytosis on major histocompatibility complex class I (MHC-I) or MHC-II protein complex to naïve CD8+ or CD4+ T cells, respectively. The second set of signals delivered via costimulatory molecules expressed on the cell surface of activated APCs activates T cells, initiating an adaptive immune response.
8. ILCs are innate immune cells belonging to the lymphoid lineage but lacking adaptive antigen-specic receptors [27]. Depending on their ability to synthesize and release cytokines and their transcription factor prole, ILCs are divided into three major helper-like subsets, ILC1, ILC2, and ILC3, which are considered the innate counterparts of T helper 1 (Th1), Th2, and Th17 cells, respectively. ILC1 cells, which include NK cells, secrete IFN-γ and TNF-α, and express the T-box transcription factor T-bet or eomesodermin (Eomes). ILC2 cells produce IL-4, IL-5, IL-9, and IL-13in response to IL-25, IL-33, and thymic stromal lympho­poietin and express high levels of the Th2 signature transcription factor GATA-3. ILC3 cells release IL-17, IL-22, and GM-CSF at mucosal sites, functioning as early orchestrators of lung tissue remodeling and brogenesis. Although repre­senting a small portion of the pulmonary immune cells, ILCs play a signicant role in early protective antimicrobial responses and facilitate the acquisition of adaptive immunity. They also play pathogenic roles in inammation, allergy, autoimmunity, and tissue brosis [28].
9. Neutrophils are recruited rapidly to the site of inammation following stimula- tion by chemotactic factors such as chemokines (CXCL1–8, CXCL-12, CCL2, and CCL17), lipid mediators (eicosanoids/leukotrienes), C5a, and interleukins (i.e., IL-8) released from the damaged lung tissues [29]. They localize mainly in the bronchoalveolar space, engaging in short-term host–pathogen interactions. Activated neutrophils eliminate microorganisms by phagocytosis, oxidative burst, degranulation, and by means of NETosis (neutrophil extracellular traps formation) [1, 29].
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5.2 Adaptive Immunity

Adaptive immunity involves a tightly regulated interplay between antigen- presenting cells and the effectors, T and B lymphocytes, which facilitate pathogen-specic immunologic effector pathways, immunologic memory generation, and regulation of host immune homeostasis. Cell-mediated immunity is controlled by T cells, and humoral immunity is controlled by antibody-producing B cells. Highly mobile lym­phocytes trafc to secondary lymphoid organs after developing in the primary lym­phoid organs (thymus and bone marrow) and serve to capture circulating antigens from lymph. T cells are primed in the lymphoid areas, often inuenced by innate immune system signals provided by APCs migrating to the secondary lymphoid organs. Naive lymphocytes undergo a stepwise process of activation, proliferation, clonal expansion, and differentiation to become effector cells that can migrate to the lung and mediate antimicrobial immune responses [30].
The activation of T helper cells by APC causes them to differentiate into different subtypes with specic functions mediated by cytokine secretion and cell-to-cell contact. T helper 1 cells secrete cytokines such as IFN-γ, IL-6, and IL-12 and play a crucial role in cellular response formation [15]. Th2 cells help humoral responses by providing a second signal to B cells, mostly through IL-4 secretion and CD40/ CD40L interaction. During the rst encounter with an antigen (pathogen), long­lived memory T and B cells are established. In subsequent encounters with the same pathogen, the memory cells are quickly activated to yield a more rapid and robust protective response. The activated B cells secrete antibodies circulating in the body and coat the microbes, targeting them for efcient phagocytosis. T follicular helper cells (Tfh) control the critical interactions in the germinal centers essential for the maturation of memory B cells and long-lived high-afnity antibody-producing plasma cells [31]. Another subset of CD4+ T cells differentiates into a pool of mem­ory T helper cells. Activated CD8+ cytotoxic T lymphocytes (CTL) cause apoptosis of the infected host cells. Some CTLs differentiate into memory cytotoxic T cells, which have the role of fast restoration of the CTL response with secondary antigen contacts. A similar destruction mechanism occurs when NK cells interact with the virally infected cell [31]. They contain granules with IFN-γ and TNF-α in their cytoplasm. NK cells form pores in the membranes of target cells by perforin. Granzymes pass through the pores, and together with cytokines, they initiate apop­tosis, resulting in the death of infected cells.
After the control of infection, clones from the antigen induces the infection to circulate, creating lymphocytes that are specic to the circulating antigen. Initially, these lymphocytes are observed in small populations; however, they can act fast upon the recolonization of the known antigen, giving the immune system the time to produce more specic lymphocytes.
Lymphocytes can be found either singly or in clusters in the airway lamina propria and the submucosa [3, 15]. Effector and memory CD4+ and CD8+ T cells and B cells are present in the airway mucosa (in the intraepithelial and within the underlying lamina propria). They may play a role in the constitution of BALT, which has a sig­nicant role in local immunological homeostasis in the respiratory tract. Most
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intraepithelial T cells express CD8+, whereas CD4+ T cells are more frequently found in the lamina propria. B cells contribute to local antigen presentation in the lymph nodes that drain the lungs. Some B cells differentiate into plasma cells. Plasma cells located in the lamina propia mainly produce IgA but also IgM to clear inhaled patho­gens [32, 33]. IgG subclasses are also present in the alveoli and airway secretions.
The lungs are a major site of entry of innocuous inhaled antigens and presumably by commensal microorganisms into the body. The absolute requirement of the pul­monary immune system is to limit the infectious and inammatory consequences of inhaled agents while maintaining tolerance to harmless aeroallergens. The immune response in the lung must be tightly regulated such that pathogens are cleared. Furthermore, immunopathology due to chronic or excessive inammation is avoided. Critical antimicrobial monitoring and downregulation of the activated immune response are vital to protect the lung from inammatory damage. The immune homeostasis and tolerance in the lung are maintained by a complex net­work of cells and molecules interacting with lung stromal cells, such as regulatory T cells (Tregs), resident interstitial lung macrophages, plasmacytoid dendritic cells, γδT cells, cytokines IL-10, and TGF-β [3335]. The coordinated and close interplay between resident (airway epithelial cells) and inltrating immune cells is important to establish the protective respiratory innate and adaptive immune responses.

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N. E. Karaca et al.
Innate andAdaptive Immunity oftheRespiratory System
EsraHazar, MehmetAliKaraselek, andSevgiKeles

6.1 Introduction

The respiratory tract (RT) is a complex system that provides gas exchange and oxy­genation of the blood, while at the same time forming a physical and immunological barrier between the external environment and tissues. Hereby, the respiratory tracts are constantly exposed to inhaled agents including allergens, pollutants, commensal or pathogenic microorganisms, and respiratory pathogens [1]. The RT compromises the upper (URT) and lower respiratory tracts (LRT), and drains the localized lym­phoid tissue including cervical and mediastinal lymph nodes to start a localized immune response against antigens. The tract is covered with a barrier that is com­posed of a mucus layer, cilia, and airway epithelial cells. The rst line of defense starts in URT or LRT by interaction between environmental agents and this barrier in the respiratory tract. This barrier is supported by a complex network of immune systems which is composed of innate and adaptive immune systems. These systems recognize and react to a wide variety of stimuli. They also eliminate unwanted pathogens to keep the tract free from infections. This system also regulates maxi­mizing pathogen clearance while minimizing excessive inammation and tissue injury. Maintaining balance in the respiratory tract during injury or infection is cru­cial to host survival [2]. The distribution of these protective mechanisms contributes to the pathogenesis of many pulmonary diseases. Many diseases, such as asthma, allergies, and acute or chronic lung diseases, result from dysregulated responses in the airways. In addition, numerous infectious agents, including viral, bacterial,
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E. Hazar Pediatric Allergy and Immunology Unit, Faculty of Medicine, Alanya Alaaddin Keykubat University, Antalya, Turkey
M. A. Karaselek · S. Keles (*) Pediatric Allergy and Immunology Unit, Faculty of Medicine, Necmettin Erbakan University, Konya, Turkey
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 H. Yüksel et al. (eds.), Pediatric Airway Diseases, Comprehensive ENT,
https://doi.org/10.1007/978-3-031-74853-0_6
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fungal, and protozoan, target airway cells for replication, then cause direct damage to barrier sites by triggering inammation-related tissue damage.
The respiratory immune system is composed of innate and adaptive immune systems. Less-virulent pathogens are generally obliterated by the primary defense like mucociliary clearance and alveolar macrophage, which is a part of innate immunity in the tract. Contrary, virulent microorganisms and most of the inhaled antigens/pathogens need to be eliminated by the inammatory process initiated by the innate immune system. In the early phase of infection with a respiratory patho­gen, there is a balance between pathogen clearance and immune response which is closely controlled by the epithelial immune cell axis. Dysregulation in this response can cause serious tissue damage. In the late stages of infection, a balance must be established between inammation and tissue repair to recover proper lung function. On the other hand, dysregulated airway response to pathogens by innate and adap­tive immune systems results in hyperinammatory syndromes, site destruction in the respiratory tract leading to a sequela such as lung brosis. As a consequence, innate and adaptive pulmonary immune responses are strictly regulated to maintain this homeostasis following injury and infection [1]. Hence, knowing the role of adaptive and innate immune responses in the respiratory tract is important to under­standing the pathophysiology and improving the management of respiratory dis­eases. Here, we have summarized various aspects of immune hemostasis which is regulated by innate and adaptive immune responses in the respiratory tract.

6.2 Innate Immunity

The innate immune system is the rst line of defense against inhaled materials, and nonspecically identies the microorganisms by recognition of their common micro­bial motifs. Thus, it provides a nonspecic response against antigens. Innate immu­nity is contributed by epithelial cells, dendritic cells, macrophages, neutrophils, innate lymphoid cells, and monocytes, which respond rapidly to inhaled materials. Activation of these innate immunity cells induces the production of anti-microbial peptides, che­mokines, and cytokines [2]. The intercellular communication between the airway and the immune cells is facilitated by complement factors, lipid mediators, chemo-attrac­tants, and chemokines. The biological function of chemokines is relayed by different cytokines, including several interleukins and thymic stromal lymphopoietin (TSLP). These substances, secreted by local airway cells, generate customized immunological responses [2, 3]. Important components of theinnate immunity system in the respira­tory tract are summarized in the following part of the chapter and in Fig.6.1 [1].
6.2.1 Mucosal Immunity intheRespiratory System
The epithelium is the primary defense line against airborne harmful microorgan­isms. It captures particles in the air and removes them from the airways. The pri­mary function of this epithelia is to be a physical boundary between the airways and
a bc
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Fig. 6.1 Components and cells of innate immunity in the respiratory tract showing at the mucosal barrier (a), activation of antigen-presenting cells by antigens
(b), and additional cells in the lower respiratory system (c)
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vascular structures. The epithelium accomplishes this by creating tight junctions that include occludins, claudins, and adherens. Damage to tight junctions is an important cause of epithelial barrier dysfunction during inammation of the lung. The epithelial integrity is critical to avoid the colonization and dissemination of microorganisms, as well as to prevent uid accumulation in the lung [4]. The tight junction formation can be modied with viruses that target the epithelium. Inuenza disrupts claudin-4 [5] and respiratory syncytial virus (RSV) [6] and reduces the expression of claudin-1 and occludins. Some bacterial infections, e.g., lung infec­tion due to Pseudomonas aeruginosa, may cause edema secondary depletion of zonula occludins-1 proteins [7].
The cartilaginous airway epithelium is constituted of glands, ciliated cells, and goblet cells. Noncartilaginous airways have no glands or goblet cells, but have an increasing number of columnar epithelial cells [8]. An important feature of the pul­monary mucosa is the thin uid layer called mucus that covers the airway lumen. The mucus that is produced by the goblet cells is composed of mucin proteins, complements, cytokines, secretory IgA, antimicrobial peptides (AMP), and com­mensal bacteria. Mucins in mucus are extra-cellular proteins that are secreted by goblet cells, club cells, and pseudostratied columnar ciliated cells of the respira­tory epithelia. These proteins play an important role in viral transmission, which can capture and block virus entry in the affected host. The most prevalent mucins in the respiratory system are MUC5AC and MUC5B, which are signicant in the protec­tive barrier task [1, 9].
During the acute inammatory phase, unique molecular signatures referred as pathogen-associated molecular patterns (PAMPs), found in immunogenic vaccines, bacteria, fungi, viruses, and protozoa, are detected by pattern recognition receptors (PRRs) secreted by immune cells of epithelia. PRRs such as Nod-like receptors (NLRs), Toll-like receptors (TLRs), and retinoic acid inducible gene I- (RIG-I-)­like receptors (RLRs) are players of innate immunity and apoptosis. Therefore, PR-intermediated signal paths have an essential task in inammatory responses and the stability of tissue homeostasis. Respiratory epithelia and cells of innate immu­nity secrete TLR1, TLR2, TLR3, TLR4, TLR5, TLR6, TLR7, TLR8, TLR9, and TLR10, which recognized distinct antigens. While TLR1, TLR2, TLR4, TLR5, TLR6, and TLR10 are located at the cell surface, TLR3, TLR7, TLR8, and TLR9 are locatede in intracellular vesicules (endoplasmic reticulum, endosome, lyso­some, and endolysosome). Plasma membrane-associated TLRs and endosome membrane-associated TLRs are primarily responsible for recognizing bacteria in the lung, while TLR3, TLR7, and TLR8 detect virus nucleic acids in lung infections [10]. Studies have shown that dsRNA recognized by TLR3 (such as in the inuenza virus) was the most potent activator of epithelial cells in the lung, and stimulates a potent cytokine and chemokine response. TLR2 and TLR5 promote an increased response of the airway epithelium, leading to a more efcient response to bacteria and allergens. TLR4 is capable of recognizing Gram-negative bacteria and stimulat­ing upregulation of TLR3in alveolar macrophages [4].
Another subtype of PRRs is the nucleotide-binding oligomerization domain (NOD)-like receptors (NLRs). NLRs are secreted in the cytoplasm and nucleus.
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There are more than 20 receptors in the NLR family. There are four kinds of effector domains with specic functional features that allow the NLR to be divided into ve different subfamilies: NLRA, NLRB, NLRC, NLRP, and NLRX.The human NLRC is a subfamily of NLR composed of ve members (NLRC1–5). NLRC1 and NLRC2, also called NOD1 and NOD2, are the two major components of the NLRC subfamily [10].
NOD1 is widely expressed in respiratory epithelia, endothelia, smooth muscles, and leukocytes. However, NOD2 expression is limited in myeloid cells, which include dendritic cells, macrophages, and human bronchial epithelial cells. Following ligand recognition, NLRC members induce the activation of distinct sig­naling paths through CARD–CARD interactions with several types of proteins. While NOD1 and NOD2 both recognize different ligands via leucine-rich repeat (LRR) domains, they act through the same protein called receptor-interacting ser­ine/threonine-protein kinase 2 (RIPK2). RIPK2-mediated activation gives rise to the regulation of several pathways involved in different cellular responses, includ­ing inammatory responses through nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB) and mitogen-activated protein kinase (MAPK) activation. NOD1 or NOD2 codependent induction of these paths can interfere with other PRRs, e.g., TLRs [11].
NLRP is the biggest NLR sub-family counting 14 members. At a minimum, ve of the NLRP elements, including NLRP1, NLRP3, NLRP6, NLRP7, and NLRP12, can activate the generation of inammasome, and modulate the release of IL1β and IL18 in response to different damage-associated molecular pattern (DAMP) or microbe-associated molecular pattern (MAMP). NLRP1 inammasome is the rst identied intracellular molecule capable of activating pro-caspase 1. NLRP3 is the well-characterized member of the NLRP sub-family, and the most studied inam­masome. The initial signal by DAMP or MAMP inammatory stimulus induces NF-κB-mediated NLRP3 expression. Following the rst signal, the NLRP3 stimu­lation is driven by a secondary signal, which is induced by a broad range of stimuli, in particular bacterially sourced molecules such as LPS, endogenous DAMP such as ATP, viral RNA, hyphae of fungi, or exposed to other environmentally irritating substances. NLRP1 is expressed in the digestive and respiratory epithelial immune cells and brain. NLRP3 is expressed in various immune cells (macrophages, den­dritic cells, neutrophils, and T and B lymphocytes). In addition, NLRP3 is found in respiratory and intestinal epithelium [10, 11].
Antimicrobial peptides (AMPs) are widely expressed in the lung, serving as the initial defensive line for protection against infection. Defensins (alpha and beta), surfactant proteins, RegIIIγ, and LL-37 are some AMPs in the respiratory system. Defensins are primarily expressed in neutrophils and epithelial cells. Alpha defen­sins have a potent anti-viral impact by targeting viral particles and disrupting their capability to invade cells. Beta-defensins also act as chemokines, indirectly enhanc­ing immunity to infections. LL-37 secreted by myeloid and epithelial cells is a member of the cathelicidin family. It has antimicrobial properties by inhibiting LPS and disrupting the bacterial membrane. It also promotes the expression of IL-8 and activation of the epithelial growth factor receptor (EGFR) in epithelial cells [4].
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One other signicant anti-microbial peptide is regenerating islet-derived 3 γ (RegIIIγ), which is particularly targeting Gram-positive bacteria. It is vital for the elimination of methicillin-resistant Staphylococcus aureus (MRSA) associated pneumonia. STAT3 regulates the expression of RegIIIγ, which is highly expressed in the lung epithelium during MRSA infection [12].
Surfactant proteins A (SP-A) and D (SP-D) are known to be members of the col­lectin AMP family. The binding of collectins to pathogens leads to opsonization and subsequent phagocytosis. SP-D has a potent anti-infective activity against inuenza and is proposed as a promising treatment to boost mucosal immunity during inu­enza epidemics [13]. SP-C has been demonstrated to have immunomodulatory effects in lung repair through JAK/STAT activation after acute respiratory distress syndrome (ARDS) [14].
The complement system is composed of plasma proteins that serve as immune system effectors by inducing phagocytosis, increasing active inammatory media­tors, and targeting the pathogen’s membrane [4]. Overactivation of complement may lead to damaged tissues. For example, H5N1 avian inuenza has been reported to cause acute lung injury and ARDS by leading the hyperactivation of complement. In this model, the inhibition of complement activation helps to reduce injury in the lung [15].
6.2.1.1 Cells ofInnate Immunity
The major cells of the innate immune system are epithelial cells, neutrophils, den­dritic cells, macrophages, monocytes, and innate lymphoid cells. Alveolar epithelial cells (AECs) are one of the important cells of innate immunity in the lung. Both AEC I and AEC II coordinate different immune pathways to provide homeostasis in the lung. AEC I covers almost 99% of the lung surface area. Besides acting as a physical barrier, both AEC I and AEC II have a crucial role in the lung’s immune response. However, AEC II is more immunologically active. These cells produce several immune factors such as cytokines and chemokines that are responsible for immune cell activation and differentiation. They act as antigen-presenting cells for specic T cells [2].
Macrophages are the other important cells of the innate immunity to response to infections. They express numerous surfaces, vesicular and cytosolic PRR to detect signals, and start appropriate immune responses. Following its activation, these cells phagocytize, directly kill infectious agents, then recruit other innate immune cells by releasing numerous cytokines and chemokines. After stimulation, in circu­lation, monocytes are differentiated into dendritic cells (DCs) or macrophages, and initiate innate immune response in the lung. On the other hand, tissue-resident mac­rophages are present in the lung. These macrophages are the initial responders and have signicant tasks in homeostasis, immunomodulation, and tissue repair. Macrophages in the lungs are classied into two groups: alveolar macrophages (AMs) and interstitial macrophages (IMs). AMs are supposed to have a central role in a clearance of pathogens, while IMs act as a major immunomodulator of adaptive immunity because of their elevated expression of MHCII [4]. Both macrophages produce robust responses to a wide range of stimuli. AMs promote viral clearance