Hypercapnia-induced activation of brainstem GABAergic neurons during early development

Central and peripheral chemoreceptors in sudden infant death syndrome

The pathogenesis of sudden infant death syndrome (SIDS) has been ascribed to an underlying biological vulnerability to stressors during a critical period of development. This paper reviews the main data in the literature supporting the role of central (e.g. retrotrapezoid nucleus, serotoninergic raphe nuclei, locus coeruleus, orexinergic neurons, ventral medullary surface, solitary tract nucleus) and peripheral (e.g. carotid body) chemoreceptors in the pathogenesis of SIDS. Clinical and experimental studies indicate that central and peripheral chemoreceptors undergo critical development during the initial postnatal period, consistent with the age range of SIDS (<1 year). Most of the risk factors for SIDS (gender, genetic factors, prematurity, hypoxic/hyperoxic stimuli, inflammation, perinatal exposure to cigarette smoke and/or substance abuse) may structurally and functionally affect the developmental plasticity of central and peripheral chemoreceptors, strongly suggesting the involvement of these structures in the pathogenesis of SIDS. Morphometric and neurochemical changes have been found in the carotid body and brainstem respiratory chemoreceptors of SIDS victims, together with functional signs of chemoreception impairment in some clinical studies. However, the methodological problems of SIDS research will have to be addressed in the future, requiring large and highly standardized case series. Up-to-date autopsy protocols should be produced, involving substantial, and exhaustive sampling of all potentially involved structures (including peripheral arterial chemoreceptors). Morphometric approaches should include unbiased stereological methods with three-dimensional probes. Prospective clinical studies addressing functional tests and risk factors (including genetic traits) would probably be the gold standard, allowing markers of intrinsic or acquired vulnerability to be properly identified.

Intermittent hypercapnia enhances CO₂ responsiveness and overcomes serotonergic dysfunction

Serotonergic dysfunction compromises ventilatory chemosensitivity and may enhance vulnerability to pathologies such as the Sudden Infant Death Syndrome (SIDS). We have shown raphé contributions to central chemosensitivity involving serotonin (5-HT)-and γ-aminobutyric acid (GABA)-mediated mechanisms. We tested the hypothesis that mild intermittent hypercapnia (IHc) induces respiratory plasticity, due in part to strengthening of GABA mechanisms. Rat pups were IHc-pretreated (eight consecutive cycles; 5 min 5% CO2 - air, 10 min air) or constant normocapnia-pretreated as a control, each day for 5 consecutive days beginning at P12. We subsequently assessed CO2 responsiveness using the in situ perfused brainstem preparation. Hypercapnic responses were determined with and without pharmacological manipulation. Results show IHc-pretreatment induces plasticity sufficient for responsiveness despite removal of otherwise critical ketanserin-sensitive mechanisms. Responsiveness following IHc-pretreatment was absent if ketanserin was combined with GABAergic antagonism, indicating that plasticity depends on GABAergic mechanisms. We propose that IHc-induced plasticity could reduce the severity of reflex dysfunctions underlying pathologies such as SIDS.

[Autonomic regulation and bradycardia during the neonatal period]

The high frequency of bradycardia observed during the neonatal period requires cardiac monitoring but also understanding its intrinsic mechanisms, including responsiveness of the autonomic nervous system (ANS). Heart rate variability and spontaneous baroreflex analysis can help understand the autonomic dysregulation of cardiorespiratory control, possibly responsible for sudden infant death. In clinical neonatology practice, neonatal bradycardia does not warrant continuation of monitoring if it remains isolated, asymptomatic, and short (<10 s), followed by a rapid cardiac acceleration indicating an adapted sympathetic response. Further evaluation of ANS responsiveness is possible for newborns including analyzing the complexity of the heart rate and respiratory variability. This allows better targeting children with high risk after discharge. The real-time evaluation of autonomic regulation could become a valuable tool in clinical practice.

The effect of a clinically effective and non-effective dose of lorazepam on 7.5% CO₂-induced anxiety

Symptoms of anxiety induced by 7.5% CO₂ inhalation can be attenuated by acute administration of GABA(A) receptor anxiolytics such as lorazepam and alprazolam. This study investigated if these effects are dose-related, by comparing a 0.5 mg dose (considered non-clinically effective) and a 2 mg dose of lorazepam (clinically effective) on 7.5% CO₂ inhalation. Eighteen healthy males (mean age 20.6 years, SD 1.29), judged physically and mentally fit, attended three visits, each one week apart, to take each treatment in a randomised double-blind crossover design. Drugs were given 60 min prior to 20 min air inhalation, followed by 20 min 7.5% CO₂ inhalation. The order of gas presentation was single blind. Subjective ratings using visual analogue scales (VAS) and questionnaires were recorded before and after each inhalation. Blood pressure (BP), heart rate (HR), respiration rate (RR) and expired CO₂ were recorded during each inhalation. Inhalation of 7.5% CO₂ significantly raised BP, HR, RR and expired CO₂. Ratings of feeling like leaving the room were significantly lower on 2 mg compared with 0.5 mg and placebo, and dose-dependent trends were seen in scores for VAS fearful, anxious, stressed, tense, and worried. Results may be indicative of dose-dependent effects of lorazepam in a CO₂ model of anxiety.

Apnea of prematurity: from cause to treatment

Apnea of prematurity (AOP) is a common problem affecting premature infants, likely secondary to a "physiologic" immaturity of respiratory control that may be exacerbated by neonatal disease. These include altered ventilatory responses to hypoxia, hypercapnia, and altered sleep states, while the roles of gastroesophageal reflux and anemia remain controversial. Standard clinical management of the obstructive subtype of AOP includes prone positioning and continuous positive or nasal intermittent positive pressure ventilation to prevent pharyngeal collapse and alveolar atelectasis, while methylxanthine therapy is a mainstay of treatment of central apnea by stimulating the central nervous system and respiratory muscle function. Other therapies, including kangaroo care, red blood cell transfusions, and CO(2) inhalation, require further study. The physiology and pathophysiology behind AOP are discussed, including the laryngeal chemoreflex and sensitivity to inhibitory neurotransmitters, as are the mechanisms by which different therapies may work and the potential long-term neurodevelopmental consequences of AOP and its treatment.

The caudal solitary complex is a site of central CO(2) chemoreception and integration of multiple systems that regulate expired CO(2)

The solitary complex is comprised of the nucleus tractus solitarius (NTS, sensory) and dorsal motor nucleus of the vagus (DMV, motor), which functions as an integrative center for neural control of multiple systems including the respiratory, cardiovascular and gastroesophageal systems. The caudal NTS-DMV is one of the several sites of central CO(2) chemoreception in the brain stem. CO(2) chemosensitive neurons are fully responsive to CO(2) at birth and their responsiveness seems to depend on pH-sensitive K(+) channels. In addition, chemosensitive neurons are highly sensitive to conditions such as hypoxia (e.g., neural plasticity) and hyperoxia (e.g., stimulation), suggesting they employ redox and nitrosative signaling mechanisms. Here we review the cellular and systems physiological evidence supporting our hypothesis that the caudal NTS-DMV is a site for integration of respiratory, cardiovascular and gastroesophageal systems that work together to eliminate CO(2) during acute and chronic respiratory acidosis to restore pH homeostasis.

Increased vasopressin transmission from the paraventricular nucleus to the rostral medulla augments cardiorespiratory outflow in chronic intermittent hypoxia-conditioned rats

A co-morbidity of sleep apnoea is hypertension associated with elevated sympathetic nerve activity (SNA) which may result from conditioning to chronic intermittent hypoxia (CIH). Our hypothesis is that SNA depends on input to the rostral ventrolateral medulla (RVLM) from neurons in the paraventricular nucleus (PVN) that release arginine vasopressin (AVP) and specifically, that increased SNA evoked by CIH depends on this excitatory input. In two sets of neuroanatomical experiments, we determined if AVP neurons project from the PVN to the RVLM and if arginine vasopressin (V(1A)) receptor expression increases in the RVLM after CIH conditioning (8 h per day for 10 days). In the first set, cholera toxin beta subunit (CT-beta) was microinjected into the RVLM to retrogradely label the PVN neurons. Immunohistochemical staining demonstrated that 14.6% of CT-beta-labelled PVN neurons were double-labelled with AVP. In the second set, sections of the medulla were immunolabelled for V(1A) receptors, and the V(1A) receptor-expressing cell count was significantly greater in the RVLM (P < 0.01) and in the neighbouring rostral ventral respiratory column (rVRC) from CIH- than from room air (RA)-conditioned rats. In a series of physiological experiments, we determined if blocking V(1A) receptors in the medulla would normalize blood pressure in CIH-conditioned animals and attenuate its response to disinhibition of PVN. Blood pressure (BP), heart rate (HR), diaphragm (D(EMG)) and genioglossus muscle (GG(EMG)) activity were recorded in anaesthetized, ventilated and vagotomized rats. The PVN was disinhibited by microinjecting a GABA(A) receptor antagonist, bicuculline (BIC, 0.1 nmol), before and after blocking V(1A) receptors within the RVLM and rVRC with SR49059 (0.2 nmol). In RA-conditioned rats, disinhibition of the PVN increased BP, HR, minute D(EMG) and GG(EMG) activity and these increases were attenuated after blocking V(1A) receptors. In CIH-conditioned rats, a significantly greater dose of blocker (0.4 nmol) was required to blunt these physiological responses (P < 0.05). Further, this dose normalized the baseline BP. In summary, AVP released by a subset of PVN neurons modulates cardiorespiratory output via V(1A) receptors in the RVLM and rVRC, and increased SNA in CIH-conditioned animals depends on up-regulation of V(1A) receptors in the RVLM.

Neonatal apnea: what's new?

Apnea of prematurity (AOP) remains a major clinical problem in present day neonatology that warrants frequent evaluations and imposes challenges in therapeutic strategies. Although the pathogenesis of AOP is poorly understood, it is probably a manifestation of physiologic immaturity of breathing control rather than a pathologic disorder. Immature breathing responses to hypoxia, hypercapnia and exaggerated inhibitory pulmonary reflexes in preterm infants might also contribute to the occurrence or severity of AOP. Recent data suggest a role for genetic predisposition. Although typically resolve with maturation, the role of bradycardia and desaturation episodes associated with AOP in the development of sleep disorder breathing and neurodevelopmental delay needs further clarification. Pharmacological treatment with methylxanthines and CPAP remain the mainstay for treatment of AOP. However, recent studies have implicated central inhibitory neuromodulators including prostaglandins, GABA and adenosine in its pathogenesis, the fact that might provide future specific targets for treatment. This review will summarize new insights involving these issues as well as others involving the pathogenesis, treatment strategies and consequences of apnea in premature infants.

GABA-A receptors and the response to CO(2) inhalation - a translational trans-species model of anxiety?

The mechanisms by which the inhalation of carbon dioxide (CO(2)) produces anxiety and panic are not fully understood, although more recently there is evidence to suggest the involvement of a neural 'fear circuit'. We have suggested that this neural fear circuit is partly mediated by the brain noradrenaline network [Bailey, J.E., Argyropoulos, S.V., Lightman, S.L. and Nutt, D.J., (2003) Does the brain noradrenaline network mediate the effects of the CO(2) challenge? J Psychopharmacol 17(3): 252-259.]. However, we now review evidence that GABA-A may also play an important role in the modulation of CO(2)-induced anxiety. The review of this evidence starts with a key publication showing that 1 min of 35% CO(2)/65% air produced anxiogenic effects in a rat model of anxiety, to a similar extent to the anxiogenic betacarboline derivative FG7142, a benzodiazepine receptor inverse agonist. The effects of both anxiogenic stimuli were abolished with pre-treatment with alprazolam (0.5 mg/kg), but only those of FG7142, not CO(2), was blocked by a benzodiazepine antagonist [Cuccheddu, T., Floris, S., Serra, M., Porceddu, L., Sanna, E., Biggio, G., (1995) Proconflict effect of carbon dioxide inhalation in rats. Life Sci 56: PL 321-324.]. Although the evidence from this study did not conclusively prove that CO(2) had an action to reduce GABA function, it was an experiment designed to be translational to compare what was known about CO(2)-induced anxiety in patients, and to also to explore if GABA mechanisms are involved. Additional evidence from the literature is found in the association between GABA and chemoreceptors, both in laboratory and human studies and GABA and anxiety disorders. Evidence of this association is found across species from stress-induced change in GABA levels in plants and insects to humans, where there is now much evidence of abnormalities in GABA/benzodiazepine receptors in anxiety and other psychiatric disorders. This paper reviews some of the evidence and attempts to relate and compare these findings across species from the human to the Drosophila.

Prenatal nicotine exposure alters glycinergic and GABAergic control of respiratory frequency in the neonatal rat brainstem-spinal cord preparation

Bath application of GABA-A receptor agonists in neonatal rat brainstem-spinal cord preparations (BSSC) reduces respiratory frequency, an effect that is enhanced by prenatal nicotine exposure. Here we test the hypothesis that these effects can be reproduced by microinjection of GABAergic and glycinergic agonists into the pre-Botzinger complex region (PBC). We recorded the activity of phrenic motor axons from the fourth cervical ventral root in 1-3 days old BSSC that were exposed to either nicotine (6 mg/(kg day)) or saline prenatally. Microinjection of glycine or muscimol into the PBC caused abrupt, reversible apnea in all experiments. Apnea duration with glycine averaged 50.3+/-5 s in saline-exposed (N=12), and 95.7+/-9.9 s in nicotine-exposed (N=12) neonates (P<0.001). Apnea duration with muscimol averaged 51+/-5.1 s in saline-exposed (N=10), and 86+/-10.6 s in nicotine-exposed (N=12) neonates (P<0.05). These data show that prenatal nicotine exposure alters development of central ventilatory control, and that neurons in the PBC region are involved.

Effect of prevention of lung inflation on metamorphosis and respiration in the developing bullfrog tadpole, Rana catesbeiana

We tested the hypothesis that respiratory development would be retarded in tadpoles reared in aquaria in which a barrier prevented access to the air-water interface. To test this hypothesis, we examined swimming behavior and respiration in intact tadpoles and gill and lung respiratory activity and central chemosensory responses in an in vitro brainstem preparation. The "barrier" tadpoles had significantly lower resting gill frequencies and higher lung breath attempts than control tadpoles at the same metamorphic stage. Control tadpoles swam greater distances and spent more time in the upper one third of the aquaria, while barrier tadpoles spent significantly more time at the bottom of the aquaria. There was significantly greater mortality for barrier tadpoles compared to control animals in the earliest and latest metamorphic stages. Mean body weight was significantly greater, and metamorphic rate was reduced in barrier tadpoles. Neither control nor barrier tadpole brainstem preparations demonstrated a gill ventilatory response to CO(2); however, both control and barrier preparations possessed significant lung frequency responses to central CO(2) chemoreceptor stimulation. Bath application of the GABA(A) and glycine receptor antagonists, bicuculline and strychnine, had greater effects on control tadpole gill burst activity and produced a similar large-amplitude bursting pattern in both control and barrier tadpoles, that was insensitive to CO(2) chemoreceptor stimulation. We conclude that development of the respiratory pattern was perturbed by the barrier, but the major effect was on gill ventilation rather than lung ventilation as we had expected.

Adenosine A2A receptors are expressed by GABAergic neurons of medulla oblongata in developing rat

During early development, adenosine contributes to the occurrence of respiratory depression and recurrent apneas. Recent physiological studies indicate that GABAergic mechanisms may be involved in this inhibitory action of adenosine, via their A(2A) receptors. In the present study, in situ hybridization with ribonucleotide probes for A(2A) receptor (A(2A)R) mRNA was combined with the immunolabeling technique for parvalbumin and transneuronal retrograde tracing method using green fluorescent protein expressing pseudorabies virus (GFP-PRV) to (1) characterize age-dependent changes in the expression of adenosine A(2A)Rs mRNA in brain stem regions where GABAergic neurons are located; (2) determine whether GABA-containing neurons express A(2A)R mRNA traits, and (3) identify whether bulbospinal GABAergic neurons projecting to phrenic nuclei contain A(2A)R mRNA. Results revealed expression of A(2A) receptors in regions of medulla oblongata containing GABAergic neurons, namely in the ventral aspect of the medulla, within the Bötzinger region and caudal to it, the gigantocellular reticular nucleus, midline neurons and the caudal ventrolateral medulla oblongata. Furthermore, a subpopulation of identified GABAergic neurons, projecting to the phrenic motor nuclei, possess A(2A)R mRNA. It is concluded that adenosine A(2A)Rs expressed by GABAergic neurons are likely to play a role in mediating adenosine-induced respiratory depression.

Development of respiratory control: Evolving concepts and perspectives

The mechanisms underlying respiratory system immaturity in newborns have been investigated, both in vivo and in vitro, in humans and in animals. Immaturity affects breathing rhythmicity and its modulation by suprapontine influences and by afferents from central and peripheral chemoreceptors. Recent research has moved from bedside tools to sophisticated technologies, bringing new insights into the plasticity and genetics of respiratory control development. Genetic research has benefited from investigations of newborn mice having targeted deletions of genes involved in respiratory control. Genetic variability may govern the normal programming of development and the processes underlying adaptation to homeostasis disturbances induced by prenatal and postnatal insults. Studies of plasticity have emphasized the role of neurotrophic factors. Improvements in our understanding of the mechanistic effects of these factors should lead to new neuroprotective strategies for infants at risk for early respiratory control disturbances, such as apnoeas of prematurity, sudden infant death syndrome and congenital central hypoventilation syndrome.

Adenosine A2A receptors mediate GABAergic inhibition of respiration in immature rats

Adenosine is a known inhibitor of respiratory output during early life. In this study we investigated the developmental changes in adenosine A2A-receptor activation on respiratory timing, as well as the relationship between adenosine and GABA. The specific adenosine A2A-receptor agonist CGS-21680 (CGS) or vehicle control was injected into the fourth ventricle of 14-day (n = 9), 21-day (n = 9), and adult (n = 5) urethane-anesthetized rats while diaphragm electromyogram was monitored as an index of respiratory neural output. CGS injection resulted in a decrease in frequency and/or apnea in all 14-day-old rats and in 66% of 21-day-old rats. There was no effect of CGS injection on respiratory timing in adult rats. Prior injection of the GABA(A)-receptor blocker bicuculline at 14 and 21 days eliminated the CGS-induced decrease in frequency and apnea. We conclude from these studies that the inhibitory effect of A2A-receptor activation on respiratory drive is age dependent and is mediated via GABAergic inputs to the inspiratory timing neural circuitry. These findings demonstrate an important mechanism by which xanthine therapy alleviates apnea of prematurity.

Adenosine A2A receptors interact with GABAergic pathways to modulate respiration in neonatal piglets

GABA and adenosine contribute to respiratory inhibition in early postnatal life. In this study the adenosine A2A receptor agonist CGS21680 was used to evaluate adenosine receptor specificity and the interrelation of adenosine and GABA in the inhibition of inspiratory drive. In neonatal piglets (n = 10), CGS21680 was injected into the fourth ventricle resulting in apnea and/or decreased burst area and frequency of phrenic discharge. Phrenic burst area decreased to 58.9 +/- 8.6% (S.E.M.) after CGS21680 injection (control = 91.8 +/- 1.0%). Expiratory time increased 261.0 +/- 59.9% after CGS21680 from control (87.7 +/- 2.7%). When bicuculline was injected locally within the rostral ventrolateral medulla (n = 5), or into the fourth ventricle (n = 5), the CGS21680 induced inhibition of phrenic was abolished. To define expression of A2A receptor at the message level (mRNA), we employed in situ hybridization with a digoxigenin-coupled oligonucleotide. Adenosine A2A receptor mRNA was expressed in regions of the medulla oblongata known to contain GABAergic neurons. We conclude that GABAergic inputs affecting respiratory timing and inspiratory drive are modulated by activation of A2A receptors. These findings offer new insight into the mechanism whereby xanthine therapy diminishes apnea of prematurity.

Ventilatory effects of gap junction blockade in the RTN in awake rats

We tested the hypothesis that carbenoxolone, a pharmacological inhibitor of gap junctions, would reduce the ventilatory response to CO(2) when focally perfused within the retrotrapezoid nucleus (RTN). We tested this hypothesis by measuring minute ventilation (V(E)), tidal volume (V(T)), and respiratory frequency (F(R)) responses to increasing concentrations of inspired CO(2) (Fi(CO(2)) = 0-8%) in rats during wakefulness. We confirmed that the RTN was chemosensitive by perfusing the RTN unilaterally with either acetazolamide (AZ; 10 microM) or hypercapnic artificial cerebrospinal fluid equilibrated with 50% CO(2) (pH approximately 6.5). Focal perfusion of AZ or hypercapnic aCSF increased V(E), V(T), and F(R) during exposure to room air. Carbenoxolone (300 microM) focally perfused into the RTN decreased V(E) and V(T) in animals <11 wk of age, but V(E) and V(T) were increased in animals >12 wk of age. Glyzyrrhizic acid, a congener of carbenoxolone, did not change V(E), V(T), or F(R) when focally perfused into the RTN. Carbenoxolone binds to the mineralocorticoid receptor, but spironolactone (10 microM) did not block the disinhibition of V(E) or V(T) in older animals when combined with carbenoxolone. Thus the RTN is a CO(2) chemosensory site in all ages tested, but the function of gap junctions in the chemosensory process varies substantially among animals of different ages: gap junctions amplify the ventilatory response to CO(2) in younger animals, but appear to inhibit the ventilatory response to CO(2) in older animals.