Maturation of respiratory control in the behaving mammal

Ambulatory pediatric adenotonsillectomy

PURPOSE

This Continuing Professional Development module aims to help the general anesthesiologist recognize common pitfalls in ambulatory pediatric adenotonsillectomy and perform appropriate risk stratification, analgesic management, and disposition planning.

PRINCIPAL FINDINGS

Pediatric adenotonsillectomy is a widely performed procedure. An updated approach to preoperative risk assessment of commonly associated comorbidities allows the practitioner to anticipate and plan for adverse events. Risks include obstructive sleep apnea, airway hyperresponsiveness, asthma, recent upper respiratory tract infections, obesity, and young age. Risk-modifying interventions consist of delaying surgery, preoperative bronchodilator therapy, recognizing the limitations of volatile agents, and referral of high-risk patients to specialized pediatric centres. Appropriate selection of intraoperative and postoperative analgesia can optimize patient comfort, avoid readmission, and limit adverse events such as postoperative hemorrhage or respiratory depression.

CONCLUSIONS

Ambulatory pediatric adenotonsillectomy is a common surgical procedure, performed both in the community as well as tertiary care pediatric centres. To optimize outcomes in this heterogenous patient population, anesthesiologists must risk stratify and anticipate perioperative respiratory adverse events.

Mechanisms underlying a critical period of respiratory development in the rat

Twenty-five years ago, Filiano and Kinney (1994) proposed that a critical period of postnatal development constitutes one of the three risk factors for sudden infant death syndrome (SIDS). The underlying mechanism was poorly understood. In the last 17 years, much has been uncovered on this period in the rat. Against several expected trends of development, abrupt neurochemical, metabolic, ventilatory, and electrophysiological changes occur in the respiratory system at P12-13. This results in a transient synaptic imbalance with suppressed excitation and enhanced inhibition, and the response to acute hypoxia is the weakest at this time, both at the cellular and system's levels. The basis for the synaptic imbalance is likely to be contributed by a reduced expression of brain-derived neurotrophic factor (BDNF) and its TrkB receptors in multiple brain stem respiratory-related nuclei during the critical period. Exogenous BDNF or a TrkB agonist partially reverses the synaptic imbalance, whereas a TrkB antagonist accentuates the imbalance. A transient down-regulation of pituitary adenylate cyclase-activating polypeptide (PACAP) at P12 in respiratory-related nuclei also contributes to the vulnerability of this period. Carotid body denervation during this time or perinatal hyperoxia merely delays and sometimes prolongs, but not eliminate the critical period. The rationale for the necessity of the critical period in postnatal development is discussed.

Perinatal development of inhibitory synapses in the nucleus tractus solitarii of the rat

The nucleus tractus solitarii (NTS) plays a key role in the central control of the autonomic nervous system. In adult rats, both GABA and glycine are used as inhibitory neurotransmitter in the NTS. Using a quantitative morphological approach, we have investigated the perinatal development of inhibitory synapses in the NTS. The density of both inhibitory axon terminals and synapses increased from embryonic day 20 until the end of the second postnatal week (postnatal day 14). Before birth, only GABAergic axon terminals developed and their number increased during the first postnatal week. Mixed GABA/glycine axon terminals appeared at birth and their number increased during the first postnatal week. This suggests the development of a mixed GABA/glycine inhibition in parallel to pure GABA inhibition. However, whereas GABAergic axon terminals were distributed throughout the NTS, mixed GABA/glycine axon terminals were strictly located in the lateral part of the NTS. Established at birth, this specific topography remained in the adult rat. From birth, GABA(A) receptors, glycine receptors and gephyrin were clustered in inhibitory synapses throughout the NTS, revealing a neurotransmitter-receptor mismatch within the medial part of the NTS. Together these results suggest that NTS inhibitory networks develop and mature until postnatal day 14. Developmental changes in NTS synaptic inhibition may play an important role in shaping neural network activity during a time of maturation of autonomic functions. The first two postnatal weeks could represent a critical period where the impact of the environment influences the physiological phenotypes of adult rats.

Neurochemical and physiological correlates of a critical period of respiratory development in the rat

Despite its vital importance to life, respiration is not mature at birth in mammals, but rather, it undergoes a great deal of growth, refinement, and adjustments postnatally. Many adjustments do not follow smooth paths, but assume abrupt changes during certain postnatal periods that may render the animal less capable of responding to respiratory stressors. The present review focuses on neurochemical and physiological correlates of a critical period of respiratory development in the rat. In addition to an imbalanced expression of reduced excitatory and enhanced inhibitory neurotransmitters, a switch in the expressions of gamma-aminobutyric acid (GABA)A receptor subunits from alpha3 to alpha1 occurs around postnatal day (P)12 in the pre-Bötzinger nucleus and the ventrolateral subnucleus of the solitary tract nucleus. Possible subunit switches in a number of other neurotransmitter receptors are discussed. These neurochemical changes are paralleled by ventilatory adjustments at the end of the second postnatal week. At P13 and under normoxia, respiratory frequency reaches its peak before assuming a gradual fall, and both tidal volume and minute ventilation exhibit a significant rise prior to a plateau or a gradual decline until P21. The response to acute hypoxia is markedly reduced between P12 and P16, being lowest at P13. Thus, the end of the second postnatal week can be considered as a critical period of respiratory development, during which multiple neurochemical and physiological adjustments and switches are orchestrated at the same time, rendering the system extremely dynamic but, at the same time, vulnerable to externally imposed perturbations and insults. The critical period embodies a time of multi-system, multifaceted growth and adjustments. It is a plastic, transitional period that is also a part of the normal development of the respiratory system.

Silent synapses in developing rat nucleus tractus solitarii have AMPA receptors

NMDA-only synapses, called silent synapses, are thought to be the initial step in synapse formation in several systems. However, the underlying mechanism and the role in circuit construction are still a matter of dispute. Using combined morphological and electrophysiological approaches, we searched for silent synapses at the level of the nucleus tractus solitarii (NTS), a brainstem structure that is a gateway for many visceral sensory afferent fibers. Silent synapses were detected at birth by using electrophysiological recordings and minimal stimulation protocols. However, anatomical experiments indicated that nearly all, if not all, NTS synapses had AMPA receptors. Based on EPSC fluctuation measurements and differential blockade by low-affinity competitive and noncompetitive glutamate antagonists, we then demonstrated that NTS silent synapses were better explained by glutamate spillover from neighboring fibers and/or slow dynamic of fusion pore opening. Glutamate spillover at immature NTS synapses may favor crosstalk between active synapses during development when glutamate transporters are weakly expressed and contribute to synaptic processing as well as autonomic circuit formation.

Postnatal changes in ventilation during normoxia and acute hypoxia in the rat: implication for a sensitive period

Previously, we found heightened expression of inhibitory neurochemicals and depressed expression of excitatory neurochemicals with a sudden drop in metabolic activity around postnatal day (P) 12 in rat brainstem respiratory nuclei, suggesting that this period is a critical window during which respiratory control or regulation may be distinctly different. To test this hypothesis, the hypoxic ventilatory responses (HVR) to 10% oxygen were tested in rats every day from P0 to P21. Our data indicate that (1) during normoxia (N), breathing frequency (f) increased with age, peaking at P13, followed by a gradual decline, whereas both tidal volume (V(T)) and minute ventilation (.V(E) ) significantly increased in the second postnatal week, followed by a progressive increase in V(T) and a relative plateau in .V(E); (2) during 5 min of hypoxia (H), .V(E) exhibited a biphasic response from P3 onward. Significantly, the ratio of .V(E)(H) to .V(E)(N) was generally > 1 during development, except for P13-16, when it was < 1 after the first 1-2 min, with the lowest value at P13; (3) the H : N ratio for f, V(T) and .V(E) during the first 30 s and the last minute of hypoxia all showed a distinct dip at P13, after which the V(T) and .V(E) values rose again, while the f values declined through P21; and (4) the H : N ratios for f, V(T) and .V(E) averaged over 5 min of hypoxia all exhibited a sudden fall at P13. The f ratio remained low thereafter, while those for V(T) and .V(E) increased again with age until P21. Thus, hypoxic ventilatory response is influenced by both f and V(T) before P13, but predominantly by V(T) after P13. The striking changes in normoxic ventilation as well as HVR at or around P13, together with our previous neurochemical and metabolic data, strongly suggests that the end of the second postnatal week is a critical period of development for brainstem respiratory nuclei in the rat.

Glutamatergic synapses in the rat nucleus tractus solitarii develop by direct insertion of calcium-impermeable AMPA receptors and without activation of NMDA receptors

Calcium influxes through ionotropic glutamate receptors (AMPA and NMDA receptors, AMPARs and NMDARs) are considered to be critical for the shaping and refinement of neural circuits during synaptogenesis. Using a combined morphological and electrophysiological approach, we evaluated this hypothesis at the level of the nucleus tractus solitarii (NTS), a brainstem structure that is a gateway for many visceral sensory afferent fibres. We confirmed that in the NTS, the first excitatory synapses appeared at embryonic day 18. We next characterized the biophysical properties of NTS AMPARs. Throughout perinatal development, both evoked and miniature EPSCs recorded in the presence of an NMDAR blocker were insensitive to polyamines and had linear current-voltage relationships. This demonstrated that AMPARs at NTS excitatory synapses were calcium-impermeable receptors composed of a majority of GluR2 subunits. We then investigated the influence of calcium influxes through NMDARs on the development of NTS synaptic transmission. We found that NMDAR expression at synaptic sites did not precede AMPAR expression. Moreover, NMDAR blockade in utero did not prevent the development of AMPAR synaptic currents and the synaptic clustering of GluR2 subunits. Thus, our data support an alternative model of synaptogenesis that does not depend on calcium influxes through either AMPARs or NMDARs. This model may be particularly relevant to the formation of neural networks devoted to basic behaviours required at birth for survival.

Developmental changes in the expression of GABAA receptor subunits alpha1, alpha2, and alpha3 in the rat pre-Botzinger complex

Previously, we reported that the pre-Bötzinger complex (PBC) exhibited a dramatic reduction in cytochrome oxidase activity at postnatal day (P) 12. This coincided in time with decreases in glutamate and NMDA receptor subunit 1 and increases in GABA, GABAB, glycine receptor, and glutamate receptor GluR2. To test our hypothesis that various alpha-subunits of GABAA receptors also undergo changes in their expression during postnatal development, as they do in other brain regions, we undertook an in-depth immunohistochemical study of GABAA receptor subunits alpha1, alpha2, and alpha3 in the PBC of P0 to P21 rats. We found that 1) GABAA alpha3-subunit was expressed at relatively high levels at P0, which then declined with age; 2) GABAA alpha1-subunit was expressed at relatively low levels at P0 but increased with age; 3) the developmental trends of subunits alpha1 and alpha3 intersected at P12; and 4) GABAA alpha2-subunit expression was moderate to light at P0 and remained quite constant during development, being lowest at P21. These findings suggest that the apparent switch in relative expressions of subunits alpha3 and alpha1 during development and the intersection of slopes around P12 may be associated with possible changes in GABAA receptor subtypes that would mediate different functional properties of GABA transmission, such as primarily a less efficient inhibitory transmission before P12 and a more mature inhibitory effect at P12 and thereafter, as suggested by the kinetics of distinct postsynaptic potentials. This mechanism may contribute partially to the dramatic reduction in cytochrome oxidase activity within the PBC at P12, as shown previously.

N-methyl-d-aspartate receptor activation exerts a dual control on postnatal development of nucleus tractus solitarii neurons in vivo

We have used a morphological approach to evaluate the role of NMDA receptors (NMDAR) in postnatal development of brainstem neurons in awake rats. Chronic NMDAR blockade was performed by placing drug-impregnated Elvax implants over the brainstem at the fifth postnatal day (P5). Compared with control, NMDAR blockade led to a transient increase in dendritic arbor area and filopodium density until P12 followed by a rapid decline in both parameters. Electron microscopy observations showed that these changes correlated with an increase in synapse density at P14 followed by a decrease in synapse density at P28 if chronic NMDAR blockade was maintained until P21. These results support the hypothesis that synapse formation does not require NMDAR activation. In addition, our data suggest a dual role for NMDAR in controlling the synapse number. Early in development NMDARs may be involved in controlling the rate of synapse elimination. Later on, they may subserve synapse stabilization. The physiological significance of these results is discussed.

Postnatal changes in cytochrome oxidase expressions in brain stem nuclei of rats: implications for sensitive periods

Previously, we reported that cytochrome oxidase (CO) activity in the rat pre-Bötzinger complex (PBC) exhibited a plateau on postnatal days (P) 3-4 and a prominent decrease on P12 (Liu and Wong-Riley, J Appl Physiol 92: 923-934, 2002). These changes were correlated with a concomitant reduction in the expression of glutamate and N-methyl-d-aspartate receptor subunit 1 and an increase in GABA, GABAB, glycine receptor, and glutamate receptor 2. To determine whether changes were limited to the PBC, the present study aimed at examining the expression of CO in a number of brain stem nuclei, with or without known respiratory functions from P0 to P21 in rats: the ventrolateral subnucleus of the solitary tract nucleus, nucleus ambiguus, hypoglossal nucleus, nucleus raphe obscurus, dorsal motor nucleus of the vagus nerve, medial accessory olivary nucleus, spinal nucleus of the trigeminal nerve, and medial vestibular nucleus (MVe). Results indicated that, in all of the brain stem nuclei examined, CO activity exhibited a general increase with age from P0 to P21, with MVe having the slowest rise. Notably, in all of the nuclei examined except for MVe, there was a plateau or decrease at P3-P4 and a prominent rise-fall-rise pattern at P11-P13, similar to that observed in the PBC. In addition, there was a fall-rise-fall pattern at P15-P17 in these nuclei, instead of a plateau pattern in the PBC. Our data suggest that the two postnatal periods with reduced CO activity, P3-P4 and especially P12, may represent common sensitive periods for most of the brain stem nuclei with known or suspected respiratory control functions.