Receptors responding to changes in upper airway pressure

Our purpose was to characterize receptors which respond to changes in upper airway pressures. Such changes cause alterations in hypoglossal and phrenic nerve activities. Decerebrate, vagotomized, paralyzed and ventilated cats were prepared so that pressures could be altered within segments of upper airways. Activities of single fibers in the superior laryngeal and glossopharyngeal nerves were monitored. Most superior laryngeal receptors discharged tonically at zero transmural pressure. Discharges of approximately half decreased (A) and the rest increased (B) with pressure reductions of -7 to -28 cm H2O. Pressure increases of +7 to +28 cm H2O caused increases in Group A activities while Group B responses varied. The remaining receptors were silent, being activated by pressure decreases and/or increases. Activities of other silent receptors, similarly activated, were recorded from glossopharyngeal nerve. Tonically active glossopharyngeal receptors increased discharge after both pressure increases and decreases. Most tonically active and silent receptors, having afferents in either nerve, adapted incompletely to sustained pressures. These may have major functions in hypoglossal responses to changes in upper airway pressures.     

Influence of lung volume on phrenic, hypoglossal and mylohyoid nerve activities

In decerebrate, paralyzed cats, ventilated by a servo-respirator in accordance with phrenic nerve activity, we examined the influence of lung volume on the activities of the phrenic, hypoglossal and mylohyoid nerves. When lung inflation was briefly withheld, the durations of inspiration (TI) and expiration (TE) and the activities of all three nerves increased. The relative increase in hypoglossal activity greatly exceeded that of phrenic activity and was apparent earlier in the course of inspiration. This hypoglossal response was enhanced by hypercapnia and isocapnic hypoxia. The responses of mylohyoid activity were quite variable: withholding lung inflation augmented inspiratory activity in some cats, but expiratory discharge in others. Sustained increases in end-expiratory lung volume were induced by application of 3-4 cm H2O of positive end-expiratory pressure (PEEP). Steady-state PEEP did not influence nerve activities or the breathing pattern. Bilateral vagotomy increased TI, TE, and the activities of all three nerves. No response to withoholding lung inflation could be discerned after vagal section. The results provide further definition of the influence of vagally mediated, lung volume dependent reflexes on the control of upper airway muscles. These reflexes are well suited to relieve or prevent upper airway obstruction.     

Dynamic changes of hypoglossal and phrenic activities by hypoxia and hypercapnia

Steady-state responses of unanesthetized subjects to hypercapnia or hypoxia provide no evidence that chemoreceptor afferents are differentially distributed upon hypoglossal and bulbospinalphrenic neurons, as suggested by results in anesthetized animals. We hypothesized that dynamic changes in activities of phrenic and hypoglossal nerves might differ following sudden alterations of inspired gases. This hypothesis was based on the observation that episodes of obstructive apnea may follow central apnea. The obstruction might reflect phrenic activity increasing more quickly than that of the hypoglossal upon resumption of ventilation. In decerebrate, vagotomized, paralyzed and ventilated cats, we recorded phrenic and hypoglossal activities before and during abrupt, sustained exposure to hypercapnia, hypoxia and hypoxic hypercapnia, and following sudden withdrawal of these stimuli. For all such manoeuvres, activities of phrenic and hypoglossal nerves increased or decreased in parallel fashion. Our findings cause rejection of the hypothesis of differing dynamic phrenic and hypoglossal responses to chemoreceptor stimuli. The concept that the ventilatory control system is well organized to prevent upper airway obstructions is discussed.     

Characterization of respiratory-related activity of the facial nerve

Activities of the facial, hypoglossal and phrenic nerves were recorded in decerebrate and paralyzed cats. These animals were ventilated with a servo-respirator which produced lung inflations in parallel with phrenic activity. Peak inspiratory phrenic, hypoglossal and facial activities increased in hypercapnia or hypoxia. When pulmonary inflation was prevented, hypoglossal and facial activities increased more than phrenic. Responses to withholding lung inflation differed from those following vagotomy. These differences were observed in expiratory facial and hypoglossal activities and in hypercapnia- and hypoxia-induced changes in facial activity. Administration of pentobarbital or hyperventilation to hypocapnia caused greater suppressions of hypoglossal than facial activity; the latter declined more than phrenic activity. The results support the hypothesis that influences from the brainstem reticular formation and from pulmonary stretch receptors are differentially distributed to motoneurons innervating upper airway muscles compared to those of the bulbospinal-phrenic system. The concept that ventilatory activity is influenced by tonic, as well as phasic discharge of pulmonary receptors is discussed.     

Differential elevation by protriptyline and depression by diazepam of upper airway respiratory motor activity

Effects of systemically administered protriptyline and diazepam on the respiratory activity of the phrenic, hypoglossal, and recurrent laryngeal nerves were investigated in vagotomized, decerebrate cats. Both hypoglossal and recurrent laryngeal nerve activities were consistently increased after protriptyline administration, whereas the phrenic nerve discharge was not systematically altered. Similar changes were observed in cats with bilateral carotid sinus nerve sections. Diazepam induced a reduction of hypoglossal and recurrent laryngeal nerve activities at doses that did not alter phrenic nerve discharge. These results with diazepam were the same in carotid chemodenervated cats. We conclude that neural mechanisms controlling upper airway muscles are much more sensitive to protriptyline and diazepam than are those of the bulbospinal-phrenic system. The selective augmentation of hypoglossal and recurrent laryngeal discharges by protriptyline could account for the reported decrease in the frequency of obstructive sleep apneas in patients receiving this antidepressant. In contrast, diazepam, by depressing motor activity to upper airway muscles, may exacerbate oropharyngeal obstruction during sleep.     

The effects of hypercapnia and cooling the ventral medullary surface on capsaicin induced respiratory reflexes

The effect of right atrial (RA) injection of 3 micrograms/kg capsaicin on phrenic, hypoglossal and recurrent laryngeal activities was studied in chloralose anesthetized, paralyzed and artificially ventilated cats. Within 2 sec following capsaicin injection, the phrenic and hypoglossal activities completely disappeared (apnea), while the recurrent laryngeal activity markedly increased. Similar responses were also obtained with RA injection of phenyldiguinide (PDG), suggesting that the respiratory responses of both drugs are essentially similar. Sino-aortic denervation did not affect the capsaicin induced respiratory responses. Bilateral vagotomy abolished the responses, suggesting that vagal sensory receptors are responsible for the reflex effects. Hyperoxic hypercapnia (3 and 7% CO2 in O2) reduced the apneic duration of phrenic and hypoglossal nerves. The magnitude of the recurrent laryngeal excitation was decreased during CO2 breathing. Graded focal cooling of the intermediate area (Is area) of the ventral medullary surface (to inhibit central chemoreceptor activity) significantly prolonged capsaicin induced apneic duration of hypoglossal nerves more than the phrenic. The recurrent laryngeal responses, however, were unaffected by cooling of the ventral medullary surface. The results show that capsaicin and PDG, presumably by stimulating C fibers, affect cranial nerves as well as the phrenic. The reflex responses to C fiber stimulation seem to be altered by intervention which stimulate (hypercapnia) or depress (Is cooling) 'central chemoreceptors.'     

Phrenic and hypoglossal neural responses to cold airflow in the upper airway.

Cold air flowing through the larynx is known to alter the activities of laryngeal receptors with afferents in the superior laryngeal nerves (SLNs) and to induce reflex apnea in neonatal mammals. To examine the ventilatory response in adult animals and to explore associated upper airway motor responses, we recorded phrenic and hypoglossal neural responses to cooling the isolated larynx with cold air in decerebrate, vagotomized, paralyzed, ventilated cats. The most consistent response was phrenic inhibition, which occurred in all animals tested. Either excitation or inhibition of hypoglossal activity was seen consistently in individual cats, with the result that the group response was not statistically significant. All responses to laryngeal cooling were abolished by section of the SLNs. The findings confirm that directing cold air through the larynx causes reflex inhibition of ventilatory (phrenic) activity, but raise new questions as to how the two, directionally opposite hypoglossal responses are mediated.     

Nonvagal modulation of hypoglossal neural activity.

Upper airway dilating muscle activity is characterized by an early-peaking pattern which serves to dilate or stiffen the upper airway at the time when the greatest negative intraluminal pressure is generated by contraction of chest wall muscles. This pattern has been attributed to phasic afferent inputs from pulmonary stretch receptors. The present study examines the hypothesis that nonvagal factors may also influence the discharge pattern and coordination of upper airway and chest wall muscle activities. Therefore, in anesthetized, paralyzed, vagotomized and artificially ventilated cats, we examined the effects of changes in respiratory drive produced by activation of cholinergic and GA-BAergic (gamma-aminobutyric acid) receptors at the ventrolateral aspects of the medulla oblongata on phasic intrabreath discharge patterns of hypoglossal and phrenic nerves. Cholinergic agents (acetylcholine, carbachol, methacholine, physostigmine) applied directly to chemoreceptive areas on the ventral medullary surface increased hypoglossal activity, and in addition converted inspiratory discharge from an augmenting to a decrementing pattern of activity. The reverse effect on the discharge pattern of hypoglossal activity was observed with a decrease in respiratory drive. While the amplitude of the phrenic nerve discharge was also affected by these interventions, the augmenting discharge pattern of phrenic nerve activity did not change. These results suggest that the early peaking pattern of hypoglossal nerve discharge in vagotomized cats also depends on the level of respiratory drive, and is not solely dependent on vagal afferent inputs. In addition, the data suggest that structures near the ventral surface of the medulla are influential in shaping the pattern of hypoglossal nerve activity and maintaining balanced activity of upper airway and chest wall muscles.     

Influence of reticular mechanisms upon hypoglossal, trigeminal and phrenic activities

Studies were undertaken to evaluate the hypothesis that mechanisms within the reticular formation influence activities of nerves to muscles of the upper airways more than the bulbospinal-phrenic system. In decerebrate, vagotomized, paralyzed and ventilated cats, activities of the phrenic, trigeminal, and the hypoglossal nerves were monitored. Activity of the pontile and medullary reticular formation was increased directly by electrical stimulation within the brainstem and indirectly by stimulating the sciatic nerve. Trigeminal and hypoglossal discharges increased more than phrenic during stimulations at many brainstem loci. Changes were typically maintained for one or more respiratory cycles following termination of stimulation. At some loci, activation of neurons by microinjections of glutamate increased trigeminal and hypoglossal activities more than phrenic. Although responses were extremely variable, activities of the trigeminal and/or hypoglossal nerves usually increased more than phrenic during stimulations of the sciatic nerve or upon termination of stimulation. The results support the conclusion that respiratory-modulated trigeminal and hypoglossal discharges are dependent upon reticular mechanisms for their expression.     

Twitch airway pressure elicited by magnetic phrenic nerve stimulation in anesthetized healthy children

Children with diaphragm dysfunction may be unable to maintain adequate ventilation. Accurate diagnosis is important, but can only be achieved using an appropriate test and reference range. The aim of this study, therefore, was to measure diaphragm contractility and examine the influence of age and maturation, using magnetic phrenic nerve stimulation in healthy children. Anterolateral magnetic stimulation (MS) of the phrenic nerves was performed using a 43-mm figure-eight coil in 23 children (14 male; mean age, 7.8 years; range, 1.8-15.7) anesthetized for minor surgery with sevoflurane gas. The airway was maintained with a cuffed laryngeal mask airway (LMA) which was briefly occluded during MS. Diaphragm contractility was assessed by measuring the airway pressure (TwPaw) elicited by MS. TwPaw responses were obtained in all subjects, with mean (SD) TwPaw 18.2 (6.8) cm H2O bilateral, 7.3 (3.2) cm H2O left unilateral, and 8.6 (3.1) cm H2O right unilateral. Subgroup analysis was performed in 17 of the children who were prepubertal. Their mean (SD) TwPaw was 17.3 (6.8) cm H2O bilateral, 7.1 (3.7) cm H2O left unilateral, and 8.3 (3.3) right unilateral. The mean (SD) intrapatient coefficients of variation for bilateral and left and right unilateral TwPaw were 8.4% (5.2), 6.7% (3.5), and 11.7% (10.3), respectively. Bilateral and left and right unilateral TwPaw were significantly related to age (P < 0.05). In healthy prepubertal children, diaphragm contractility is primarily influenced by age.     

Influence of lung volume on respiratory responses to spontaneous bladder contractions

Spontaneous bladder contractions (SBCs) in decerebrate, vagotomized, paralyzed, ventilated cats have been shown to decrease phrenic and hypoglossal inspiratory nerve activities, as well as the activities of other respiratory motor nerves. To determine whether vagal afferents from the lung influence the respiratory inhibition associated with SBCs, we recorded phrenic and hypoglossal nerve activities in decerebrate, paralyzed, vagally intact cats. The animals were ventilated by a servo-respirator, which inflated the lungs in accordance with integrated phrenic nerve activity. Maintained increases in end-expiratory lung volume were produced by the application of 2–10 cm H₂O positive end-expiratory pressure (PEEP). SBCs were accompanied by decreases in both phrenic and hypoglossal peak integrated nerve activities, as well as by marked decreases in respiratory frequency. The reduction of respiratory frequency was greater with higher levels of PEEP, a few animals becoming apneic during SBCs. After bilateral vagotomy, SBCs continued to decrease phrenic and hypoglossal peak integrated nerve activities as previously reported, but the reduction of respiratory frequency was much less striking than when the vagi were intact. These results indicate that activity of vagal afferents from the lung augments the respiratory influence of SBCs. Furthermore, SBCs in vagally intact animals can induce periodic breathing.     

Influence of laryngeal CO2 on respiratory activities of motor nerves to accessory muscles.

Intralaryngeal CO2 in decerebrate, vagotomized cats decreases phrenic nerve activity and increases the respiratory activity of the hypoglossal (HG) nerve. These responses are mediated by afferents in the superior laryngeal nerves. To explore the responses of other respiratory motor nerves to this stimulus, we have recorded the activities of the nasolabial (NL) branch of the facial nerve, the posterior cricoarytenoid (PCA) and thyroarytenoid (TA) branches of the recurrent laryngeal nerve and the nerve to triangularis sterni (TS) muscle. In response to 5 and 10% CO2 in the surgically isolated upper airway, we found dose-related decreases in phrenic activity, increases in HG and NL activity and characteristic, but intermittent, exaggeration of early expiratory bursts of TA activity. The activities of the PCA and TS nerves showed no consistent responses. These results broaden the definition of the reflex response to intralaryngeal CO2, revealing components that reflect ventilatory inhibition, upper airway dilation and laryngeal protection.     

Influence of morphine on respiratory activities of phrenic and hypoglossal nerves in cats

Anesthetic and sedative drugs have been found to diminish the respiratory motor activity of the hypoglossal nerve more than that of the phrenic nerve. This differential depression of motor activity to the upper airway may contribute to the exacerbation of obstructive sleep apnea by sedative drugs. To determine whether morphine has a similar selective action, we recorded phrenic and hypoglossal nerve activities before and after morphine administration in decerebrate, vagotomized cats, paralyzed with gallamine. Morphine diminished the activities of both nerves in most animals, but the responses were highly variable, and no consistent pattern of differential depression was apparent. The variability of the results may reflect the complex nature of opiate actions on the control of breathing.     

Regional effects of selective pharyngeal muscle activation on airway shape

Pharyngeal airway fiberoptic imaging was performed in 10 decerebrate cats to determine the effect of selective pharyngeal muscle activation on airway shape. At intraluminal pressures from 6 to -6 cm H2O, maximum anteroposterior and lateral diameters were measured in the rostral oropharynx, caudal oropharynx, and velopharynx with and without bilateral stimulation of the medial hypoglossus (HG), lateral HG, whole HG, glossopharyngeus, and pharyngeal branch of vagus nerves. At all three airway levels without nerve stimulation, the increase in diameter with increasing pressure was greater in the lateral than anteroposterior dimension. Stimulation of the hypoglossal and glossopharyngeus nerves caused greater increases in lateral than anteroposterior diameter in all three regions with different effects across nerves and regions. Stimulation of these four nerves frequently caused greater increases in both diameters, as the airway cross-sectional area was decreased by lowering airway pressure. Stimulation of the pharyngeal branch of vagus resulted in greater decreases in lateral than anteroposterior dimension in the caudal oropharynx and velopharynx, especially as airway cross-sectional area was increased by increasing intraluminal pressure. The results indicate that selective activation of pharyngeal muscles in cats frequently results in greater changes in lateral than anteroposterior airway diameter and that these effects are dependent on airway region and cross-sectional area.     

Transdiaphragmatic twitch pressure. Effects of lung volume and chest wall shape

The effect of lung volume and thoracoabdominal shape on the transdiaphragmatic twitch pressure (Pdit) amplitude was evaluated in six volunteers during airway occlusion. Twitch stimulation was applied through fine wire electrodes implanted near both phrenic nerves. Stimulations were tolerated with little discomfort and constant phrenic nerve responses were maintained for hours. At FRC the group mean Pdit was 31.4 cm H2O (range, 19 to 36 cm H2O), and its coefficient of variation ranged between 2 and 5% in individual subjects. At 1 L above FRC, the Pdit decreased a mean of 7.8 cm H2O (range, 2.8 to 11.9 cm H2O). This change was caused primarily by a decrease in esophageal pressure amplitude. The shape of the relaxed chest wall was altered by loading the rib cage with a force of 5 to 9 kg. Load and shape had little effect on Pdit independently of lung volume. Our modified technique of phrenic nerve stimulation through small wire electrodes is ideally suited for longitudinal intervention studies in patients. We conclude that the variability of Pdit with shape is small compared with its expected decrease with lung volume.     

Selective depression by ethanol of upper airway respiratory motor activity in cats

We studied the effects of systemically administered ethyl alcohol on the respiratory motor activity of the phrenic, hypoglossal and recurrent laryngeal nerves in unanesthetized, decerebrate cats. Some of the cats were studied after carotid sinus nerve section. In addition, parallel studies were done in intact, awake cats with chronic electromyographic electrodes in the diaphragm, genioglossus, and posterior cricoarytenoid (PCA) muscles. In decerebrate animals, alcohol induced a significant reduction of hypoglossal and recurrent laryngeal nerve activities at doses that had little or no effect on the phrenic nerve discharge. Similar changes were observed in chemodenervated cats. In awake animals, genioglossal and PCA muscle activities were depressed by alcohol, whereas diaphragm activity showed no consistent change. Alcohol caused a significant increase in respiratory frequency in awake cats and reduced the responses of genioglossal and PCA muscle activities to hypercapnia and normocapnic hypoxia. We conclude that alcohol induces a selective reduction in upper airway respiratory motor activity by an action that does not require intact suprapontile structures, vagal afferents, or peripheral chemoreceptors. This reduction may contribute to the alcohol-induced exacerbation of obstructive sleep apnea.     

The effect of treatment on diaphragm contractility in obstructive sleep apnea syndrome

In untreated obstructive sleep apnea syndrome (OSAS) inspiratory efforts are made against an occluded airway and diaphragm fatigue might therefore complicate OSAS. To test this hypothesis we measured twitch transdiaphragmatic pressure (Tw Pdi) in response to bilateral cervical magnetic stimulation of the phrenic nerve roots in nine patients with OSAS before and one month after successful therapy with nasal continuous positive airways pressure (nCPAP). The mean Tw Pdi before therapy was 23.2cm H2O and after therapy was 22.8cm H2O (P = 0.59); the mean change after initiation of nCPAP was 0.4cm H2O with 95% confidence intervals of -1.3cm H2O and +2.1 cm H2O. We conclude that low frequency diaphragm fatigue does not complicate untreated OSAS.     

The respiratory activity of the superior laryngeal nerve in the rat.

The aim of this study was to characterize the laryngeal afferent activity of the rat. The animals were anesthetized and breathing spontaneously. Laryngeal afferent activity was recorded from both the whole superior laryngeal nerve (SLN) and from single fibers isolated from this nerve. An overall inspiratory augmenting activity was observed in the whole SLN during tracheostomy breathing, tracheal occlusion and upper airway breathing, but an expiratory augmenting activity was present during upper airway occlusion. The inspiratory modulated activity was abolished by bilateral section of the hypoglossal nerves but not the recurrent laryngeal nerves. A great number of receptors (46/80, 58%) were identified as 'drive' receptors, and others as 'pressure' (22/80, 28%) and 'irritant' type receptors (9/80, 11%). Nineteen pressure receptors were stimulated by positive transmural pressure, while only three stimulated by negative pressure. Nine drive receptors were also stimulated by positive pressure and inhibited by negative pressure. Such response to pressure was further evaluated by applying maintained pressures to the functionally isolated upper airway. These results are essentially consistent with findings obtained in the rabbit, but differ from those reported for the dog.     

Diaphragm pacing and continuous positive airway pressure

The effect of changes in continuous positive airway pressure (CPAP) on the tidal volume generation by the diaphragm during electrical stimulation of the phrenic nerves in a quadriplegic patient is presented. Measurements of tidal volume, end-tidal PCO2, arterial PCO2, oxygen consumption, physiologic dead space to tidal volume ratio, diaphragm length, and thoracic and abdominal dimensions were made at values of CPAP from 0 to 20 cm H2O during periods of diaphragm pacing. Total respiratory compliance (TRC) was measured during controlled ventilation with incremental positive end-expiratory pressure (PEEP) from 0 to 20 cm H2O. A significant negative correlation was found between increasing CPAP and generated tidal volumes. This correlation was seen to occur even when TRC was constant at degrees of CPAP from 0 to 7.5 cm H2O. When phrenic nerve stimulation was commenced, oxygen consumption rose significantly from values obtained during controlled ventilation, but there was no significant correlation between changes in CPAP and the rise in oxygen consumption. Using inductance methods, thoracic and abdominal diameters were seen to rise as CPAP was increased. As suggested by the decrease in the length of the vertical and horizontal portions of the diaphragm in the chest roentgenogram, the conformation of the diaphragm also changed. It is suggested that the operating length and conformation of the diaphragm are principal factors affecting tidal volume generation during electrical stimulation of the phrenic nerves.     

Reversibility of airflow obstruction by hypoglossus nerve stimulation in anesthetized rabbits

RATIONALE: Anesthesia-induced uncoupling of upper airway dilating and inspiratory pump muscles activation may cause inspiratory flow limitation, thereby mimicking obstructive sleep apnea/hypopnea. OBJECTIVES: Determine whether inspiratory flow limitation occurs in spontaneously breathing anesthetized rabbits and whether this can be reversed by direct hypoglossal nerve stimulation and by the application of continuous positive airway pressure. METHODS: Ten New Zealand White rabbits were anesthetized, instrumented, and studied supine while breathing spontaneously at ambient pressure or during the application of positive or negative airway pressure. Under each of these conditions, the effect of unilateral or bilateral hypoglossal nerve stimulation was investigated. MEASUREMENTS: Inspiratory flow and tidal volume were measured together with esophageal pressure and the electromyographic activity of diaphragm, alae nasi, and genioglossus muscles. MAIN RESULTS: Anesthesia caused a marked increase in inspiratory resistance, snoring, and in eight rabbits, inspiratory flow limitation. Hypoglossus nerve stimulation was as effective as continuous positive airway pressure in reversing inspiratory flow limitation and snoring. Its effectiveness increased progressively as airway opening pressure was lowered, reached a maximum at -5 cm H2O, but declined markedly at lower pressures. With negative airway opening pressure, airway collapse eventually occurred during inspiration that could be prevented by hypoglossus nerve stimulation. The recruitment characteristics of hypoglossus nerve fibers was steep, and significant upper airway dilating effects already obtained with stimulus intensities 36 to 60% of maximum. CONCLUSION: This study supports hypoglossus nerve stimulation as a treatment option for obstructive sleep apnea.