Plasticity in respiratory motor control: intermittent hypoxia and hypercapnia activate opposing serotonergic and noradrenergic modulatory systems

Experimental results consistently show that the respiratory control system is plastic, such that environmental factors and experience can modify its performance. Such plasticity may represent basic neurobiological principles of learning and memory, whereby intermittent sensory stimulation produces long-term alterations (i.e. facilitation or depression) in synaptic transmission depending on the timing and intensity of the stimulation. In this review, we propose that intermittent chemosensory stimulation produces long-term changes in respiratory motor output via specific neuromodulatory systems. This concept is based on recent data suggesting that intermittent hypoxia produces a net long-term facilitation of respiratory output via the serotonergic system, whereas intermittent hypercapnia produces a net long-term depression by a mechanism associated with the noradrenergic system. There is suggestive evidence that, although both respiratory stimuli activate both modulatory systems, the balance is different. Thus, these opposing modulatory influences on respiratory motor control may provide a 'push-pull' system, preventing unchecked and inappropriate fluctuations in ventilatory drive.

Invited review: Intermittent hypoxia and respiratory plasticity

Intermittent hypoxia elicits long-term facilitation (LTF), a persistent augmentation (hours) of respiratory motor output. Considerable recent progress has been made toward an understanding of the mechanisms and manifestations of this potentially important model of respiratory plasticity. LTF is elicited by intermittent but not sustained hypoxia, indicating profound pattern sensitivity in its underlying mechanism. During intermittent hypoxia, episodic spinal serotonin receptor activation initiates cell signaling events, increasing spinal protein synthesis. One associated protein is brain-derived neurotrophic factor, a neurotrophin implicated in several forms of synaptic plasticity. Our working hypothesis is that increased brain-derived neurotrophic factor enhances glutamatergic synaptic currents in phrenic motoneurons, increasing their responsiveness to bulbospinal inspiratory inputs. LTF is heterogeneous among respiratory outputs, differs among experimental preparations, and is influenced by age, gender, and genetics. Furthermore, LTF is enhanced following chronic intermittent hypoxia, indicating a degree of metaplasticity. Although the physiological relevance of LTF remains unclear, it may reflect a general mechanism whereby intermittent serotonin receptor activation elicits respiratory plasticity, adapting system performance to the ever-changing requirements of life.

Chronic intermittent hypoxia elicits serotonin-dependent plasticity in the central neural control of breathing

We tested the hypothesis that chronic intermittent hypoxia (CIH) elicits plasticity in the central neural control of breathing via serotonin-dependent effects on the integration of carotid chemoafferent inputs. Adult rats were exposed to 1 week of nocturnal CIH (11-12% O(2)/air at 5 min intervals; 12 hr/night). CIH and untreated rats were then anesthetized, paralyzed, vagotomized, and artificially ventilated. Time-dependent hypoxic responses were assessed in the phrenic neurogram during and after three 5 min episodes of isocapnic hypoxia. Integrated phrenic amplitude (integralPhr) responses during hypoxia were greater after CIH at arterial oxygen pressures (PaO(2)) between 25 and 45 mmHg (p < 0.05), but not at higher PaO(2) levels. CIH did not affect hypoxic phrenic burst frequency responses, although the post-hypoxia frequency decline that is typical in rats was abolished. integralPhr and frequency responses to electrical stimulation of the carotid sinus nerve were enhanced by CIH (p < 0.05). Serotonin-dependent long-term facilitation (LTF) of integralPhr was enhanced after CIH at 15, 30, and 60 min after episodic hypoxia (p < 0.05). Pretreatment with the serotonin receptor antagonists methysergide (4 mg/kg, i.v.) and ketanserin (2 mg/kg, i.v.) reversed CIH-induced augmentation of the short-term hypoxic phrenic response and restored the post-hypoxia frequency decline in CIH rats. Whereas methysergide abolished CIH-enhanced phrenic LTF, the selective 5-HT(2) antagonist ketanserin only partially reversed this effect. The results suggest that CIH elicits unique forms of serotonin-dependent plasticity in the central neural control of breathing. Enhanced LTF after CIH may involve an upregulation of a non-5-HT(2) serotonin receptor subtype or subtypes.

Phrenic long-term facilitation requires 5-HT receptor activation during but not following episodic hypoxia

Episodic hypoxia evokes a sustained augmentation of respiratory motor output known as long-term facilitation (LTF). Phrenic LTF is prevented by pretreatment with the 5-hydroxytryptamine (5-HT) receptor antagonist ketanserin. We tested the hypothesis that 5-HT receptor activation is necessary for the induction but not maintenance of phrenic LTF. Peak integrated phrenic nerve activity (integralPhr) was monitored for 1 h after three 5-min episodes of isocapnic hypoxia (arterial PO(2) = 40 +/- 2 Torr; 5-min hyperoxic intervals) in four groups of anesthetized, vagotomized, paralyzed, and ventilated Sprague-Dawley rats [1) control (n = 11), 2) ketanserin pretreatment (2 mg/kg iv; n = 7), and ketanserin treatment 0 and 45 min after episodic hypoxia (n = 7 each)]. Ketanserin transiently decreased integralPhr, but it returned to baseline levels within 10 min. One hour after episodic hypoxia, integralPhr was significantly elevated from baseline in control and in the 0- and 45-min posthypoxia ketanserin groups. Conversely, ketanserin pretreatment abolished phrenic LTF. We conclude that 5-HT receptor activation is necessary to initiate (during hypoxia) but not maintain (following hypoxia) phrenic LTF.

Long term facilitation of respiratory motor output decreases with age in male rats

Long term facilitation (LTF) is a serotonin-dependent augmentation of respiratory motor output (phrenic and hypoglossal) following episodic hypoxia. Since ageing influences respiratory control mechanisms and serotonergic function, we tested the hypothesis that LTF decreases with age in male rats. Young (3-4 month) and aged (13 month) male Sprague-Dawley rats were anaesthetized with urethane, vagotomized, paralysed and pump ventilated. Integrated phrenic and hypoglossal (XII) nerve activities were measured before (baseline), during and for 60 min after three 5 min episodes of isocapnic hypoxia (Pa,O2 35-45 mmHg) separated by 5 min of hyperoxia (Pa,O2 > 150 mmHg). In young rats, LTF was observed as an augmentation in peak integrated phrenic (n = 8) and XII (n = 7) amplitudes following episodic hypoxia (56 +/- 14 and 73 +/- 16 % (means +/- S.E.M.) at 60 min post-hypoxia, respectively; both P < 0.05). In aged rats, LTF was significantly increased compared to baseline in phrenic (25 +/- 8 % at 60 min, P < 0.05), but not in XII (4 +/- 7 %, P > 0.05) motor output. LTF was significantly greater in young than in aged rats in both motor outputs (P < 0.05). Decreased phrenic and XII LTF suggests that serotonergic modulation of respiratory motor output decreases in ageing male rats. We speculate that decreased serotonergic modulation may contribute to age-related breathing disorders.

Responses of single-unit carotid body chemoreceptors in adult rats

1. Our goal was to describe the in situ responses in rats of single-unit carotid body chemoreceptors to changes in arterial PO2 and PCO2. We identified single-unit carotid chemoreceptor activity in male, adult Sprague-Dawley rats by their rapid responses to i.v. NaCN (20 microg) and transient (10 s) asphyxia. 2. Single-unit chemoreceptor responses to isocapnic changes in oxygenation within the arterial oxygen pressure range 34-114 mmHg were described by the power function: f(dis) = 74010(Pa,O2)-2.5; (r2 = 0.6), where f(dis) is the discharge frequency (spikes s-1), P(a,O2) is the arterial oxygen partial pressure (mmHg) and r2 is the correlation coefficient. 3. The responses to iso-oxic changes in CO2, assumed to be linear, had a slope of 0.089 spikes s-1 (mmHg Pa,CO2)-1 (r2 = 0.7). 4. We conclude that carotid body chemoreceptors in adult rats have responses to changes in Pa,O2 and Pa,CO2 similar to those of other species.

Expression of hypoglossal long-term facilitation differs between substrains of Sprague-Dawley rat

Long-term facilitation (LTF) is a prolonged, serotonin-dependent augmentation of respiratory motor output following episodic hypoxia. Previous observations lead us to hypothesize that LTF is subject to genetic influences and, as a result, differs between Sprague-Dawley (SD) rats from two vendors, Harlan (H) and Charles River Laboratories/Sasco (CRL/S). Using a blinded experimental design, we recorded integrated phrenic (integralPhr) and hypoglossal neurograms in anesthetized, vagotomized, paralyzed, and ventilated rats. At 60 min following three 5-min hypoxic episodes (Pa(O(2)) = 40 +/- 1 Torr; 5-min hyperoxic intervals), integralPhr was elevated from baseline in both SD substrains (i.e., LTF; P < 0.05). Conversely, hypoglossal LTF was present in CRL/S but not H rats (P < 0.05 between substrains). Serotonin immunoreactivity within the hypoglossal nucleus was not different between H and CRL/S rats. We conclude that the expression of hypoglossal LTF differs between SD rat substrains, indicating a difference in their genetic predisposition to neural plasticity.

Time domains of the hypoxic ventilatory response in awake ducks: episodic and continuous hypoxia

Time-dependent ventilatory responses to episodic and continuous isocapnic hypoxia were measured in unidirectionally ventilated, awake ducks. Three protocols were used: (1) ten 3-min episodes of moderate hypoxia (10% O(2)) with 5-min normoxic intervals; (2) three 3-min episodes of severe hypoxia (8% O(2)) with 5-min normoxic intervals; and (3) 30-min of continuous moderate hypoxia. Ventilation (V(I)) increased immediately within a hypoxic episode (acute response), followed by a further slow rise in V(I) (short-term potentiation). The peak V(T) response increased from the first to second moderate hypoxic episode (progressive augmentation), but was unchanged thereafter. During normoxic intervals, V(I) increased progressively (56% following the tenth episode; long term facilitation). Time-dependent changes were not observed during or following 30-min of continuous hypoxia. Although several time-dependent ventilatory responses to episodic hypoxia are observed in awake ducks, they are relatively small and biased towards facilitation versus inhibitory mechanisms.

Episodic but not continuous hypoxia elicits long-term facilitation of phrenic motor output in rats

1. Intermittent hypoxia elicits long-term facilitation (LTF) of phrenic motor output in anaesthetized rats. We tested the hypothesis that an equal cumulative duration of continuous hypoxia would not elicit phrenic LTF. 2. Integrated phrenic nerve activity was recorded in urethane-anaesthetized, vagotomized, paralysed and ventilated rats exposed to: (1) 3 X 3 min hypoxic episodes (inspired O2 fraction (FI, O2) = 0.11) separated by 5 min hyperoxia (FI,O2 = 0.5; n = 6), (2) 9 min continuous hypoxia (n = 6), or (3) 20 min continuous hypoxia (n = 7). Isocapnia was maintained throughout the protocol. 3. Consistent with previous studies, phrenic amplitude was significantly elevated for at least 1 h following intermittent hypoxia (78 +/- 15% 60 min post-hypoxia; P < 0.05) with an associated increase in burst frequency (11 +/- 2.1 bursts min-1; P < 0.05). In contrast, 9 or 20 min continuous hypoxia did not elicit LTF of either phrenic amplitude (4.7 +/- 5.1 and 10.1 +/- 10.2% 60 min post-hypoxia, respectively; P > 0.05) or frequency (4.6 +/- 1.3 and 5.1 +/- 2 bursts min-1 60 min post-hypoxia, respectively; P > 0.05). 4. The results indicate that hypoxia-induced long-term facilitation of phrenic motor output is sensitive to the pattern of hypoxic exposure in anaesthetized rats.

Effects of phrenicotomy and exercise on hypoxia-induced changes in phrenic motor output

To investigate models of plasticity in respiratory motor output, we determined the effects of chronic unilateral phrenicotomy and/or exercise on time-dependent responses to episodic hypoxia in the contralateral phrenic nerve. Anesthetized (urethane), ventilated, and vagotomized rats were presented with three, 5-min episodes of isocapnic hypoxia (11% O(2)), separated by 5 min of hyperoxia (50% O(2)). Integrated phrenic (and hypoglossal) nerve discharge were recorded before and during each hypoxic episode, for the first 5 min after the first hypoxic episode, and at 30 and 60 min after the final episode. Of 36 rats, one-half were sedentary while the other one-half had free access to a running wheel; each of these groups was split into three subgroups: 1) unoperated, 2) chronic left phrenicotomy (27-37 days), and 3) sham operated. Neither unilateral phrenicotomy nor running wheel activity influenced the short-term hypoxic phrenic response (during hypoxia) or long-term facilitation (posthypoxia). Posthypoxia frequency decline was exaggerated in phrenicotomized-sedentary rats relative to unoperated-sedentary rats (change in burst frequency = -23+/-4 vs. -11 +/-5 bursts/min, respectively; 5 min posthypoxia; P<0.05), an effect that was eliminated by spontaneous exercise. The results indicate that neither voluntary running nor unilateral phrenicotomy has major effects on time-dependent hypoxic phrenic responses, with the exception of an unexpected effect of phrenicotomy on posthypoxia frequency decline in sedentary rats.

Short-term modulation of the exercise ventilatory response in goats: effects of 8-OH-DPAT and MPPI

Increased respiratory dead space increases the exercise ventilatory response, a response known as short-term modulation (STM). We hypothesized that STM results from a spinal, serotonin (5-HT)-dependent mechanism. Because 5-HT(1A) autoreceptors on caudal brain stem raphe neurons inhibit 5-HT release, we hypothesized that 5-HT(1A)-receptor agonists would inhibit, whereas 5-HT(1A)-receptor antagonists would enhance, STM. Ventilatory and arterial blood-gas measurements were made at rest and during exercise (4.0-4.5 km/h, 5% grade) in goats with the respiratory mask alone or with increased dead space (0.20-0.25 liter), before and after intravenous administration of the 5-HT(1A)-receptor agonist 8-hydroxy-2-(di-n-propylamino)tetralin (8-OH-DPAT; 0.1 mg/kg) or the antagonist 4-iodo-N-(2-[4-(methoxyphenyl)-1-piperazinyl]ethyl)-N-2-pyridinylbenz amide (MPPI; 0.08 mg/kg). 8-OH-DPAT increased the slope of the arterial PCO(2) vs. metabolic CO(2) production relationship and decreased the ventilation vs. metabolic CO(2) production relationship during exercise with increased dead space (not with the mask alone), indicating an impairment of STM. In contrast, MPPI had minimal effects on any measured variable. Although nonspecific effects of 8-OH-DPAT cannot be ruled out, impaired STM is consistent with the hypothesis that STM requires active raphe serotonergic neurons and 5-HT release.

Increased spinal monoamine concentrations after chronic thoracic dorsal rhizotomy in goats

In goats, bilateral thoracic dorsal rhizotomy (TDR) causes severe ventilatory failure during exercise, followed by progressive functional recovery. We investigated spinal neurochemical changes associated with TDR and/or functional recovery by measuring spinal concentrations of the monoamines serotonin (5-HT), norepinephrine, and dopamine via HPLC. Changes in 5-HT and calcitonin gene-related peptide were visualized with immunohistochemistry. Goat spinal cords were compared 4-15 mo after TDR from T(2) to T(12) (n = 7) with sham-operated (n = 4) or unoperated controls (n = 4). TDR increased the concentration of cervical 5-HT (C(5)-C(6); 122% change), caudal thoracic norepinephrine (T(7)-T(11); 53% change), and rostral thoracic dopamine (T(3)-T(6); 234% change). TDR increased 5-HT-immunoreactive terminal density (dorsal and ventral horns) and nearly eliminated calcitonin gene-related peptide immunoreactivity in the superficial laminae of the dorsal horn in rostral thoracic segments; both effects became less pronounced in caudal thoracic segments. Thus TDR elevates monoamine concentrations in discrete spinal regions, including possible compensatory changes in descending serotonergic inputs to spinal segments not directly affected by TDR (i.e., cervical) but associated with functionally related motor nuclei (i.e., phrenic nucleus).

Cultivating critical thinking in the clinical learning environment

The dental education knowledge base suggests a lack of understanding and research about how to teach critical thinking skills in the clinical learning environment. The acquisition of critical thinking skills is essential to the development of future practitioners, yet difficult to measure quantitatively. This study used qualitative research methods to assess the frequency and nature of teaching critical thinking skills in the University of Florida College of Dentistry predoctoral student clinics. Thirteen faculty and forty-four students in six clinics (oral diagnosis/treatment planning, endodontics, periodontology, operative dentistry, prosthodontics, and emergency care/oral surgery) were observed by an independent evaluator. Critical thinking skills were infrequently taught, and teacher-dominated instruction predominated. The findings underscore the need for thoughtful curriculum planning prior to predoctoral clinical instruction and periodic appraisal of clinical instruction. Suggestions for improving critical thinking in the clinical learning environment are presented.

Long term facilitation of phrenic motor output

Episodic hypoxia or electrical stimulation of carotid chemoafferent neurons elicits a sustained, serotonin-dependent augmentation of respiratory motor output known as long term facilitation (LTF). The primary objectives of this paper are to provide an updated review of the literature pertaining to LTF, to investigate the influence of selected variables on LTF via meta-analysis of a large data set from LTF experiments on anesthetized rats, and to propose an updated mechanism of LTF. LTF has been demonstrated in anesthetized and awake experimental preparations, and can be evoked in some human subjects during sleep. The mechanism underlying LTF requires episodic chemoafferent stimulation, and is not elicited by similar cumulative durations of sustained hypoxia. Meta-analysis of phrenic nerve responses following episodic hypoxia in 63 experiments on anesthetized rats (conducted by four investigators over a period of several years) indicates that phrenic LTF magnitude correlates with peak phrenic responses during hypoxia and hypercapnia, but not with the level of hypoxia during episodic exposures. Potential mechanisms underlying these relationships are discussed, and currently available data are synthesized into an updated mechanistic model of LTF. In this model, we propose that LTF arises predominantly from episodic activation of serotonergic receptors on phrenic motoneurons, activating intracellular kinases and, thus, phosphorylating and potentiating ionic currents associated with the glutamate receptors that mediate respiratory drive.

Serotonin reuptake inhibition does not enhance short term modulation of the exercise ventilatory response

Increased respiratory dead space causes a serotonin (5-HT) dependent augmentation of the exercise ventilatory response known as short term modulation (STM). Contrary to predictions, 5-HT reuptake inhibition with fluoxetine failed to enhance, and even impaired STM with large dead space volumes (0.4-0.6 L). In this study, we tested the hypotheses that: (1) fluoxetine similarly impairs STM with smaller dead space volumes (0.2 L); whereas (2) acute 5-HT release and reuptake inhibition with fenfluramine would enhance STM. Ventilatory and blood gas measurements were made on five goats (37-58 kg) during rest and exercise, with the mask alone or with increased dead space (0.2 L). STM protocols were performed following chronic fluoxetine (>/=21 days, 1 mg/kg, SQ, SID) and acute fenfluramine administration (1 mg/kg, IV). Following fluoxetine, STM was partially impaired. Fenfluramine had no detectable effects on STM. The data suggest that: (1) chronic fluoxetine diminishes STM, possibly via down-regulation of relevant 5-HT receptors, and (2) drugs that release 5-HT acutely do not enhance STM.

Cervical dorsal rhizotomy increases brain-derived neurotrophic factor and neurotrophin-3 expression in the ventral spinal cord

Although neurotrophic factors have been implicated in several forms of neuroplasticity, little is known concerning their potential role in spinal plasticity. Cervical dorsal rhizotomy (CDR) enhances serotonin terminal density near (spinal) phrenic motoneurons and serotonin-dependent long-term facilitation of phrenic motor output (Kinkead et al., 1998). We tested the hypothesis that selected neurotrophic factors change in a manner consistent with an involvement in this model of spinal plasticity. Brain-derived neurotrophic factor (BDNF), neurotrophin-3 (NT-3), glial cell line-derived neurotrophic factor (GDNF), and transforming growth factor-beta(1) (TGF-beta(1)) concentrations were measured (ELISA) in three regions of interest to respiratory control: (1) ventral cervical spinal segments associated with the phrenic motor nucleus (C3-C6), (2) ventral thoracic spinal segments associated with inspiratory intercostal motor output (T3-T6) and (3) the diaphragm. Tissues were harvested from rats 7 d after bilateral CDR and compared with sham-operated and unoperated control rats. CDR increased BDNF (110%; p = 0.002) and NT-3 (100%; p = 0.002) in the cervical and NT-3 in the thoracic spinal cord (98%; p = 0.009). GDNF and TGF-beta(1) were not altered by CDR in any tissue. Immunohistochemistry localized BDNF and NT-3 to motoneurons and interneurons of the ventral spinal cord. These studies provide novel, suggestive evidence that BDNF and NT-3, possibly through their trophic effects on serotonergic neurons and/or motoneurons, may underlie serotonin-dependent plasticity in (spinal) respiratory motor control after CDR.

Activity-dependent plasticity of descending synaptic inputs to spinal motoneurons in an in vitro turtle brainstem-spinal cord preparation

An in vitro brainstem-spinal cord preparation from adult turtles was used to test the hypothesis that descending synaptic inputs to multifunctional spinal motoneurons (i.e., involved in respiration and locomotion) express activity-dependent depression or potentiation. The tissue was placed in a chamber that allowed for separate superfusion of the brainstem, spinal segments C(2)-C(4), and C(5)-D(1). Action potential conduction between the brainstem and spinal segments C(5)-D(1) was blocked by superfusing C(2)-C(4) with Na(+)-free solution. With C(5)-D(1) at [K(+)] = 10 mM, electrical stimulation at C(5) every 2 min evoked potentials in intact pectoralis (expiratory, inward rotation of shoulder) and serratus (inspiratory, outward rotation of shoulder) nerves that were stable for at least 2 hr. Application of conditioning stimulation (900 pulses at 1 or 10 Hz) at C(5) decreased pectoralis evoked potential amplitudes by approximately 40% initially and by 20% after 90 min; serratus evoked potentials were unaltered. Conditioning stimulation (100 Hz, 900 pulses) transiently depressed pectoralis evoked potential amplitude by <20% but produced a delayed 72% increase in serratus evoked potential amplitude after approximately 80 min. Conditioning stimulation (10 Hz) at C(5) also reduced the amplitude of sensory afferent evoked potentials in pectoralis produced by stimulating ipsilateral dorsal roots at C(8). Thus, long-lasting changes in descending synaptic inputs to multifunctional spinal motoneurons were frequency-dependent and heterosynaptic. We hypothesize that activity-dependent plasticity may modulate descending synaptic drive to spinal motoneurons involved in both respiration and locomotion.