A single minute lesion around the ventral respiratory group in medulla produces fatal apnea in cats

Clinical and Radiological Characteristics Associated with Respiratory Failure in Unilateral Lateral Medullary Infarction

BACKGROUND

The prognosis for unilateral lateral medullary infarction (ULMI) is generally good but may be aggravated by respiratory failure with fatal outcome. Respiratory failure has been reported in patients with severe bulbar dysfunction and large rostral medullary lesions, but its associated factors have not been systematically studied. We aimed to assess clinical and radiological characteristics associated with respiratory failure in patients with pure acute ULMI.

MATERIALS AND METHODS

Seventy-one patients (median age 55 years, 59 males) with MRI-confirmed acute pure ULMI were studied retrospectively. Clinical characteristics were assessed and bulbar symptoms were scored using a scale developed for this study. MRI lesions were classified into 4 groups based on their vertical extent (localized/extensive) and the involvement of the open and/or closed medulla. Clinical characteristics, bulbar scores and MRI lesion characteristics were compared between patients with and without respiratory failure.

RESULTS

Respiratory failure occurred in 8(11%) patients. All patients with respiratory failure were male (p = 0.336), had extensive lesions involving the open medulla (p = 0.061), progression of bulbar symptoms (p=0.002) and aspiration pneumonia (p < 0.001). Peak bulbar score (OR, 7.9 [95% CI, 2.3-160.0]; p < 0.001) and older age (OR, 1.2 [95%CI, 1.0-1.6]; p=0.006) were independently associated with respiratory failure.

CONCLUSIONS

Extensive damage involving the open/rostral medulla, clinically presenting with severe bulbar dysfunction, in conjunction with factors such as aspiration pneumonia and older age appears to be crucial for the development of respiratory failure in pure ULMI. Further prospective studies are needed to identify other potential risk factors, pathophysiology, and effective preventive measures for respiratory failure in these patients.

Central respiratory failure during acute organophosphate poisoning

Organophosphate (OP) pesticide poisoning is a global health problem with over 250,000 deaths per year. OPs affect neuronal signaling through acetylcholine (Ach) neurotransmission via inhibition of acetylcholinesterase (AChE), leading to accumulation of Ach at the synaptic cleft and excessive stimulation at post-synaptic receptors. Mortality due to OP agents is attributed to respiratory dysfunction, including central apnea. Cholinergic circuits are integral to many aspects of the central control of respiration, however it is unclear which mechanisms predominate during acute OP intoxication. A more complete understanding of the cholinergic aspects of both respiratory control as well as neural modification of pulmonary function is needed to better understand OP-induced respiratory dysfunction. In this article, we review the physiologic mechanisms of acute OP exposure in the context of the known cholinergic contributions to the central control of respiration. We also discuss the potential central cholinergic contributions to the known peripheral physiologic effects of OP intoxication.

Large lesions in the pre-Bötzinger complex area eliminate eupneic respiratory rhythm in awake goats

In awake goats, 29% bilateral destruction of neurokinin-1 receptor-expressing neurons in the pre-Bötzinger complex (pre-BötzC) area with saporin conjugated to substance P results in transient disruptions of the normal pattern of eupneic respiratory muscle activation (Wenninger JM, Pan LG, Klum L, Leekley T, Bastastic J, Hodges MR, Feroah T, Davis S, and Forster HV. J Appl Physiol 97: 1620-1628, 2004). Therefore, the purpose of these studies was to determine whether large or total lesioning in the pre-BötzC area of goats would eliminate phasic diaphragm activity and the eupneic breathing pattern. In awake goats that already had 29% bilateral destruction of neurokinin-1 receptor-expressing neurons in the pre-BötzC area, bilateral ibotenic acid (10 microl, 50 mM) injection into the pre-BötzC area resulted in a tachypneic hyperpnea that reached a maximum (132 +/- 10.1 breaths/min) approximately 30-90 min after bilateral injection. Thereafter, breathing frequency declined, central apneas resulted in arterial hypoxemia (arterial Po2 approximately 40 Torr) and hypercapnia (arterial Pco2 approximately 60 Torr), and, 11 +/- 3 min after the peak tachypnea, respiratory failure was followed by cardiac arrest in three airway-intact goats. However, after the peak tachypnea in four tracheostomized goats, mechanical ventilation was initiated to maintain arterial blood gases at control levels, during which there was no phasic diaphragm or abdominal muscle activity. When briefly removed from the ventilator (approximately 90 s), these goats became hypoxemic and hypercapnic. During this time, minimal, passive inspiratory flow resulted from phasic abdominal muscle activity. We estimate that 70% of the neurons within the pre-BötzC area were lesioned in these goats. We conclude that, in the awake state, the pre-BötzC is critical for generating a diaphragm, eupneic respiratory rhythm, and that, in the absence of the pre-BötzC, spontaneous breathing reflects the activity of an expiratory rhythm generator.

Identification of central mechanisms vital for breathing in the channel catfish, Ictalurus punctatus

To investigate central respiratory control mechanisms in channel catfish, microinjections of kainic acid (causing chemical lesion of neurons) or kynurenic acid (an antagonist of N-methyl-D-aspartate (NMDA), kainate and alpha-amino-3-OH-5-methyl-4-isooxazole-propionic-acid (AMPA) receptors) were made into the general visceral nucleus (nGV) of the medulla in anaesthetised spontaneously breathing animals. Kainic acid abolished the ventilatory movements, indicating that neurons in the nGV are crucial for maintaining normal breathing. Kynurenic acid did not affect normal breathing, but abolished the ventilatory responses to hypoxia, showing that ionotropic glutamate receptors in the nGV are vital for the production of oxygen chemoreceptor activated respiratory reflexes. In addition, immunohistochemistry of brain slices showed that interneurons and nerve fibres in the nGV display NMDA-immunoreactivity, which corroborates the physiological experiments. The results of this study suggest that neurons and glutamatergic pathways in the nGV are essential for ventilatory functions and hypoxic reflexes in channel catfish.

Breathing: rhythmicity, plasticity, chemosensitivity

Breathing is a vital behavior that is particularly amenable to experimental investigation. We review recent progress on three problems of broad interest. (i) Where and how is respiratory rhythm generated? The preBötzinger Complex is a critical site, whereas pacemaker neurons may not be essential. The possibility that coupled oscillators are involved is considered. (ii) What are the mechanisms that underlie the plasticity necessary for adaptive changes in breathing? Serotonin-dependent long-term facilitation following intermittent hypoxia is an important example of such plasticity, and a model that can account for this adaptive behavior is discussed. (iii) Where and how are the regulated variables CO2 and pH sensed? These sensors are essential if breathing is to be appropriate for metabolism. Neurons with appropriate chemosensitivity are spread throughout the brainstem; their individual properties and collective role are just beginning to be understood.

Respiratory changes induced by kainic acid lesions in rostral ventral respiratory group of rabbits

The role played by the Bötzinger complex (BötC), the pre-Bötzinger complex (pre-BötC), and the more rostral extent of the inspiratory portion of the ventral respiratory group (iVRG) in the genesis of the eupneic pattern of breathing was investigated in anesthetized, vagotomized, paralyzed, and artificially ventilated rabbits by means of kainic acid (KA, 4.7 mM) microinjections (20-30 nl). Unilateral KA microinjections into all of the investigated VRG subregions caused increases in respiratory frequency associated with moderate decreases in peak phrenic amplitude in the BötC and pre-BötC regions. Bilateral KA microinjections into either the BötC or pre-BötC transiently eliminated respiratory rhythmicity and caused the appearance of tonic phrenic activity ("tonic apnea"), whereas injections into the rostral iVRG completely suppressed inspiratory activity. Rhythmic activity resumed as low-amplitude, high-frequency oscillations and displayed a progressive, although incomplete, recovery. Combined bilateral KA microinjections (BötC and pre-BötC) caused persistent (>3 h) tonic apnea. Results show that all of the investigated VRG subregions exert a potent control on both the intensity and frequency of inspiratory activity, thus suggesting that these areas play a major role in the genesis of the eupneic pattern of breathing.

Tumor necrosis factor-alpha induces cFOS and strongly potentiates glutamate-mediated cell death in the rat spinal cord

Excitotoxic cell death due to glutamate release is important in the secondary injury following CNS trauma or ischemia. Proinflammatory cytokines also play a role. Both glutamate and tumor necrosis factor-alpha (TNF(alpha)) are released immediately after spinal cord injury. Neurophysiological studies show that TNF(alpha) can potentiate the effects of glutamatergic afferent input to produce hyperactivation of brain-stem sensory neurons. Therefore, we hypothesized that TNF(alpha) might act cooperatively with glutamate to affect cell death in the spinal cord as well. Nanoinjections of either TNF(alpha) (60 pg) or kainate (KA; 32 ng) alone into the thoracic gray resulted in almost no tissue damage or cell death 90 min after injection. However, the combination of TNF(alpha) plus KA at these same doses produced a large area of tissue necrosis and neuronal cell death, an effect which was blocked by the AMPA receptor antagonist CNQX (17 ng). These results suggest that secondary injury may involve potentiation of AMPA receptor-mediated excitatory cell death by TNF(alpha).

Models of respiratory rhythm generation in the pre-Bötzinger complex. III. Experimental tests of model predictions

We used the testable predictions of mathematical models proposed by Butera et al. to evaluate cellular, synaptic, and population-level components of the hypothesis that respiratory rhythm in mammals is generated in vitro in the pre-Bötzinger complex (pre-BötC) by a heterogeneous population of pacemaker neurons coupled by fast excitatory synapses. We prepared thin brain stem slices from neonatal rats that capture the pre-BötC and maintain inspiratory-related motor activity in vitro. We recorded pacemaker neurons extracellularly and found: intrinsic bursting behavior that did not depend on Ca(2+) currents and persisted after blocking synaptic transmission; multistate behavior with transitions from quiescence to bursting and tonic spiking states as cellular excitability was increased via extracellular K(+) concentration ([K(+)](o)); a monotonic increase in burst frequency and decrease in burst duration with increasing [K(+)](o); heterogeneity among different cells sampled; and an increase in inspiratory burst duration and decrease in burst frequency by excitatory synaptic coupling in the respiratory network. These data affirm the basis for the network model, which is composed of heterogeneous pacemaker cells having a voltage-dependent burst-generating mechanism dominated by persistent Na(+) current (I(NaP)) and excitatory synaptic coupling that synchronizes cell activity. We investigated population-level activity in the pre-BötC using local "macropatch" recordings and confirmed these model predictions: pre-BötC activity preceded respiratory-related motor output by 100-400 ms, consistent with a heterogeneous pacemaker-cell population generating inspiratory rhythm in the pre-BötC; pre-BötC population burst amplitude decreased monotonically with increasing [K(+)](o) (while frequency increased), which can be attributed to pacemaker cell properties; and burst amplitude fluctuated from cycle to cycle after decreasing bilateral synaptic coupling surgically as predicted from stability analyses of the model. We conclude that the pacemaker cell and network models explain features of inspiratory rhythm generation in vitro.

Functional synaptic connections among respiratory neurons

This presentation focuses on the application of methods to determine functional connections between neurons in the respiratory network of adult decerebrate rats. We employ a general network investigation paradigm that first examines the intracellular recordings of a respiratory neuron and then determines which neurons synapse with it to produce the observed membrane potential changes. It is used to pursue the source of respiratory excitation and inhibition from its arrival at phrenic motoneurons to respiratory neurons in the medulla, and then examine some of the interactions among these neurons that shape their patterns of activity. Findings include a demonstration that phrenic motoneuron activity is determined by excitation from medullary inspiratory premotor neurons and inhibition by Bötzinger complex expiratory neurons, and that the latter neurons inhibit both medullary inspiratory premotor neurons and themselves. We conclude that these functional interconnections explain the activity patterns of some respiratory neurons, but the connections between neurons thought to be involved in rhythm generation remain to be demonstrated in adult rats.

Multiple sites for central chemoreception: their roles in response sensitivity and in sleep and wakefulness

Central chemoreceptors appear to be widely distributed in the brainstem. Why are there so many central chemoreceptor sites? This review focuses on two hypotheses. (1) The high sensitivity of the respiratory control system as a whole to small changes in systemic P(CO(2)) results from an additive, or greater, effect of the multiple central chemoreceptor sites. Each site provides a fraction of the total response and, importantly, provides tonic excitatory input in eucapnia as well. (2) Individual central chemoreceptor sites vary in effectiveness depending on the arousal or vigilance state of the animal. For example, some sites are more important in wakefulness; others in sleep. Proof for these hypotheses depends critically on obtaining accurate measures of stimulus intensity at each chemoreceptor site in vivo.

CO2, brainstem chemoreceptors and breathing

The regulation of breathing relies upon chemical feedback concerning the levels of CO2 and O2. The carotid bodies, which detect O2, provide tonic excitation to brainstem respiratory neurons under normal conditions and dramatic excitation if O2 levels fall. Feedback for CO2 involves the carotid body and receptors in the brainstem, central chemoreceptors. Small increases in CO2 produce large increases in breathing. Decreases in CO2 below normal can, in sleep and anesthesia, decrease breathing, even to apnea. Central chemoreceptors, once thought localized to the surface of the ventral medulla, are likely distributed more widely with sites presently identified in the: (1) ventrolateral medulla; (2) nucleus of the solitary tract; (3) ventral respiratory group; (4) locus ceruleus; (5) caudal medullary raphé; and (6) fastigial nucleus of the cerebellum. Why so many chemoreceptor sites? Hypotheses, some with supporting data, include the following. Geographical specificity; all regions of the brainstem with respiratory neurons contain chemoreceptors. Stimulus intensity; some sites operate in the physiological range of CO2 values, others only with more extreme changes. Stimulus specificity; CO2 or pH may be sensed by multiple mechanisms. Temporal specificity; some sites respond more quickly to changes on blood or brain CO2 or pH. Syncytium; chemosensitive neurons may be connected via low resistance, gap junctions. Arousal state: sites may vary in effectiveness and importance dependent on state of arousal. Overall, as judged by experiments of nature, and in the laboratory, central chemoreceptors are critical for adequate breathing in sleep, but other aspects of the control system can maintain breathing in wakefulness.

Transient, reversible apnoea following ablation of the pre-Bötzinger complex in rats

1. In some anaesthetized preparations, eupnoea is eliminated following a blockade or destruction of neurons in a rostral medullary pre-Botzinger complex. 2. Neurons in this region might underlie the neurogenesis of eupnoea, or be the source of an input which is necessary for eupnoea to be expressed. If the latter, any apnoea following ablation of the pre-Botzinger complex might be reversed by an augmentation in 'tonic input.' Contrariwise, this apnoea should be permanent if the neuronal activities of the pre- Botzinger complex are an exclusive generator of the eupnoeic rhythm. 3. Decerebrate, vagotomized, paralysed and ventilated adult rats were studied. Efferent activity of the phrenic nerve was recorded as an index of ventilatory activity. 4. Blockade or destruction of neuronal activities of the pre-Botzinger complex by unilateral and/or bilateral injections of muscimol or kainic acid eliminated eupnoea only transiently. Eupnoea returned following activation of the peripheral chemoreceptors and spontaneously over time. 5. Results do not support the concept that neuronal activities of the pre-Botzinger complex play an exclusive role in the neurogenesis of eupnoea in vivo. Rather, these neuronal activities appear to provide a tonic input to the ponto-medullary circuit which generates eupnoea and/or appear to be one component of this circuit.

Correlation of vasomotor- and respiratory-controlling mechanisms around the caudal ventrolateral medulla in cats

We examined the involvement of caudal ventrolateral medulla (CVLM) in respiratory control. Microinjection of glutamate (Glu) into CVLM decreased systemic arterial blood pressure (SAP) and altered phrenic nerve activities (PNA). Among 143 depressor sites, 55% (78/143) increased respiratory frequency (Rf), while 72% altered PNA amplitude (36% increased and 36% decreased). A small but significant positive correlation was observed between the magnitudes of depressor responses and inhibition of PNA amplitude (r = 0.1718, n = 143), indicating a substantial cross-talk between depressor and PNA inhibitory neurons. Furthermore, microinjections of acetylcholine (ACh) mimicked the Glu-induced depressor responses. However, ACh did not alter Rf, but still reduced PNA amplitude. Our findings suggest that Rf-regulating and depressor neurons are two separate neuronal populations, coexisting in CVLM. The PNA inhibitory and depressor neurons, in contrast, could have stronger correlation.