Influence of arousal threshold and depth of sleep on respiratory stability in man: analysis using a mathematical model.

We examined the effect of arousals (shifts from sleep to wakefulness) on breathing during sleep using a mathematical model. The model consisted of a description of the fluid dynamics and mechanical properties of the upper airways and lungs, as well as a controller sensitive to arterial and brain changes in CO(2), changes in arterial oxygen, and a neural input, alertness. The body was divided into multiple gas store compartments connected by the circulation. Cardiac output was constant, and cerebral blood flows were sensitive to changes in O(2) and CO(2) levels. Arousal was considered to occur instantaneously when afferent respiratory chemical and neural stimulation reached a threshold value, while sleep occurred when stimulation fell below that value. In the case of rigid and nearly incompressible upper airways, lowering arousal threshold decreased the stability of breathing and led to the occurrence of repeated apnoeas. In more compressible upper airways, to maintain stability, increasing arousal thresholds and decreasing elasticity were linked approximately linearly, until at low elastances arousal thresholds had no effect on stability. Increased controller gain promoted instability. The architecture of apnoeas during unstable sleep changed with the arousal threshold and decreases in elasticity. With rigid airways, apnoeas were central. With lower elastances, apnoeas were mixed even with higher arousal thresholds. With very low elastances and still higher arousal thresholds, sleep consisted totally of obstructed apnoeas. Cycle lengths shortened as the sleep architecture changed from mixed apnoeas to total obstruction. Deeper sleep also tended to promote instability by increasing plant gain. These instabilities could be countered by arousal threshold increases which were tied to deeper sleep or accumulated aroused time, or by decreased controller gains.

Analysis of the interplay between neurochemical control of respiration and upper airway mechanics producing upper airway obstruction during sleep in humans.

Increased loop gain (a function of both controller gain and plant gain), which results in instability in feedback control, is of major importance in producing recurrent central apnoeas during sleep but its role in causing obstructive apnoeas is not clear. The purpose of this study was to investigate the role of loop gain in producing obstructive sleep apnoeas. Owing to the complexity of factors that may operate to produce obstruction during sleep, we used a mathematical model to sort them out. The model used was based on our previous model of neurochemical control of breathing, which included the effects of chemical stimuli and changes in alertness on respiratory pattern generator activity. To this we added a model of the upper airways that contained a narrowed section which behaved as a compressible elastic tube and was tethered during inspiration by the contraction of the upper airway dilator muscles. These muscles in the model, as in life, responded to changes in hypoxia, hypercapnia and alertness in a manner similar to the action of the chest wall muscles, opposing the compressive action caused by the negative intraluminal pressure generated during inspiration which was magnified by the Bernoulli Effect. As the velocity of inspiratory airflow increased, with sufficiently large increase in airflow velocity, obstruction occurred. Changes in breathing after sleep onset were simulated. The simulations showed that increases in controller gain caused the more rapid onset of obstructive apnoeas. Apnoea episodes were terminated by arousal. With a constant controller gain, as stiffness decreased, obstructed breaths appeared and periods of obstruction recurred longer after sleep onset before disappearing. Decreased controller gain produced, for example, by breathing oxygen eliminated the obstructive apnoeas resulting from moderate reductions in constricted segment stiffness. This became less effective as stiffness was reduced more. Contraction of the upper airway muscles with hypercapnia and hypoxia could prevent obstructed apnoeas with moderate but not with severe reductions in stiffness. Increases in controller gain, as might occur with hypoxia, converted obstructive to central apnoeas. Breathing CO2 eliminated apnoeas when the activity of the upper airway muscles was considered to change as a function of CO2 to some exponent. Low arousal thresholds and increased upper airway resistance are two factors that promoted the occurrence and persistence of obstructive sleep apnoeas.

Purines, the carotid body and respiration.

The carotid body is essential to detecting levels of oxygen in the blood and initiating the compensatory response. Increasing evidence suggests that the purines ATP and adenosine make a key contribution to this signaling by the carotid body. The glomus cells release ATP in response to hypoxia. This released ATP can stimulate P2X receptors on the carotid body to elevate intracellular Ca(2+) and to produce an excitatory response. This released ATP can be dephosphorylated to adenosine by a series of extracellular enzymes, which in turn can stimulate A(1), A(2A) and A(2B) adenosine receptors. Levels of extracellular adenosine can also be altered by membrane transporters. Endogenous adenosine stimulates these receptors to increase the ventilation rate and may modulate the catecholamine release from the carotid sinus nerve. Prolonged hypoxic challenge can alter the expression of purinergic receptors, suggesting a role in the adaptation. This review discusses evidence for a key role of ATP and adenosine in the hypoxic response of the carotid body, and emphasizes areas of new contributions likely to be important in the future.

Causes of Cheyne-Stokes respiration.

Cheyne-Stokes respiration (CSR) is one of several types of unusual breathing with recurrent apneas (dysrhythmias). Reported initially in patients with heart failure or stroke, it was then recognized both in other diseases and as a component of the sleep apnea syndrome. CSR is potentiated and perpetuated by changing states of arousal that occur during sleep. The recurrent hypoxia and surges of sympathetic activity that often occur during the apneas may have serious health consequences. Heart failure and stroke are risk factors for sleep apnea. The recurrent apneas and intermittent hypoxia occurring with sleep apnea further damage the heart and brain. Although all breathing dysrhythmias do not have the same cause, instability in the feedback control involved in the chemical regulation of breathing is the leading cause of CSR. Mathematical models have helped greatly in the understanding of the causes of recurrent apneas.

The perception of dyspnea in patients with mild asthma.

BACKGROUND: Airway function, as assessed by standard spirometry, and the intensity of dyspnea reported by asthmatic patients correlate poorly. OBJECTIVE: This study tests the following two hypotheses: (1) that measures of the tendency of a patient to somatize will reduce the variation in the report of dyspnea not explained by airway function; and (2) that plethysmography is a better tool with which to estimate the degree of dyspnea associated with asthma. DESIGN: A prospective laboratory study carried out over one study session. PARTICIPANTS: Forty asthmatic subjects who had withheld bronchodilator (BD) therapy overnight. INTERVENTIONS: We performed spirometry, plethysmography, and an assessment of dyspnea (ie, modified Borg scale) on all subjects before and after they received BD therapy. Standard questionnaires pertaining to psychological state and trait were administered as well. RESULTS: The change in specific airway conductance with BD therapy correlated with a decline in the Borg score (r = 0.47; p = 0.007). By contrast, neither spirographic measures nor measures of static lung volumes correlated. Correlation with the Borg scale score was not improved by adding indexes of either somatization or psychological state or trait. CONCLUSION: The relief of dyspnea reported by patients with mild asthma after BD therapy is related to dilatation of the central airways.

Intracellular pathways linking hypoxia to activation of c-fos and AP-1.

Organisms respond to hypoxia through detection of blood oxygen levels by sensors at peripheral chemoreceptors and by receptors in certain key cells of the body. The pathways over which peripheral chemoreceptor signals are transmitted to respiratory muscles are well established. However, the intracellular pathways that transmit hypoxic stimulus to gene activation are just being identified. Using anti-sense c-fos strategy, we have shown that c-fos is essential for the activation of activator protein-1 transcription factor complex (AP-1) and subsequent stimulation of downstream genes such as tyrosine hydroxylase (TH; Mishra et al. 1998). The purpose of the present study was to identify intracellular pathways that link hypoxia to activation of c-fos. The results of the present study show that hypoxia causes Ca2+ influx through L-type voltage gated Ca2+ channels and that hypoxia-induced c-fos gene expression is Ca2+/calmodulin dependent. We also demonstrate that hypoxia activates the extracellular-regulated kinase (ERK) and p38, but not JNK. Further, phosphorylation of ERK is essential for c-fos activation via SRE cis-element. Further characterization of nuclear signalling pathways provides evidence for the involvement of Src, a non receptor protein tyrosine kinase, and Ras, a small G protein, in the hypoxia-induced c-fos gene expression. These results suggest a possible role for non-receptor protein tyrosine kinases in propagating signals from G-protein coupled receptors to the activation of immediate early genes such as c-fos during hypoxia.

L-type Ca(2+) channel activation regulates induction of c-fos transcription by hypoxia.

In the present study we examined the intracellular pathways that link hypoxia to activation of c-fos gene expression. Experiments were performed on rat pheocromocytoma-12 (PC-12) cells. c-fos mRNA and promoter activities were analyzed by RT-PCR and reporter gene assays, respectively. BAPTA, a Ca(2+) chelator, inhibited c-fos mRNA and promoter activation by hypoxia. Nitrendipine, an L-type Ca(2+)-channel blocker, abolished, whereas BAY K 8644, an L-type channel agonist, enhanced c-fos activation by hypoxia. Ca(2+) currents were augmented reversibly by hypoxia, suggesting that Ca(2+) influx mediated by L-type Ca(2+) channels is essential for c-fos activation by hypoxia. We next determined downstream pathways activated by intracellular Ca(2+) concentration. Immunoblot analysis revealed Ca(2+)/calmodulin-dependent kinase II (CaMKII) protein in PC-12 cells and revealed that hypoxia increased the enzyme activity. KN-93, a CaMK inhibitor, blocked CaMKII activation and c-fos promoter stimulation by hypoxia. Ectopic expression of an active mutant of CaMKII (pCaMKII290) stimulated c-fos promoter activity under normoxia. Hypoxia increased phosphorylation of CREB at the serine residue 133 (Ser-133), and KN-93 attenuated this effect. Point mutations at the Ca(2+)/cAMP-responsive cis-element (Ca/CRE) attenuated, whereas point mutations in the serum-responsive cis-element (SRE) abolished transcriptional activation of c-fos by hypoxia. These results demonstrate that c-fos activation by hypoxia involves CaMK activation and CREB phosphorylation at Ser-133 and requires Ca/CRE and SRE. These observations demonstrate that Ca(2+)-dependent signaling pathways play a crucial role in induction of c-fos gene expression, which may underlie long-term adaptive responses to hypoxia.

Psychological profile and ventilatory response to inspiratory resistive loading.

The purpose of this study was to explore the contribution of psychological state to both the ventilatory response and the intensity of dyspnea experienced after the addition of small inspiratory loads to breathing. We hypothesized that patients with either a specific psychiatric diagnosis or a specific psychological trait will associate a greater degree of dyspnea with a loaded breathing task than will control subjects. To insure the inclusion of persons with relevant psychological profiles, we recruited both subjects enrolled in the Chronic Fatigue Center and normal control subjects. In all, 52 subjects inspired first through a small (1.34 cm H(2)O/L/s) and second through a moderate (3.54 cm H(2)O/L/s) inspiratory resistive load (IRL). Ventilation was monitored throughout the 5-min sessions. Dyspnea was quantified with the Borg scale at specified times during the protocol. Standard psychological tests were administered. We found that subjects could be divided into two groups. One, the "responders," reported Borg scores higher than those of the second, or "nonresponder" group, at all times during the protocol. By contrast, there was no difference between groups with respect to ventilation. Responders had higher scores on tests of depression (the Center for Epidemiological Study depression scale) than did nonresponders. We conclude that the variability observed in subjective responses to IRL is explained, in part, by differences in psychological state.

Altered structure and function of the carotid body at high altitude and associated chemoreflexes.

The ventilatory response to hypoxia is complex. First contact with hypoxia causes an increase in ventilation within seconds that reaches full intensity within minutes because of an increase in carotid sinus nerve (CSN) input to the brain stem. With continued exposure, ventilation increases further over days (ventilatory acclimatization). Initially, it was hypothesized that ventilatory acclimatization arose from a central nervous system (CNS) mechanism. Compensation for alkalosis in the brain and restoration of pH in the vicinity of central chemoreceptors was believed to cause the secondary increase in ventilation. However, when this hypothesis could not be substantiated, attention was turned to the peripheral chemoreceptors. With the lowering of arterial PO2 at high altitude, there is an immediate increase in firing of afferents from chemoreceptors in the carotid body. After peaking over the next few minutes, the firing rate of afferents begins to rise again within hours until a steady state is reached. This secondary increase occurs along with increase in neurotransmitter synthesis and release and altered gene expression followed by hypertrophy of carotid body glomus cells. Further exposure to hypoxia eventually leads to blunting of the CSN output and ventilatory response in some species. This mini review is about the altered structure and function of the carotid body at high altitude and the associated blunting of the chemoreceptor and ventilatory responses observed in some species.