Regional velopharyngeal compliance in the rat: influence of tongue muscle contraction

Exploring hypoglossal nerve stimulation therapy for obstructive sleep apnea: A comprehensive review of clinical and physiological upper airway outcomes

Obstructive sleep apnea (OSA) is a chronic disorder characterized by recurrent episodes of upper airway collapse during sleep, which can lead to serious health issues like cardiovascular disease and neurocognitive impairments. While positive airway pressure serves as the standard treatment, intolerance in some individuals necessitates exploration of alternative therapies. Hypoglossal nerve stimulation (HGNS) promises to mitigate OSA morbidity by stimulating the tongue muscles to maintain airway patency. However, its effectiveness varies, prompting research for optimization. This review summarizes the effects of HGNS on upper airway obstruction from human and animal studies. It examines physiological responses including critical closing pressure, maximal airflow, nasal and upper airway resistance, compliance, stiffness, and geometry. Interactions among these parameters and discrepant findings in animal and human studies are explored. Additionally, the review summarizes the impact of HGNS on established OSA metrics, such as the apnea-hypopnea index, oxygen desaturation index, and sleep arousals. Various therapeutic modalities, including selective unilateral or bilateral HGNS, targeted unilateral HGNS, and whole unilateral or bilateral HGNS, are discussed. This review consolidates our understanding of HGNS mechanisms, fostering exploration of under-investigated outcomes and approaches to drive advancements in HGNS therapy.

Critical to Know Pcrit: A Review on Pharyngeal Critical Closing Pressure in Obstructive Sleep Apnea

It is crucial to understand the underlying pathophysiology of obstructive sleep apnea (OSA). Upper airway collapsibility is an important pathophysiological factor that affects the upper airway in OSA. The aim of the current study was to review the existing body of knowledge on the pharyngeal collapsibility in OSA. After a thorough search through Medline, PubMed, Scopus, and Web of science, the relevant articles were found and used in this study. Critical closing pressure (Pcrit) is the gold standard measure for the degree of collapsibility of the pharyngeal airway. Various physiological factors and treatments affect upper airway collapsibility. Recently, it has been shown that the baseline value of Pcrit is helpful in the upfront selection of therapy options. The standard techniques to measure Pcrit are labor-intensive and time-consuming. Therefore, despite the importance of Pcrit, it is not routinely measured in clinical practice. New emerging surrogates, such as finite element (FE) modeling or the use of peak inspiratory flow measurements during a routine overnight polysomnography, may enable clinicians to have an estimate of the pharyngeal collapsibility. However, validation of these techniques is needed.

Muscles of Breathing: Development, Function, and Patterns of Activation

This review is a comprehensive description of all muscles that assist lung inflation or deflation in any way. The developmental origin, anatomical orientation, mechanical action, innervation, and pattern of activation are described for each respiratory muscle fulfilling this broad definition. In addition, the circumstances in which each muscle is called upon to assist ventilation are discussed. The number of "respiratory" muscles is large, and the coordination of respiratory muscles with "nonrespiratory" muscles and in nonrespiratory activities is complex-commensurate with the diversity of activities that humans pursue, including sleep (8.27). The capacity for speech and adoption of the bipedal posture in human evolution has resulted in patterns of respiratory muscle activation that differ significantly from most other animals. A disproportionate number of respiratory muscles affect the nose, mouth, pharynx, and larynx, reflecting the vital importance of coordinated muscle activity to control upper airway patency during both wakefulness and sleep. The upright posture has freed the hands from locomotor functions, but the evolutionary history and ontogeny of forelimb muscles pervades the patterns of activation and the forces generated by these muscles during breathing. The distinction between respiratory and nonrespiratory muscles is artificial, as many "nonrespiratory" muscles can augment breathing under conditions of high ventilator demand. Understanding the ontogeny, innervation, activation patterns, and functions of respiratory muscles is clinically useful, particularly in sleep medicine. Detailed explorations of how the nervous system controls the multiple muscles required for successful completion of respiratory behaviors will continue to be a fruitful area of investigation. © 2019 American Physiological Society. Compr Physiol 9:1025-1080, 2019.

Effects of targeted activation of tongue muscles on oropharyngeal patency in the rat

Laboratory rats were acutely implanted with an electrode array composed of eight independently controllable contacts applied to ventral and dorsal aspects of the left and right hypoglossal nerves (HGNs) and their branches. Bipolar intramuscular electromyographic (EMG) electrodes were implanted into the left and right genioglossus, hyoglossus and styloglossus muscles to identify which muscles were activated during stimulation via the contacts. Elicited movements, including changes in the position of the tongue and in the size and the shape of the airway, were documented video-graphically through a surgery microscope and an endoscope. Constant current electrical stimulation activated various combinations of electrode contacts and the stimulation patterns were correlated with corresponding oral movements, airway sizes, and EMG activities. Results demonstrate that graded responses and differential activation of the various tongue muscles are achievable by stimulation of specific contacts in the electrode array. These effects are interpreted to result from the targeted activation of regions of the nerve lying under and between the electrodes. Further testing established that the muscle responses elicited by unilateral electrical stimulation with the present approach can be smoothly graded, that the muscle responses resulted in opening of the airway and could be reliably maintained for long durations.

Peripharyngeal tissue deformation and stress distributions in response to caudal tracheal displacement: pivotal influence of the hyoid bone?

Caudal tracheal displacement (TD) leads to improvements in upper airway (UA) function and decreased collapsibility. To better understand the mechanisms underlying these changes, we examined effects of TD on peripharyngeal tissue stress distributions [i.e., extraluminal tissue pressure (ETP)], deformation of its topographical surface (UA lumen geometry), and hyoid bone position. We studied 13 supine, anesthetized, tracheostomized, spontaneously breathing, adult male New Zealand white rabbits. Graded TD was applied to the cranial tracheal segment from 0 to ∼10 mm. ETP was measured at six locations distributed around/along the length of the UA, covering three regions: tongue, hyoid, and epiglottis. Axial images of the UA (nasal choanae to glottis) were acquired with computed tomography and used to measure lumen geometry (UA length; regional cross-sectional area) and hyoid bone displacement. TD resulted in nonuniform decreases in ETP (generally greatest at tongue region), ranging from −0.07 (−0.11 to −0.03) [linear mixed-effects model slope (95% confidence interval)] to −0.27 (−0.31 to −0.23) cmH2O/mm TD, across all sites. UA length increased by 1.6 (1.5–1.8)%/mm, accompanied by nonuniform increases in cross-sectional area (greatest at hyoid region) ranging from 2.8 (1.7–3.9) to 4.9 (3.8–6.0)%/mm. The hyoid bone was displaced caudally by 0.22 (0.18–0.25) mm/mm TD. In summary, TD imposes a load on the UA that results in heterogeneous changes in peripharyngeal tissue stress distributions and resultant lumen geometry. The hyoid bone may play a pivotal role in redistributing applied caudal tracheal loads, thus modifying tissue deformation distributions and determining resultant UA geometry outcomes.

Alteration of functional loads after tongue volume reduction

OBJECTIVES

An earlier study revealed that the patterns of biomechanical loads on bones around the tongue altered significantly right after tongue volume reduction surgery. The current study was to examine whether these alterations persist or vanish over time post-surgery.

DESIGN

Five sibling pairs of 12-week-old Yucatan minipigs were used. For each pair, one had surgery reducing tongue volume by about 15% (reduction) while the other had same incisions without tissue removal (sham). All animals were raised for 4 weeks after surgery. Three rosette strain gauges were placed on the bone surfaces of pre-maxilla (PM), mandibular incisor (MI), and mandibular molar (MM); two single-element gauges were placed across the pre-maxilla-maxillar suture (PMS) and mandibular symphysis (MSP), and two pressure transducers were placed on the bone surfaces of hard palate (PAL) and mandibular body (MAN). These bone strains and pressures were recorded during natural mastication.

RESULTS

Overall amount of all loads increased significantly as compared to those in previous study in all animals. Instead of decreased loads in reduction animals as seen in that study, shear strains at PM, MI, and MM, tensile strains at PMS, and pressure at MAN were significantly higher in reduction than sham animals. Compared to the sham, strain dominance shifted at PM, MI, and MM and orientation of tensile strain altered at MI in reduction animals.

CONCLUSION

A healed volume-reduced tongue may change loading regime significantly by elevating loading and altering strain-dominant pattern and orientation on its surrounding structures, and these changes are more remarkable in mandibular than maxillary sites.

Tongue anatomy and physiology, the scientific basis for a novel targeted neurostimulation system designed for the treatment of obstructive sleep apnea

INTRODUCTION

 Obstructive sleep apnea (OSA) is a chronic condition that affects millions adults. The effective standard treatment is positive airway pressure (PAP). However, approximately half of the patients that are prescribed PAP are unable or unwilling to comply with this therapy. Untreated OSA ultimately leads to very serious comorbidities. An alternative therapy for this patient population, therefore, is desirable. Hypoglossal nerve (HGN) stimulation is under investigation by multiple groups as a possible alternative therapy for OSA.

OBJECTIVE

To understand the underlying mechanisms of actions related to HGN stimulation, and the implication of this knowledge for specifying and designing a neurostimulation system for the treatment of OSA.

RESULTS

 Loss of lingual and pharyngeal tone within a narrow airway is the primary mechanism for OSA. Posterior and anterior tongues are different in their anatomy and physiology. Muscle fibers in the posterior tongue are predominantly fatigue resistant that are responsible for the long sustained tonic activities required for maintaining the tongue's position and preventing its mass from falling into the retroglossal airway. The human tongue is a muscular hydrostat and hence would benefit from a sophisticated HGN stimulation system that is capable of achieving a concerted spatio-temporal interplay of multiple lingual muscles, including retrusors.

CONCLUSION

 Targeted neurostimulation of the proximal HGN presents as a viable system approach that is far more versatile and physiologic and quite different than prior systems.

Influence of tongue muscle contraction and transmural pressure on nasopharyngeal geometry in the rat

The mammalian pharynx is a hollow muscular tube that participates in ingestion and respiration, and its size, shape, and stiffness can be altered by contraction of skeletal muscles that lie inside or outside of its walls. MRI was used to determine the interaction between pharyngeal pressure and selective stimulation of extrinsic tongue muscles on the shape of the rat nasopharynx. Pressure (-9, -6, -3, 3, 6, and 9 cmH₂O) was applied randomly to the isolated pharyngeal airway of anesthetized rats that were positioned in a 4.7-T MRI scanner. The anterior-posterior (AP) and lateral diameters of the nasopharynx were measured in eight axial slices at each level of pressure, with and without bilateral hypoglossal nerve stimulation (0.1-ms pulse, 1/3 maximal force, 80 Hz). The rat nasopharynx is nearly circular, and positive pharyngeal pressure caused similar expansion of AP and lateral diameters; as a result, airway shape (ratio of lateral to AP diameter) remained constant. Negative pressure did not change AP or lateral diameter significantly, suggesting that a negative pressure reflex activated the tongue or other pharyngeal muscles. Stimulation of tongue protrudor muscles alone or coactivation of protrudor and retractor muscles caused greater AP than lateral expansion, making the nasopharynx slightly more elliptical, with the long axis in the AP direction. These effects tended to be more pronounced at negative pharyngeal pressures and greater in the caudal than rostral nasopharynx. These data show that stimulation of rodent tongue muscles can adjust pharyngeal shape, extending previous work showing that tongue muscle contraction alters pharyngeal compliance and volume, and provide physiological insight that can be applied to the treatment of obstructive sleep apnea.

Respiratory modulation of the pharyngeal airway in lean and obese mice

Obesity is an important risk factor for pharyngeal airway collapse in obstructive sleep apnea (OSA). To examine the effect of obesity on pharyngeal airway size on inspiration and expiration, respiratory-gated MRI of the pharynx was compared in New Zealand obese (NZO) and New Zealand white (NZW) mice (weights: 50.4g vs. 34.7g, p<0.0001).

RESULTS

(1) pharyngeal airway cross-sectional area was greater during inspiration than expiration in NZO mice, but in NZW mice airway area was greater in expiration than inspiration; (2) inspiratory-to-expiratory changes in both mouse strains were largest in the caudal pharynx; and (3) during expiration, airway size tended to be larger, though non-significantly, in NZW than NZO mice. The respiratory pattern differences are likely attributable to obesity that is the main difference between NZO and NZW mice. The data support an hypothesis that pharyngeal airway patency in obesity is dependent on inspiratory dilation and may be vulnerable to loss of neuromuscular pharyngeal activation.

Influence of tongue muscle contraction and dynamic airway pressure on velopharyngeal volume in the rat

The mammalian pharynx is a collapsible tube that narrows during inspiration as transmural pressure becomes negative. The velopharynx (VP), which lies posterior to the soft palate, is considered to be one of the most collapsible pharyngeal regions. I tested the hypothesis that negative transmural pressure would narrow the VP, and that electrical stimulation of extrinsic tongue muscles would reverse this effect. Pressure (−6, −3, 3, and 6 cmH2O) was applied to the isolated pharyngeal airway of anesthetized rats that were positioned in a 4.7-T MRI scanner. The volume of eight axial slices encompassing the length of the VP was computed at each level of pressure, with and without bilateral hypoglossal nerve stimulation (0.1-ms pulse, one-third maximum force, 80 Hz). Negative pressure narrowed the VP, and either whole hypoglossal nerve stimulation (coactivation of protrudor and retractor muscles) or medial nerve branch stimulation (independent activation of tongue protrudor muscles) reversed this effect, with the greatest impact in the caudal one-third of the VP. The dilating effects of medial branch stimulation were slightly larger than whole nerve stimulation. Positive pressure dilated the VP, but tongue muscle contraction did not cause further dilation under these conditions. I conclude that the narrowest and most collapsible segment of the rat pharynx is in the caudal VP, posterior to the tip of the soft palate. Either coactivation of protrudor and retractor muscles or independent contraction of protrudor muscles caused dilation of this region, but the latter was slightly more effective.