Neural processing of respiratory sensations when breathing becomes more difficult and unpleasant

Differences in uni-dimensional breathlessness measures and thresholds for clinical response in a randomised controlled trial in people with chronic breathlessness: an exploratory study

INTRODUCTION

Optimally measuring improvements in chronic breathlessness in clinical practice and research continues to evolve. The aim of this study was to consider the performance of uni-dimensional measures in chronic breathlessness limiting exertion.

METHODS

We report five measures of breathlessness (intensity: worst, best and average in the previous 24 hours; breathlessness now; and an affective component unpleasantness now) and two clinical thresholds over baseline on their 0-100 mm visual analogue scale (8.9 mm absolute improvement; and 15% relative improvement) collected in a multi-site, randomised, double-blind, parallel-arm, placebo-controlled trial of regular, low-dose, sustained-release morphine for people with chronic breathlessness with optimally treated underlying causes.

RESULTS

Participants (n=284) were mostly elderly men with severe, chronic breathlessness. Worst breathlessness in the previous 24 hours showed improvement in people with more severe breathlessness and chronic obstructive pulmonary disease. By contrast, breathlessness now and average breathlessness in the previous 24 hours generated similar patterns of response, as did unpleasantness now and breathlessness now. Best breathlessness added little value. The two clinical thresholds showed differing patterns of significance.

DISCUSSION

Consistent with other recent work, worst breathlessness may be an important uni-dimensional outcome in evaluating chronic breathlessness clinically and in research. This study does not support a differential between unpleasantness now and breathlessness now, previously observed in laboratory-generated, acute-on-chronic breathlessness. Timeframe for recall (now or the last 24 hours) and the threshold for a clinical meaningful improvement (absolute (8.9 mm) or relative (15%)) affect assessment performance.

Heartbeat-evoked potentials following voluntary hyperventilation in epilepsy patients: respiratory influences on cardiac interoception

Introduction

Current evidence indicates a modulating role of respiratory processes in cardiac interoception, yet whether altered breathing patterns influence heartbeat-evoked potentials (HEP) remains inconclusive.

Methods

Here, we examined the effects of voluntary hyperventilation (VH) as part of a clinical routine examination on scalp-recorded HEPs in epilepsy patients (N = 80).

Results

Using cluster-based permutation analyses, HEP amplitudes were compared across pre-VH and post-VH conditions within young and elderly subgroups, as well as for the total sample. No differences in the HEP were detected for younger participants or across the full sample, while an increased late HEP during pre-VH compared to post-VH was fond in the senior group, denoting decreased cardiac interoceptive processing after hyperventilation.

Discussion

The present study, thus, provides initial evidence of breathing-related HEP modulations in elderly epilepsy patients, emphasizing the potential of HEP as an interoceptive neural marker that could partially extend to the representation of pulmonary signaling. We speculate that aberrant CO2-chemosensing, coupled with disturbances in autonomic regulation, might constitute the underlying pathophysiological mechanism behind the obtained effect. Available databases involving patient records of routine VH assessment may constitute a valuable asset in disentangling the interplay of cardiac and ventilatory interoceptive information in various patient groups, providing thorough clinical data to parse, as well as increased statistical power and estimates of effects with higher precision through large-scale studies.

The effect of unpredictability on the perception of breathlessness: a narrative review

Breathlessness is an aversive bodily sensation impacting millions of people worldwide. It is often highly detrimental for patients and can lead to profound distress and suffering. Notably, unpredictable breathlessness episodes are often reported as being more severe and unpleasant than predictable episodes, but the underlying reasons have not yet been firmly established in experimental studies. This review aimed to summarize the available empirical evidence about the perception of unpredictable breathlessness in the adult population. Specifically, we examined: (1) effects of unpredictable relative to predictable episodes of breathlessness on their perceived intensity and unpleasantness, (2) potentially associated neural and psychophysiological correlates, (3) potentially related factors such as state and trait negative affectivity. Nine studies were identified and integrated in this review, all of them conducted in healthy adult participants. The main finding across studies suggested that unpredictable compared to predictable, breathlessness elicits more frequently states of high fear and distress, which may contribute to amplify the perception of unpredictable breathlessness, especially its unpleasantness. Trait negative affectivity did not seem to directly affect the perception of unpredictable breathlessness. However, it seemed to reinforce state fear and anxiety, hence possible indirect modulatory pathways through these affective states. Studies investigating neural correlates of breathlessness perception and psychophysiological measures did not show clear associations with unpredictability. We discuss the implication of these results for future research and clinical applications, which necessitate further investigations, especially in clinical samples suffering from breathlessness.

The impact of emotional context on neural substrates of respiratory sensory gating

Psychological challenges have been found to impact respiratory symptom perception in healthy individuals as well as in patients with various neurological disorders. Human respiratory sensory gating is an objective measure to examine respiratory sensory information processing of repetitive respiratory mechanical stimuli in the central nervous system. With this electrophysiological method, patients with higher anxiety levels showed reduced respiratory sensory gating function in the cortex, and increased symptom perception. In addition, positive emotional contexts were found to increase the respiratory sensory gating function using RREPs. However, neural substrates related to emotional impacts on respiratory sensory gating remain still unclear. In the present study, we examined the emotion processing of respiratory sensory gating using functional magnetic resonance imaging. We hypothesized that positive compared with neutral stimuli would result in reduced brain activations in cortical areas with the paired occlusion paradigm. Thirty-five healthy adults participated in this event-designed fMRI experiment. Paired inspiratory occlusions (two transient occlusions with a 500 ms inter-stimulus-interval are delivered during one inspiration) were provided using an external trigger outside of the scanner. At least 40 paired inspiratory occlusions were collected for each trial. The experiment contained three runs during which participants underwent 12 min for the paired inspiratory occlusion paradigm while watching a fixation cross (the control condition), neutral and positive emotional picture series. The order of emotional picture series was randomized across the participants. Our results revealed an overall trend of reduction of brain activity from the neutral (minus fixation) condition, to the pleasant (minus fixation) condition. For bilateral thalamus and primary visual cortices, there was no significant difference in neural activation between the two contrasts of pleasant (Contrast_P–F) and neutral condition (Contrast_N–F). The activation of the mid-cingulate and the orbitofrontal cortex was lower in Contrast_P–F compared to Contrast_N–F. In conclusion, our results suggest that emotional context, especially positive valence, modulates neural correlates in middle cingulate cortex and orbitofrontal cortex in terms of respiratory sensory gating. Future studies are recommended to test emotional impacts on respiratory sensations in patients with neurological disorders.

Inspiratory threshold loading negatively impacts attentional performance

Rationale

There are growing concerns over the occurrence of adverse physiologic events (PEs) occurring in pilots during operation of United States Air Force and Navy high-performance aircraft. We hypothesize that a heightened inspiratory work of breathing experienced by jet pilots by virtue of the on-board life support system may constitute a “distraction stimulus” consequent to an increased sensation of respiratory muscle effort. As such, the purpose of this study was to determine whether increasing inspiratory muscle effort adversely impacts on attentional performance.

Methods

Twelve, healthy participants (age: 29 ± 6 years) were recruited for this study. Participants completed six repetitions of a modified Masked Conjunctive Continuous Performance Task (MCCPT) protocol while breathing against four different inspiratory threshold loads to assess median reaction times (RTs). A computer-controlled threshold loading device was used to set the inspiratory threshold loads. Repeated measures analysis of variances (ANOVAs) were performed to examine: (i) the efficacy of the threshold loading device to impose significantly higher loading at each loading condition; (ii) the effects of loading condition on respiratory muscle effort sensation; and (iii) the influence of hypercapnia on MCCPT scores during inspiratory threshold loading. Generalized additive mixed effects models (GAMMs) were used to examine the potential non-linear effects of respiratory muscular effort sensation, device loading, and hypercapnia, on MCCPT scores during inspiratory threshold loading.

Results

Inspiratory threshold loading significantly augmented (P < 0.05) inspiratory effort sensation and the inspiratory pressure-time product (PTP). Our analyses also revealed that median hit RT was positively associated with inspiratory effort sensation during inspiratory loading trials.

Conclusion

The findings of this work suggest that it was not increasing inspiratory muscle effort (i.e., PTP) per se, but rather participant’s subjective perception of inspiratory “load” that impacts negatively on attentional performance; i.e., as the degree of inspiratory effort sensation increased, sotoo did median hit RT. As such, it is reasonable to suggest that minimizing inspiratory effort sensation (independent of the mechanical output of the inspiratory muscles) during high-performance flight operations may prove useful in reducing pilot RTs during complex behavioral tasks.

The impact of unpredictability of dyspnea offset on dyspnea perception, fear, and respiratory neural gating

Dyspnea is a debilitating and threatening symptom in various diseases. Affected patients often report the unpredictability of dyspnea episodes being particularly anxiety-provoking and amplifying the perception of dyspnea. Experimental studies testing dyspnea unpredictability together with related neural processes, physiological fear responses, and dyspnea-related personality traits are sparse. Therefore, we investigated the impact of unpredictability of dyspnea offset on dyspnea perception and fear ratings, respiratory neural gating and physiological fear indices, as well as the influence of interindividual differences in fear of suffocation (FoS). Forty healthy participants underwent a task manipulating the offset predictability of resistive load-induced dyspnea including one unloaded safety condition. Respiratory variables, self-reports of dyspnea intensity, dyspnea unpleasantness, and fear were recorded. Moreover, respiratory neural gating was measured in a paired inspiratory occlusion paradigm using electroencephalography, while electrodermal activity, startle eyeblink, and startle probe N100 were assessed as physiological fear indices. Participants reported higher dyspnea unpleasantness and fear when dyspnea offset was unpredictable compared to being predictable. Individuals with high levels of FoS showed the greatest increase in fear and overall higher levels of fear and physiological arousal across all conditions. Respiratory neural gating, startle eyeblink, and startle probe N100 showed general reductions during dyspnea conditions but no difference between unpredictable and predictable dyspnea conditions. Together, the current results suggest that the unpredictable offset of dyspnea amplifies dyspnea perception and fear, especially in individuals with high levels of FoS. These effects were unrelated to respiratory neural gating or physiological fear responses, requiring future studies on underlying mechanisms.

Breath-hold task induces temporal heterogeneity in electroencephalographic regional field power in healthy subjects

We demonstrated that changes in CO₂ values cause oscillations in the cortical activity in δ-and α-bands. The analysis of the regional field power (RFP) showed evidence that different cortical areas respond with different time delays to CO₂ challenges. An opposite behavior was found for the end-tidal O₂. We suppose that the different cortical time delays likely expresse specific ascending pathways to the cortex, generated by chemoreceptor nuclei in the brain stem. Although the brain stem is in charge of the automatic control of ventilation, the cortex is involved in the voluntary control of breathing but also receives inputs from the brain stem, which influences the perception of breathing, the arousal state and sleep architecture in conditions of hypoxia/hypercapnia. We evaluated in 11 healthy subjects the effects of breath hold (BH; 30 s of apneas and 30 s of normal breathing) and BH-related CO₂/O₂ changes on electroencephalogram (EEG) global field power (GFP) and RFP in nine different areas (3 rostrocaudal sections: anterior, central, and posterior; and 3 sagittal sections: left, middle, and right) in the δ- and α-bands by cross correlation analysis. No significant differences were observed in GFP or RFP when comparing free breathing (FB) with the BH task. Within the BH task, the shift from apnea to normal ventilation was accompanied by an increase in the δ-power and a decrease in the α-power. The end-tidal pressure of CO₂ ([Formula: see text]) was positively correlated with the δ-band and negatively with the α- band with a positive time shift, whereas an opposite behavior was found for the end-tidal pressure of O₂ ([Formula: see text]). Notably, the time shift between [Formula: see text] / [Formula: see text] signals and cortical activity at RFP was heterogenous and seemed to follow a hierarchical activation, with the δ-band responding earlier than the α-band. Overall, these findings suggest that the effect of BH on the cortex may follow specific ascending pathways from the brain stem and be related to chemoreflex stimulation.NEW & NOTEWORTHY We demonstrated that the end tidal CO₂ oscillation causes oscillations of delta and alpha bands. The analysis of the regional field power showed that different cortical areas respond with different time delays to CO₂ challenges. An opposite behavior was found for the end-tidal O₂. We can suppose that the different cortical time delay response likely expresses specific ascending pathways to the cortex generated by chemoreceptor nuclei in the brainstem.

Psychological Mediation of Dysfunction and Hyperfunction of Respiratory Regulation

This research investigates the continuum between the dysfunction and the hyperfunction of breath regulation and presents the psychological mediation that supports or disrupts this regulation. The pilot study compared breathing regulation in patients with hyperventilation syndrome (HVS), free divers, and healthy volunteers. To examine the ability of voluntary respiration regulation, breath holding involving "easy-going" and "struggling" phases was used. Psychological mediation was assessed through (a) respiratory experience interviews, (b) anxiety levels, and (c) psycho-semantic techniques. Free divers have a bigger "positive breathing vocabulary" and can endure the conflict between the physiological need to inhale and the voluntary motivation to hold their breath for longer. The connection between emotions and negative breathing experience in patients with HVS leads to less breathing control.

The impact of dyspnea and threat of dyspnea on error processing

Dyspnea (breathlessness) is a threatening and aversive bodily sensation and a major symptom of various diseases. It has been suggested to impair several aspects of functioning in affected patients, but experimental proof for this assumption is widely absent. Error processing is an important domain of functioning and has intensively been studied using electrophysiological measures. Specifically, the error-related negativity (ERN) has been suggested to reflect early performance monitoring and error detection, while the error positivity (Pe) has been linked to subsequent error awareness. So far, little is known about the effects of anticipated or perceived dyspnea on error processing. Therefore, in 49 healthy participants, we studied the effects of experimentally induced dyspnea and threat of dyspnea on the ERN/Pe and behavioral task performance. Participants performed the arrowhead version of the flanker task during three experimental conditions: an unloaded baseline condition, a dyspnea condition, and a threat of dyspnea condition. Dyspnea was induced by breathing through inspiratory resistive loads, while high-density EEG was continuously measured. No differences in task performance (reaction times, error rates) and ERN mean amplitudes were found between conditions. However, mean amplitudes for the Pe differed between conditions with smaller Pe amplitudes during threat of dyspnea compared to baseline and dyspnea conditions, with the latter two conditions showing no difference. These results may suggest that threat of dyspnea, but not dyspnea itself, reduces error awareness, while both seem to have no impact on early error processing and related behavioral performance.

Effect of anticipation triggered by a prior dyspnea experience on brain activity

[Purpose] Oxygenated hemoglobin (oxy-Hb) concentrations in the prefrontal cortex are closely associated with dyspnea. Dyspnea is influenced not only by physical activity, but also by visual stimuli, and several studies suggest that oxy-Hb concentrations change in response to certain external stimuli. However, the effects of internal psychological states on dyspnea have not been reported. This study explored the influence of anticipation triggered by previous episodes of dyspnea on brain activity. [Subjects] The subjects were 15 healthy volunteers with a mean age of 25.0 ± 3.0 years. [Methods] The subjects were shown a variety of photographs and instructed to expect breathing resistance matched to the affective nature of the particular photograph. After viewing the images, varying intensities of breathing resistance that were identical to, easier than, or harder than those shown in the images were randomly administered to the subjects; in fact, the image and resistance were identical 33% of the time and discordant 66% of the time. [Results] The concentrations of oxy-Hb in the right medial prefrontal cortex (rMPFC) increased significantly with an inspiratory pressure that was 30% of the maximum intensity in the subjects shown a pleasant image compared to the concentrations in subjects shown an unpleasant image. Moreover, rMPFC activity was significantly correlated with the magnitude of the dyspnea experienced. [Conclusion] These results suggest that a correlation exists between increased oxy-Hb in the rMPFC and the effects of expectations on dyspnea.

The effect of anxiety on respiratory sensory gating measured by respiratory-related evoked potentials

Respiratory sensory gating is evidenced by decreased amplitudes of the respiratory-related evoked potentials (RREP) N1 peak for the second (S2) compared to the first occlusion (S1) when two paired occlusions are presented with a 500-millisecond (ms) inter-stimulus-interval during one inspiration. Because anxiety is prevalent in respiratory diseases and associated with altered respiratory perception, we tested whether anxiety can modulate individuals' respiratory neural gating mechanism. By using high-density EEG, RREPs were measured in a paired inspiratory occlusion paradigm in 11 low and 10 higher anxious individuals with normal lung function. The N1 peak gating S2/S1 ratio and the N1 S2 amplitudes were greater in higher compared to low anxious individuals (p's<0.05). In addition, higher anxiety levels were correlated with greater S2/S1 ratios (r=0.54, p<0.05) and S2 amplitudes (r=-0.49, p<0.05). The results demonstrate that anxiety is associated with reduced respiratory sensory gating which might underlie altered respiratory symptom perception in anxious individuals.