Olfactory sniffing signals consciousness in unresponsive patients with brain injuries.

After severe brain injury, it can be difficult to determine the state of consciousness of a patient, to determine whether the patient is unresponsive or perhaps minimally conscious1, and to predict whether they will recover. These diagnoses and prognoses are crucial, as they determine therapeutic strategies such as pain management, and can underlie end-of-life decisions2,3. Nevertheless, there is an error rate of up to 40% in determining the state of consciousness in patients with brain injuries4,5. Olfaction relies on brain structures that are involved in the basic mechanisms of arousal6, and we therefore hypothesized that it may serve as a biomarker for consciousness7. Here we use a non-verbal non-task-dependent measure known as the sniff response8-11 to determine consciousness in patients with brain injuries. By measuring odorant-dependent sniffing, we gain a sensitive measure of olfactory function10-15. We measured the sniff response repeatedly over time in patients with severe brain injuries and found that sniff responses significantly discriminated between unresponsive and minimally conscious states at the group level. Notably, at the single-patient level, if an unresponsive patient had a sniff response, this assured future regaining of consciousness. In addition, olfactory sniff responses were associated with long-term survival rates. These results highlight the importance of olfaction in human brain function, and provide an accessible tool that signals consciousness and recovery in patients with brain injuries.

Respiration-triggered olfactory stimulation reduces obstructive sleep apnea severity: A prospective pilot study.

Obstructive sleep apnea is a prevalent sleep-disordered breathing condition characterized by repetitive reduction in breathing during sleep. The current care standard for obstructive sleep apnea is continuous positive air pressure devices, often suffering from low tolerance due to limited adherence. Capitalizing on the unique neurocircuitry of olfactory perception and its retained function during sleep, we conducted a pilot study to test transient, respiration-based olfactory stimulation as a treatment for obstructive sleep apnea markers. Thirty-two patients with obstructive sleep apnea (apnea-hypopnea index ≥ 15 events per hr) underwent two polysomnography sessions, "Odour" and "Control", in random order. In "Odour" nights, patients were presented with transient respiratory-based olfactory stimulation delivered via a computer-controlled commercial olfactometer (Scentific). The olfactometer, equipped with a wireless monitoring, analysed respiratory patterns and presented odour upon detection of respiratory events. No odours were presented in "Control" nights. Following exclusions, 17 patients entered the analysis (four women, 47.4 (10.5) years, body mass index: 29.4 (6.3) kg m-2). We observed that olfactory stimulation during sleep reduced the apnea-hypopnea index ("Odour": 17.2 (20.9), "Control": 28.2 (18.6), z = -3.337, p = 0.000846, BF10 [Bayesian Factor 10]= 57.9), reflecting an average decrease of 31.3% in the number of events. Relatedly, stimulation reduced the oxygen desaturation index by 26.9% ("Odour": 12.5 (15.8), "Control": 25.7 (25.9), z = -3.337, p = 0.000846, BF10 = 9.522). This effect was not linked to the severity of baseline obstructive sleep apnea markers (ρ = -0.042, p = 0.87). Olfactory stimulation did not arouse from sleep or affect sleep structure, measured as time per sleep stage (F1,16 = 0.088, p = 0.77). In conclusion, olfactory stimulation during sleep was effective in reducing the severity of obstructive sleep apnea markers without inducing arousals, and may provide a novel treatment for obstructive sleep apnea, prompting continued research.

New Behavioral Signs of Consciousness in Patients with Severe Brain Injuries.

Diagnostic and prognostic assessment of patients with disorders of consciousness (DoC) presents ethical and clinical implications as they may affect the course of medical treatment and the decision to withdraw life-sustaining therapy. There has been increasing research in this field to lower misdiagnosis rates by developing standardized and consensual tools to detect consciousness. In this article, we summarize recent evidence regarding behavioral signs that are not yet included in the current clinical guidelines but could detect consciousness. The new potential behavioral signs of consciousness described here are as follows: resistance to eye opening, spontaneous eye blink rate, auditory localization, habituation of auditory startle reflex, olfactory sniffing, efficacy of swallowing/oral feeding, leg crossing, facial expressions to noxious stimulation, and subtle motor behaviors. All of these signs show promising results in discriminating patients' level of consciousness. Multimodal studies with large sample sizes in different centers are needed to further evaluate whether these behaviors reliably indicate the presence of consciousness. Future translation of these research findings into clinical practice has potential to improve the accuracy of diagnosis and prognostication for patients with DoC.

Neural Dynamics of Associative Learning during Human Sleep.

Recent evidence indicates that humans can learn entirely new information during sleep. To elucidate the neural dynamics underlying sleep-learning, we investigated brain activity during auditory-olfactory discriminatory associative learning in human sleep. We found that learning-related delta and sigma neural changes are involved in early acquisition stages, when new associations are being formed. In contrast, learning-related theta activity emerged in later stages of the learning process, after tone-odor associations were already established. These findings suggest that learning new associations during sleep is signaled by a dynamic interplay between slow-waves, sigma, and theta activity.

Odors enhance slow-wave activity in non-rapid eye movement sleep.

Most forms of suprathreshold sensory stimulation perturb sleep. In contrast, presentation of pure olfactory or mild trigeminal odorants does not lead to behavioral or physiological arousal. In fact, some odors promote objective and subjective measures of sleep quality in humans and rodents. The brain mechanisms underlying these sleep-protective properties of olfaction remain unclear. Slow oscillations in the electroencephalogram (EEG) are a marker of deep sleep, and K complexes (KCs) are an EEG marker of cortical response to sensory interference. We therefore hypothesized that odorants presented during sleep will increase power in slow EEG oscillations. Moreover, given that odorants do not drive sleep interruption, we hypothesized that unlike other sensory stimuli odorants would not drive KCs. To test these hypotheses we used polysomnography to measure sleep in 34 healthy subjects (19 women, 15 men; mean age 26.5 ± 2.5 yr) who were repeatedly presented with odor stimuli via a computer-controlled air-dilution olfactometer over the course of a single night. Each participant was exposed to one of four odorants, lavender oil (n = 13), vetiver oil (n = 5), vanillin (n = 12), or ammonium sulfide (n = 4), for durations of 5, 10, and 20 s every 9-15 min. Consistent with our hypotheses, we found that odor presentation during sleep enhanced the power of delta (0.5-4 Hz) and slow spindle (9-12 Hz) frequencies during non-rapid eye movement sleep. The increase was proportionate to odor duration. In addition, odor presentation did not modulate the occurrence of KCs. These findings imply a sleep-promoting olfactory mechanism that may deepen sleep through driving increased slow-frequency oscillations.

Olfactory aversive conditioning during sleep reduces cigarette-smoking behavior.

Recent findings suggest that novel associations can be learned during sleep. However, whether associative learning during sleep can alter later waking behavior and whether such behavioral changes last for minutes, hours, or days remain unknown. We tested the hypothesis that olfactory aversive conditioning during sleep will alter cigarette-smoking behavior during ensuing wakefulness. A total of 66 human subjects wishing to quit smoking participated in the study (23 females; mean age, 28.7 ± 5.2 years). Subjects completed a daily smoking diary detailing the number of cigarettes smoked during 7 d before and following a 1 d or night protocol of conditioning between cigarette odor and profoundly unpleasant odors. We observed significant reductions in the number of cigarettes smoked following olfactory aversive conditioning during stage 2 and rapid eye movement (REM) sleep but not following aversive conditioning during wakefulness (p < 0.05). Moreover, the reduction in smoking following aversive conditioning during stage 2 (34.4 ± 30.1%) was greater and longer lasting compared with the reduction following aversive conditioning during REM (11.9 ± 19.2%, p < 0.05). Finally, the reduction in smoking following aversive conditioning during sleep was significantly greater than in two separate control sleep experiments that tested aversive odors alone and the effects of cigarette odors and aversive odors without pairing. To conclude, a single night of olfactory aversive conditioning during sleep significantly reduced cigarette-smoking behavior in a sleep stage-dependent manner, and this effect persisted for several days.

Mirror sniffing: humans mimic olfactory sampling behavior.

Ample evidence suggests that social chemosignaling plays a significant role in human behavior. Processing of odors and chemosignals depends on sniffing. Given this, we hypothesized that humans may have evolved an automatic mechanism driving sniffs in response to conspecific sniffing. To test this, we measured sniffing behavior of human subjects watching the movie Perfume, which contains many olfactory sniffing events. Despite the total absence of odor, observers sniffed when characters in the movie sniffed. Moreover, this effect was most pronounced in scenes where subjects heard the sniff but did not see the sniffed-at object. We liken this response to the orienting towards conspecific gaze in vision and argue that its robustness further highlights the significance of olfactory information processing in human behavior.

Content-state dimensions characterize different types of neuronal markers of consciousness.

Identifying the neuronal markers of consciousness is key to supporting the different scientific theories of consciousness. Neuronal markers of consciousness can be defined to reflect either the brain signatures underlying specific conscious content or those supporting different states of consciousness, two aspects traditionally studied separately. In this paper, we introduce a framework to characterize markers according to their dynamics in both the "state" and "content" dimensions. The 2D space is defined by the marker's capacity to distinguish the conscious states from non-conscious states (on the x-axis) and the content (e.g. perceived versus unperceived or different levels of cognitive processing on the y-axis). According to the sign of the x- and y-axis, markers are separated into four quadrants in terms of how they distinguish the state and content dimensions. We implement the framework using three types of electroencephalography markers: markers of connectivity, markers of complexity, and spectral summaries. The neuronal markers of state are represented by the level of consciousness in (i) healthy participants during a nap and (ii) patients with disorders of consciousness. On the other hand, the neuronal markers of content are represented by (i) the conscious content in healthy participants' perception task using a visual awareness paradigm and (ii) conscious processing of hierarchical regularities using an auditory local-global paradigm. In both cases, we see separate clusters of markers with correlated and anticorrelated dynamics, shedding light on the complex relationship between the state and content of consciousness and emphasizing the importance of considering them simultaneously. This work presents an innovative framework for studying consciousness by examining neuronal markers in a 2D space, providing a valuable resource for future research, with potential applications using diverse experimental paradigms, neural recording techniques, and modeling investigations.

The influence of odorants on respiratory patterns in sleep.

To assess the feasibility of using odors as a potential mechanism for treating sleep apnea, we set out to test the hypothesis that odorants delivered during sleep would modify respiratory patterns without inducing arousal or wake in healthy sleepers. We used 2 mildly trigeminal odorants: the pleasant lavender and unpleasant vetiver oil and 2 pure olfactory odorants: the pleasant vanillin and unpleasant ammonium sulfide. During sleep, an olfactometer delivered a transient odorant every 9, 12, or 15 min (randomized), providing 21-37 odorant presentations per night. Each of 36 participants was studied for 1 night and with 1 of the 4 different odorants tested. In addition to standard overnight polysomnography, we employed highly accurate measurements of nasal and oral respiration. Odorants did not increase the frequency of arousals or wake but did influence respiration. Specifically, all 4 odorants transiently decreased inhalation and increased exhalation for up to 6 breaths following odor onset. This effect persisted regardless of odorant valence or stage of sleep. These results suggest that the olfactory system may provide a path to manipulate respiration in sleep.

Local Targeted Memory Reactivation in Human Sleep.

Memory consolidation can be promoted via targeted memory reactivation (TMR) that re-presents training cues or context during sleep. Whether TMR acts locally or globally on cortical sleep oscillations remains unknown. Here, we exploit the unique functional neuroanatomy of olfaction with its ipsilateral stimulus processing to perform local TMR in one brain hemisphere. Participants learned associations between words and locations in left or right visual fields with contextual odor throughout. We found lateralized event-related potentials during task training that indicate unihemispheric memory processes. During post-learning naps, odors were presented to one nostril in non-rapid eye movement (NREM) sleep. Memory for specific words processed in the cued hemisphere (ipsilateral to stimulated nostril) was improved after local TMR during sleep. Unilateral odor cues locally modulated slow-wave (SW) power such that regional SW power increase was lower in the cued hemisphere relative to the uncued hemisphere and negatively correlated with select memories for cued words. Moreover, local TMR improved phase-amplitude coupling (PAC) between slow oscillations and sleep spindles specifically in the cued hemisphere. The effects on memory performance and cortical sleep oscillations were not observed when unilateral olfactory stimulation during sleep followed learning without contextual odor. Thus, TMR in human sleep transcends global action by selectively promoting specific memories associated with local sleep oscillations.

Bulbospinal neurons of the rat rostromedial medulla are highly collateralized.

The rostromedial medulla participates in a large variety of sensory, motor, and autonomic functions. We asked whether individual bulbospinal neurons in this region have localized, target-specific terminal arbors or whether they collateralize broadly in the spinal cord. Collateralization was quantified along three spinal axes, rostrocaudal, left-right, and dorsoventral, by using double retrograde labeling. Fluorogold was applied to one target, and cholera toxin B chain (CTB) was applied to the second. We determined the prevalence of neurons that retrogradely label with both tracers in the constituent nuclei of the rostromedial medulla, the raphe nuclei, the gigantocellular reticular nucleus (Gi, bilaterally), the Gi pars alpha (GiA, bilaterally), and the midline medullary reticular formation. A large fraction of neurons in each of these nuclei had bulbospinal projections, ranging from > or =56% for the raphe nuclei to > or =14% for the Gi. For reasons discussed, these values are probably underestimates. Most of the neurons that projected to the lumbar spinal cord also projected to the cervical cord. Likewise, most neurons that projected to the ventral horn also had a collateral branch in the dorsal horn. However, relatively few had bilateral projections; most projected ipsilaterally or contralaterally. A considerable degree of collateralization was also seen among vestibulospinal neurons. The high level of collateralization of the descending projections of the rostromedial medulla suggests that neurons in this area ultimately act on peripheral target tissues or functions that are widely distributed in the body, or that they play a generalized modulatory role across functional modalities, rather than playing specific topographically delimited roles.

Consciousness is more than meets the eye: a call for a multisensory study of subjective experience.

Over the last 30 years, our understanding of the neurocognitive bases of consciousness has improved, mostly through studies employing vision. While studying consciousness in the visual modality presents clear advantages, we believe that a comprehensive scientific account of subjective experience must not neglect other exteroceptive and interoceptive signals as well as the role of multisensory interactions for perceptual and self-consciousness. Here, we briefly review four distinct lines of work which converge in documenting how multisensory signals are processed across several levels and contents of consciousness. Namely, how multisensory interactions occur when consciousness is prevented because of perceptual manipulations (i.e. subliminal stimuli) or because of low vigilance states (i.e. sleep, anesthesia), how interactions between exteroceptive and interoceptive signals give rise to bodily self-consciousness, and how multisensory signals are combined to form metacognitive judgments. By describing the interactions between multisensory signals at the perceptual, cognitive, and metacognitive levels, we illustrate how stepping out the visual comfort zone may help in deriving refined accounts of consciousness, and may allow cancelling out idiosyncrasies of each sense to delineate supramodal mechanisms involved during consciousness.

A Cross Modal Performance-Based Measure of Sensory Stimuli Intricacy.

We define a new measure of sensory stimuli which has the following properties: It is cross modal, performance based, robust, and well defined. We interpret this measure as the intricacy or complexity of the stimuli, yet its validity is independent of its interpretation. We tested the validity and cross modality of our measure using three olfactory and one visual experiment. In order to test the link between our measure and cognitive performance we also conducted an additional visual experiment. We found that our measure is correlated with the results of the well-established Rapid Serial Visual Presentation masking experiment. Specifically, ranking stimuli according to our measure was correlated at r = 0.75 (p < 0.002) with masking effectiveness. Thus, our novel measure of sensory stimuli provides a new quantitative tool for the study of sensory processing.

Diminished Auditory Responses during NREM Sleep Correlate with the Hierarchy of Language Processing.

Natural sleep provides a powerful model system for studying the neuronal correlates of awareness and state changes in the human brain. To quantitatively map the nature of sleep-induced modulations in sensory responses we presented participants with auditory stimuli possessing different levels of linguistic complexity. Ten participants were scanned using functional magnetic resonance imaging (fMRI) during the waking state and after falling asleep. Sleep staging was based on heart rate measures validated independently on 20 participants using concurrent EEG and heart rate measurements and the results were confirmed using permutation analysis. Participants were exposed to three types of auditory stimuli: scrambled sounds, meaningless word sentences and comprehensible sentences. During non-rapid eye movement (NREM) sleep, we found diminishing brain activation along the hierarchy of language processing, more pronounced in higher processing regions. Specifically, the auditory thalamus showed similar activation levels during sleep and waking states, primary auditory cortex remained activated but showed a significant reduction in auditory responses during sleep, and the high order language-related representation in inferior frontal gyrus (IFG) cortex showed a complete abolishment of responses during NREM sleep. In addition to an overall activation decrease in language processing regions in superior temporal gyrus and IFG, those areas manifested a loss of semantic selectivity during NREM sleep. Our results suggest that the decreased awareness to linguistic auditory stimuli during NREM sleep is linked to diminished activity in high order processing stations.

A social chemosignaling function for human handshaking.

Social chemosignaling is a part of human behavior, but how chemosignals transfer from one individual to another is unknown. In turn, humans greet each other with handshakes, but the functional antecedents of this behavior remain unclear. To ask whether handshakes are used to sample conspecific social chemosignals, we covertly filmed 271 subjects within a structured greeting event either with or without a handshake. We found that humans often sniff their own hands, and selectively increase this behavior after handshake. After handshakes within gender, subjects increased sniffing of their own right shaking hand by more than 100%. In contrast, after handshakes across gender, subjects increased sniffing of their own left non-shaking hand by more than 100%. Tainting participants with unnoticed odors significantly altered the effects, thus verifying their olfactory nature. Thus, handshaking may functionally serve active yet subliminal social chemosignaling, which likely plays a large role in ongoing human behavior.

Sniffing patterns uncover implicit memory for undetected odors.

Consciously undetected events are represented at the sensory-motor level and in the neurons of sensory-motor control, for example, consciously undetected visual targets drive eye movements [1] and neural activity [2]. Olfaction offers an opportunity to investigate processing of undetected stimuli through measurements of the sniff-response: odorant-specific modulations of nasal airflow [3-6]. Here, we report evidence that consciously undetected odorants modulate sniffing in a predicted manner. Moreover, in our study we observed that sniff-modulations recurred at least 10 seconds after the onset of an undetected odor, implying that information which was not consciously perceived was nevertheless maintained in memory, available for future decision making.

Humans can learn new information during sleep.

During sleep, humans can strengthen previously acquired memories, but whether they can acquire entirely new information remains unknown. The nonverbal nature of the olfactory sniff response, in which pleasant odors drive stronger sniffs and unpleasant odors drive weaker sniffs, allowed us to test learning in humans during sleep. Using partial-reinforcement trace conditioning, we paired pleasant and unpleasant odors with different tones during sleep and then measured the sniff response to tones alone during the same nights' sleep and during ensuing wake. We found that sleeping subjects learned novel associations between tones and odors such that they then sniffed in response to tones alone. Moreover, these newly learned tone-induced sniffs differed according to the odor pleasantness that was previously associated with the tone during sleep. This acquired behavior persisted throughout the night and into ensuing wake, without later awareness of the learning process. Thus, humans learned new information during sleep.

Olfactory perception as a compass for olfactory neural maps.

The mammalian brain commonly uses structural proximity to reflect proximity in stimulus and perceptual space. Objects or object features that are near each other in physical structure or perception are also near each other in the brain. This generates sensory maps. The topography of olfactory connectivity implies a rudimentary map in the olfactory epithelium, a more intricate map in the olfactory bulb, but no ordered topography is evident in piriform cortex. Currently, we are largely unable to link the ordered topography in epithelium and bulb to meaningful olfactory axes within a strong predictive framework. We argue that the path to uncovering such a predictive framework depends on systematically characterizing olfactory perception, and we describe initial efforts in this direction.

Spatial perception: time tells where a smell comes from.

A new study has found that when a shark turns towards an odor, its directional decision is based on inter-nostril differences in odorant time of arrival, rather than on inter-nostril differences in odorant concentration.

Reaching across the abyss: recent advances in functional magnetic resonance imaging and their potential relevance to disorders of consciousness.

Disorders of consciousness (DOC) raise profound scientific, clinical, ethical, and philosophical issues. Growing knowledge on fundamental principles of brain organization in healthy individuals offers new opportunities for a better understanding of residual brain function in DOCs. We here discuss new perspectives derived from a recently proposed scheme of brain organization underlying consciousness in healthy individuals. In this scheme, thalamo-cortical networks can be divided into two, often antagonistic, global systems: (i) a system of externally oriented, sensory-motor networks (the "extrinsic" system); and (ii) a system of inward-oriented networks (the "intrinsic" or default system). According to this framework, four distinct mental states would be possible that could be relevant for understanding DOCs. In normal healthy volunteers and locked-in syndrome patients, a state of high functionality of both the extrinsic and intrinsic or default systems is expected--associated with full awareness of environment and self. In this case, mental imagery tasks combined with fMRI can be used to detect covert awareness in patients that are unable to communicate. According to the framework, two complementary states of system imbalance are also possible, in which one system is in a hyperfunctional state, while the other is hypoactive. Extrinsic system hyperfunction is expected to lead to a state of total sensory-motor "absorption" or "lost self." In contrast, intrinsic or default system hyperfunction is expected to lead to a state of complete detachment from the external world. A state where both extrinsic and intrinsic systems are hypofunctional is predicted to lead to markedly impaired consciousness as seen in DOCs. Finally, we review the potential use of ultra-slow fluctuations in BOLD signal as a tool for assessing the functional integrity of extrinsic and intrinsic systems during "resting state" fMRI acquisitions. In particular, we discuss the potential provided by assessment of these slow spontaneous BOLD fluctuations as a novel tool in assessing the cognitive state and chances of recovery from brain pathologies underlying DOCs.