Search for evidence of lung chemoreflexes in man: study of respiratory and circulatory effects of phenyldiguanide and lobeline

Physiology of static breath holding in elite apneists

NEW FINDINGS

What is the topic of this review? This review provides an up-to-date assessment of the physiology involved with extreme static dry-land breath holding in trained apneists. What advances does it highlight? We specifically highlight the recent findings involved with the cardiovascular, cerebrovascular and metabolic function during a maximal breath hold in elite apneists.

ABSTRACT

Breath-hold-related activities have been performed for centuries, but only recently, within the last ∼30 years, has it emerged as an increasingly popular competitive sport. In apnoea sport, competition relates to underwater distances or simply maximal breath-hold duration, with the current (oxygen-unsupplemented) static breath-hold record at 11 min 35 s. Remarkably, many ultra-elite apneists are able to suppress respiratory urges to the point where consciousness fundamentally limits a breath-hold duration. Here, arterial oxygen saturations as low as ∼50% have been reported. In such cases, oxygen conservation to maintain cerebral functioning is critical, where responses ascribed to the mammalian dive reflex, e.g. sympathetically mediated peripheral vasoconstriction and vagally mediated bradycardia, are central. In defence of maintaining global cerebral oxygen delivery during prolonged breath holds, the cerebral blood flow may increase by ∼100% from resting values. Interestingly, near the termination of prolonged dry static breath holds, recent studies also indicate that reductions in the cerebral oxidative metabolism can occur, probably attributable to the extreme hypercapnia and irrespective of the hypoxaemia. In this review, we highlight and discuss the recent data on the cardiovascular, metabolic and, particularly, cerebrovascular function in competitive apneists performing maximal static breath holds. The physiological adaptation and maladaptation with regular breath-hold training are also summarized, and future research areas in this unique physiological field are highlighted; particularly, the need to determine the potential long-term health impacts of extreme breath holding.

Dyspnea related to reversibly-binding P2Y12 inhibitors: A review of the pathophysiology, clinical presentation and diagnostics

Dyspnea is a common symptom physiologically associated with strenuous exercise and pathologically reflecting well-known diseases and conditions that are predominantly pulmonary, cardiovascular, and weight-related in origin. Dyspnea improves with appropriate measures that enhance physical performance and treatment of the underlying diseases. Dyspnea is less commonly triggered by other causes such as the environment (e.g., ozone), drugs, and others, some of which do not seem to affect bronchopulmonary function as evidenced by normal results of comprehensive pulmonary function testing. In cardiovascular medicine, dyspnea has recently attracted attention because it has been reported that this symptom occurs more frequently with the administration of the new oral reversibly-binding platelet P2Y12 receptor inhibitors ticagrelor [1-6], cangrelor [7-10], and elinogrel [11]. This paper succinctly addresses the current understanding of the pathophysiology, clinical presentation, and diagnostics of dyspnea, associated either with bronchopulmonary function impairment, as triggered mainly by pulmonary and cardiovascular diseases, or without bronchopulmonary function impairment, as induced by endogenous or external compounds such as drugs in order to provide a context for understanding, recognizing and managing P2Y12 inhibitor-induced dyspnea.

Intravenous adenosine activates diffuse nociceptive inhibitory controls in humans

Experimentally induced pain can be attenuated by concomitant heterotopic nociceptive stimuli (counterirritation). Animal data indicate that this stems from supraspinal “diffuse noxious inhibitory controls” (DNICs) triggered by C and Aδ fibers. In humans, only noxious stimuli induce counterirritation. This points at C fibers, but the effects of pharmacologically stimulating C fibers have not been studied. Intravenous adenosine activates pulmonary C fibers and induces dyspnea. This study tests the hypothesis that putative activation of pulmonary C fibers by adenosine would trigger DNICs in humans and induce counterirritation. Twelve healthy volunteers were included (with valid results available in 9) and studied according to a double-blind, randomized, cross-over design (intravenous adenosine, 140 μg·kg−1·min−1, during 5 min vs. placebo). We measured ventilatory variables and end-tidal CO2 tension, dyspnea intensity by visual analog scale, and the intensity of putative chest pain. The primary outcome was the amplitude of the RIII component of the nociceptive flexor reflex recorded by biceps femoris electromyogram in response to painful electrical sural nerve stimulation (RIII), taken as a substitute for pain perception. Placebo did not induce any significant effect. Adenosine induced dyspnea, hyperpnea, tachycardia, and significant RIII inhibition (24 ± 8% at the 4th min, P < 0.0001). The temporal dynamics of adenosine-induced dyspnea and RIII inhibition differed (immediate onset followed by a slow decrease for dyspnea, slower onset for RIII inhibition). Intravenous adenosine in normal humans induces counterirritation, fueling the notion that C-fiber stimulation trigger DNICs in humans. The temporal dissociation between adenosine-induced dyspnea and RIII inhibition suggests that C fibers other than pulmonary ones might be involved.

Mechanisms of dyspnea

The mechanisms and pathways of the sensation of dyspnea are incompletely understood, but recent studies have provided some clarification. Studies of patients with cord transection or polio, induced spinal anesthesia, or induced respiratory muscle paralysis indicate that activation of the respiratory muscles is not essential for the perception of dyspnea. Similarly, reflex chemostimulation by CO₂ causes dyspnea, even in the presence of respiratory muscle paralysis or cord transection, indicating that reflex chemoreceptor stimulation per se is dyspnogenic. Sensory afferents in the vagus nerves have been considered to be closely associated with dyspnea, but the data were conflicting. However, recent studies have provided evidence of pulmonary vagal C-fiber involvement in the genesis of dyspnea, and recent animal data provide a basis to reconcile differences in responses to various C-fiber stimuli, based on the ganglionic origin of the C fibers. Brain imaging studies have provided information on central pathways subserving dyspnea: Dyspnea is associated with activation of the limbic system, especially the insular area. These findings permit a clearer understanding of the mechanisms of dyspnea: Afferent information from reflex stimulation of the peripheral sensors (chemoreceptors and/or vagal C fibers) is processed centrally in the limbic system and sensorimotor cortex and results in increased neural output to the respiratory muscles. A perturbation in the ventilatory response due to weakness, paralysis, or increased mechanical load generates afferent information from vagal receptors in the lungs (and possibly mechanoreceptors in the respiratory muscles) to the sensorimotor cortex and results in the sensation of dyspnea.

Blockade of airway sensory nerves and dyspnea in humans

Evidence has accumulated from previous studies that vagal fibers in the lungs are involved in the genesis of dyspnea. In a series of human studies, based on our previous animal data (J Physiol 1998; 508:109-18; J Appl Physiol 1998; 84:417-24; J Appl Physiol 2003; 95:1315-24) we established that intravenous adenosine has a dyspnogenic effect (J Appl Physiol 2005; 98:180-5; Respir Res 2006; 7:139; Pulm Pharmacol Ther 2008; 21:208-13), strongly implicating a role for vagal C-fibers in the genesis of dyspnea. We have now analyzed the relative effects of blockade of vagal C-fibers by two methods and routes of delivery: by inhibition of the sodium channel and interruption of action potential conduction in the nerve by inhaled local anesthetic (lidocaine), and by blockade by systemic theophylline, a known, nonselective adenosine receptor antagonist. Both techniques significantly (p < 0.05) attenuated the dyspneic response to intravenous adenosine. However, the attenuation was significantly (p < 0.05) greater with pretreatment with systemic theophylline (mean change in response, DeltaAUC -44%) versus pretreatment with inhaled lidocaine (mean change in response, DeltaAUC -11.8%). These differences in the results of airway sensory nerve blockade probably reflect different populations of C fiber receptors and may explain conflicting results of previous studies of dyspnea and airway anesthesia.

Respiratory sensations evoked by activation of bronchopulmonary C-fibers

C-fibers represent the majority of vagal afferents innervating the airways and lung, and can be activated by inhaled chemical irritants and certain endogenous substances. Stimulation of bronchopulmonary C-fibers with selective chemical activators by either inhalation or intravenous injection evokes irritation, burning and choking sensations in the throat, neck and upper chest (mid-sternum region) in healthy human subjects. These irritating sensations are often accompanied by bouts of coughs either during inhalation challenge or when a higher dose of the chemical activator is administered by intravenous injection. Dyspnea and breathless sensation are not always evoked when these afferents are activated by different types of chemical stimulants. This variability probably reflects the chemical nature of the stimulants, as well as the possibility that different subtypes of C-fibers encoded by different receptor proteins are activated. These respiratory sensations and reflex responses (e.g., cough) are believed to play an important role in protecting the lung against inhaled irritants and preventing overexertion under unusual physiological stresses (e.g., during strenuous exercise) in healthy individuals. More importantly, recent studies have revealed that the sensitivity of bronchopulmonary C-fibers can be markedly elevated in acute and chronic airway inflammatory diseases, probably caused by a sensitizing effect of certain endogenously released inflammatory mediators (e.g., prostaglandin E(2)) that act directly or indirectly on specific ion channels expressed on the sensory terminals. Normal physiological actions such as an increase in tidal volume (e.g., during mild exercise) can then activate these C-fiber afferents, and consequently may contribute, in part, to the lingering respiratory discomforts and other debilitating symptoms in patients with lung diseases.

The pulmonary effects of intravenous adenosine in asthmatic subjects

BACKGROUND

We have shown that intravenous adenosine in normal subjects does not cause bronchospasm, but causes dyspnea, most likely by an effect on vagal C fibers in the lungs [Burki et al. J Appl Physiol 2005; 98:180-5]. Since airways inflammation and bronchial hyperreactivity are features of asthma, it is possible that intravenous adenosine may be associated with an increased intensity of dyspnea, and may cause bronchospasm, as noted anecdotally in previous reports.

METHODS

We compared the effects of placebo and 10 mg intravenous adenosine, in 6 normal and 6 asthmatic subjects.

RESULTS

Placebo injection had no significant (p > 0.05) effect on the forced expiratory spirogram, heart rate, minute ventilation (Ve), or respiratory sensation. Similarly, adenosine injection caused no significant changes (p > 0.05) in the forced expiratory spirogram; however, there was a rapid development of dyspnea as signified visually on a modified Borg scale, and a significant (p < 0.05) tachycardia in each subject (Asthmatics +18%, Normals + 34%), and a significant (p < 0.05) increase in Ve (Asthmatics +93%, Normals +130%). The intensity of dyspnea was significantly greater (p < 0.05) in the asthmatic subjects.

CONCLUSION

These data indicate that intravenous adenosine does not cause bronchospasm in asthmatic subjects, and supports the concept that adenosine-induced dyspnea is most likely secondary to stimulation of vagal C fibers in the lungs. The increased intensity of adenosine-induced dyspnea in the asthmatic subjects suggests that airways inflammation may have sensitized the vagal C fibers.

Ventilation is unstable during drowsiness before sleep onset

Ventilation is unstable during drowsiness before sleep onset. We have studied the effects of transitory changes in cerebral state during drowsiness on breath duration and lung volume in eight healthy subjects in the absence of changes in airway resistance and fluctuations of ventilation and CO2 tension, characteristic of the onset of non-rapid eye movement sleep. A volume-cycled ventilator in the assist control mode was used to maintain CO2 tension close to that when awake. Changes in cerebral state were determined by the EEG on a breath-by-breath basis and classified as alpha or theta breaths. Breath duration and the pause in gas flow between the end of expiratory airflow and the next breath were computed for two alpha breaths which preceded a theta breath and for the theta breath itself. The group mean (SD) results for this alpha-to-theta transition was associated with a prolongation in breath duration from 5.2 (SD 1.3) to 13.0 s (SD 2.1) and expiratory pause from 0.7 (SD 0.4) to 7.5 s (SD 2.2). Because the changes in arterial CO2 tension (PaCO2) are unknown during the theta breaths, we made in two subjects a continuous record of PaCO2 in the radial artery. PaCO2 remained constant from the alpha breaths through to the expiratory period of the theta breath by which time the duration of breath was already prolonged, representing an immediate and altered ventilatory response to the prevailing PaCO2. In the eight subjects, the CO2 tension awake was 39.6 Torr (SD 2.3) and on assisted ventilation 38.0 Torr (1.4). We conclude that the ventilatory instability recorded in the present experiments is due to the apneic threshold for CO2 being at or just below that when awake.

Intravenous adenosine and dyspnea in humans

Intravenous adenosine for the treatment of supraventricular tachycardia is reported to cause bronchospasm and dyspnea and to increase ventilation in humans, but these effects have not been systematically studied. We therefore compared the effects of 10 mg of intravenous adenosine with placebo in 21 normal subjects under normoxic conditions and evaluated the temporal sequence of the effects of adenosine on ventilation, dyspnea, and heart rate. The study was repeated in 11 of these subjects during hyperoxia. In all subjects, adenosine resulted in the development of dyspnea, assessed by handgrip dynamometry, without any significant change ( P > 0.1) in lung resistance as measured by the interrupter technique. There were significant increases ( P < 0.05) in ventilation and heart rate in response to adenosine. The dyspneic response occurred slightly before the ventilatory or heart rate responses in every subject, but the timing of the dyspneic, ventilatory, and heart rate responses was not significantly different when the group data were analyzed (18.9 ± 5.8, 20.3 ± 5.5, and 19.7 ± 4.5 s, respectively). During hyperoxia, adenosine resulted in similar effects, with no significant differences in the magnitude of the ventilatory response; however, compared with the normoxic state, the intensity of the dyspneic response was significantly ( P < 0.05) reduced, whereas the heart rate response increased significantly ( P < 0.05). These data indicate that intravenous adenosine-induced dyspnea is not associated with bronchospasm in normal subjects. The time latency of the response indicates that the dyspnea is probably not a consequence of peripheral chemoreceptor or brain stem respiratory center stimulation, suggesting that it is most likely secondary to stimulation of receptors in the lungs, most likely vagal C fibers.

How does lobeline injected intravenously produce a cough?

In order to examine, whether the lobeline-induced cough is a true reflex or a voluntary effort to get rid of its irritating sensations in the upper respiratory tract, we systematically studied the cough response to lobeline, of subjects who were unable to make conscious discriminations i.e. were either comatose (n=4) or anaesthetized (n=5). 8 microg/kg lobeline injected into the right atrium of one and 29 microg/kg intravenously (i.v.) into another evenly and spontaneously breathing comatose subject produced a cough after 4s and 12s, respectively. Cough was repeatable and showed a dose response relationship i.e., its latency decreasing and its duration/intensity increasing with the dose. In a third subject, capable only of weak spontaneous respiration, a relatively high dose injected into the right atrium (44 microg/kg) generated a pronounced cough-like respiratory movement superimposed on the artificial ventilation and also during the apnoea after disconnecting the pump. No respiratory response was evoked in a fourth subject who had no evidence of brainstem reflexes. In five normals, cough was elicited with a mean dose of 35+/-5 microg/kg i.v. (latency 14+/-2 s; duration 10+/-3 s). After thiopental anaesthesia, injecting 41+/-7 microg/kg produced a cough within 13+/-2 s that lasted for 12+/-2 s. It may be noted that neither the later dose nor the latency or duration of cough that it produced were significantly different from the pre anaesthesia values (P>0.05). These two sets of results show unequivocally that the lobeline-induced cough is evoked reflexly; its magnitude in the conscious state could vary by subjective influences. We discuss the likelihood of its origin from juxtapulmonary capillary receptors.

Presence of lobeline-like sensations in exercising patients with left ventricular dysfunction

Since there is evidence that lobeline-induced sensations, associated with discomfort in the mouth, throat and chest arise by stimulating juxtapulmonary or J receptors, we were interested in investigating if similar sensations are felt by patients with left ventricular dysfunction (LVD) in whom a natural stimulation of these receptors would occur by transient interstitial oedema or during augmentation of the stimulus, by increased pulmonary blood flow during exercise. Threshold doses of lobeline produced three or more respiratory sensations simultaneously in 9 out of 10 patients, which was greater than the response of the controls (P < 0.01). With mild exercise, a greater number of patients (7) than controls (1) reported feeling two or more sensations (P < 0.01); in fact half the controls did not express a respiratory sensation with equivalent exercise (P < 0.05). The predominant lobeline-like sensations reported by patients with exercise were a feeling of heat or burning and pressure in the throat or chest (P < 0.05). The presence of cough in three patients and in none of the controls was noteworthy. The mean latency with which sensations appeared during exercise in patients (4.4 +/- 0.3 min) was almost half that in controls (7.4 +/- 0.2 min) (P < 0.005). Since, respiratory sensations in response to lobeline and exercise were intensified in patients compared to controls and since both lobeline and exercise-induced sensations were similar (P < 0.05), we speculate that a common origin exists. Despite important caveats, that we discuss, in our view these respiratory sensations and cough arise from stimulation of J receptors.

Noxious activation of spinal or vagal afferents evokes distinct patterns of fos-like immunoreactivity in the ventrolateral periaqueductal gray of unanaesthetised rats

The consequences of a severe traumatic injury--deep pain and haemorrhage--usually evoke a passive emotional coping reaction characterised by: quiescence and immobility, decreased vigilance, hypotension and bradycardia. Results of studies utilising microinjections of excitatory amino acids suggest that passive coping reactions are mediated, at least in part, by activation of the midbrain, ventrolateral periaqueductal gray (vlPAG) region. Further, experiments in anaesthetised rats, using the expression of the immediate-early gene, c-fos, as a marker of neuronal activation, report that pain arising from muscles, joints or viscera selectively activates the vlPAG. Anaesthesia alone, however, evokes substantial Fos-like immunoreactivity (IR) within the vlPAG and this may have obscured any differences in patterns of Fos expression following noxious deep somatic versus noxious visceral activation. In these experiments, in unanaesthetised rats, the effects of noxious spinal versus noxious vagal primary afferent activation were re-examined and distinct rostrocaudal patterns of Fos-expression were observed. Specifically: (i) injection of algesic substances into muscle, which preferentially activates spinal afferents, evoked Fos expression predominantly within the caudal vlPAG; whereas, (ii) noxious manipulations whose effects are mediated by (cardiopulmonary) vagal activation evoked preferential Fos-expression within the rostral vlPAG. On the other hand, hypotensive haemorrhage evoked substantial Fos expression along the entire rostrocaudal extent of the vlPAG, a finding which fits with suggestions that haemorrhagic shock is triggered by a combination of: (i) spinally-relayed nociceptive signals originating from ischaemic tissue, and (ii) vagally-relayed signals reflecting poor cardiac filling.

High strength stimulation of the vagus nerve in awake humans: a lack of cardiorespiratory effects

Vagus nerve stimulation is used to reduce the frequency and intensity of seizures in patients with epilepsy. In the present study four such patients were studied while awake. We analyzed the physiological responses to vagus nerve stimulation over a broad range of tolerable stimulus parameters to identify vagal A-fiber threshold and to induce respiratory responses typical of C-fiber activation. A-fiber threshold was determined by increasing stimulation current until laryngeal motor A-fibers were excited (frequency=30 Hz). With A-fiber threshold established, C-fiber excitation was attempted with physiologically appropriate stimulus parameters (low frequency and high amplitude).

RESULTS

A-fiber thresholds were established in all patients, threshold currents ranged between 0.5 and 1.5 mA. Stimulation at lower frequency (2-10 Hz) and higher amplitudes (2.75-3.75 mA) did not produce cardiorespiratory effects consistent with C-fiber activation. It is possible that such effects were not observed because vagal C-fibers were not excited, because C-fiber effects were masked by the 'wakeful drive' to breathe, or because epilepsy or the associated therapy had altered central processing of the vagal afferent inputs.

Changes in respiratory sensations induced by lobeline after human bilateral lung transplantation

1. The sensations evoked by the injection of lobeline into the right antecubital vein were studied in 8 subjects after bilateral lung transplantation and 10 control subjects. In control subjects, two distinct sensations were experienced. There was an early noxious sensation (onset approximately 10 s) followed by a late sensation of breathlessness (onset approximately 26 s) associated with involuntary hyperventilation. The early sensation was accompanied by respiratory and cardiovascular changes. 2. In contrast to control subjects, the early respiratory events and the noxious sensations evoked by injections of lobeline (18-60 microg kg(-1)) did not occur in subjects with recent bilateral lung transplantation. This suggests that the early respiratory sensations are mediated by the discharge of receptors in the lungs. 3. The late hyperventilation and the accompanying sensation of breathlessness occurred in both transplant and control subjects and are therefore likely to be mediated by receptors elsewhere in the body, presumably systemic arterial chemoreceptors stimulated by lobeline. 4. In control subjects, but not transplant subjects, there was a consistent decrease in mean arterial pressure associated with the lobeline injection. This suggests that pulmonary afferents mediate the hypotension. 5. For transplant subjects studied more than a year after transplantation, there was some evidence that the noxious respiratory sensations evoked by lobeline had returned. This suggests that some functional reinnervation of pulmonary afferents may occur.

Role of vagal afferents in the reflex effects of capsaicin and lobeline in monkeys

Reflex effects of pulmonary C-fiber receptor stimulation by right atrial injections of capsaicin and lobeline were investigated in conscious monkeys (n=17). Capsaicin injection (15.0+/-1.4 microg/kg) produced apnea mostly (n=15, latency-1.7+/-0.2 s) and bradycardia, which were abolished by vagotomy (n=4). Lobeline administration (142+/-6 microg/kg) produced either apnea (n=7, latency -2.0+/-0.3 s) or excitation of breathing (n=8, latency -3.5+/-0.3 s) and no change in heart rate. After vagotomy (n=4), the apneic response was abolished, but the respiratory excitation persisted. Neither capsaicin nor lobeline produced cough. In the anesthetized monkey also (n=7), lobeline injection (50-150 microg/kg) did not produce any cardiovascular response. However, it produced excitation of breathing, which persisted after vagotomy but was abolished by carotid sinus denervation. It is concluded that in the non-human primate, it is capsaicin that produces reflexes typical of pulmonary C-fiber receptor stimulation, and cough is not a part of this reflex.

Afferent properties and reflex functions of bronchopulmonary C-fibers

Bronchopulmonary C-fiber afferents are characterized by their distinct sensitivity to chemical stimuli in the airways or pulmonary circulation. Responses evoked by activating these afferents are mediated by both central reflex pathways and by local or axon reflexes involving the release of tachykinins from sensory endings. Bronchopulmonary C-fiber stimulation reflexly reduces tidal volume and increases respiratory rate, constricts the airways, increases mucus secretion in the airways, and is associated with coughing. Cardiovascular effects include bradycardia, a fall in cardiac output, and bronchial vasodilation that increases airway blood flow despite systemic hypotension. In animals, C-fiber stimulation inhibits skeletal muscle activity, and in humans, is accompanied by burning and choking sensations in the throat and upper chest. Recent studies have identified additional physiologic and pharmacologic stimuli to these afferents, such as hydrogen ions, adenosine, reactive oxygen species, and hyperosmotic solutions. Furthermore, increasing evidence indicates that the excitability of these afferents is enhanced by the local release of certain autocoids (e.g. PGE2) during airway inflammation. These findings further indicate that vagal C-fiber endings in the lungs and airways play an important role in regulating the cardiopulmonary functions under both normal and abnormal physiologic conditions.

Periodic breathing in heart failure patients: testing the hypothesis of instability of the chemoreflex loop

In this study, we applied time- and frequency-domain signal processing techniques to the analysis of respiratory and arterial O(2) saturation (Sa(O(2))) oscillations during nonapneic periodic breathing (PB) in 37 supine awake chronic heart failure patients. O(2) was administered to eight of them at 3 l/min. Instantaneous tidal volume and instantaneous minute ventilation (IMV) signals were obtained from the lung volume signal. The main objectives were to verify 1) whether the timing relationship between IMV and Sa(O(2)) was consistent with modeling predictions derived from the instability hypothesis of PB and 2) whether O(2) administration, by decreasing loop gain and increasing O(2) stores, would have increased system stability reducing or abolishing the ventilatory oscillation. PB was centered around 0.021 Hz, whereas respiratory rate was centered around 0.33 Hz and was almost stable between hyperventilation and hypopnea. The average phase shift between IMV and Sa(O(2)) at the PB frequency was 205 degrees (95% confidence interval 198-212 degrees). In 12 of 37 patients in whom we measured the pure circulatory delay, the predicted lung-to-ear delay was 28.8 +/- 5.2 s and the corresponding observed delay was 30.9 +/- 8.8 s (P = 0.13). In seven of eight patients, O(2) administration abolished PB (in the eighth patient, Sa(O(2)) did not increase). These results show a remarkable consistency between theoretical expectations derived from the instability hypothesis and experimental observations and clearly indicate that a condition of loss of stability in the chemical feedback control of ventilation might play a determinant role in the genesis of PB in awake chronic heart failure patients.

Stopping Exercise: Role of Pulmonary C Fibers and Inhibition Of Motoneurons

In animals, the J reflex evoked by pulmonary C fibers provides potent inhibition of limb muscles and would act to limit exercise. However, recent work shows that although activation of these fibers causes severe respiratory discomfort, it does not impair the output of limb motoneurons to voluntary, reflex, or locomotor drives in awake humans.

Cardiorespiratory variables and sensation during stimulation of the left vagus in patients with epilepsy

We studied physiological and sensory effects of left cervical vagal stimulation in six adult patients receiving this stimulation as adjunctive therapy for intractable epilepsy. Stimulus strength varied among subjects from 0.1 to 2.1 microCoulomb (microC) per pulse, delivered in trains of 30-45 s at frequencies from 20 to 30 Hz; these stimulation parameters were standard in a North American study. The stimulation produced no systematic changes in ECG, arterial pressure, breathing frequency tidal volume or end-expiratory volume. Five subjects experienced hoarseness during stimulation. Three subjects with high stimulus strength (0.9-2.1 microC) recalled shortness of breath during stimulation when exercising; these sensations were seldom present during stimulation at rest. No subjects reported the thoracic burning sensation or cough previously reported with chemical stimulation of pulmonary C fibers. Four of six subjects (all those receiving stimuli at or above 0.6 microC) experienced a substantial reduction in monthly seizure occurrence at the settings used in our studies. Although animal models of epilepsy suggest that C fibers are the most important fibers mediating the anti-seizure effect of vagal stimulation, our present findings suggest that the therapeutic stimulus activated A fibers (evidenced by laryngeal effects) but was not strong enough to activate B or C fibers.

Absence of viscerosomatic inhibition with injections of lobeline designed to activate human pulmonary C fibres

1. Activation of pulmonary C fibres (J receptors) in animals produces inhibition of spinal motoneurones. Intravenous bolus injections of lobeline are believed to activate pulmonary C fibres (J receptors) in human subjects and to produce characteristic sensations and cardiorespiratory responses. This study quantified the respiratory sensations evoked by such injections and then used a range of suprathreshold doses of lobeline and tested for the presence of reflex or descending inhibition of motoneuronal output. 2. Injections of lobeline produced dose-dependent sensations of respiratory discomfort referred to the throat and upper chest beginning within about 10 s and often associated with coughing. As the dose increased the latency for the sensations decreased while their duration and intensity increased. Reflex changes in blood pressure, heart rate and ventilation also occurred. 3. Injections of lobeline at doses sufficient to evoke respiratory discomfort lasting 25-32 s (37-73 microgram kg-1) increased the size of the H reflex in soleus with an onset latency of about 10 s and lasting about 20 s. 4. The size of EMG responses evoked in upper limb muscles by transcranial magnetic stimulation of the motor cortex increased shortly after injections and remained elevated for about 30-35 s. 5. Injections of lobeline during sustained voluntary contractions of the elbow flexors at submaximal or maximal levels did not impair the ability to produce force. 6. Walking was not disrupted by repeated suprathreshold doses of lobeline. 7. It is concluded that injections of lobeline sufficient to evoke cardiorespiratory reflexes and sensations of severe respiratory discomfort are not associated with functionally important inhibition of motor performance. The results cast doubt on the ability of the J reflex to limit exercise in humans.

Chemoreceptors and cardiovascular control in acute and chronic systemic hypoxia

This review describes the ways in which the primary bradycardia and peripheral vasoconstriction evoked by selective stimulation of peripheral chemoreceptors can be modified by the secondary effects of a chemoreceptor-induced increase in ventilation. The evidence that strong stimulation of peripheral chemoreceptors can evoke the behavioural and cardiovascular components of the alerting or defence response which is characteristically evoked by novel or noxious stimuli is considered. The functional significance of all these influences in systemic hypoxia is then discussed with emphasis on the fact that these reflex changes can be overcome by the local effects of hypoxia: central neural hypoxia depresses ventilation, hypoxia acting on the heart causes bradycardia and local hypoxia of skeletal muscle and brain induces vasodilatation. Further, it is proposed that these local influences can become interdependent, so generating a positive feedback loop that may explain sudden infant death syndrome (SIDS). It is also argued that a major contributor to these local influences is adenosine. The role of adenosine in determining the distribution of O2 in skeletal muscle microcirculation in hypoxia is discussed, together with its possible cellular mechanisms of action. Finally, evidence is presented that in chronic systemic hypoxia, the reflex vasoconstrictor influences of the sympathetic nervous system are reduced and/or the local dilator influences of hypoxia are enhanced. In vitro and in vivo findings suggest this is partly explained by upregulation of nitric oxide (NO) synthesis by the vascular endothelium which facilitates vasodilatation induced by adenosine and other NO-dependent dilators and attenuates noradrenaline-evoked vasoconstriction.

Contribution of peripheral chemoreceptor drive in exercise hyperpnea in humans

The peripheral chemoreceptors play a dominant role in the respiratory compensation of lactic acidosis during heavy exercise of humans. Our object was to determine the contribution of peripheral chemoreceptors to exercise hyperpnea during mild to moderate and heavy exercise above the anaerobic threshold. We used a hyperoxic suppression test in six normal male subjects. Inspired gas was abruptly changed without the subject's knowledge from air to pure oxygen for 5 to 6 breaths. The maximal ventilatory depression after O2 breathing was 5.5 +/- 1.7 L/min (BTPS) at mild exercise, and the depression increased with increasing exercise intensity up to 12.8 +/- 4.1 L/min (BTPS). The relative contribution of the peripheral chemoreceptors to ventilation in terms of percentage of the maximal ventilatory depression was maintained, being 20% throughout the entire work ranges studied. The contribution of the peripheral chemoreceptors to total ventilation is hardly altered by lactic acidosis caused by heavy exercise above the anaerobic threshold according to our data. These results suggested that the peripheral chemoreceptors may not be solely responsible for excessive hyperventilation, or residual activities of peripheral chemoreceptors still exist after O2 breathing especially during heavy exercise above the anaerobic threshold.

Role of vagal lung C-fibres in the cardiorespiratory effects of capsaicin in monkeys

Apnoea, bradycardia and hypotension were elicited by right atrial injections of capsaicin in anaesthetized monkeys. At the threshold dose (2.5 +/- 0.3 microgram/kg), tachypnoea was elicited (latency 1.6 +/- 0.2 s) which got replaced by apnoea with higher doses of capsaicin. These responses persisted (1) after cooling the cervical vagi to 6-8 degrees C, and (2) after instilling xylocaine into the pericardial sac. Tachypnoea and apnoea were elicited after bilateral cervical vagotomy also, but only with higher doses and after a longer latency (5.0 +/- 0.3 s). Right atrial injection of capsaicin and insufflation of halothane stimulated vagal pulmonary C-fibre receptors with a latency of 1.7 +/- 0.7 s and 0.2 +/- 0.1 s, respectively. Tachypnoea/apnoea, bradycardia and hypotension were elicited by left atrial injection of capsaicin also (threshold dose: 5.0 +/- 1.2 micrograms/kg). The respiratory responses persisted (1) after instilling xylocaine into the pericardial sac, and (2) after bilateral cervical vagotomy suggesting that they were due to stimulation of non-cardiac receptors with sympathetic afferents. It is concluded that the initial respiratory responses elicited by right atrial injection of capsaicin were due to stimulation of pulmonary C-fibre receptors with vagal afferents.

Modulation by "central" PCO2 of the response to carotid body stimulation in man

We describe a method to assess the effects of PCO2, around and below eucapnia, on the neuromuscular ventilatory response to a standard peripheral chemoreceptor stimulus. Subjects were "passively" hyperventilated (without respiratory muscle activity), at a constant level of ventilation. Stimuli (3-7 breaths N2) were delivered over a range of steady-state PETCO2 (25-43 mmHg). Stimuli during hypocapnia were coupled with a transient increase in FICO2 so that the stimulus to the peripheral chemoreceptors was always "hypoxia at eucapnia". Responses to the stimuli (quantified from the reduction in peak inflation pressure and the magnitude of the evoked diaphragm electromyographic activity) decreased in a graded manner as steady-state PETCO2 fell, disappearing at 7.5 mmHg below eucapnia. Carotid body chemoreceptor recordings from two anaesthetised cats, indicated that the peak firing rate during such stimuli was independent of steady-state PETCO2. The results suggest that the central sensitivity to a peripheral chemoreceptor input may be modulated by changes in steady-state PCO2 around eucapnia and during mild hypocapnia.

Some recent advances in studies on J receptors

While describing recent advances in studies on J receptors it was shown that the discovery of the principle of the relative dilution of multiple solutes in flowing fluids paved the way for developing a new method for measuring in vivo the concentration of injected drugs in the blood of the pulmonary artery. This led to the finding that excitatory solutes move out of the capillaries through a process of diffusion not through filtration. Increase in the permeability of the capillaries causes a marked increase in the responses of the J receptors to excitants by causing greater movement of the excitants to the receptors. This information is likely to yield a method for distinguishing permeability edema from hamodynamic edema in man. The most recent advance relates to the evidence showing conclusively that the sensations and dry cough produced by injecting lobeline intravenouly in man is due to the stimulation of the J receptors. The slowly and rapidly adapting receptors play little or no role in this. The nature of the sensations felt is somewhat variable, most commonly it is choking and pressure localised in the throat and upper chest. Similar sensations are felt by subjects with high altitude pulmonary edema (HAPE). From this data it is extrapolated that the same kinds of sensations that accompany breathlessness after moderate or severe exercise at sea level are also J receptor induced.

Sensory origin of lobeline-induced sensations: a correlative study in man and cat

1. Intravenous injections of lobeline HCl into twenty-six normal young male human volunteers produced sensations of choking, pressure or fumes in the throat and upper chest at a mean threshold dose of 12 micrograms kg-1. 2. Reflex changes in breathing pattern usually appeared just before the sensations. Increasing the dose of lobeline increased the intensity of the sensations gradually until a dry cough appeared at a mean threshold dose of 24.3 micrograms kg-1. At these doses there was a mean difference of 0.3s in the latencies for sensation and respiratory reflex; in four subjects there was no difference at all. 3. In cats anaesthetized with 35 mg kg-1 sodium pentobarbitone, injecting 25-67 micrograms kg-1 lobeline into the right atrium sensitized thirteen out of seventeen rapidly adapting receptors (RARs). In three out of four cats lobeline had no excitatory effect on the RARs in the absence of normal activity (i.e. when it was injected while artificial respiration was suspended), but on restarting the respiration the activity increased greatly. After injecting lobeline, the activity increased during inflation or deflation or in both phases of the respiratory cycle. It also increased greatly during deflation produced by suction of air from the lungs after lobeline. Such presumed increased activity in the RARs of man produced by forced expiration to residual volume at the time lobeline-induced sensations were expected did not enhance the sensations in any subject. 4. In all the subjects tested, forced expiration alone, which should stimulate RARs, never produced a dry cough or sensations similar to those produced by lobeline.(ABSTRACT TRUNCATED AT 250 WORDS)

Latency of the ventilatory chemoreflex response to hypoxia in humans

Latencies for the ventilatory response to hypoxia have been estimated from data from experiments in which square waves of isocapnic hypoxia (periods 30 sec and 60 sec) were presented to 5 subjects. Distorted steps were excluded from the analysis, and the remaining steps were time-aligned relative to the step and then averaged. For the 30 sec data, the median latency for the response to the step into hypoxia was 1 breath or 5.1 sec (time to mid-point of first significantly different breath) and for the step out of hypoxia was 1 breath or 4.7 sec. The number of transients analyzed averaged 87 per subject per transition type. For the 60 sec data, the median latency for the step into hypoxia was 2 breaths or 6.8 sec, and for the step out of hypoxia was 2 breaths or 6.0 sec. The number of transients analyzed averaged 40 per subject per transition type. These latencies are generally shorter than those reported previously and suggest that the ventilatory variability may have served to lengthen the measured latency of response in previous studies.

Dynamics of the ventilatory response in man to step changes of end-tidal carbon dioxide and of hypoxia during exercise

1. Four human subjects exercised in hypoxia (end-tidal partial pressure of O2 (P(ET),O2) ca 55 Torr; heart rate ca 100-130 beats min-1), and the contribution to the respiratory drive of the peripheral and central chemoreflex pathways have been separated on the basis of the latencies and the time courses of the responses to sudden changes of stimulus. 2. The subjects were exposed to repeated end-tidal step changes in PCO2 of ca 3-3.5 Torr (at nearly constant P(ET),O2) and PO2 (between ca 55 and 230 Torr) at three regions along the expiratory ventilation VE-P(ET),CO2 response line (hypocapnia, eucapnia, hypercapnia). The dynamics of the ventilatory responses were calculated using a two-compartment non-linear least-squares optimization method. 3. The component of the response attributable to the peripheral chemoreflex loop may in some subjects contribute up to 75% of the ventilatory drive during mild hypocapnic hypoxic exercise and ca 72% of the total gain following steps of P(ET),CO2 during hypoxic exercise. These data support the notion that the effectiveness of the peripheral chemoreceptor pathway is enhanced in moderate exercise. 4. During hypoxic exercise, the time delays and time constants attributed to the peripheral chemoreflex pathways (ca 3.5 and 9 s respectively) and to the central chemoreflex pathways (ca 9.5 and 47 s respectively) are some of the shortest reported. 5. The dynamics of the peripheral and central chemoreflex pathways appeared to be largely independent of each other. 6. There was a notable absence of systematic change of inspiratory and expiratory durations during the step-induced transients.

Tussive effect of a fentanyl bolus

The aim of this study was to investigate the incidence of pre-induction coughing, after an iv bolus of fentanyl. The study sample was 250 ASA physical status I-II patients, scheduled for various elective surgical procedures. The first 100 were randomly allocated to receive 1.5 micrograms.kg-1 fentanyl via a peripheral venous cannula (Group 1), or an equivalent volume of saline (Group 2). Twenty-eight per cent of patients who received fentanyl, but none given saline, coughed within one minute (P less than 0.0001). The second 150 patients were then randomly assigned to three equal pretreatment groups. Group 3 received 0.01 mg.kg-1 atropine iv one minute before fentanyl. Groups 4 and 5 received 0.2 mg.kg-1 morphine im, and 7.5 mg midazolam po, respectively, one hour before fentanyl. Thirty per cent of patients in Group 3, 6% in Group 4, and 40% in Group 5, had a cough response to fentanyl. Fentanyl, when given through a peripheral cannula, provoked cough in a considerable proportion of patients. This was not altered by premedication with atropine or midazolam, but was reduced after morphine (P less than 0.01). Coughing upon induction of anaesthesia is undesirable in some patients, and stimulation of cough by fentanyl in unpremedicated patients may be of clinical importance.

Chemosensitive cardiopulmonary afferents and the haemodynamic response to simulated haemorrhage in conscious rabbits

1. We set out to test whether the signal from the heart that initiates the decompensatory phase of acute central hypovolaemia in conscious rabbits is conveyed by chemosensitive afferents. 2. Haemorrhage was simulated by inflating an inferior vena caval cuff so that cardiac output fell at a constant rate of 8% of its baseline level per min. After sham or vehicle treatments the haemodynamic response had two phases. In the first, sympathoexcitatory, phase systemic vascular conductance fell in proportion to cardiac output so that mean arterial pressure fell by only 13 mmHg. When cardiac output had fallen by approximately 50% a second, sympathoinhibitory, phase supervened. There was an abrupt rise of systemic vascular conductance and an abrupt fall of mean arterial pressure, to approximately 40 mmHg. 3. The sympathoinhibitory phase was prevented by injection of the delta-opioid antagonist ICI 174864 (100-300 nmol) or the mu-opioid agonist H-Tyr-D-Ala-Gly-MePhe-NH(CH2)2OH (DAMGO) (100-300 pmol) into the fourth cerebral ventricle. 4. 5-HT3 receptors on myocardial or pulmonary afferents were excited by injection of ascending doses of phenylbiguanide (6.25-400 micrograms) into the left or right atrium respectively. Neuronal-type nicotinic cholinoceptors in the epicardium were excited by injecting ascending doses of nicotine bitartrate (6.25-400 micrograms) into the pericardial sac. Each of these treatment regimens caused a reproducible, dose-dependent, fall in mean arterial pressure. Intravenous injection of the 5-HT3 antagonist MDL 72222 (1.0 mg kg-1) markedly attenuated the responses to phenylbiguanide. Intrapericardial injection of the neuronal-type nicotinic cholinoceptor antagonist mecamylamine HCl (0.1 mgkg- ') abolished the effects of intrapericardial nicotine. Neither of these treatments affected the haemodynamic response to simulated haemorrhage. 5. Injection into the fourth ventricle of ICI 174864 (100-300nmol) or DAMGO (100-300pmol) had no effects on the dose-response relationships for phenylbiguanide or nicotine. 6. We conclude that the cardiac afferents responsible for initiating the sympathoinhibitory phase of simulated haemorrhage in conscious rabbits do not correspond to the populations of phenylbiguanidesensitive cardiopulmonary afferents, nor to the population of nicotine-sensitive epicardial afferents. We also conclude that the reflex haemodynamic responses to atrial phenylbiguanide and intrapericardial nicotine do not depend on an endogenous delta-opioid receptor mechanism in the brainstem, and are not affected by exposure of the brainstem to exogeneous DAMGO.

Cardiac chemoreceptors: pharmacological curiosities or physiological tools?

1. We have tested in unanaesthetized rabbits two hypotheses regarding a physiological role for cardiogenic chemoreflexes in acute central hypovolaemia. 2. In rabbits, the sympathoinhibitory phase of acute central hypovolaemia depends on the activation of a brain-stem delta-opioid receptor mechanism by a signal from the heart. Blockade of this by fourth ventricular injection of the delta-receptor antagonist ICI 174864 had no effect on the reflex haemodynamic responses to left atrial phenylbiguanide or intrapericardial nicotine. 3. Intravenous administration of the 5-HT3 receptor antagonist MDL 72222, or intrapericardial administration of the nicotinic ganglionic cholinoceptor antagonist mecamylamine HCl, had no effect on the haemodynamic response to acute central hypovolaemia. 4. We conclude that phenylbiguanide-sensitive myocardial afferents and nicotine-sensitive epicardial afferents play no part in the response to acute hypovolaemia in rabbits, and that the reflex effects evoked by chemically exciting these afferents do not depend on a brain-stem delta-opioid mechanism.

Visceral pain: a review of experimental studies

This paper reviews clinical and basic science research reports and is directed toward an understanding of visceral pain, with emphasis on studies related to spinal processing. Four main types of visceral stimuli have been employed in experimental studies of visceral nociception: (1) electrical, (2) mechanical, (3) ischemic, and (4) chemical. Studies of visceral pain are discussed in relation to the use and 'adequacy' of these stimuli and the responses produced (e.g., behavioral, pseudoaffective, neuronal, etc.). We propose a definition of an adequate noxious visceral stimulus and speculate on spinal mechanisms of visceral pain.

Tussive effect of a fentanyl bolus administered through a central venous catheter

One hundred and ten male patients scheduled for coronary artery bypass grafting were allocated randomly into one of three groups. Patients in group A received fentanyl 7 micrograms/kg via a central venous catheter, those in group B were given fentanyl 7 micrograms/kg through a peripheral venous cannula, and patients in group C received sterile water via a central venous catheter. In group A, 45.9% of patients coughed after injection of fentanyl; the mean onset time from the end of fentanyl administration to the beginning of coughing was 10.6 seconds. Only one patient in group B and no patient in the control group exhibited a cough response (p less than 0.0001). We hypothesise that fentanyl can evoke the pulmonary chemoreflex.

Effects of peripheral and central chemoreflex activation on the isopnoeic rating of breathing in exercising humans

1. Respiratory sensation during exercise is generally considered to be related to respiratory mechanical factors which may be manifest as an abnormal relationship between the force applied to the lungs and chest wall and the resulting motion (if any); that is, a 'length-tension' inappropriateness (Campbell & Howell, 1963). This suggests that there should be a direct correlation between ventilation (VE) and the associated intensity of the perceived sensation, such that the sensation associated with a particular level of VE should remain essentially constant regardless of the source of respiratory stimulation. 2. In order to establish whether certain respiratory stimuli might be 'dyspnoeagenic' (i.e. capable of evoking an intensity of respiratory sensation out of proportion to their influence on VE), we investigated the influence of both peripheral chemoreflex activation (induced by isocapnic hypoxia) and central chemoreflex activation (induced by hypercapnic hyperoxia) on the intensity of respiratory sensation in seven healthy adults during moderate cycle ergometer exercise (i.e. below the lactate threshold, theta 1ac). 3. In each test, an 'isopnoea' was established for which a particular level of VE was sustained over a prolonged period (approximately 30 min) while the proportional contributions to the ventilatory drive from either exercise and the peripheral chemoreflex or from exercise and the central chemoreflex were slowly altered to new stable levels, without the subject's knowledge, VE, tidal volume, inspiratory and expiratory durations, mean inspiratory flow, and end-tidal PCO2 and PO2 (PET,CO2, PET,O2) were monitored breath-by-breath. The intensity of respiratory sensation was rated with a visual analogue scale. 4. Isopnoeic ratings of respiratory sensation were systematically greater for peripheral chemoreflex activation by isocapnic hypoxia during exercise at 50% theta 1ac (for which the degree of peripheral chemoreflex activation, estimated by hyperoxic transition or 'Dejours' testing, averaged approximately 23% of the total VE), compared to 90% theta 1ac during isocapnic hyperoxia. Ratings during exercise at 50% theta 1ac for central chemoreflex activation by hypercapnic hyperoxia were not systematically different from 90% theta 1ac during isocapnic hyperoxia, however. 5. As VE was stable throughout each isopnoea and the MVV (maximum voluntary ventilation) was uninfluenced by the test condition, the dyspnoea index (VE x 100/MVV) was not affected. Breathing pattern was also unaffected. 6. We conclude that in normal subjects exercising moderately, activation of the peripheral chemoreceptors by isocapnic hypoxia evokes an intensity of respiratory sensation which is out of proportion to that evoked by an isopnoeic stimulation of the central chemoreceptors with hypercapnic hyperoxia at the same level of exercise.(ABSTRACT TRUNCATED AT 400 WORDS)

The contribution of peripheral chemoreceptors to ventilation during heavy exercise

The purpose of this study was to determine, in man, the contribution of peripheral chemoreceptors to ventilation during constant-load, heavy exercise above anaerobic threshold at sea level, using hyperoxic suppression of peripheral chemoreceptor drive which was obtained by abrupt and surreptitious replacement of inspired air with 100% oxygen for a period of 20-30 sec during the exercise. There was a delay of at least 1 sec from the time of peripheral chemoreceptor blockade to the initial change in ventilation, suggesting the operation of a central neural reverberatory mechanism after the cessation of peripheral chemoreceptor drive. In contrast to Wasserman (1976), whose results indicated a 25% decrease in ventilation within two breaths, in the present study no significant drop was observed until some 4-6 breaths after the air-to-oxygen switch. Furthermore, the drop in ventilation, magnitude of which was of the order of 15%, was transient in 5 out of 8 subjects. In one subject, the ventilation increased following oxygen administration. It is concluded that the peripheral chemoreceptors are not the sole mediators of hyperventilation of heavy exercise above anaerobic threshold in man.

Reflex control of nasal blood vessels

The effect of stimulation of vagal afferent fibers on nasal blood vessels was studied in 36 cats. Volume change of the nasal capacitance vessels was measured by plethysmographic balloons inserted into the nose. Electrical stimulation of the vagus nerve produced a vasodilatation of nasal mucosa. Pulmonary stretch receptor stimulation by veratridine alkaloid and progressive lung inflation in open-chest cats also produced a vasodilatation of the nasal mucosa. These reflexes were abolished by sectioning the vagus nerves. These results suggest a reflex arc between the lung and nasal capacitance vessels which arises from pulmonary stretch receptors.

Patterns of breathing in response to alternating patterns of alveolar carbon dioxide pressures in man

The time profile of alveolar PCO2 within the respiratory cycle has been forced to follow contrasting patterns in alternate breaths, in two different ways. Within-breath changes (w.b.c., with a CO2-rich inspirate supplied early or late in alternate inspirations) involved minimal alternation of end-tidal PCO2. Between-breath changes (b.b.c., with whole inspirates of CO2-free or CO2-rich gas) involved large swings of end-tidal PCO2. As previously reported (Metias, Cunningham, Howson, Petersen & Wolff, 1981), both patterns of forcing were associated with alternation of ventilation, but only when hypoxia was present. The patterns of the alternating reflex responses in 118 runs on four human subjects in steady hypoxia are described in terms of alternation of inspiratory and expiratory tidal volume, time and mean flow. These patterns often disappeared, or changed unpredictably in mid-run. The inspiratory pattern of reflex alternation depended in part on the type of forcing, but alternation of inspiratory tidal volume was usually observed with both types. No single pattern of expiratory alternation emerged as predominant. The pattern of reflex expiratory alternation was surprisingly independent of the pattern of inspiratory alternation: indeed, in w.b.c., but not in b.b.c., alternation of mean expiratory flow and of mean inspiratory flow were mutually exclusive. It is concluded that in man, as in cats and dogs, the arterial chemoreceptor pathway has access to various parts of the respiratory pattern generator, the exact response depending to some extent on the timing within the respiratory cycle. In particular, expiratory variables may be influenced directly through the arterial chemoreceptor pathway, i.e. without any supposedly mediating inspiratory alternation being demonstrable. The results are discussed briefly in relation to some current views on the organization of respiratory control.

Mouth occlusion pressure (P0.1) in acute respiratory failure

We studied 20 unselected patients admitted to our Intensive Care Unit (ICU) suffering from acute respiratory failure (ARF), who needed mechanical ventilatory support. In all of them we followed a prospective protocol to investigate the value of mouth occlusion pressure (P0.1) as an indicator for weaning. Fifty-two tests were classified into three groups: a need to be reconnected to mechanical ventilation (MV), stable on intermittent mandatory ventilation (IMV), or spontaneous breathing on a T-tube (TT). The results showed that at increased values of P0.1 there were more difficulties in weaning patients from MV. Seventy-eight percent (78%) of the occasions where weaning was successful, values of P0.1 were less than or equal to 4.2 cm H2O, in chronic or non-chronic patients. Eighty-nine percent (89%) of the times when P0.1 values were higher than 4.2 cm H2O the same patients required ventilatory support, total (MV) or partial (IMV). These differences were statistically significant (p less than 0.01). We conclude that the P0.1 is an easily obtained non-invasive parameter, that can contribute along with other more conventional measurements to a superior indication for weaning.