Hypothermia and physiological control: the respiratory system

Hypothermia: Beyond the Narrative Review-The Point of View of Emergency Physicians and Medico-Legal Considerations

Hypothermia is a widespread condition all over the world, with a high risk of mortality in pre-hospital and in-hospital settings when it is not promptly and adequately treated. In this review, we aim to describe the main specificities of the diagnosis and treatment of hypothermia through consideration of the physiological changes that occur in hypothermic patients. Hypothermia can occur due to unfavorable environmental conditions as well as internal causes, such as pathological states that result in reduced heat production, increased heat loss or ineffectiveness of the thermal regulation system. The consequences of hypothermia affect several systems in the body-the cardiovascular system, the central and peripheral nervous systems, the respiratory system, the endocrine system and the gastrointestinal system-but also kidney function, electrolyte balance and coagulation. Once hypothermia is recognized, prompt treatment, focused on restoring body temperature and supporting vital functions, is fundamental in order to avert preventable death. It is important to also denote the fact that CPR has specificities related to the unique profile of hypothermic patients.

Respiratory effects of low and high doses of fentanyl in control and β-arrestin 2-deficient mice

We have investigated the potential acute desensitizing role of the β arrestin 2 (β-arr2) pathway on the ventilatory depression produced by levels of fentanyl ranging from analgesic to life-threatening (0.1 to 60 mg/kg ip) in control and β-arr2-deficient nonsedated mice. Fentanyl at doses of 0.1, 0.5, and 1 mg/kg ip-corresponding to the doses previously used to study the role of β-arr2 pathway-decreased ventilation, but along the V̇e/V̇co₂ relationship established in baseline conditions. This reduction in ventilation was therefore indistinguishable from the decrease in breathing during the periods of spontaneous immobility. Above 1.5 mg/kg, however, ventilation was depressed out of proportion of the changes in metabolic rate, suggesting a specific depression of the drive to breathe. The ventilatory responses were similar between the two groups. At high doses of fentanyl (60 mg/kg ip) 1 out of 20 control mice died by apnea versus 8 out of 20 β-arr2-deficient mice (P = 0.008). In the surviving mice, ventilation was however identical in both groups. The ventilatory effects of fentanyl in β-arr2-deficient mice, reported in the literature, are primarily mediated by the "indirect" effects of sedation/hypometabolism on breathing control. There was an excess mortality at very high doses of fentanyl in the β-arr2-deficient mice, mechanisms of which are still open to question, as the capacity of maintaining a rhythmic, although profoundly depressed, breathing activity remains similar in all of the surviving control and β-arr2-deficient mice.NEW & NOTEWORTHY When life-threatening doses of fentanyl are used in mice, the β-arrestin 2 pathway appears to play a critical role in the recovery from opioid overdose. This observation calls into question the use of G protein-biased μ-opioid receptor agonists, as a strategy for safer opioid analgesic drugs.

Hypoxia alters the thermogenic response to cold in adult homeothermic and heterothermic rodents

KEY POINTS

For small mammals living in a cold, hypoxic environment, supplying enough O₂ to sustain thermogenesis can be challenging. While heterothermic mammals are generally more tolerant of cold and hypoxia than homeothermic mammals, how they regulate O₂ supply and demand during progressive cooling in hypoxia is largely unknown. We show that as ambient temperature is reduced in hypoxia, body temperature falls in both homeotherms and heterotherms. In the homeothermic rat, a decrease in O₂ consumption rate and lung O₂ extraction accompany this fall in body temperature, despite a relative hyperventilation. Paradoxically, in heterothermic mice, hamsters and ground squirrels, body temperature decreases more than in the homeothermic rat, even though they maintain ventilation, increase lung O₂ extraction and maintain or elevate their O₂ consumption rates. Variation in cold and hypoxia tolerance among homeotherms and heterotherms reflects divergent strategies in how O₂ supply and demand are regulated under thermal and hypoxic challenges.

ABSTRACT

Compared to homeothermic mammals, heterothermic mammals are reported to be exceptionally tolerant of cold and hypoxia. We hypothesised that this variation in tolerance stems from divergent strategies in how homeotherms and heterotherms regulate O₂ supply versus O₂ demand when exposed to hypoxia during progressive cooling. To test this hypothesis, we exposed adult rodents ranging in their degree of heterothermic expression (homeotherm: rats, facultative heterotherms: mice and hamsters, and obligate heterotherm: ground squirrels) to either normoxia (21% O₂ ) or environmental hypoxia (7% O₂ ), while reducing ambient temperature from 38 to 5°C. We found that when ambient temperature was reduced in normoxia, all species increased their O₂ consumption rate and ventilation in parallel, maintaining a constant ventilatory equivalent and level of lung O₂ extraction. Surprisingly, body temperature fell in all species, significantly so in the heterotherms. When ambient temperature was reduced in hypoxia, however, the homeothermic rat decreased their O₂ consumption rate and lung O₂ extraction despite an increase in their ventilatory equivalent, indicative of a relative hyperventilation. Heterotherms (mice, hamsters and ground squirrels), on the other hand, decreased their ventilatory equivalent, but increased lung O₂ extraction and maintained or elevated their O₂ consumption rates, yet their body temperature fell even more than in the rat. These results are consistent with the idea that homeotherms and heterotherms diverge in the strategies they use to match O₂ supply and O₂ demand, and that enhanced cold and hypoxia tolerance in heterotherms may stem from an improved ability to extract O₂ from the inspired air.

Prenatal nicotine exposure increases hyperventilation in α4-knock-out mice during mild asphyxia

Prenatal nicotine exposure alters breathing and ventilatory responses to stress through stimulation of nicotine acetylcholine receptors (nAChRs). We tested the hypothesis that α4-containing nAChRs are involved in mediating the effects of prenatal nicotine exposure on ventilatory and metabolic responses to intermittent mild asphyxia (MA). Using open-flow plethysmography, we measured ventilation (V̇(E)) and rate of O2 consumption ( V̇(O2)) of wild-type (WT) and α4-knock-out (KO) mice, at postnatal (P) days 1-2 and 7-8, with and without prenatal nicotine exposure (6 mg kg(-1) day(-1) beginning on embryonic day 14). Mice were exposed to seven 2 min cycles of mild asphyxia (10% O2 and 5% CO2), each interspersed with 2 min of air. Compared to WT, α4 KO mice had increased air V̇(E) and V̇(O2) at P7-8, but not P1-2. Irrespective of age, genotype had no effect on the hyperventilatory response (increase in V̇(E)/V̇(O2)) to MA. At P1-2, nicotine suppressed air V̇(E) and V̇(O2) in both genotypes but did not affect the hyperventilatory response to MA. At P7-8 nicotine suppressed air V̇(E) and V̇(O2) of only α4 KO's but also significantly enhanced V̇(E) during MA (nearly double that of WT; p<0.001). This study has revealed complex effects of α4 nAChR deficiency and prenatal nicotine exposure on ventilatory and metabolic interactions and responses to stress.

The pathophysiological mechanisms of the onset of death through accidental hypothermia and the presentation of "The little match girl" case

Hypothermia and death caused by hypothermia may be found in a number of fiction works, mainly in novels. In the well-known story “The Little Match Girl” by Hans Christian Andersen, one can notice that the descriptions of the phenomena occurring before the girl’s death are in fact a literary presentation of the pathophysiological mechanisms of the onset of death through accidental hypothermia. This essay presents the medical aspects of the story written by Andersen.

Influência da temperatura corporal de cascavéis (Crotalus durissus) submetidas à anestesia com cetamina

O estudo objetivou verificar a influência da temperatura corporal nos parâmetros fisiológicos e nos períodos de indução e recuperação anestésicos de cascavéis (Crotalus durissus) anestesiadas com cetamina. Os animais foram previamente submetidos à hipotermia (HIPO) (<22°C) e normotermia (30°C) (NORMO) e anestesiados com 80mg/kg IM de cetamina. Foram avaliados os períodos de latência e recuperação da anestesia por meio do tônus de cabeça, tônus muscular e reflexo de endireitamento. Mensurou-se a frequência cardíaca (FC), tempo de apnéia e temperatura corporal em 0 min e 5, 10, 15, 30, 60, 90, 120 min e análise dos gases sanguíneos em 0 min, 30 e 60 min. Não houve diferença em relação ao período de latência entre os grupos. A recuperação dos animais em HIPO foi mais prolongada (5,5 horas) que em NORMO (3,5 horas). Obteve-se FC no grupo NORMO superior que no grupo HIPO. O tempo de apnéia manteve o mesmo padrão em ambos os grupos. Em relação ao basal, tanto em HIPO quanto em NORMO o tempo de apnéia diminuiu acentuadamente entre 5 e 30 min. Observou-se acidose respiratória no grupo NORMO apenas em 0 min. O SvO2 elevou-se significativamente após 30 min, o mesmo ocorrendo com a PvO2. A PvCO2 diminuiu em ambos os grupos após 30 min. Evidenciou-se que a temperatura corporal influencia intrinsecamente o período de recuperação de cascavéis anestesiadas com cetamina.

[Heat exchanges and thermoregulation in the neonate]

The newborn's energy expenditure is used in order of priority for: (i) basic metabolism; (ii) body temperature regulation and (iii) body growth. Thermal regulation is an important part of energy expenditure, especially for low birth-weight infants or preterm newborns. The heat exchanges with the environment are greater in the infant than in the adult, explaining the increased risk of body hypo- or hyperthermia. The newborn infant is a homeotherm, but over a long period of time, he cannot maintain the thermal processes. Further developments are expected to improve the infant's thermal environment, with assessment of the various heat exchange mechanisms by conduction, convection, radiation and evaporation. The quantification of the respective parts of these exchanges would improve nursing care through clinical procedures or equipment used to ensure the control of the optimal thermohygrometric conditions in incubators, especially when the likelihood of excessive body cooling is high. The present review focuses on the various body heat exchange mechanisms, the thermoregulation processes of the newborn, and their implications in clinical usage and limitations in the neonatal intensive care unit.

Ventilation and metabolic rate in the platypus: insights into the evolution of the mammalian breathing pattern

The platypus (Ornithorhyncus anatinus) is characterized by a rate of oxygen consumption (V(O2))that is higher than that reported for other similar sized monotremes, similar to marsupials and somewhat lower than eutherians. The platypus is also characterized by a breathing pattern, more typical of a diving mammal, with a high 'inspiratory drive' and a post-inspiratory pause. Further, the platypus reveals an attenuated hyperventilatory response to hypoxia and a reduced hyperpnoea to hypercapnia; such a response to these chemical stimuli is commonly observed in semi-fossorial and diving mammals. Nevertheless, under conditions of normoxia, ventilation (V(E))is matched to (V(O(2)) such that the convection requirement (V(E)/V(O2)) is similar to that reported for other mammals (approx. 37). The apparent consistency of the convection requirement in mammals suggests the blueprint for the design of the mammalian respiratory system has remained an interspecies constant in the three divergent extant sub-classes of mammals.

Ventilatory responses to changes in temperature in mammals and other vertebrates

This article reviews the relationship between pulmonary ventilation (VE) and metabolic rate (oxygen consumption) during changes in ambient temperature. The main focus is on mammals, although for comparative purposes the VE responses of ectothermic vertebrates are also discussed. First, the effects of temperature on pulmonary mechanics, chemoreceptors, and airway receptors are summarized. Then we review the main VE responses to cold and warm stimuli and their interaction with exercise, hypoxia, or hypercapnia. In these cases, mammals attempt to maintain both oxygenation and body temperature, although conflicts can arise because of the respiratory heat loss associated with the increase in ventilation. Finally, we consider the VE responses of mammals when body temperature changes, as during torpor, fever, sleep, and hypothermia. In ectotherms, during changes in temperature, VE control becomes part of a general strategy to maintain constant relative alkalinity and ensure a constancy of pH-dependent protein functions (alphastat regulation). In mammals on the other hand, VE control is aimed to balance metabolic needs with homeothermy. Therefore, alphastat regulation in mammals seems to have a low priority, and it may be adopted only in exceptional cases.