Electrical stimulation of the anterior ethmoidal nerve produces the diving response

Impact of trigeminal and/or olfactory nerve stimulation on measures of inspiratory neural drive: Implications for breathlessness

The perception of breathlessness is mechanistically linked to the awareness of increased inspiratory neural drive (IND). Stimulation of upper airway cold receptors on the trigeminal nerve (TGN) with TGN agonists such as menthol or cool air to the face/nose has been hypothesized to reduce breathlessness by decreasing IND. The aim of this systematic scoping review was to identify and summarize the results of studies in animals and humans reporting on the impact of TGN stimulation or blockade on measures of IND. Thirty-one studies were identified, including 19 in laboratory animals and 12 in human participants. Studies in laboratory animals consistently reported that as TGN activity increased, measures of IND decreased (e.g., phrenic nerve activity). In humans, stimulation of the TGN with a stream of cool air to the face/nose decreased the sensitivity of the ventilatory chemoreflex response to hypercapnia. Otherwise, TGN stimulation with menthol or cool air to the face/note had no effect on measures of IND in humans. This review provides new insight into a potential neural mechanism of breathlessness relief with selected TGN agonists.

Olfactory epithelium and ontogeny of the nasal chambers in the bowhead whale (Balaena mysticetus)

In a species of baleen whale, we identify olfactory epithelium that suggests a functional sense of smell and document the ontogeny of the surrounding olfactory anatomy. Whales must surface to breathe, thereby providing an opportunity to detect airborne odorants. Although many toothed whales (odontocetes) lack olfactory anatomy, baleen whales (mysticetes) have retained theirs. Here, we investigate fetal and postnatal specimens of bowhead whales (Balaena mysticetus). Computed tomography (CT) reveals the presence of nasal passages and nasal chambers with simple ethmoturbinates through ontogeny. Additionally, we describe the dorsal nasal meatuses and olfactory bulb chambers. The cribriform plate has foramina that communicate with the nasal chambers. We show this anatomy within the context of the whole prenatal and postnatal skull. We document the tunnel for the ethmoidal nerve (ethmoid foramen) and the rostrolateral recess of the nasal chamber, which appears postnatally. Bilateral symmetry was apparent in the postnatal nasal chambers. No such symmetry was found prenatally, possibly due to tissue deformation. No nasal air sacs were found in fetal development. Olfactory epithelium, identified histologically, covers at least part of the ethmoturbinates. We identify olfactory epithelium using six explicit criteria of mammalian olfactory epithelium. Immunohistochemistry revealed the presence of olfactory marker protein (OMP), which is only found in mature olfactory sensory neurons. Although it seems that these neurons are scarce in bowhead whales compared to typical terrestrial mammals, our results suggest that bowhead whales have a functional sense of smell, which they may use to find prey.

Prophylactic Intra-Arterial Injection of Lidocaine Prevents Trigeminocardiac Reflex During Endovascular Embolization for Dural Arteriovenous Fistula: A Report of 2 Cases

Case series

Patients: Male, 56-year-old • Male, 57-year-old

Final Diagnosis: Trigeminocardiac reflex

Symptoms: Bradycardia • severe hemodynamic fluctuation

Medication: —

Clinical Procedure: —

Specialty: Anesthesiology • Neurosurgery

Trigeminal Nerve Control of Cerebral Blood Flow: A Brief Review

The trigeminal nerve, the fifth cranial nerve, is known to innervate much of the cerebral arterial vasculature and significantly contributes to the control of cerebrovascular tone in both healthy and diseased states. Previous studies have demonstrated that stimulation of the trigeminal nerve (TNS) increases cerebral blood flow (CBF) via antidromic, trigemino-parasympathetic, and other central pathways. Despite some previous reports on the role of the trigeminal nerve and its control of CBF, there are only a few studies that investigate the effects of TNS on disorders of cerebral perfusion (i.e., ischemic stroke, subarachnoid hemorrhage, and traumatic brain injury). In this mini review, we present the current knowledge regarding the mechanisms of trigeminal nerve control of CBF, the anatomic underpinnings for targeted treatment, and potential clinical applications of TNS, with a focus on the treatment of impaired cerebral perfusion.

Air Pollution-Induced Autonomic Modulation

Air pollutants pose a serious worldwide health hazard, causing respiratory and cardiovascular morbidity and mortality. Pollutants perturb the autonomic nervous system, whose function is critical to cardiopulmonary homeostasis. Recent studies suggest that pollutants can stimulate defensive sensory nerves within the cardiopulmonary system, thus providing a possible mechanism for pollutant-induced autonomic dysfunction. A better understanding of the mechanisms involved would likely improve the management and treatment of pollution-related disease.

Noninvasive Ventilation in the Delivery Room for the Preterm Infant

A decade ago, preterm infants were prophylactically intubated and mechanically ventilated starting in the delivery room; however, now the shift is toward maintaining even the smallest of neonates on noninvasive respiratory support. The resuscitation of very low gestational age neonates continues to push the boundaries of neonatal care, as the events that transpire during the golden minutes right after birth prove ever more important for determining long-term neurodevelopmental outcomes. Continuous positive airway pressure (CPAP) remains the most important mode of noninvasive respiratory support for the preterm infant to establish and maintain functional residual capacity and decrease ventilation/perfusion mismatch. However, the majority of extremely low gestational age infants require face mask positive pressure ventilation during initial stabilization before receiving CPAP. Effectiveness of face mask positive pressure ventilation depends on the ability to detect and overcome mask leak and airway obstruction. In this review, the current evidence on devices and techniques of noninvasive ventilation in the delivery room are discussed.

The Mammalian Diving Response: Inroads to Its Neural Control

The mammalian diving response (DR) is a remarkable behavior that was first formally studied by Laurence Irving and Per Scholander in the late 1930s. The DR is called such because it is most prominent in marine mammals such as seals, whales, and dolphins, but nevertheless is found in all mammals studied. It consists generally of breathing cessation (apnea), a dramatic slowing of heart rate (bradycardia), and an increase in peripheral vasoconstriction. The DR is thought to conserve vital oxygen stores and thus maintain life by directing perfusion to the two organs most essential for life-the heart and the brain. The DR is important, not only for its dramatic power over autonomic function, but also because it alters normal homeostatic reflexes such as the baroreceptor reflex and respiratory chemoreceptor reflex. The neurons driving the reflex circuits for the DR are contained within the medulla and spinal cord since the response remains after the brainstem transection at the pontomedullary junction. Neuroanatomical and physiological data suggesting brainstem areas important for the apnea, bradycardia, and peripheral vasoconstriction induced by underwater submersion are reviewed. Defining the brainstem circuit for the DR may open broad avenues for understanding the mechanisms of suprabulbar control of autonomic function in general, as well as implicate its role in some clinical states. Knowledge of the proposed diving circuit should facilitate studies on elite human divers performing breath-holding dives as well as investigations on sudden infant death syndrome (SIDS), stroke, migraine headache, and arrhythmias. We have speculated that the DR is the most powerful autonomic reflex known.

Photoactivation of olfactory sensory neurons does not affect action potential conduction in individual trigeminal sensory axons innervating the rodent nasal cavity

Olfactory and trigeminal chemosensory systems reside in parallel within the mammalian nose. Psychophysical studies in people indicate that these two systems interact at a perceptual level. Trigeminal sensations of pungency mask odour perception, while olfactory stimuli can influence trigeminal signal processing tasks such as odour localization. While imaging studies indicate overlap in limbic and cortical somatosensory areas activated by nasal trigeminal and olfactory stimuli, there is also potential cross-talk at the level of the olfactory epithelium, the olfactory bulb and trigeminal brainstem. Here we explored the influence of olfactory and trigeminal signaling in the nasal cavity. A forced choice water consumption paradigm was used to ascertain whether trigeminal and olfactory stimuli could influence behaviour in mice. Mice avoided water sources surrounded by both volatile TRPV1 (cyclohexanone) and TRPA1 (allyl isothiocyanate) irritants and the aversion to cyclohexanone was mitigated when combined with a pure odorant (rose fragrance, phenylethyl alcohol, PEA). To determine whether olfactory-trigeminal interactions within the nose could potentially account for this behavioural effect we recorded from single trigeminal sensory axons innervating the nasal respiratory and olfactory epithelium using an isolated in vitro preparation. To circumvent non-specific effects of chemical stimuli, optical stimulation was used to excite olfactory sensory neurons in mice expressing channel-rhodopsin (ChR2) under the olfactory marker protein (OMP) promoter. Photoactivation of olfactory sensory neurons produced no modulation of axonal action potential conduction in individual trigeminal axons. Similarly, no evidence was found for collateral branching of trigeminal axon that might serve as a conduit for cross-talk between the olfactory and respiratory epithelium and olfactory dura mater. Using direct assessment of action potential activity in trigeminal axons we observed neither paracrine nor axon reflex mediated cross-talk between olfactory and trigeminal sensory systems in the rodent nasal cavity. Our current results suggest that olfactory sensory neurons exert minimal influence on trigeminal signals within the nasal cavity.

Supporting breathing of preterm infants at birth: a narrative review

Most very preterm infants have difficulty aerating their lungs and require respiratory support at birth. Currently in clinical practice, non-invasive ventilation in the form of continuous positive airway pressure (CPAP) and positive pressure ventilation (PPV) is applied via facemask. As most very preterm infants breathe weakly and unnoticed at birth, PPV is often administered. PPV is, however, frequently ineffective due to pressure settings, mask leak and airway obstruction. Meanwhile, high positive inspiratory pressures and spontaneous breathing coinciding with inflations can generate high tidal volumes. Evidence from preclinical studies demonstrates that high tidal volumes can be injurious to the lungs and brains of premature newborns. To reduce the need for PPV in the delivery room, it should be considered to optimise spontaneous breathing with CPAP. CPAP is recommended in guidelines and commonly used in the delivery room after a period of PPV, but little data is available on the ideal CPAP strategy and CPAP delivering devices and interfaces used in the delivery room. This narrative review summarises the currently available evidence for why PPV can be inadequate at birth and what is known about different CPAP strategies, devices and interfaces used the delivery room.

Innervation of the Nose and Nasal Region of the Rat: Implications for Initiating the Mammalian Diving Response

Most terrestrial animals demonstrate an autonomic reflex that facilitates survival during prolonged submersion under water. This diving response is characterized by bradycardia, apnea and selective increases in peripheral vascular resistance. Stimulation of the nose and nasal passages is thought to be primarily responsible for providing the sensory afferent signals initiating this protective reflex. Consequently, the primary objective of this research was to determine the central terminal projections of nerves innervating the external nose, nasal vestibule and nasal passages of rats. We injected wheat germ agglutinin (WGA) into specific external nasal locations, into the internal nasal passages of rats both with and without intact anterior ethmoidal nerves (AENs), and directly into trigeminal nerves innervating the nose and nasal region. The central terminations of these projections within the medulla were then precisely mapped. Results indicate that the internal nasal branch of the AEN and the nasopalatine nerve, but not the infraorbital nerve (ION), provide primary innervation of the internal nasal passages. The results also suggest afferent fibers from the internal nasal passages, but not external nasal region, project to the medullary dorsal horn (MDH) in an appropriate anatomical way to cause the activation of secondary neurons within the ventral MDH that express Fos protein during diving. We conclude that innervation of the anterior nasal passages by the AEN and nasopalatine nerve is likely to provide the afferent information responsible for the activation of secondary neurons within MDH during voluntary diving in rats.

Restoration of the nasopharyngeal response after bilateral sectioning of the anterior ethmoidal nerve in the rat

In response to stimulation of the nasal passages with volatile ammonia vapors, the nasopharyngeal reflex produces parasympathetically mediated bradycardia, sympathetically mediated increased peripheral vascular tone, and apnea. The anterior ethmoidal nerve (AEN), which innervates the anterior nasal mucosa, is thought to be primarily responsible for providing the sensory afferent signals that initiate these protective reflexes, as bilateral sectioning causes an attenuation of this response. However, recent evidence has shown cardiovascular responses to nasal stimulation with ammonia vapors are fully intact 9 days after bilateral AEN sectioning, and are similar to control animals without bilaterally sectioned AENs. To investigate this restoration of the nasopharyngeal response, we recorded the cardiorespiratory responses to nasal stimulation with ammonia vapors immediately after, and 3 and 9 days after, bilateral AEN sectioning. We also processed brainstem tissue for Fos to determine how the restoration of the nasopharyngeal response would affect the activity of neurons in the medullary dorsal horn (MDH), the part of the ventral spinal trigeminal nucleus caudalis region that receives primary afferent signals from the nose and nasal passages. We found 3 days after bilateral AEN sectioning the cardiorespiratory responses to nasal stimulation are partially restored. The bradycardic response to nasal stimulation is significantly more intense 3 days after AEN sectioning compared to Acute AEN sectioning. Surprisingly, 3 days after AEN sectioning the number of Fos-positive neurons within MDH decreased, even though the cardiorespiratory responses to nasal stimulation intensified. Collectively these findings indicate that, besides the AEN, there are alternate sensory pathways that can activate neurons within the trigeminal nucleus in response to nasal stimulation. The findings further suggest trigeminal neuronal plasticity involving these alternate sensory pathways occurs in as few as 3 days after bilateral AEN sectioning. Finally, activation of even a significantly reduced number of MDH neurons is sufficient to initiate the nasopharyngeal response.

Breath-Hold Diving

Breath-hold diving is practiced by recreational divers, seafood divers, military divers, and competitive athletes. It involves highly integrated physiology and extreme responses. This article reviews human breath-hold diving physiology beginning with an historical overview followed by a summary of foundational research and a survey of some contemporary issues. Immersion and cardiovascular adjustments promote a blood shift into the heart and chest vasculature. Autonomic responses include diving bradycardia, peripheral vasoconstriction, and splenic contraction, which help conserve oxygen. Competitive divers use a technique of lung hyperinflation that raises initial volume and airway pressure to facilitate longer apnea times and greater depths. Gas compression at depth leads to sequential alveolar collapse. Airway pressure decreases with depth and becomes negative relative to ambient due to limited chest compliance at low lung volumes, raising the risk of pulmonary injury called "squeeze," characterized by postdive coughing, wheezing, and hemoptysis. Hypoxia and hypercapnia influence the terminal breakpoint beyond which voluntary apnea cannot be sustained. Ascent blackout due to hypoxia is a danger during long breath-holds, and has become common amongst high-level competitors who can suppress their urge to breathe. Decompression sickness due to nitrogen accumulation causing bubble formation can occur after multiple repetitive dives, or after single deep dives during depth record attempts. Humans experience responses similar to those seen in diving mammals, but to a lesser degree. The deepest sled-assisted breath-hold dive was to 214 m. Factors that might determine ultimate human depth capabilities are discussed. © 2018 American Physiological Society. Compr Physiol 8:585-630, 2018.

Definition and Diagnosis of the Trigeminocardiac Reflex: A Grounded Theory Approach for an Update

Background

The trigeminocardiac reflex (TCR) is defined as sudden onset of parasympathetic dysrhythmias including hemodynamic irregularities, apnea, and gastric hypermotility during stimulation of sensory branches of the trigeminal nerve. Since the first description of the TCR in 1999, there is an ongoing discussion about a more emergent clinical definition. In this work, the author worked out an approach to such an improved definition.

Methods

In this study, a grounded theory approach was used. Literature about TCR was systematically identified through PubMed (MEDLINE), EMBASE (Ovid SP), and ISI Web of Sciences databases from 1/2005 until 8/2015. TCR was defined as a drop of heart rate (HR) below 60 bpm or 20% to the baseline. A grounded theory approach was used to analyze and interpret the data through a synthesis by the researcher’s perspectives, values, and positions.

Results

Out of the included studies, the authors formed available data to an update of the understanding of changes in hemodynamic parameters (HR and blood pressure) in a TCR. According to this update, an HR deceleration should be a constant observation to identify a TCR episode while a drop in blood pressure should probably not being fixed to a certain percentage of decrease.

Conclusion

The here presented working definition improves our understanding of the TCR. It leads the way to a new understanding of the TCR for a proper clinical definition.

Neuroprotective Effects of Trigeminal Nerve Stimulation in Severe Traumatic Brain Injury

Following traumatic brain injury (TBI), ischemia and hypoxia play a major role in further worsening of the damage, a process referred to as 'secondary injury'. Protecting neurons from causative factors of secondary injury has been the guiding principle of modern TBI management. Stimulation of trigeminal nerve induces pressor response and improves cerebral blood flow (CBF) by activating the rostral ventrolateral medulla. Moreover, it causes cerebrovasodilation through the trigemino-cerebrovascular system and trigemino-parasympathetic reflex. These effects are capable of increasing cerebral perfusion, making trigeminal nerve stimulation (TNS) a promising strategy for TBI management. Here, we investigated the use of electrical TNS for improving CBF and brain oxygen tension (PbrO2), with the goal of decreasing secondary injury. Severe TBI was produced using controlled cortical impact (CCI) in a rat model, and TNS treatment was delivered for the first hour after CCI. In comparison to TBI group, TBI animals with TNS treatment demonstrated significantly increased systemic blood pressure, CBF and PbrO2 at the hyperacute phase of TBI. Furthermore, rats in TNS-treatment group showed significantly reduced brain edema, blood-brain barrier disruption, lesion volume, and brain cortical levels of TNF-α and IL-6. These data provide strong early evidence that TNS could be an effective neuroprotective strategy.

Anesthesia for Ophthalmic Artery Chemosurgery

Pediatric anesthesiologists should be aware of severe cardiopulmonary events that can occur during intraarterial chemotherapy for retinoblastoma.

Sudden Infant Death Syndrome - Role of Trigeminocardiac Reflex: A Review

Sudden infant death syndrome (SIDS) is an unexplained death in infants, which usually occurs during sleep. The cause of SIDS remains unknown and multifactorial. In this regard, the diving reflex (DR), a peripheral subtype of trigeminocardiac reflex (TCR), is also hypothesized as one of the possible mechanisms for this condition. The TCR is a well-established neurogenic reflex that manifests as bradycardia, hypotension, apnea, and gastric hypermotility. The TCR shares many similarities with the DR, which is a significant physiological adaptation to withstand hypoxia during apnea in many animal species including humans in clinical manifestation and mechanism of action. The DR is characterized by breath holding (apnea), bradycardia, and vasoconstriction, leading to increase in blood pressure. Several studies have described congenital anomalies of autonomic nervous system in the pathogenesis of SIDS such as hypoplasia, delayed neuronal maturation, or decreased neuronal density of arcuate nucleus, hypoplasia, and neuronal immaturity of the hypoglossal nucleus. The abnormalities of autonomic nervous system in SIDS may explain the role of TCR in this syndrome involving sympathetic and parasympathetic nervous system. We reviewed the available literature to identify the role of TCR in the etiopathogenesis of SIDS and the pathways and cellular mechanism involved in it. This synthesis will help to update our knowledge and improve our understanding about this mysterious, yet common condition and will open the door for further research in this field.

Diving Response in Rats: Role of the Subthalamic Vasodilator Area

Diving response (DR) is a powerful integrative response targeted toward survival of the hypoxic/anoxic conditions. Being present in all animals and humans, it allows to survive adverse conditions like diving. Earlier, we discovered that forehead stimulation affords neuroprotective effect, decreasing infarction volume triggered by permanent occlusion of the middle cerebral artery in rats. We hypothesized that cold stimulation of the forehead induces DR in rats, which, in turn, exerts neuroprotection. We compared autonomic [AP, heart rate (HR), cerebral blood flow (CBF)] and EEG responses to the known DR-triggering stimulus, ammonia stimulation of the nasal mucosa, cold stimulation of the forehead, and cold stimulation of the glabrous skin of the tail base in anesthetized rats. Responses in AP, HR, CBF, and EEG to cold stimulation of the forehead and ammonia vapors instillation into the nasal cavity were comparable and differed significantly from responses to the cold stimulation of the tail base. Excitotoxic lesion of the subthalamic vasodilator area (SVA), which is known to participate in CBF regulation and to afford neuroprotection upon excitation, failed to affect autonomic components of the DR evoked by forehead cold stimulation or nasal mucosa ammonia stimulation. We conclude that cold stimulation of the forehead triggers physiological response comparable to the response evoked by ammonia vapor instillation into nasal cavity, which is considered as stimulus triggering protective DR. These observations may explain the neuroprotective effect of the forehead stimulation. Data demonstrate that SVA does not directly participate in the autonomic adjustments accompanying DR; however, it is involved in diving-evoked modulation of EEG. We suggest that forehead stimulation can be employed as a stimulus capable of triggering oxygen-conserving DR and can be used for neuroprotective therapy.

Recurrent asystole as an electrocardiographic artifact during microdebrider use in functional endoscopic sinus surgery

INTRODUCTION

Electrocardiographic (EKG) artifacts can lead to unnecessary treatment and costly diagnostic workup. Two previous studies reported a ventricular tachycardia artifact as a result of microdebrider malfunction. In this study, we report the first case of EKG artifacts that mimick asystole from microdebrider use during functional endoscopic sinus surgery (FESS).

CASE

A healthy 19-year-old woman presented with chronic rhinosinusitis, nasal polyposis, and a deviated nasal septum. She was scheduled for a bilateral FESS and septoplasty. During surgery, the microdebrider was changed after 1 hour. While using the second microdebrider, the EKG monitor showed three distinct asystolic events, all lasted approximately 3 seconds. The EKG tracing returned to normal sinus rhythm every time the microdebrider was stopped. The patient's oxygen saturation remained at 100%, and blood pressure remained stable during the episodes. The procedure was aborted, and an extensive cardiology workup was performed, which returned negative results. Biomedical engineering investigated the microdebrider and found a far greater than expected chassis leak, which likely caused electrical interference. Six months later, the patient underwent a right-sided FESS and revision left frontal FESS. There were no EKG abnormalities during the second surgery.

DISCUSSION

Although other EKG artifacts have been reported in the literature, this is the first case report of an artifact that mimicked asystole that stemmed from microdebrider use. Improved awareness of this potential EKG artifact for both the surgeon and the anesthesiologist may prevent an unnecessary costly workup.

Brainstem-mediated sniffing and respiratory modulation during odor stimulation

The trigeminal and olfactory systems interact during sensory processing of odor. Here, we investigate odor-evoked modulations of brainstem respiratory networks in a decerebrated perfused brainstem preparation of rat with intact olfactory bulbs. Intranasal application of non-trigeminal odors (rose) did not evoke respiratory modulation in absence of cortico-limbic circuits. Conversely, trigeminal odors such as menthol or lavender evoked robust respiratory modulations via direct activation of preserved brainstem circuits. Trigeminal odors consistently triggered short phrenic nerve bursts (fictive sniff), and the strong trigeminal odor menthol also triggered a slowing of phrenic nerve frequency. Phrenic and vagal nerve recordings reveal that fictive sniffs transiently interrupted odor evoked tonic postinspiratory vagal discharge. This motor pattern is significantly different from normal (eupneic) respiratory activity. In conclusion, we show for the first time the direct involvement of brainstem circuits in primary odor processing to evoke protective sniffs and respiratory modulation in the complete absence of forebrain commands.

Trigeminocardiac reflex by mandibular extension on rat pial microcirculation: role of nitric oxide

In the present study we have extended our previous findings about the effects of 10 minutes of passive mandibular extension in anesthetized Wistar rats. By prolonging the observation time to 3 hours, we showed that 10 minutes mandibular extension caused a significant reduction of the mean arterial blood pressure and heart rate respect to baseline values, which persisted up to 160 minutes after mandibular extension. These effects were accompanied by a characteristic biphasic response of pial arterioles: during mandibular extension, pial arterioles constricted and after mandibular extension dilated for the whole observation period. Interestingly, the administration of the opioid receptor antagonist naloxone abolished the vasoconstriction observed during mandibular extension, while the administration of N_ω-Nitro-L-arginine methyl ester, a nitric oxide synthase inhibitor, abolished the vasodilation observed after mandibular extension. Either drug did not affect the reduction of mean arterial blood pressure and heart rate induced by mandibular extension. By qRT-PCR, we also showed that neuronal nitric oxide synthase gene expression was significantly increased compared with baseline conditions during and after mandibular extension and endothelial nitric oxide synthase gene expression markedly increased at 2 hours after mandibular extension. Finally, western blotting detected a significant increase in neuronal and endothelial nitric oxide synthase protein expression. In conclusion mandibular extension caused complex effects on pial microcirculation involving opioid receptor activation and nitric oxide release by both neurons and endothelial vascular cells at different times.

Direct reticular projections of trigeminal sensory fibers immunoreactive to CGRP: potential monosynaptic somatoautonomic projections

Few trigeminal sensory fibers project centrally beyond the trigeminal sensory complex, with only projections of fibers carried in its sensory anterior ethmoidal (AEN) and intraoral nerves described. Fibers of the AEN project into the brainstem reticular formation where immunoreactivity against substance P and CGRP are found. We investigated whether the source of these peptides could be from trigeminal ganglion neurons by performing unilateral rhizotomies of the trigeminal root and looking for absence of label. After an 8–14 days survival, substance P immunoreactivity in the trigeminal sensory complex was diminished, but we could not conclude that the sole source of this peptide in the lateral parabrachial area and lateral reticular formation arises from primary afferent fibers. Immunoreactivity to CGRP after rhizotomy however was greatly diminished in the trigeminal sensory complex, confirming the observations of others. Moreover, CGRP immunoreactivity was nearly eliminated in fibers in the lateral parabrachial area, the caudal ventrolateral medulla, both the peri-ambiguus and ventral parts of the rostral ventrolateral medulla, in the external formation of the nucleus ambiguus, and diminished in the caudal pressor area. The nearly complete elimination of CGRP in the lateral reticular formation after rhizotomy suggests this peptide is carried in primary afferent fibers. Moreover, the arborization of CGRP immunoreactive fibers in these areas mimics that of direct projections from the AEN. Since electrical stimulation of the AEN induces cardiorespiratory adjustments including an apnea, peripheral vasoconstriction, and bradycardia similar to those seen in the mammalian diving response, we suggest these perturbations of autonomic behavior are enhanced by direct somatic primary afferent projections to these reticular neurons. We believe this to be first description of potential direct somatoautonomic projections to brainstem neurons regulating autonomic activity.

Parasympathetic preganglionic cardiac motoneurons labeled after voluntary diving

A dramatic bradycardia is induced by underwater submersion in vertebrates. The location of parasympathetic preganglionic cardiac motor neurons driving this aspect of the diving response was investigated using cFos immunohistochemistry combined with retrograde transport of cholera toxin subunit B (CTB) to double-label neurons. After pericardial injections of CTB, trained rats voluntarily dove underwater, and their heart rates (HR) dropped immediately to 95 ± 2 bpm, an 80% reduction. After immunohistochemical processing, the vast majority of CTB labeled neurons were located in the reticular formation from the rostral cervical spinal cord to the facial motor nucleus, confirming previous studies. Labeled neurons caudal to the rostral ventrolateral medulla were usually spindle-shaped aligned along an oblique line running from the dorsal vagal nucleus to the ventrolateral reticular formation, while those more rostrally were multipolar with extended dendrites. Nine percent of retrogradely-labeled neurons were positive for both cFos and CTB after diving and 74% of these were found rostral to the obex. CTB also was transported transganglionically in primary afferent fibers, resulting in large granular deposits in dorsolateral, ventrolateral, and commissural subnuclei of the nucleus tractus solitarii (NTS) and finer deposits in lamina I and IV-V of the trigeminocervical complex. The overlap of parasympathetic preganglionic cardiac motor neurons activated by diving with those activated by baro- and chemoreceptors in the rostral ventrolateral medulla is discussed. Thus, the profound bradycardia seen with underwater submersion reinforces the notion that the mammalian diving response is the most powerful autonomic reflex known.

The mammalian diving response: an enigmatic reflex to preserve life?

The mammalian diving response is a remarkable behavior that overrides basic homeostatic reflexes. It is most studied in large aquatic mammals but is seen in all vertebrates. Pelagic mammals have developed several physiological adaptations to conserve intrinsic oxygen stores, but the apnea, bradycardia, and vasoconstriction is shared with those terrestrial and is neurally mediated. The adaptations of aquatic mammals are reviewed here as well as the neural control of cardiorespiratory physiology during diving in rodents.

Trigeminal Medullary Dorsal Horn Neurons Activated by Nasal Stimulation Coexpress AMPA, NMDA, and NK1 Receptors

Afferent information initiating the cardiorespiratory responses during nasal stimulation projects from the nasal passages to neurons within the trigeminal medullary dorsal horn (MDH) via the anterior ethmoidal nerve (AEN). Central AEN terminals are thought to release glutamate to activate the MDH neurons. This study was designed to determine which neurotransmitter receptors (AMPA, kainate, or NMDA glutamate receptor subtypes or the Substance P receptor NK1) are expressed by these activated MDH neurons. Fos was used as a neuronal marker of activated neurons, and immunohistochemistry combined with epifluorescent microscopy was used to determine which neurotransmitter receptor subunits were coexpressed by activated MDH neurons. Results indicate that, during nasal stimulation with ammonia vapors in urethane-anesthetized Sprague-Dawley rats, activated neurons within the superficial MDH coexpress the AMPA glutamate receptor subunits GluA1 (95.8%) and GluA2/3 (88.2%), the NMDA glutamate receptor subunits GluN1 (89.1%) and GluN2A (41.4%), and NK1 receptors (64.0%). It is therefore likely that during nasal stimulation the central terminals of the AEN release glutamate and substance P that then produces activation of these MDH neurons. The involvement of AMPA and NMDA receptors may mediate fast and slow neurotransmission, respectively, while NK1 receptor involvement may indicate activation of a nociceptive pathway.

Bilateral sectioning of the anterior ethmoidal nerves does not eliminate the diving response in voluntarily diving rats

The diving response is characterized by bradycardia, apnea, and increased peripheral resistance. This reflex response is initiated by immersing the nose in water. Because the anterior ethmoidal nerve (AEN) innervates the nose, our hypothesis was that intact AENs are essential for initiating the diving response in voluntarily diving rats. Heart rate (HR) and arterial blood pressure (BPa) were monitored using implanted biotransmitters. Sprague-Dawley rats were trained to voluntarily swim 5 m underwater. During diving, HR decreased from 480 ± 15 to 99 ± 5 bpm and BPa increased from 136 ± 2 to 187 ± 3 mmHg. Experimental rats (N = 9) then received bilateral AEN sectioning, while Sham rats (N = 8) did not. During diving in Experimental rats 7 days after AEN surgery, HR decreased from 478 ± 13 to 76 ± 4 bpm and BPa increased from 134 ± 3 to 186 ± 4 mmHg. Responses were similar in Sham rats. Then, during nasal stimulation with ammonia vapors in urethane-anesthetized Experimental rats, HR decreased from 368 ± 7 to 83 ± 4 bpm, and BPa increased from 126 ± 7 to 175 ± 4 mmHg. Responses were similar in Sham rats. Thus, 1 week after being sectioned the AENs are not essential for initiating a full cardiorespiratory response during both voluntary diving and nasal stimulation. We conclude that other nerve(s) innervating the nose are able to provide an afferent signal sufficient to initiate the diving response, although neuronal plasticity within the medullary dorsal horn may be necessary for this to occur.

Computer-assisted paranasal sinus operation induces diving bradycardia

Unintentional mechanical manipulation anywhere in the distribution of the trigeminal nerve might activate a reflexive bradycardia. Neurosurgeons need to bear in mind detrimental consequences on cardiac function. A female patient (53 years) underwent a computer-assisted (CAS), paranasal sinus operation performed under general anesthesia. During left sided CAS and preparation of the sinus ethmoidalis, heart rate significantly fell from 68 to 32 /min, while systolic arterial blood pressure decreased from 105 to 75 mmHg. Continuation of the preparation again decreased heart rate progressing to transient asystole lasting for 15 s. After removal of the instruments, asystole terminated without medical support. As heart rate decreased after renewed insertion of the CAS probe, sinus ethmoidalis surgery was completed after atropine administration. During neurosurgical procedures, the incidence of the reflex varies between 10 and 18%. To the best of our knowledge, we report for the first time on a direct stimulation of the ethmoidal nerve with instruments (CAS probe) during paranasal surgery. Although normally cardioprotective, exaggeration of the diving reflex can be detrimental and has been implicated in cardiorespiratory disorders, including sudden death and the sudden infant death syndrome.

Animal models for investigating the central control of the Mammalian diving response

Pioneering studies by Per Scholander indicated that the diving response consists of reflexly induced apnea, bradycardia and an alteration of blood flow that maintains perfusion of the heart and brain. More recently field physiological studies have shown that many marine animals can adjust cardiorespiratory aspects of their diving response depending upon the behavioral situation. This could suggest that the very labile heart rate during diving is under direct cortical control. However, the final control of autonomic nervous system functioning resides within the brainstem and not the cortex. Many physiologists regard the brain as a "black box" where important neuronal functioning occurs, but the complexity of such functioning leaves systematic investigation a daunting task. As a consequence the central control of the diving response has been under-investigated. Thus, to further advance the field of diving physiology by understanding its central neuronal control, it would be first necessary to understand the reflex circuitry that exists within the brainstem of diving animals. To do this will require an appropriate animal model. In this review, two animals, the muskrat and rat, will be offered as animal models to investigate the central aspects of the diving response. Firstly, although these rodents are not marine animals, natural histories indicate that both animals can and do exploit aquatic environments. Secondly, physiological recordings during natural and simulated diving indicate that both animals possess the same basic physiological responses to underwater submersion that occur in marine animals. Thirdly, the size and ease of housing of both animals makes them attractive laboratory research animals. Finally, the enormous amount of scientific literature regarding rodent brainstem autonomic control mechanisms, and the availability of brain atlases, makes these animals ideal choices to study the central control of the mammalian diving response.

Activation of brainstem neurons by underwater diving in the rat

The mammalian diving response is a powerful autonomic adjustment to underwater submersion greatly affecting heart rate, arterial blood pressure, and ventilation. The bradycardia is mediated by the parasympathetic nervous system, arterial blood pressure is mediated via the sympathetic system and still other circuits mediate the respiratory changes. In the present study we investigate the cardiorespiratory responses and the brainstem neurons activated by voluntary diving of trained rats, and, compare them to control and swimming animals which did not dive. We show that the bradycardia and increase in arterial blood pressure induced by diving were significantly different than that induced by swimming. Neuronal activation was calculated after immunohistochemical processing of brainstem sections for Fos protein. Labeled neurons were counted in the caudal pressor area, the medullary dorsal horn, subnuclei of the nucleus tractus solitarii (NTS), the nucleus raphe pallidus (RPa), the rostroventrolateral medulla, the A5 area, the nucleus locus coeruleus, the Kölliker–Fuse area, and the external lateral and superior lateral subnuclei of the parabrachial nucleus. All these areas showed significant increases in Fos labeling when data from voluntary diving rats were compared to control rats and all but the commissural subnucleus of the NTS, A5 area, and RPa were significantly different from swimming rats. These data provide a substrate for more precise experiments to determine the role of these nuclei in the reflex circuits driving the diving response.

Persistence of the nasotrigeminal reflex after pontomedullary transection

Most behaviors have numerous components based on reflexes, but the neural circuits driving most reflexes rarely are documented. The nasotrigeminal reflex induced by stimulating the nasal mucosa causes an apnea, a bradycardia, and variable changes in mean arterial blood pressure (MABP). In this study we tested the nasotrigeminal reflex after transecting the brainstem at the pontomedullary junction. The nasal mucosae of anesthetized rats were stimulated with ammonia vapors and their brainstems then were transected. Complete transections alone induced an increase in resting heart rate (HR; p<0.001) and MABP (p<0.001), but no significant change in ventilation. However, the responses to nasal stimulation after transection were similar to those seen prior to transection. HR still dropped significantly (p<0.001), duration of apnea remained the same, as did changes in MABP. Results from rats whose transection were incomplete are discussed. These data implicate that the neuronal circuitry driving the nasotrigeminal reflex, and indirectly the diving response, is intrinsic to the medulla and spinal cord.

A trigeminoreticular pathway: implications in pain

Neurons in the caudalmost ventrolateral medulla (cmVLM) respond to noxious stimulation. We previously have shown most efferent projections from this locus project to areas implicated either in the processing or modulation of pain. Here we show the cmVLM of the rat receives projections from superficial laminae of the medullary dorsal horn (MDH) and has neurons activated with capsaicin injections into the temporalis muscle. Injections of either biotinylated dextran amine (BDA) into the MDH or fluorogold (FG)/fluorescent microbeads into the cmVLM showed projections from lamina I and II of the MDH to the cmVLM. Morphometric analysis showed the retrogradely-labeled neurons were small (area 88.7 µm(2)±3.4) and mostly fusiform in shape. Injections (20-50 µl) of 0.5% capsaicin into the temporalis muscle and subsequent immunohistochemistry for c-Fos showed nuclei labeled in the dorsomedial trigeminocervical complex (TCC), the cmVLM, the lateral medulla, and the internal lateral subnucleus of the parabrachial complex (PBil). Additional labeling with c-Fos was seen in the subnucleus interpolaris of the spinal trigeminal nucleus, the rostral ventrolateral medulla, the superior salivatory nucleus, the rostral ventromedial medulla, and the A1, A5, A7 and subcoeruleus catecholamine areas. Injections of FG into the PBil produced robust label in the lateral medulla and cmVLM while injections of BDA into the lateral medulla showed projections to the PBil. Immunohistochemical experiments to antibodies against substance P, the substance P receptor (NK1), calcitonin gene regulating peptide, leucine enkephalin, VRL1 (TPRV2) receptors and neuropeptide Y showed that these peptides/receptors densely stained the cmVLM. We suggest the MDH- cmVLM projection is important for pain from head and neck areas. We offer a potential new pathway for regulating deep pain via the neurons of the TCC, the cmVLM, the lateral medulla, and the PBil and propose these areas compose a trigeminoreticular pathway, possibly the trigeminal homologue of the spinoreticulothalamic pathway.

Cardiorespiratory and neural consequences of rats brought past their aerobic dive limit

The mammalian diving response is a dramatic autonomic adjustment to underwater submersion affecting heart rate, arterial blood pressure, and ventilation. The bradycardia is known to be modulated by the parasympathetic nervous system, arterial blood pressure is modulated via the sympathetic system, and still other circuits modulate the respiratory changes. In the present study, we investigate the submergence of rats brought past their aerobic dive limit, defined as the diving duration beyond which blood lactate concentration increases above resting levels. Hemodynamic measurements were made during underwater submergence with biotelemetric transmitters, and blood was drawn from cannulas previously implanted in the rats' carotid arteries. Such prolonged submersion induces radical changes in blood chemistry; mean arterial PCO(2) rose to 62.4 Torr, while mean arterial PO(2) and pH reached nadirs of 21.8 Torr and 7.18, respectively. Despite these radical changes in blood chemistry, the rats neither attempted to gasp nor breathe while underwater. Immunohistochemistry for Fos protein done on their brains revealed numerous Fos-positive profiles. Especially noteworthy were the large number of immunopositive profiles in loci where presumptive chemoreceptors are found. Despite the activation of these presumptive chemoreceptors, the rats did not attempt to breathe. Injections of biotinylated dextran amine were made into ventral parts of the medullary dorsal horn, where central fibers of the anterior ethmoidal nerve terminate. Labeled fibers coursed caudal, ventral, and medial from the injection to neurons on the ventral surface of the medulla, where numerous Fos-labeled profiles were seen in the rats brought past their aerobic dive limit. We propose that this projection inhibits the homeostatic chemoreceptor reflex, despite the gross activation of chemoreceptors.

The rat: a laboratory model for studies of the diving response

Underwater submersion in mammals induces apnea, parasympathetically mediated bradycardia, and sympathetically mediated peripheral vasoconstriction. These effects are collectively termed the diving response, potentially the most powerful autonomic reflex known. Although these physiological responses are directed by neurons in the brain, study of neural control of the diving response has been hampered since 1) it is difficult to study the brains of animals while they are underwater, 2) feral marine mammals are usually large and have brains of variable size, and 3) there are but few references on the brains of naturally diving species. Similar responses are elicited in anesthetized rodents after stimulation of their nasal mucosa, but this nasopharyngeal reflex has not been compared directly with natural diving behavior in the rat. In the present study, we compared hemodynamic responses elicited in awake rats during volitional underwater submersion with those of rats swimming on the water's surface, rats involuntarily submerged, and rats either anesthetized or decerebrate and stimulated nasally with ammonia vapors. We show that the hemodynamic changes to voluntary diving in the rat are similar to those of naturally diving marine mammals. We also show that the responses of voluntary diving rats are 1) significantly different from those seen during swimming, 2) generally similar to those elicited in trained rats involuntarily "dunked" underwater, and 3) generally different from those seen from dunking naive rats underwater. Nasal stimulation of anesthetized rats differed most from the hemodynamic variables of rats trained to dive voluntarily. We propose that the rat trained to dive underwater is an excellent laboratory model to study neural control of the mammalian diving response, and also suggest that some investigations may be done with nasal stimulation of decerebrate preparations to decipher such control.

Unmyelinated fibers of the anterior ethmoidal nerve in the rat co-localize with neurons in the medullary dorsal horn and ventrolateral medulla activated by nasal stimulation

The anterior ethmoidal nerve (AEN) innervates the nasal passages and external nares, and serves as the afferent limb of the nasopharyngeal and diving responses. However, although 65% of the AEN is composed of unmyelinated fibers, it has not been determined whether this afferent signal is carried by unmyelinated or myelinated fibers. We used the transganglionic tracers WGA-HRP, IB4-HRP, and CTB-HRP to trace the central projections of the AEN of the rat. Interpretation of the labeling patterns suggests that AEN unmyelinated fibers project primarily to the ventral tip of the ipsilateral medullary dorsal horn (MDH) at the level of the area postrema. Other unmyelinated projections were to the ventral paratrigeminal nucleus and ventrolateral medulla, specifically the Bötzinger and RVLM/C1 regions. Myelinated AEN fibers projected to the ventral paratrigeminal and mesencephalic trigeminal nuclei. Stimulating the nasal passages of urethane-anesthetized rats with ammonia vapors produced the nasopharyngeal response that included apnea, bradycardia and an increase in arterial blood pressure. Central projections of the AEN co-localized with neurons within both MDH and RVLM/C1 that were activated by nasal stimulation. Within the ventral MDH the density of AEN terminal projections positively correlated with the rostral-caudal location of activated neurons, especially at and just caudal to the obex. We conclude that unmyelinated AEN terminal projections are involved in the activation of neurons in the MDH and ventrolateral medulla that participate in the nasopharyngeal response in the rat. We also found that IB4-HRP was a much less robust tracer than WGA-HRP.

The trigemino-cardiac reflex: an update of the current knowledge

The trigemino-cardiac reflex (TCR) is clinically defined as the sudden onset of parasympathetic activity, sympathetic hypotension, apnea, or gastric hypermotility during central or peripheral stimulation of any of the sensory branches of the trigeminal nerve. Clinically, the TCR has been reported to occur during craniofacial surgery, manipulation of the trigeminal nerve/ganglion and during surgery for lesion in the cerebellopontine angle, cavernous sinus, and the pituitary fossa. Apart from the few clinical reports, the physiologic function of this brainstem reflex has not yet been fully explored. The manifestation of the TCR can vary from bradycardia and hypotension to asystole. From the experimental findings, the TCR represents an expression of a central reflex leading to rapid cerebrovascular vasodilatation generated from excitation of oxygen-sensitive neurons in the rostral ventro-lateral medulla oblongata. By this physiologic response, the systemic and cerebral circulations may be adjusted in a way that augments cerebral perfusion. This review summarizes the current state of knowledge about TCR.

Serotonergic modulation of the trigeminocardiac reflex neurotransmission to cardiac vagal neurons in the nucleus ambiguus

Stimulation of the trigeminal nerve evokes a dramatic decrease in heart rate and blood pressure, and this reflex has generally been termed the trigeminocardiac reflex. A subset of the trigeminocardiac reflex is the diving reflex in which the nasal mucosa is stimulated with water or air-borne chemical irritants. Activation of the diving reflex evokes a pronounced bradycardia, mediated by increased parasympathetic cardiac activity, and is the most powerful autonomic reflex. However, exaggeration of this protective response could be detrimental and has been implicated in Sudden Infant Death Syndrome (SIDS). Despite the importance and strength of the trigeminocardiac reflex, there is little information about the cellular mechanisms and brain stem pathways that constitute this reflex. To address these issues, stimulation of trigeminal afferent fibers and the evoked excitatory postsynaptic currents were recorded in cardiac vagal neurons (CVNs) in an in vitro brain stem slice preparation. This synaptic pathway is robust and activation of the trigeminal pathway often evoked action potentials in CVNs. Application of the serotonin (5-HT) reuptake inhibitor citalopram significantly enhanced these responses. Consistent with the hypothesis this pathway is endogenously modulated by 5-HT receptors the 5-HT1A receptor antagonist, WAY 100635 inhibited, whereas the 5-HT2A/C receptor antagonist, ketanserin facilitated the excitatory neurotransmission to CVNs. The 5-HT1A receptor agonist 8-hydroxy-2-(dipropylamino)tetralin hydrobromide increased, whereas the 5-HT2 receptor agonist, alpha-methylserotonin maleate salt inhibited this reflex pathway. These results indicate stimulation of trigeminal fibers evokes a powerful excitatory and polysynaptic pathway to CVNs, and this pathway is endogenously modulated and differentially enhanced and depressed, by 5-HT1A and 5-HT2 receptors, respectively.

The cold face test: A non-baroreflex mediated test of cardiac vagal function

Application of cold to the face evokes potent bradycardia and a pressor response, similar to the diving reflex. However, the role of the baroreceptors in this response is unclear. Ten healthy controls and two patients with baroreflex impairment were recruited. A cold face test (CFT) was induced by the application of three cold packs (0.5 degrees C) to the face. Heart rate (ECG), blood pressure (Finapres) and skin temperature (forehead electrode) were recorded continuously. All data were analyzed using unpaired Students t-tests, and expressed as mean +/- SD. In all controls, CFT induced bradycardia. The mean onset latency was 5.6 +/- 4.6 s, and the maximal bradycardia was seen at 35.8 +/- 15.8 s. Systolic blood pressure increased in eight controls, with a mean onset latency of 18.8 +/- 16.6 s and a peak rise at 38.7 +/- 22.7 s. In the controls, bradycardia preceded the pressor response. The heart rate and blood pressure changes during CFT had a longer latency than baroreflex evoked responses. Moreover, one subject had bradycardia despite a fall in blood pressure. The two patients had abnormal Valsalva ratios and no change in heart rate during tilt, indicating impairment of the baroreflex. However, both their heart rate and blood pressure responses to CFT were normal. These data are further evidence of the limited role of the baroreflex in the autonomic responses to CFT. They suggest that the CFT may be of use in assessing the integrity of the efferent cardiovascular autonomic pathways in patients with suspected baroreflex impairment.

The anterior ethmoidal nerve is necessary for the initiation of the nasopharyngeal response in the rat

Stimulation of the nasal passages with ammonia vapors can initiate a nasopharyngeal response that resembles the diving response. This response consists of a sympathetically mediated increase in peripheral vascular resistance, parasympathetically mediated bradycardia and an apnea. The current study investigated the role of the anterior ethmoidal nerve (AEN) in the nasopharyngeal response in the rat, as it is thought that the AEN provides the main sensory innervation of the nasal passages. When both AENs were intact, nasal stimulation caused significant bradycardia, hypertension, and apnea and produced Fos label ventrally within the ipsilateral medullary dorsal horn (MDH) and paratrigeminal nucleus just caudal to the obex. This labeling presumably represents activation of second-order trigeminal neurons. When only one AEN was intact, the nasopharyngeal response was slightly attenuated, and a similar pattern of Fos labeling was only seen in the trigeminal nucleus ipsilateral to the intact AEN. The trigeminal labeling contralateral to the intact AEN was significantly reduced. When both AENs were cut, the nasopharyngeal response to nasal stimulation consisted of only a slight apnea and an increase in arterial pressure; the resultant Fos labeling within the trigeminal nucleus was significantly reduced. Cutting both AENs but not stimulating the nasal passages also produced some Fos labeling within the trigeminal nucleus. These findings suggest that a single AEN can provide sufficient afferent input to initiate the cardiorespiratory changes consistent with the nasopharyngeal response. We conclude that the AEN provides a unique afferent contribution that is capable of producing the diving response.

Brainstem projections from recipient zones of the anterior ethmoidal nerve in the medullary dorsal horn

Stimulation of the anterior ethmoidal nerve or the nasal mucosa induces cardiorespiratory responses similar to those seen in diving mammals. We have utilized the transganglionic transport of a cocktail of horseradish peroxidase conjugates and anterograde and retrograde tract tracing techniques to elucidate pathways which may be important for these responses in the rat. Label was seen throughout the trigeminal sensory complex after the horseradish peroxidase conjugates were applied to the anterior ethmoidal nerve peripherally. Reaction product was most dense in the medullary dorsal horn, especially in laminae I and II. Injections were made of biotinylated dextran amine into the recipient zones of the medullary dorsal horn from the anterior ethmoidal nerve, and the anterogradely transported label documented. Label was found in many brainstem areas, but fibers with varicosities were noted in specific subdivisions of the nucleus tractus solitarii and parabrachial nucleus, as well as parts of the caudal and rostral ventrolateral medulla and A5 (noradrenergic cell group in ventrolateral pons) area. The retrograde transport of FluoroGold into the medullary dorsal horn after injections into these areas showed most neurons in laminae I, II, and V. Label was especially dense in areas which received primary afferent fibers from the anterior ethmoidal nerve. These data identify potential neural circuits for the diving response of the rat.

Target site of inhibition of baroreflex vagal bradycardia by nasal stimulation

We have previously reported that stimulation of nasal mucosa inhibits baroreflex vagal bradycardia (BVB) and this inhibition was mediated exclusively by the trigeminal nerve, and occurred principally at pontomedullary level. In this study, to identify the target site of the inhibition, several types of experiments were conducted in chloralose-urethane-anesthetized, beta-adrenergic receptor-blocked rats. Afferent discharges in the ethmoidal nerve (EN5) were increased in response to nasal stimulation by smoke, and electrical stimulation of the EN5 suppressed BVB induced by electrical stimulation of the aortic depressor nerve (ADN). Electrical stimulation of the EN5 inhibited vagal bradycardia evoked by either electrical or chemical stimulation of the nucleus tractus solitarius (NTS), while it rather facilitated bradycardia by stimulation of the nucleus ambiguus (NA) region. Microstimulation of the NTS induced antidromic compound spike potential along the ADN but this was not affected by stimulation of the EN5. ADN-evoked field potentials and unitary responses of neurons in the NTS were suppressed by stimulation of the EN5. These results suggested that barosensitive neurons in the NTS are the major target sites of inhibition of BVB by nasal stimulation in rats.

Nasal trigeminal inputs release the A5 inhibition received by the respiratory rhythm generator of the mouse neonate

Experiments were performed on neonatal mice to analyze why, in vitro, the respiratory rhythm generator (RRG) was silent and how it could be activated. We demonstrated that in vitro the RRG in intact brain stems is silenced by a powerful inhibition arising from the pontine A5 neurons through medullary alpha(2) adrenoceptors and that in vivo nasal trigeminal inputs facilitate the RRG as nasal continuous positive airway pressure increases the breathing frequency, whereas nasal occlusion and nasal afferent anesthesia depress it. Because nasal trigeminal afferents project to the A5 nuclei, we applied single trains of negative electric shocks to the trigeminal nerve in inactive ponto-medullary preparations. They induced rhythmic phrenic bursts during the stimulation and for 2-3 min afterward, whereas repetitive trains produced on-going rhythmic activity up to the end of the experiments. Electrolytic lesion or pharmacological inactivation of the ipsilateral A5 neurons altered both the phrenic burst frequency and occurrence after the stimulation. Extracellular unitary recordings and trans-neuronal tracing experiments with the rabies virus show that the medullary lateral reticular area contains respiratory-modulated neurons, not necessary for respiratory rhythmogenesis, but that may provide an excitatory pathway from the trigeminal inputs to the RRG as their electrolytic lesion suppresses any phrenic activity induced by the trigeminal nerve stimulation. The results lead to the hypothesis that the trigeminal afferents in the mouse neonate involve at least two pathways to activate the RRG, one that may act through the medullary lateral reticular area and one that releases the A5 inhibition received by the RRG.

Inhibitory synaptic mechanisms regulating upper airway patency

The breathing cycle of vertebrates comprises three phases (inspiration, postinspiration and expiration) that are apparent in the activities generated in the ponto-medullary respiratory network. A large body of evidence now indicates that in adult mammals generation of this three-phase pattern is based on reciprocal synaptic inhibition between distinct subsets of respiratory neurones. This review summarises our recent experiments focused on the role of glycinergic inhibition in respiratory pattern formation: e.g. in co-ordinating the activity of spinal and cranial motor outputs that drive the ventilatory pump (thoracic and abdominal muscles) and adjust airflow by regulating laryngeal resistance (laryngeal abductors and adductors). We used arterially perfused in situ preparations of neonatal and mature rat and show that specific blockade of glycine receptors within the ponto-medullary network caused a severe disruption of the co-ordination of spinal and cranial motor outputs: postinspiratory neurones lose their characteristic inspiratory inhibition revealing excitatory synaptic drive coincident with inspiratory phrenic nerve activity. The resulting simultaneous discharge of inspiratory and postinspiratory neurones caused co-activation of both glottal abductors and adductors during neural inspiration. The latter resulted in a paradoxical inspiratory adduction of the vocal fold and severe disruption of the eupneic breathing pattern. The effect of blocking glycine receptors was the same in both mature and newborn rats suggesting that glycinergic inhibition is essential for co-ordinating cranial and spinal motor outputs from birth.

Trigeminal reflex regulation of the glottis depends on central glycinergic inhibition in the rat

In an unanesthetized decerebrate in situ arterially perfused brain stem preparation of mature rat, strychnine (0.05-0.2 microM) blockade of glycine receptors caused postinspiratory glottal constriction to occur earlier, shifting from early expiration to inspiration. This resulted in a paradoxical inspiratory-related narrowing of the upper airway. Stimulation of the trigeminal ethmoidal nerve (EN5; 20 Hz, 100 micros, 0.5-2 V) evoked a diving response, which included a reflex apnea, glottal constriction, and bradycardia. After strychnine administration, this pattern was converted to a maintained phrenic nerve discharge and a reduced glottal constriction that was interrupted intermittently by transient abductions. The onset of firing of postinspiratory neurons shifted from early expiration into neural inspiration in the presence of strychnine, but neurons maintained their tonic activation during EN5 stimulation, as observed during control. Inspiratory neurons that were hyperpolarized by EN5 stimulation in control conditions were powerfully excited after loss of glycinergic inhibition. Thus the integrity of glycinergic inhibition within the pontomedullary respiratory network is critical for the coordination of cranial and spinal motor outflows during eupnea but also for protective reflex regulation of the upper airway.

Risks and benefits of therapies for apnoea in premature infants

Apnoea in infants can result from a wide range of causes, and requires thorough evaluation before deciding on appropriate treatment. Continuous monitoring of premature infants with apnoea is mandatory in order to define the pathophysiology and type of apnoea; selection of treatment involves careful assessment of aetiology, as well as efficacy and tolerability in each individual case. The objective of treatment is to prevent the deleterious consequences of apnoeas that last >20 seconds and/or are associated with bradycardia, cyanosis or pallor, and occur more often than once an hour over a 12-hour period. Apnoea management involves both pharmacological and nonpharmacological treatment. We suggest methylxanthines as first-line therapy for idiopathic apnoeas; evidence suggests that caffeine is better tolerated and as efficacious as theophylline (since it is particularly efficacious against the 'central' component of idiopathic apnoea of prematurity). If treatment fails, additional measures such as doxapram may be appropriate when hypoventilation is present, or nasal continuous positive airway pressure when upper airway instability or obstructive apnoeas are predominant. Apnoea prophylaxis is an additional reason to advocate prenatal maturation with betamethasone. Weaning from treatment is attempted 4 to 5 days after complete resolution of apnoea, beginning with the last treatment introduced. Monitoring should be maintained for 4 to 5 days to detect any relapse of recurrent and severe apnoeas, which would lead to the resumption of the most recently withdrawn treatment.

Trigemino-autonomic connections in the muskrat: the neural substrate for the diving response

Stimulation of the anterior ethmoidal nerve of the muskrat produces a cardiorespiratory depression similar to the diving response. This includes an apnea, a parasympathetic bradycardia, and a selective increase in sympathetic vascular tone. However, the brainstem circuitry that links the afferent stimulus to the efferent autonomic responses is unknown. We used the anterograde transneuronal transport of the herpes simplex virus (HSV-1), strain 129, after its injection into the anterior ethmoidal nerve to determine the primary, secondary, and tertiary brainstem relays responsible for this cardiorespiratory response. In an effort to check the validity of this relatively untested tracer, we also injected the medullary dorsal horn with biotinylated dextran amine to determine the secondary trigemino-autonomic projections. Approximately 1 microl (6x10(6) PFU) of the HSV-1 virus was injected directly into the anterior ethmoidal nerve of muskrats. After 2-6 days, their trigeminal ganglions, spinal cords and brainstems were cut and immunohistologically processed for HSV-1. Initially (2 days), HSV-1 was observed only in the trigeminal ganglion. After approximately 3 days, HSV-1 was observed first in many brainstem areas optimally labeled between 4 and 4.5 days. In these cases, the ventrolateral superficial medullary dorsal horn, the ventral paratrigeminal nucleus and the interface between the interpolar and caudal subnuclei were labeled ipsilaterally. The nucleus tractus solitarius (NTS), especially its ventrolateral, dorsolateral, and commissural subnuclei were labeled as well as the caudal, intermediate and rostral ventrolateral medulla. Within the pons, the superior salivatory nucleus, the A5 area, the ventrolateral part of the parabrachial nucleus and the Kölliker-Fuse nucleus were labeled. Only after a survival of 4 days or more, the locus coeruleus, the nucleus raphe magnus, the nucleus paragigantocellularis, pars alpha, and the pontine raphe nucleus were labeled. Injections of biotinylated dextran amine were made into the medullary dorsal horn (MDH) in a location similar to that labeled after the viral injections. Fine fibers and terminals were labeled in the same brainstem areas labeled after injections of HSV-1 into the anterior ethmoidal nerve. This study outlines the potential brainstem circuit for the diving response, the most powerful autonomic reflex known. It also confirms the efficacy for using HSV-1, strain 129, as an anterograde transneuronal transport method.