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Chan PYS, Lee LY, Davenport PW. Neural mechanisms of respiratory interoception. Auton Neurosci 2024; 253:103181. [PMID: 38696917 DOI: 10.1016/j.autneu.2024.103181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/03/2024] [Accepted: 04/22/2024] [Indexed: 05/04/2024]
Abstract
Respiratory interoception is one of the internal bodily systems that is comprised of different types of somatic and visceral sensations elicited by different patterns of afferent input and respiratory motor drive mediating multiple respiratory modalities. Respiratory interoception is a complex system, having multiple afferents grouped into afferent clusters and projecting into both discriminative and affective centers that are directly related to the behavioral assessment of breathing. The multi-afferent system provides a spectrum of input that result in the ability to interpret the different types of respiratory interceptive sensations. This can result in a response, commonly reported as breathlessness or dyspnea. Dyspnea can be differentiated into specific modalities. These respiratory sensory modalities lead to a general sensation of an Urge-to-Breathe, driven by a need to compensate for the modulation of ventilation that has occurred due to factors that have affected breathing. The multiafferent system for respiratory interoception can also lead to interpretation of the sensory signals resulting in respiratory related sensory experiences, including the Urge-to-Cough and Urge-to-Swallow. These behaviors are modalities that can be driven through the differentiation and integration of multiple afferent input into the respiratory neural comparator. Respiratory sensations require neural somatic and visceral interoceptive elements that include gated attention and detection leading to respiratory modality discrimination with subsequent cognitive decision and behavioral compensation. Studies of brain areas mediating cortical and subcortical respiratory sensory pathways are summarized and used to develop a model of an integrated respiratory neural network mediating respiratory interoception.
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Affiliation(s)
- Pei-Ying Sarah Chan
- Department of Occupational Therapy, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Psychiatry, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
| | - Lu-Yuan Lee
- Department of Physiology, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Paul W Davenport
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL, USA.
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2
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Tunnell NC, Corner SE, Roque AD, Kroll JL, Ritz T, Meuret AE. Biobehavioral approach to distinguishing panic symptoms from medical illness. Front Psychiatry 2024; 15:1296569. [PMID: 38779550 PMCID: PMC11109415 DOI: 10.3389/fpsyt.2024.1296569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/19/2024] [Indexed: 05/25/2024] Open
Abstract
Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.
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Affiliation(s)
- Natalie C. Tunnell
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Psychiatry & Behavioral Sciences, The University of Kansas Medical Center, Kansas City, KS, United States
| | - Sarah E. Corner
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Andres D. Roque
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Primary Care Department, Miami VA Healthcare System, Miami, FL, United States
| | - Juliet L. Kroll
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Thomas Ritz
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Alicia E. Meuret
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
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3
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Burt JS, Davenport MP, Welch JF, Davenport PW. fNIRS analysis of rostral prefrontal cortex activity and perception of inspiratory loads. Respir Physiol Neurobiol 2023; 316:104113. [PMID: 37442516 DOI: 10.1016/j.resp.2023.104113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 06/20/2023] [Accepted: 07/09/2023] [Indexed: 07/15/2023]
Abstract
It is well-established that the brainstem is responsible for the automatic control of breathing, however, cortical areas control perception and conscious breathing. This study investigated activity in the prefrontal cortex (PFC) during breathing difficulty using functional near-infrared spectroscopy (fNIRS). It was hypothesized that extrinsic inspiratory loads will elicit regional changes in PFC activity and increased perception ratings, as a function of load magnitude and type. Participants were exposed to varying magnitudes of resistive (R) and pressure threshold (PT) inspiratory loads to increase breathing effort. Perception ratings of breathing effort and load magnitude were positively correlated (p < 0.05). PT loads were rated more effortful than R loads (p < 0.05). Differences in perceived effort were a function of inspiratory pressure-time-product (PTP) and inspiratory work of breathing (WoB). PFC activity increased with the largest PT load (p < 0.01), suggesting that the PFC is involved in processing respiratory stimuli. The results support the hypothesis that the PFC is an element of the neural network mediating effortful breathing perception.
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Affiliation(s)
- Juliana S Burt
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, 1333 Center Drive, Gainesville, FL 32610, USA
| | - Matthew P Davenport
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, 1333 Center Drive, Gainesville, FL 32610, USA
| | - Joseph F Welch
- Department of Physical Therapy, College of Veterinary Medicine, University of Florida, 1333 Center Drive, Gainesville, FL 32610, USA; School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Paul W Davenport
- Department of Physiological Sciences, College of Veterinary Medicine, University of Florida, 1333 Center Drive, Gainesville, FL 32610, USA.
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4
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Aucoin R, Lewthwaite H, Ekström M, von Leupoldt A, Jensen D. Impact of trigeminal nerve and/or olfactory nerve stimulation on activity of human brain regions involved in the perception of breathlessness. Respir Physiol Neurobiol 2023; 311:104036. [PMID: 36804472 DOI: 10.1016/j.resp.2023.104036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/07/2023] [Accepted: 02/12/2023] [Indexed: 02/17/2023]
Abstract
Breathlessness is a centrally processed symptom, as evidenced by activation of distinct brain regions such as the insular cortex and amygdala, during the anticipation and/or perception of breathlessness. Inhaled L-menthol or blowing cool air to the face/nose, both selective trigeminal nerve (TGN) stimulants, relieve breathlessness without concurrent improvements in physiological outcomes (e.g., breathing pattern), suggesting a possible but hitherto unexplored central mechanism of action. Four databases were searched to identify published reports supporting a link between TGN stimulation and activation of brain regions involved in the anticipation and/or perception of breathlessness. The collective results of the 29 studies demonstrated that TGN stimulation activated 12 brain regions widely implicated in the anticipation and/or perception of breathlessness, including the insular cortex and amygdala. Inhaled L-menthol or cool air to the face activated 75% and 33% of these 12 brain regions, respectively. Our findings support the hypothesis that TGN stimulation contributes to breathlessness relief by altering the activity of brain regions involved in its central neural processing.
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Affiliation(s)
- Rachelle Aucoin
- Clinical Exercise & Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, McGill University, 475 Pine Avenue West, Montréal, Quebec H2W 1S4, Canada.
| | - Hayley Lewthwaite
- College of Engineering, Science and Environment, School of Environment & Life Sciences, The University of Newcastle, 10 Chittaway Road, Ourimbah, NSW 2258, Australia
| | - Magnus Ekström
- Department of Respiratory Medicine, Allergology and Palliative Medicine, Institution for Clinical Sciences in Lund, Lund University, SE-221 00 Lund, Sweden
| | - Andreas von Leupoldt
- Health Psychology, University of Leuven, Tiensestraat 102 Box 3726, 3000 Leuven, Belgium
| | - Dennis Jensen
- Clinical Exercise & Respiratory Physiology Laboratory, Department of Kinesiology and Physical Education, McGill University, 475 Pine Avenue West, Montréal, Quebec H2W 1S4, Canada; Research Institute of the McGill University Health Centre, Translational Research in Respiratory Diseases Program and Respiratory Epidemiology and Clinical Research Unit, 2155 Guy Street Suite 500, Montréal, Quebec H3H 2R9, Canada
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5
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Ferreira DH, Kochovska S, McNeill R, Currow DC. Current pharmacological strategies for symptomatic reduction of persistent breathlessness - a literature review. Expert Opin Pharmacother 2023; 24:233-244. [PMID: 36525673 DOI: 10.1080/14656566.2022.2160239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Persistent breathlessness is a debilitating symptom that is prevalent in the community, particularly in people with chronic and life-limiting illnesses. Treatment includes different steps, including pharmacological treatment aiming to improve the symptom and optimize people's wellbeing. AREAS COVERED PubMed and Google Scholar were screened using 'chronic breathlessness' OR 'persistent breathlessness,' AND 'pharmacological treatment,' OR 'opioids.' This review focuses on pharmacological treatments to reduce persistent breathlessness and discusses possible mechanisms involved in the process of breathlessness reduction through pharmacotherapy. Research gaps in the field of persistent breathlessness research are outlined, and future research directions are suggested. EXPERT OPINION Regular, low-dose (≤30 mg/day), sustained-release morphine is recommended as the first-line pharmacological treatment for persistent breathlessness. Inter-individual variation in response needs to be investigated in future studies in order to optimize clinical outcomes. This includes 1) better understanding the centrally mediated mechanisms associated with persisting breathlessness and response to pharmacological therapies, 2) understanding benefit from the perspective of people experiencing persistent breathlessness, small and meaningful gains in physical activity.
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Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
| | - Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, 2007, Ultimo, Australia
| | - Richard McNeill
- Department of palliative care, Nurse Maude Hospice, 8014, Christchurch, New Zealand.,Department of Medicine, University of Otago, 8011, Christchurch, New Zealand
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
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6
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Betka S, Adler D, Similowski T, Blanke O. Breathing control, brain, and bodily self-consciousness: Toward immersive digiceuticals to alleviate respiratory suffering. Biol Psychol 2022; 171:108329. [PMID: 35452780 DOI: 10.1016/j.biopsycho.2022.108329] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 04/11/2022] [Accepted: 04/11/2022] [Indexed: 01/19/2023]
Abstract
Breathing is peculiar among autonomic functions through several characteristics. It generates a very rich afferent traffic from an array of structures belonging to the respiratory system to various areas of the brain. It is intimately associated with bodily movements. It bears particular relationships with consciousness as its efferent motor control can be automatic or voluntary. In this review within the scope of "respiratory neurophysiology" or "respiratory neuroscience", we describe the physiological organisation of breathing control. We then review findings linking breathing and bodily self-consciousness through respiratory manipulations using virtual reality (VR). After discussing the currently admitted neurophysiological model for dyspnea, as well as a new Bayesian model applied to breathing control, we propose that visuo-respiratory paradigms -as developed in cognitive neuroscience- will foster insights into some of the basic mechanisms of the human respiratory system and will also lead to the development of immersive VR-based digital health tools (i.e. digiceuticals).
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Affiliation(s)
- Sophie Betka
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Ecole Polytechnique Fédérale de Lausanne, (EPFL), Geneva 1202, Switzerland.
| | - Dan Adler
- Division of Lung Diseases, University Hospital and Geneva Medical School, University of Geneva, Switzerland
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France; AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S (Respiration, Réanimation, Réhabilitation respiratoire, Sommeil), F-75013 Paris, France
| | - Olaf Blanke
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Ecole Polytechnique Fédérale de Lausanne, (EPFL), Geneva 1202, Switzerland; Department of Clinical Neurosciences, University Hospital and Geneva Medical School, University of Geneva, Switzerland
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7
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Affiliation(s)
- Toby N Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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8
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Abstract
Opiates, such as morphine, and synthetic opioids, such as fentanyl, constitute a class of drugs acting on opioid receptors which have been used therapeutically and recreationally for centuries. Opioid drugs have strong analgesic properties and are used to treat moderate to severe pain, but also present side effects including opioid dependence, tolerance, addiction, and respiratory depression, which can lead to lethal overdose if not treated. This chapter explores the pathophysiology, the neural circuits, and the cellular mechanisms underlying opioid-induced respiratory depression and provides a translational perspective of the most recent research. The pathophysiology discussed includes the effects of opioid drugs on the respiratory system in patients, as well as the animal models used to identify underlying mechanisms. Using a combination of gene editing and pharmacology, the neural circuits and molecular pathways mediating neuronal inhibition by opioids are examined. By using pharmacology and neuroscience approaches, new therapies to prevent or reverse respiratory depression by opioid drugs have been identified and are currently being developed. Considering the health and economic burden associated with the current opioid epidemic, innovative research is needed to better understand the side effects of opioid drugs and to discover new therapeutic solutions to reduce the incidence of lethal overdoses.
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9
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Abstract
The clinical term dyspnea (a.k.a. breathlessness or shortness of breath) encompasses at least three qualitatively distinct sensations that warn of threats to breathing: air hunger, effort to breathe, and chest tightness. Air hunger is a primal homeostatic warning signal of insufficient alveolar ventilation that can produce fear and anxiety and severely impacts the lives of patients with cardiopulmonary, neuromuscular, psychological, and end-stage disease. The sense of effort to breathe informs of increased respiratory muscle activity and warns of potential impediments to breathing. Most frequently associated with bronchoconstriction, chest tightness may warn of airway inflammation and constriction through activation of airway sensory nerves. This chapter reviews human and functional brain imaging studies with comparison to pertinent neurorespiratory studies in animals to propose the interoceptive networks underlying each sensation. The neural origins of their distinct sensory and affective dimensions are discussed, and areas for future research are proposed. Despite dyspnea's clinical prevalence and impact, management of dyspnea languishes decades behind the treatment of pain. The neurophysiological bases of current therapeutic approaches are reviewed; however, a better understanding of the neural mechanisms of dyspnea may lead to development of novel therapies and improved patient care.
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Affiliation(s)
- Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, United States; Faculty of Health Sciences, Virginia Tech, Blacksburg, VA, United States.
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10
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Harrison OK, Köchli L, Marino S, Luechinger R, Hennel F, Brand K, Hess AJ, Frässle S, Iglesias S, Vinckier F, Petzschner FH, Harrison SJ, Stephan KE. Interoception of breathing and its relationship with anxiety. Neuron 2021; 109:4080-4093.e8. [PMID: 34672986 PMCID: PMC8691949 DOI: 10.1016/j.neuron.2021.09.045] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 09/01/2021] [Accepted: 09/23/2021] [Indexed: 01/22/2023]
Abstract
Interoception, the perception of internal bodily states, is thought to be inextricably linked to affective qualities such as anxiety. Although interoception spans sensory to metacognitive processing, it is not clear whether anxiety is differentially related to these processing levels. Here we investigated this question in the domain of breathing, using computational modeling and high-field (7 T) fMRI to assess brain activity relating to dynamic changes in inspiratory resistance of varying predictability. Notably, the anterior insula was associated with both breathing-related prediction certainty and prediction errors, suggesting an important role in representing and updating models of the body. Individuals with low versus moderate anxiety traits showed differential anterior insula activity for prediction certainty. Multi-modal analyses of data from fMRI, computational assessments of breathing-related metacognition, and questionnaires demonstrated that anxiety-interoception links span all levels from perceptual sensitivity to metacognition, with strong effects seen at higher levels of interoceptive processes.
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Affiliation(s)
- Olivia K Harrison
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland; Department of Psychology, University of Otago, Dunedin, New Zealand; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | - Laura Köchli
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Stephanie Marino
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Roger Luechinger
- Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Franciszek Hennel
- Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Katja Brand
- Department of Psychology, University of Otago, Dunedin, New Zealand
| | - Alexander J Hess
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Stefan Frässle
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Sandra Iglesias
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Fabien Vinckier
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland; Université de Paris, Paris, France; Department of Psychiatry, Service Hospitalo-Universitaire, GHU Paris Psychiatrie & Neurosciences, Paris, France
| | - Frederike H Petzschner
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Samuel J Harrison
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Klaas E Stephan
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland; Max Planck Institute for Metabolism Research, Cologne, Germany
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11
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Harrison OK, Hayen A, Wager TD, Pattinson KT. Investigating the specificity of the neurologic pain signature against breathlessness and finger opposition. Pain 2021; 162:2933-2944. [PMID: 33990110 PMCID: PMC8600542 DOI: 10.1097/j.pain.0000000000002327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT Brain biomarkers of pain, including pain-predictive "signatures" based on brain activity, can provide measures of neurophysiological processes and potential targets for interventions. A central issue relates to the specificity of such measures, and understanding their current limits will both advance their development and explore potentially generalizable properties of pain to other states. Here, we used 2 data sets to test the neurologic pain signature (NPS), an established pain neuromarker. In study 1, brain activity was measured using high-field functional magnetic resonance imaging (7T fMRI, N = 40) during 5 to 25 seconds of experimental breathlessness (induced by inspiratory resistive loading), conditioned breathlessness anticipation, and finger opposition. In study 2, we assessed anticipation and breathlessness perception (3T, N = 19) under blinded saline (placebo) and remifentanil administration. The NPS responded to breathlessness, anticipation, and finger opposition, although no direct comparisons with painful events were possible. Local NPS patterns in anterior or midinsula, S2, and dorsal anterior cingulate responded to breathlessness and finger opposition and were reduced by remifentanil. Local NPS responses in the dorsal posterior insula did not respond to any manipulations. Therefore, significant global NPS activity alone is not specific for pain, and we offer insight into the overlap between NPS responses, breathlessness, and somatomotor demand.
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Affiliation(s)
- Olivia K. Harrison
- Translational Neuromodeling Unit, Institute of Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
- School of Pharmacy, University of Otago, New Zealand
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Wellcome Centre for NeuroImaging, University of Oxford, Oxford, United Kingdom
| | - Anja Hayen
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Wellcome Centre for NeuroImaging, University of Oxford, Oxford, United Kingdom
- School of Psychology & Clinical Language Sciences, University of Reading, Reading, United Kingdom
| | - Tor D. Wager
- USA Department of Psychological and Brain Sciences, Dartmouth College, Hanover, United States.
| | - Kyle T.S. Pattinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
- Wellcome Centre for NeuroImaging, University of Oxford, Oxford, United Kingdom
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12
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Palkovic B, Marchenko V, Zuperku EJ, Stuth EAE, Stucke AG. Multi-Level Regulation of Opioid-Induced Respiratory Depression. Physiology (Bethesda) 2021; 35:391-404. [PMID: 33052772 DOI: 10.1152/physiol.00015.2020] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Opioids depress minute ventilation primarily by reducing respiratory rate. This results from direct effects on the preBötzinger Complex as well as from depression of the Parabrachial/Kölliker-Fuse Complex, which provides excitatory drive to preBötzinger Complex neurons mediating respiratory phase-switch. Opioids also depress awake drive from the forebrain and chemodrive.
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Affiliation(s)
- Barbara Palkovic
- Medical College of Wisconsin, Milwaukee, Wisconsin.,Faculty of Medicine, University of Osijek, Osijek, Croatia
| | | | - Edward J Zuperku
- Medical College of Wisconsin, Milwaukee, Wisconsin.,Zablocki VA Medical Center, Milwaukee, Wisconsin
| | - Eckehard A E Stuth
- Medical College of Wisconsin, Milwaukee, Wisconsin.,Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Astrid G Stucke
- Medical College of Wisconsin, Milwaukee, Wisconsin.,Children's Hospital of Wisconsin, Milwaukee, Wisconsin
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13
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Vinckier F, Betka S, Nion N, Serresse L, Similowski T. Harnessing the power of anticipation to manage respiratory-related brain suffering and ensuing dyspnoea: insights from the neurobiology of the respiratory nocebo effect. Eur Respir J 2021; 58:58/3/2101876. [PMID: 34556533 DOI: 10.1183/13993003.01876-2021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 08/09/2021] [Indexed: 12/29/2022]
Affiliation(s)
- Fabien Vinckier
- Université de Paris, Paris, France.,Dept of Psychiatry, Service Hospitalo-Universitaire, GHU Paris Psychiatry and Neurosciences, Paris, France
| | - Sophie Betka
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Swiss Federal Institute of Technology (EPFL), Geneva, Switzerland
| | - Nathalie Nion
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, UMRS1158, Sorbonne Université, Paris, France.,Département R3S (Respiration, Réanimation, Réhabilitation respiratoire, Sommeil), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Laure Serresse
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, UMRS1158, Sorbonne Université, Paris, France.,Equipe mobile de soins palliatifs, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Thomas Similowski
- Neurophysiologie Respiratoire Expérimentale et Clinique, INSERM, UMRS1158, Sorbonne Université, Paris, France .,Département R3S (Respiration, Réanimation, Réhabilitation respiratoire, Sommeil), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
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14
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Zemel RA. Pharmacologic and Non-Pharmacologic Dyspnea Management in Advanced Cancer Patients. Am J Hosp Palliat Care 2021; 39:847-855. [PMID: 34510917 DOI: 10.1177/10499091211040436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As there is a high propensity for patients with advanced malignancy to experience refractory dyspnea, it is necessary for physicians to be well-versed in the management of these patients' dyspneic symptoms. For symptomatic treatment of cancer patients with dyspnea, both pharmacologic and non-pharmacologic methods should be considered. The main source of pharmacologic symptom management for dyspnea is oral and parenteral opioids; benzodiazepines and corticosteroids may serve as helpful adjuncts alongside opioid treatments. However, oxygen administration and nebulized loop diuretics have not been shown to clinically benefit dyspneic cancer patients. Applying non-pharmacologic dyspnea management methods may be valuable palliative therapies for advanced cancer patients, as they provide benefit with negligible harm to the patient. Advantageous and minimally harmful non-pharmacologic dyspnea therapies include facial airflow, acupuncture and/or acupressure, breathing exercises, cognitive behavioral therapy, music therapy, and spiritual interventions. Thus, it is vital that physicians are prepared to provide symptomatic care for dyspnea in advanced cancer patients as to minimize suffering in this patient population during definitive cancer treatments or hospice care.
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Affiliation(s)
- Rachel A Zemel
- MedStar Georgetown University Hospital, Brookeville, MD, USA
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15
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Pfabigan DM, Rütgen M, Kroll SL, Riečanský I, Lamm C. The administration of the opioid buprenorphine decreases motivational error signals. Psychoneuroendocrinology 2021; 128:105199. [PMID: 33933894 DOI: 10.1016/j.psyneuen.2021.105199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/07/2021] [Accepted: 03/09/2021] [Indexed: 11/25/2022]
Abstract
While opioid addiction has reached pandemic proportions, we still lack a good understanding of how the administration of opioids interacts with cognitive functions. Error processing - the ability to detect erroneous actions and correct one's behaviour afterwards - is one such cognitive function that might be susceptible to opioidergic influences. Errors are hypothesised to induce aversive negative arousal, while opioids have been suggested to reduce aversive arousal induced by unpleasant and stressful stimuli. Thus, this study investigated whether the acute administration of an opioid would affect error processing. In a double-blind between-subject study, 42 male volunteers were recruited and received either 0.2 mg buprenorphine (a partial µ-opioid receptor agonist and κ-opioid receptor antagonist) or a placebo pill before they performed a stimulus-response task provoking errors. Electroencephalograms (EEG) were recorded while participants performed the task. We observed no group differences in terms of reaction times, error rates, and affective state ratings during the task between buprenorphine and control participants. Additional measures of adaptive control, however, showed interfering effects of buprenorphine administration. On the neural level, decreased Pe (Error Positivity) amplitudes were found in buprenorphine compared to control participants following error commission. Further, frontal delta oscillations were decreased in the buprenorphine group after all responses. Our neural results jointly demonstrate a general reduction in error processing in those participants who received an opioid before task completion, thereby suggesting that opioids might have indeed the potential to dampen motivational error signals. Importantly, the effects of the opioid were evident in more elaborate error processing stages, thereby impacting on processes of conscious error appraisal and evidence accumulation.
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Affiliation(s)
- D M Pfabigan
- Department of Behavioural Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Sognsvannsveien 9, 0372 Oslo, Norway; Social, Cognitive and Affective Neuroscience Unit, Department of Cognition, Emotion, and Methods in Psychology, Faculty of Psychology, University of Vienna, Liebiggasse 5, 1010 Vienna, Austria.
| | - M Rütgen
- Social, Cognitive and Affective Neuroscience Unit, Department of Cognition, Emotion, and Methods in Psychology, Faculty of Psychology, University of Vienna, Liebiggasse 5, 1010 Vienna, Austria.
| | - S L Kroll
- Center for Social and Affective Neuroscience, Department of Biomedical and Clinical Sciences, Linköping University, Psychiatry Building, Entrance 27, Floor 9, 581 85 Linköping, Sweden.
| | - I Riečanský
- Social, Cognitive and Affective Neuroscience Unit, Department of Cognition, Emotion, and Methods in Psychology, Faculty of Psychology, University of Vienna, Liebiggasse 5, 1010 Vienna, Austria; Department of Behavioural Neuroscience, Institute of Normal and Pathological Physiology, Centre of Experimental Medicine, Slovak Academy of Sciences, Sienkiewiczova 1, Bratislava 81371, Slovakia.
| | - C Lamm
- Social, Cognitive and Affective Neuroscience Unit, Department of Cognition, Emotion, and Methods in Psychology, Faculty of Psychology, University of Vienna, Liebiggasse 5, 1010 Vienna, Austria.
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16
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Finnegan SL, Harrison OK, Harmer CJ, Herigstad M, Rahman NM, Reinecke A, Pattinson KTS. Breathlessness in COPD: linking symptom clusters with brain activity. Eur Respir J 2021; 58:13993003.04099-2020. [PMID: 33875493 PMCID: PMC8607925 DOI: 10.1183/13993003.04099-2020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 04/04/2021] [Indexed: 11/11/2022]
Abstract
Background Current models of breathlessness often fail to explain disparities between patients' experiences of breathlessness and objective measures of lung function. While a mechanistic understanding of this discordance has thus far remained elusive, factors such as mood, attention and expectation have all been implicated as important modulators of breathlessness. Therefore, we have developed a model to better understand the relationships between these factors using unsupervised machine learning techniques. Subsequently we examined how expectation-related brain activity differed between these symptom-defined clusters of participants. Methods A cohort of 91 participants with mild-to-moderate chronic obstructive pulmonary disease (COPD) underwent functional brain imaging, self-report questionnaires and clinical measures of respiratory function. Unsupervised machine learning techniques of exploratory factor analysis and hierarchical cluster modelling were used to model brain–behaviour–breathlessness links. Results We successfully stratified participants across four key factors corresponding to mood, symptom burden and two capability measures. Two key groups resulted from this stratification, corresponding to high and low symptom burden. Compared with the high symptom burden group, the low symptom burden group demonstrated significantly greater brain activity within the anterior insula, a key region thought to be involved in monitoring internal bodily sensations (interoception). Conclusions This is the largest functional neuroimaging study of COPD to date, and is the first to provide a clear model linking brain, behaviour and breathlessness expectation. Furthermore, it was possible to stratify participants into groups, which then revealed differences in brain activity patterns. Together, these findings highlight the value of multimodal models of breathlessness in identifying behavioural phenotypes and for advancing understanding of differences in breathlessness burden. Towards individualised treatments for chronic breathlessness with functional neuroimaging: revealing the factors underlying the breathlessness experience in COPDhttps://bit.ly/3a8fXPt
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Affiliation(s)
- Sarah L Finnegan
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Olivia K Harrison
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.,Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland.,School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Catherine J Harmer
- Department of Psychiatry, Medical Sciences, University of Oxford, Oxford, UK.,Oxford Health NHS foundation Trust, Warneford Hospital, Oxford, UK
| | - Mari Herigstad
- Department of Biosciences and Chemistry, Sheffield Hallam University, Sheffield, UK
| | - Najib M Rahman
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Andrea Reinecke
- School of Pharmacy, University of Otago, Dunedin, New Zealand.,Department of Psychiatry, Medical Sciences, University of Oxford, Oxford, UK.,Oxford Health NHS foundation Trust, Warneford Hospital, Oxford, UK
| | - Kyle T S Pattinson
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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17
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Vlemincx E, Sprenger C, Büchel C. Expectation and dyspnea: The neurobiological basis of respiratory nocebo effects. Eur Respir J 2021; 58:13993003.03008-2020. [PMID: 33574073 DOI: 10.1183/13993003.03008-2020] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 01/31/2021] [Indexed: 11/05/2022]
Abstract
Cues such as odours that do not per se evoke bronchoconstriction can become triggers of asthma exacerbations. Despite its clinical significance, the neural basis of this respiratory nocebo effect is unknown. We investigated this effect in a functional magnetic resonance imaging (fMRI) study involving 36 healthy volunteers. The experiment consisted of an Experience phase in which volunteers experienced dyspnea while being exposed to an odorous gas ("Histarinol"). Volunteers were told that "Histarinol" induces dyspnea by bronchoconstriction. This was compared to another odorous gas which did not evoke dyspnea. Actually, dyspnea was induced by a concealed, resistive load inserted into the breathing system. In a second, Expectation phase, Histarinol and the control gas were both followed by an identical, very mild load. Respiration parameters were continuously recorded and after each trial participants rated dyspnea intensity. Dyspnea ratings were significantly higher in Histarinol compared to control conditions, both in the Experience and in the Expectation phase, despite identical physical resistance in the Expectation phase. Insula fMRI signal matched the actual load, i.e. a significant difference between Histarinol and Control in the Experience phase, but no difference in the Expectation phase. The periaqueductal gray showed a significantly higher fMRI signal during the expectation of dyspnea. Finally, Histarinol related deactivations during the Expectation phase in the rostral anterior cingulate cortex mirror similar responses for nocebo effects in pain. These findings highlight the neural basis of expectation effects associated with dyspnea, which has important consequences for our understanding of the perception of respiratory symptoms.
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Affiliation(s)
- Elke Vlemincx
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany .,Department of Health Sciences, VU University Amsterdam, Amsterdam, The Netherlands
| | - Christian Sprenger
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Anaesthesiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Büchel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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18
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Abstract
The sensation that develops as a long breath hold continues is what this article is about. We term this sensation of an urge to breathe "air hunger." Air hunger, a primal sensation, alerts us to a failure to meet an urgent homeostatic need maintaining gas exchange. Anxiety, frustration, and fear evoked by air hunger motivate behavioral actions to address the failure. The unpleasantness and emotional consequences of air hunger make it the most debilitating component of clinical dyspnea, a symptom associated with respiratory, cardiovascular, and metabolic diseases. In most clinical populations studied, air hunger is the predominant form of dyspnea (colloquially, shortness of breath). Most experimental subjects can reliably quantify air hunger using rating scales, that is, there is a consistent relationship between stimulus and rating. Stimuli that increase air hunger include hypercapnia, hypoxia, exercise, and acidosis; tidal expansion of the lungs reduces air hunger. Thus, the defining experimental paradigm to evoke air hunger is to elevate the drive to breathe while mechanically restricting ventilation. Functional brain imaging studies have shown that air hunger activates the insular cortex (an integration center for perceptions related to homeostasis, including pain, food hunger, and thirst), as well as limbic structures involved with anxiety and fear. Although much has been learned about air hunger in the past few decades, much remains to be discovered, such as an accepted method to quantify air hunger in nonhuman animals, fundamental questions about neural mechanisms, and adequate and safe methods to mitigate air hunger in clinical situations. © 2021 American Physiological Society. Compr Physiol 11:1449-1483, 2021.
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Lansing
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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19
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Higginson IJ, Reilly CC, Maddocks M. Breathlessness. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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20
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Abstract
Blood oxygen level dependent (BOLD) fMRI is a common technique for measuring brain activation that could be affected by low-level carbon monoxide (CO) exposure from, e.g. smoking. This study aimed to probe the vulnerability of BOLD fMRI to CO and determine whether it may constitute a significant neuroimaging confound. Low-level (6 ppm exhaled) CO effects on BOLD response were assessed in 12 healthy never-smokers on two separate experimental days (CO and air control). fMRI tasks were breath-holds (hypercapnia), visual stimulation and fingertapping. BOLD fMRI response was lower during breath holds, visual stimulation and fingertapping in the CO protocol compared to the air control protocol. Behavioural and physiological measures remained unchanged. We conclude that BOLD fMRI might be vulnerable to changes in baseline CO, and suggest exercising caution when imaging populations exposed to elevated CO levels. Further work is required to fully elucidate the impact on CO on fMRI and its underlying mechanisms.
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Affiliation(s)
- Caroline Bendell
- Biological and Medical Sciences, Oxford Brookes University, Oxford, UK
| | - Shakeeb H Moosavi
- Biological and Medical Sciences, Oxford Brookes University, Oxford, UK
| | - Mari Herigstad
- Biomolecular Sciences Research Centre, Department of Biosciences and Chemistry, Sheffield Hallam University, Sheffield, UK
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21
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Johnson MJ, Currow DC. Opioids for breathlessness: a narrative review. BMJ Support Palliat Care 2020; 10:287-295. [DOI: 10.1136/bmjspcare-2020-002314] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 05/25/2020] [Accepted: 06/03/2020] [Indexed: 01/14/2023]
Abstract
Chronic breathlessness is a disabling and distressing condition for which there is a growing evidence base for a range of interventions. Non-pharmacological interventions are the mainstay of management and should be optimised prior to use of opioid medication. Opioids are being implemented variably in practice for chronic breathlessness. This narrative review summarises the evidence defining current opioids for breathlessness best practice and identifies remaining research gaps. There is level 1a evidence to support the use of opioids for breathlessness. The best evidence is for 10–30 mg daily de novo low-dose oral sustained-release morphine in opioid-naïve patients. This should be considered the current standard of care following independent, regulatory scrutiny by one of the world’s therapeutics regulatory bodies. Optimal benefits are seen in steady state; however, there are few published data about longer term benefits or harms. Morphine-related adverse events are common but mostly mild and self-limiting on withdrawal of drug. Early and meticulous management of constipation, nausea and vomiting is needed particularly in the first week of administration. Serious adverse events are no more common than placebo in clinical studies. Observational studies in severe chronic lung disease do not show excess mortality or hospital admission in those taking opioids. We have no long-term data on immune or endocrine function. There are promising data regarding prophylaxis for exertion-related breathlessness, but given the risks associated with transmucosal fentanyl, caution is needed with regard to clinical use pending longer term, robust safety data.
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22
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Rieger SW, Stephan KE, Harrison OK. Remote, Automated, and MRI-Compatible Administration of Interoceptive Inspiratory Resistive Loading. Front Hum Neurosci 2020; 14:161. [PMID: 32477083 PMCID: PMC7236550 DOI: 10.3389/fnhum.2020.00161] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 04/14/2020] [Indexed: 11/24/2022] Open
Abstract
Research on how humans perceive sensory inputs from their bodies (“interoception”) has been rapidly gaining momentum, with interest across a host of disciplines from physiology through to psychiatry. However, studying interoceptive processes is not without significant challenges, and many methods utilized to access internal states have been largely devoted to capturing and relating naturally occurring variations in interoceptive signals (such as heartbeats) to measures of how the brain processes these signals. An alternative procedure involves the controlled perturbation of specific interoceptive axes. This is challenging because it requires non-invasive interventions that can be repeated many times within a subject and that are potent but safe. Here we present an effective methodology for instigating these perturbations within the breathing domain. We describe a custom-built circuitry that is capable of delivering inspiratory resistive loads automatically and precisely. Importantly, our approach is compatible with magnetic resonance imaging (MRI) environments, allowing for the administration of complicated experimental designs in neuroimaging as increasingly required within developing fields such as computational psychiatry/psychosomatics. We describe the experimental setup for both the control and monitoring of the inspiratory resistive loads, and demonstrate its possible utilities within different study designs. This methodology represents an important step forward from the previously utilized, manually controlled resistive loading setups, which present significant experimental burdens with prolonged and/or complicated sequences of breathing stimuli.
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Affiliation(s)
- Sebastian W Rieger
- Oxford Centre for Human Brain Activity, Wellcome Centre for Integrative Neuroimaging, Department of Psychiatry, University of Oxford, Oxford, United Kingdom.,FMRIB Centre, Wellcome Centre for Integrative Neuroimaging, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Klaas Enno Stephan
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland.,Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom.,Max Planck Institute for Metabolism Research, Cologne, Germany
| | - Olivia K Harrison
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zürich, Zurich, Switzerland.,Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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23
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The effect of anxiety on brain activation patterns in response to inspiratory occlusions: an fMRI study. Sci Rep 2019; 9:15045. [PMID: 31636310 PMCID: PMC6803655 DOI: 10.1038/s41598-019-51396-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/30/2019] [Indexed: 11/20/2022] Open
Abstract
Respiratory sensations such as breathlessness are prevalent in many diseases and are amplified by increased levels of anxiety. Cortical activation in response to inspiratory occlusions in high- and low-anxious individuals was found different in previous studies using the respiratory-related evoked potential method. However, specific brain areas showed different activation patterns remained unknown in these studies. Therefore, the purpose of this study was to compare cortical and subcortical neural substrates of respiratory sensation in response to inspiratory mechanical occlusion stimuli between high- and low-anxious individuals using functional magnetic resonance imaging (fMRI). In addition, associations between brain activation patterns and levels of anxiety, and breathlessness were examined. Thirty-four (17 high- and 17 low-anxious) healthy non-smoking adults with normal lung function completed questionnaires on anxiety (State Trait Anxiety Inventory - State), and participated in a transient inspiratory occlusion fMRI experiment. The participants breathed with a customized face-mask while respiration was repeatedly interrupted by a transient inspiratory occlusion of 150-msec, delivered every 2 to 4 breaths. Breathlessness was assessed by self-report. At least 32 occluded breaths were collected for data analysis. The results showed that compared to the low-anxious group, the high-anxious individuals demonstrated significantly greater neural activations in the hippocampus, insula, and middle cingulate gyrus in response to inspiratory occlusions. Moreover, a significant relationship was found between anxiety levels and activations of the right inferior parietal gyrus, and the right precuneus. Additionally, breathlessness levels were significantly associated with activations of the bilateral thalamus, bilateral insula and bilateral cingulate gyrus. The above evidences support stronger recruitment of emotion-related cortical and subcortical brain areas in higher anxious individuals, and thus these areas play an important role in respiratory mechanosensation mediated by anxiety.
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24
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Abdallah SJ, Faull OK, Wanigasekera V, Finnegan SL, Jensen D, Pattinson KTS. Opioids for breathlessness: psychological and neural factors influencing response variability. Eur Respir J 2019; 54:13993003.00275-2019. [PMID: 31073088 PMCID: PMC6751386 DOI: 10.1183/13993003.00275-2019] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/27/2019] [Indexed: 12/15/2022]
Abstract
Chronic breathlessness is a multidimensional and aversive symptom, which is often poorly explained by underlying pathophysiology [1]. For many sufferers, breathlessness is refractory to maximal medical therapies that target disease processes [2]. However, opioids are thought to be a possible therapeutic avenue to treat symptomology independently of disease [3]. Importantly, research in chronic pain has demonstrated that qualities such as anxiety and depression (collectively termed negative affect here) can both exacerbate symptoms [4] and reduce opioid efficacy [5, 6]. Therefore, it may be pertinent to consider such behavioural factors when contemplating the use of opioids for breathlessness. Diminished opioid efficacy in the treatment of breathlessness is related to negative affect and anticipatory brain activity in the anterior cingulate and medial prefrontal cortex.http://bit.ly/2LXyyDo
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Affiliation(s)
- Sara J Abdallah
- Clinical Exercise & Respiratory Physiology Laboratory, Dept of Kinesiology & Physical Education, McGill University, Montréal, QC, Canada.,Joint first authors
| | - Olivia K Faull
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK.,Joint first authors
| | - Vishvarani Wanigasekera
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Sarah L Finnegan
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Dennis Jensen
- Clinical Exercise & Respiratory Physiology Laboratory, Dept of Kinesiology & Physical Education, McGill University, Montréal, QC, Canada
| | - Kyle T S Pattinson
- Wellcome Centre for Integrative Neuroimaging and Nuffield Division of Anaesthetics, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK
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25
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Abstract
PURPOSE OF REVIEW Breathlessness debilitates countless people with a wide range of common diseases. For some people, the experience of breathlessness is poorly explained by the findings of medical tests. This disparity complicates diagnostic and treatment options and means that disease-modifying treatments do not always have the expected effect upon symptoms. These observations suggest that brain processing of respiratory perceptions may be somewhat independent of disease processes. This may help to explain the dissonance observed in some patients between physical disease markers and the lived experience of breathlessness. RECENT FINDINGS A body of breathlessness research using functional neuroimaging has identified a relatively consistent set of brain areas that are associated with breathlessness. These areas include the insula, cingulate and sensory cortices, the amygdala and the periaqueductal gray matter. We interpret these findings in the context of new theories of perception that emphasize the importance of distributed brain networks. Within this framework, these perceptual networks function by checking an internal model (a set of expectations) against peripheral sensory inputs, instead of the brain acting as a passive signal transducer. Furthermore, other factors beyond the physiology of breathlessness can influence the system. SUMMARY A person's expectations and mood are major contributors to the function of the brain networks that generate perceptions of breathlessness. Breathlessness, therefore, arises from inferences made by the brain's integration of both expectations and sensory inputs. By better understanding individual differences across these contributing perceptual factors, we will be better poised to develop targeted and individualized treatments for breathlessness that could complement disease-modifying therapies.
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Affiliation(s)
- Lucy L. Marlow
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Olivia K. Faull
- Translational Neuromodeling Unit, Institute for Biomedical Engineering, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Sarah L. Finnegan
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kyle T.S. Pattinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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26
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Updates in opioid and nonopioid treatment for chronic breathlessness. Curr Opin Support Palliat Care 2019; 13:167-173. [PMID: 31335450 DOI: 10.1097/spc.0000000000000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE OF REVIEW Chronic breathlessness is a troublesome symptom experienced by people with advanced malignant and nonmalignant disease. Disease-directed therapies are often insufficient in the management of chronic breathlessness. Therefore, pharmacological and nonpharmacological breathlessness-specific interventions should be considered for select patients. RECENT FINDINGS There is some evidence to support the use of low-dose opioids (≤30 mg morphine equivalents per day) for the relief of breathlessness in the short term. However, additional studies are needed to understand the efficacy of opioids for chronic breathlessness in the long term.Nonopioid therapies, including inspiratory muscle training, fan-to-face therapy, L-menthol and inhaled nebulized furosemide show some promise for the relief of breathlessness in advanced disease. There is insufficient evidence to support the use of anxiolytics and benzodiazepines and cannabis for chronic breathlessness. SUMMARY More research is needed to identify therapies for the management of chronic breathlessness.
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27
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van Steenbergen H, Eikemo M, Leknes S. The role of the opioid system in decision making and cognitive control: A review. COGNITIVE, AFFECTIVE & BEHAVIORAL NEUROSCIENCE 2019; 19:435-458. [PMID: 30963411 PMCID: PMC6599188 DOI: 10.3758/s13415-019-00710-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The opioid system regulates affective processing, including pain, pleasure, and reward. Restricting the role of this system to hedonic modulation may be an underestimation, however. Opioid receptors are distributed widely in the human brain, including the more "cognitive" regions in the frontal and parietal lobes. Nonhuman animal research points to opioid modulation of cognitive and decision-making processes. We review emerging evidence on whether acute opioid drug modulation in healthy humans can influence cognitive function, such as how we choose between actions of different values and how we control our behavior in the face of distracting information. Specifically, we review studies employing opioid agonists or antagonists together with experimental paradigms of reward-based decision making, impulsivity, executive functioning, attention, inhibition, and effort. Although this field is still in its infancy, the emerging picture suggests that the mu-opioid system can influence higher-level cognitive function via modulation of valuation, motivation, and control circuits dense in mu-opioid receptors, including orbitofrontal cortex, basal ganglia, amygdalae, anterior cingulate cortex, and prefrontal cortex. The framework that we put forward proposes that opioids influence decision making and cognitive control by increasing the subjective value of reward and reducing aversive arousal. We highlight potential mechanisms that might underlie the effects of mu-opioid signaling on decision making and cognitive control and provide directions for future research.
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Affiliation(s)
- Henk van Steenbergen
- Cognitive Psychology Unit, Institute of Psychology, Leiden University, Wassenaarseweg 52, 2333 AK, Leiden, The Netherlands.
- Leiden Institute for Brain and Cognition, Leiden, The Netherlands.
| | - Marie Eikemo
- Department of Diagnostic Physics, Oslo University Hospital, Oslo, Norway
- Department of Psychology, University of Oslo, Oslo, Norway
| | - Siri Leknes
- Department of Psychology, University of Oslo, Oslo, Norway
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28
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Ekström M, Williams M, Johnson MJ, Huang C, Currow DC. Agreement Between Breathlessness Severity and Unpleasantness in People With Chronic Breathlessness: A Longitudinal Clinical Study. J Pain Symptom Manage 2019; 57:715-723.e5. [PMID: 30639756 DOI: 10.1016/j.jpainsymman.2019.01.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 12/31/2018] [Accepted: 01/02/2019] [Indexed: 11/25/2022]
Abstract
CONTEXT Chronic breathlessness is a cardinal symptom in cardiopulmonary disease where both overall intensity or severity (S) and unpleasantness (U) are commonly quantified. OBJECTIVE We aimed to evaluate agreement between breathlessness severity and unpleasantness over eight days in patients with chronic breathlessness. METHODS Longitudinal analysis of 265 patients with chronic breathlessness who rated current overall breathlessness severity and unpleasantness on a 0-100 mm visual analogue scale (VAS) in the morning and evening over eight days. A total of 3630 paired overall severity-unpleasantness (S-U) differences were analyzed; median 15 (IQR 13-16) per patient. Agreement was evaluated using Bland-Altman plots. Associations of the difference between severity and unpleasantness (S-U difference) with clinical factors and perceived quality of life were analyzed using multilevel linear regression adjusted for confounders. RESULTS Over eight days, severity and unpleasantness scores were highly correlated, had similar variability, and varied more between patients than within patients. The mean S-U difference was small at 2.1 mm. Agreement between overall severity and unpleasantness was similar or higher than expected from the variability in individual scores. The S-U difference was similar across evaluated factors including age, sex, diagnosis, morning/evening assessment, modified Medical Research Council breathlessness score, morphine treatment, and presence of different sensory qualities of breathlessness. Higher overall severity and unpleasantness associated with worse perceived quality of life in a similar way. CONCLUSION In patients with chronic breathlessness over eight days, overall severity and unpleasantness of breathlessness were comparable and associated to other clinical factors in a similar manner.
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Affiliation(s)
- Magnus Ekström
- Lund University, Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden; ImPaCCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
| | - Marie Williams
- School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, UK
| | - Chao Huang
- Hull York Medical School, Institute for Clinical and Applied Health Research, University of Hull, UK
| | - David C Currow
- ImPaCCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
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29
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Faull OK, Subramanian HH, Ezra M, Pattinson KTS. The midbrain periaqueductal gray as an integrative and interoceptive neural structure for breathing. Neurosci Biobehav Rev 2019; 98:135-144. [PMID: 30611797 DOI: 10.1016/j.neubiorev.2018.12.020] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 11/08/2018] [Accepted: 12/18/2018] [Indexed: 01/25/2023]
Abstract
The periaqueductal gray (PAG) plays a critical role in autonomic function and behavioural responses to threatening stimuli. Recent evidence has revealed the PAG's potential involvement in the perception of breathlessness, a highly threatening respiratory symptom. In this review, we outline the current evidence in animals and humans on the role of the PAG in respiratory control and in the perception of breathlessness. While recent work has unveiled dissociable brain activity within the lateral PAG during perception of breathlessness and ventrolateral PAG during conditioned anticipation in healthy humans, this is yet to be translated into diseases dominated by breathlessness symptomology, such as chronic obstructive pulmonary disease. Understanding how the sub-structures of the PAG differentially interact with interoceptive brain networks involved in the perception of breathlessness will help towards understanding discordant symptomology, and may reveal treatment targets for those debilitated by chronic and pervasive breathlessness.
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Affiliation(s)
- Olivia K Faull
- Translational Neuromodeling Unit, University of Zürich and ETH Zürich, Zürich, Switzerland; Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | | | - Martyn Ezra
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kyle T S Pattinson
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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30
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Moningka H, Lichenstein S, Worhunsky PD, DeVito EE, Scheinost D, Yip SW. Can neuroimaging help combat the opioid epidemic? A systematic review of clinical and pharmacological challenge fMRI studies with recommendations for future research. Neuropsychopharmacology 2019; 44:259-273. [PMID: 30283002 PMCID: PMC6300537 DOI: 10.1038/s41386-018-0232-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/11/2018] [Accepted: 09/18/2018] [Indexed: 02/04/2023]
Abstract
The current opioid epidemic is an urgent public health problem, with enormous individual, societal, and healthcare costs. Despite effective, evidence-based treatments, there is significant individual variability in treatment responses and relapse rates are high. In addition, the neurobiology of opioid-use disorder (OUD) and its treatment is not well understood. This review synthesizes published fMRI literature relevant to OUD, with an emphasis on findings related to opioid medications and treatment, and proposes areas for further research. We conducted a systematic literature review of Medline and Psychinfo to identify (i) fMRI studies comparing OUD and control participants; (ii) studies related to medication, treatment, abstinence or withdrawal effects in OUD; and (iii) studies involving manipulation of the opioid system in healthy individuals. Following application of exclusionary criteria (e.g., insufficient sample size), 45 studies were retained comprising data from ~1400 individuals. We found convergent evidence that individuals with OUD display widespread heightened neural activation to heroin cues. This pattern is potentiated by heroin, attenuated by medication-assisted treatments for opioids, predicts treatment response, and is reduced following extended abstinence. Nonetheless, there is a paucity of literature examining neural characteristics of OUD and its treatment. We discuss limitations of extant research and identify critical areas for future neuroimaging studies, including the urgent need for studies examining prescription opioid users, assessing sex differences and utilizing a wider range of clinically relevant task-based fMRI paradigms across different stages of addiction.
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Affiliation(s)
- Hestia Moningka
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Sarah Lichenstein
- Yale School of Medicine, Radiology and Bioimaging Sciences, New Haven, CT, 06510, USA
| | - Patrick D Worhunsky
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Elise E DeVito
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Dustin Scheinost
- Yale School of Medicine, Radiology and Bioimaging Sciences, New Haven, CT, 06510, USA
| | - Sarah W Yip
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, 06510, USA.
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Faull OK, Cox PJ, Pattinson KT. Cortical processing of breathing perceptions in the athletic brain. Neuroimage 2018; 179:92-101. [DOI: 10.1016/j.neuroimage.2018.06.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Revised: 06/04/2018] [Accepted: 06/06/2018] [Indexed: 01/14/2023] Open
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Stoeckel MC, Esser RW, Gamer M, von Leupoldt A. Breathlessness amplifies amygdala responses during affective processing. Psychophysiology 2018; 55:e13092. [PMID: 29667212 DOI: 10.1111/psyp.13092] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 12/11/2022]
Abstract
Breathlessness is an aversive symptom in many prevalent somatic and psychiatric diseases and is usually experienced as highly threatening. It is strongly associated with negative affect, but the underlying neural processes remain poorly understood. Therefore, using fMRI, the present study examined the effects of breathlessness on the neural processing of affective visual stimuli within candidate brain areas including the amygdala, insula, and anterior cingulate cortex (ACC). During scanning, 42 healthy volunteers, mean (SD) age: 29.0 (6.0) years, 14 female, were presented with affective picture series of negative, neutral, and positive valence while experiencing either no breathlessness (baseline conditions) or resistive-load induced breathlessness (breathlessness conditions). Respiratory measures and self-reports suggested successful induction of breathlessness and affective experiences. Self-reports of breathlessness intensity and unpleasantness were significantly higher during breathlessness conditions, mean (SD): 45.0 (16.6) and 32.3 (19.8), as compared to baseline conditions, mean (SD): 1.9 (3.0) and 2.9 (5.5). Compared to baseline conditions, stronger amygdala activations were observed during breathlessness conditions for both negative and positive affective picture series relative to neutral picture series, while no such effects were observed in insula and ACC. The present findings demonstrate that breathlessness amplifies amygdala responses during affective processing, suggesting an important role of the amygdala for mediating the interactions between breathlessness and affective states.
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Affiliation(s)
- M Cornelia Stoeckel
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Roland W Esser
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Gamer
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Psychology 1, University of Würzburg, Würzburg, Germany
| | - Andreas von Leupoldt
- Department of Systems Neuroscience, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Health Psychology, University of Leuven, Leuven, Belgium
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Star A, Boland JW. Updates in palliative care - recent advancements in the pharmacological management of symptoms. Clin Med (Lond) 2018; 18:11-16. [PMID: 29436433 PMCID: PMC6330925 DOI: 10.7861/clinmedicine.18-1-11] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Symptom management is an important part of both palliative care and end-of-life care. This article will examine the recent research evidence about drugs commonly used for symptom management in adult patients receiving palliative care. In particular, the management of symptoms where recent palliative care-based evidence has changed recommended practice will be reviewed. This includes: breathlessness, delirium, nausea and vomiting in bowel obstruction, opioid-induced constipation and upper respiratory tract secretions. For each symptom, a review of recent pharmacological evidence has been undertaken, with emphasis on potential important changes to physicians' practice.
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Affiliation(s)
| | - Jason W Boland
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
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Charususin N, Dacha S, Gosselink R, Decramer M, Von Leupoldt A, Reijnders T, Louvaris Z, Langer D. Respiratory muscle function and exercise limitation in patients with chronic obstructive pulmonary disease: a review. Expert Rev Respir Med 2017; 12:67-79. [DOI: 10.1080/17476348.2018.1398084] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Noppawan Charususin
- Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Physical Therapy, Thammasat University, Pathumthani, Thailand
| | - Sauwaluk Dacha
- Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Physical Therapy, Faculty of Associated Medical Sciences, Chiang Mai University, Chiang Mai, Thailand
| | - Rik Gosselink
- Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
| | - Marc Decramer
- Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
| | - Andreas Von Leupoldt
- Department of Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Belgium
| | - Thomas Reijnders
- Department of Health Psychology, Faculty of Psychology and Educational Sciences, KU Leuven, Leuven, Belgium
| | - Zafeiris Louvaris
- Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, “M. Simou, and G.P. Livanos Laboratories”, National and Kapodistrian University of Athens, Athens, Greece
| | - Daniel Langer
- Respiratory Rehabilitation and Respiratory Division, University Hospital Leuven, Leuven, Belgium
- Department of Rehabilitation Sciences, KU Leuven, Leuven, Belgium
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Abdallah SJ, Wilkinson-Maitland C, Saad N, Li PZ, Smith BM, Bourbeau J, Jensen D. Effect of morphine on breathlessness and exercise endurance in advanced COPD: a randomised crossover trial. Eur Respir J 2017; 50:50/4/1701235. [DOI: 10.1183/13993003.01235-2017] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 07/21/2017] [Indexed: 01/11/2023]
Abstract
The objective of the present study was to evaluate the effect of morphine on exertional breathlessness and exercise endurance in advanced chronic obstructive pulmonary disease (COPD).In a randomised crossover trial, we compared the acute effect of immediate-release oral morphineversusplacebo on physiological and perceptual responses during constant-load cardiopulmonary cycle exercise testing (CPET) in 20 adults with advanced COPD and chronic breathlessness syndrome.Compared with placebo, morphine reduced exertional breathlessness at isotime by 1.2±0.4 Borg units and increased exercise endurance time by 2.5±0.9 min (both p≤0.014). During exercise at isotime, morphine decreased ventilation by 1.3±0.5 L·min−1and breathing frequency by 2.0±0.9 breaths·min−1(both p≤0.041). Compared with placebo, morphine decreased exertional breathlessness at isotime by ≥1 Borg unit in 11 participants (responders) and by <1 Borg unit in nine participants (non-responders). Baseline participant characteristics, including pulmonary function and cardiorespiratory fitness, were similar between responders and non-responders. A higher percentage of respondersversusnon-responders stopped incremental CPET due to intolerable breathlessness: 82versus33% (p=0.028).Immediate-release oral morphine improved exertional breathlessness and exercise endurance in some, but not all, adults with advanced COPD. The locus of symptom-limitation on laboratory-based CPET may help to identify patients most likely to benefit from morphine.
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Faull OK, Hayen A, Pattinson KTS. Breathlessness and the body: Neuroimaging clues for the inferential leap. Cortex 2017; 95:211-221. [PMID: 28915367 PMCID: PMC5637166 DOI: 10.1016/j.cortex.2017.07.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/14/2017] [Accepted: 07/20/2017] [Indexed: 01/14/2023]
Abstract
Breathlessness debilitates millions of people with chronic illness. Mismatch between breathlessness severity and objective disease markers is common and poorly understood. Traditionally, sensory perception was conceptualised as a stimulus-response relationship, although this cannot explain how conditioned symptoms may occur in the absence of physiological signals from the lungs or airways. A Bayesian model is now proposed, in which the brain generates sensations based on expectations learnt from past experiences (priors), which are then checked against incoming afferent signals. In this model, psychological factors may act as moderators. They may alter priors, change the relative attention towards incoming sensory information, or alter comparisons between priors and sensations, leading to more variable interpretation of an equivalent afferent input. In the present study we conducted a supplementary analysis of previously published data (Hayen et al., 2017). We hypothesised that individual differences in psychological traits (anxiety, depression, anxiety sensitivity) would correlate with the variability of subjective perceptions of equivalent breathlessness challenges. To better understand the resulting inferential leap in the brain, we explored where these behavioural measures correlated with functional brain activity across subjects. Behaviourally, anxiety sensitivity was found to positively correlate with each subject's variability of intensity and unpleasantness during mild breathlessness, and with variability of unpleasantness during strong breathlessness. In the brain, anxiety sensitivity was found to negatively correlate with precuneus activity during anticipation, positively correlate with anterior insula activity during mild breathlessness, and negatively correlate with parietal sensorimotor areas during strong breathlessness. Our findings suggest that anxiety sensitivity may reduce the robustness of this Bayesian sensory perception system, increasing the variability of breathlessness perception and possibly susceptibility to symptom misinterpretation. These preliminary findings in healthy individuals demonstrate how differences in psychological function influence the way we experience bodily sensations, which might direct us towards better understanding of symptom mismatch in clinical populations.
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Affiliation(s)
- Olivia K Faull
- FMRIB Centre, University of Oxford, Oxford, UK; Nuffield Division of Anesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK.
| | - Anja Hayen
- FMRIB Centre, University of Oxford, Oxford, UK; Nuffield Division of Anesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK; School of Psychology and Clinical Language Sciences, University of Reading, UK
| | - Kyle T S Pattinson
- FMRIB Centre, University of Oxford, Oxford, UK; Nuffield Division of Anesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Herigstad M, Faull OK, Hayen A, Evans E, Hardinge FM, Wiech K, Pattinson KTS. Treating breathlessness via the brain: changes in brain activity over a course of pulmonary rehabilitation. Eur Respir J 2017; 50:50/3/1701029. [PMID: 28899937 PMCID: PMC5678895 DOI: 10.1183/13993003.01029-2017] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 06/17/2017] [Indexed: 12/29/2022]
Abstract
Breathlessness in chronic obstructive pulmonary disease (COPD) is often discordant with airway pathophysiology ("over-perception"). Pulmonary rehabilitation profoundly affects breathlessness, without influencing lung function. Learned associations influence brain mechanisms of sensory perception. We hypothesised that improvements in breathlessness with pulmonary rehabilitation may be explained by changing neural representations of learned associations.In 31 patients with COPD, we tested how pulmonary rehabilitation altered the relationship between brain activity during a breathlessness-related word-cue task (using functional magnetic resonance imaging), and clinical and psychological measures of breathlessness.Changes in ratings of breathlessness word cues positively correlated with changes in activity in the insula and anterior cingulate cortex. Changes in ratings of breathlessness-anxiety negatively correlated with activations in attention regulation and motor networks. Baseline activity in the insula, anterior cingulate cortex and prefrontal cortex correlated with improvements in breathlessness and breathlessness-anxiety.Pulmonary rehabilitation is associated with altered neural responses related to learned breathlessness associations, which can ultimately influence breathlessness perception. These findings highlight the importance of targeting learned associations within treatments for COPD, demonstrating how neuroimaging may contribute to patient stratification and more successful personalised therapy.
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Affiliation(s)
- Mari Herigstad
- FMRIB Centre, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK.,Dept of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK.,M. Herigstad and K.T.S. Pattinson should be considered joint correspondence authors
| | - Olivia K Faull
- FMRIB Centre, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Anja Hayen
- FMRIB Centre, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK.,School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK
| | - Eleanor Evans
- FMRIB Centre, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK
| | | | - Katja Wiech
- FMRIB Centre, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Kyle T S Pattinson
- FMRIB Centre, Nuffield Dept of Clinical Neurosciences, University of Oxford, Oxford, UK .,Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,M. Herigstad and K.T.S. Pattinson should be considered joint correspondence authors
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Faull OK, Pattinson KTS. The cortical connectivity of the periaqueductal gray and the conditioned response to the threat of breathlessness. eLife 2017; 6:e21749. [PMID: 28211789 PMCID: PMC5332157 DOI: 10.7554/elife.21749] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 02/13/2017] [Indexed: 01/15/2023] Open
Abstract
Previously we observed differential activation in individual columns of the periaqueductal grey (PAG) during breathlessness and its conditioned anticipation (Faull et al., 2016b). Here, we have extended this work by determining how the individual columns of the PAG interact with higher cortical centres, both at rest and in the context of breathlessness threat. Activation was observed in ventrolateral PAG (vlPAG) and lateral PAG (lPAG), where activity scaled with breathlessness intensity ratings, revealing a potential interface between sensation and cognition during breathlessness. At rest the lPAG was functionally correlated with cortical sensorimotor areas, conducive to facilitating fight/flight responses, and demonstrated increased synchronicity with the amygdala during breathlessness. The vlPAG showed fronto-limbic correlations at rest, whereas during breathlessness anticipation, reduced functional synchronicity was seen to both lPAG and motor structures, conducive to freezing behaviours. These results move us towards understanding how the PAG might be intricately involved in human responses to threat.
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Affiliation(s)
- Olivia K Faull
- FMRIB Centre, University of Oxford, Oxford, United Kingdom
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
| | - Kyle TS Pattinson
- FMRIB Centre, University of Oxford, Oxford, United Kingdom
- Nuffield Division of Anaesthetics, Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, United Kingdom
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