Inhibition of muscle sympathetic nerve activity during yawning

Heart rate variability in patients presenting with neurally mediated syncope in an emergency department

BACKGROUND

Neurally mediated syncope (NMS) is a disorder of autonomic nervous system (ANS) regulation. Orthostatic stress is one of the most common causative factors seen in clinical practice. Analysis of heart rate variability (HRV) is a non-invasive method that is used to assess ANS regulation. In this study, we investigated the pathophysiology of NMS using HRV in our emergency department.

METHODS

The subjects were 19 patients (age 25.8 ± 6.2 years old) who presented with NMS and 20 healthy individuals (age 26.6 ± 2.7 years old) who served as controls. HRV was measured in supine, sitting and standing positions. Heart rate (HR), low frequency (LF 0.04-0.15 Hz), high frequency (HF > 0.15 Hz), and coefficient of variation of the R-R interval (CVRR) were determined.

RESULTS

LF and HF in the supine position were significantly lower in the patients with NMS (p < 0.05). HR was higher in all positions in patients with NMS than in healthy individuals (p < 0.05). CVRR in the supine position was lower in the patients with NMS (p < 0.001), and it was significantly lower in patients who were positive in an orthostatic test (p = 0.0017). Area under the curve was calculated to be 0.824, and at the cutoff value of 4.997 of CVRR in supine, the sensitivity and the specificity were 78.9% and 85.0%.

CONCLUSION

The sympathetic and parasympathetic nervous systems were both suppressed in patients with NMS. In post-syncope, parasympathetic withdrawal, rather than sympathetic reactivation, was responsible for the increased HR after syncope. CVRR may serve as a new clinical biomarker in the emergency department.

The Treatment of Persistent Yawning with Acupuncture

Persistent and excessive yawning (greater than 1 to 4 yawns/minute) is a pathological process associated with a variety of conditions including central nervous system disorders, opiate withdrawal and drug side effects. This report describes a patient with a brain tumour who presented with persistent excessive yawning. She was successfully treated with medical acupuncture. A possible mechanism involving the autonomic nervous system is discussed.

Yawning and its physiological significance

Although yawning is a commonly witnessed human behavior, yet it has not been taught in much detail in medical schools because, until the date, no particular physiological significance has been associated with it. It is characterized by opening up of mouth which is accompanied by a long inspiration, with a brief interruption of ventilation and followed by a short expiration. Since time immemorial, yawning has been associated with drowsiness and boredom. However, this age old belief is all set to change as the results of some newer studies have pointed out that yawning might be a way by which our body is trying to accomplish some more meaningful goals. In this review, we have tried to put together some of the important functions that have been proposed by a few authors, with the hope that this article will stimulate the interest of newer researchers in this hitherto unexplored field.

The thermoregulatory theory of yawning: what we know from over 5 years of research

Over the past 5 years numerous reports have confirmed and replicated the specific brain cooling and thermal window predictions derived from the thermoregulatory theory of yawning, and no study has found evidence contrary to these findings. Here we review the comparative research supporting this model of yawning among homeotherms, while highlighting a recent report showing how the expression of contagious yawning in humans is altered by seasonal climate variation. The fact that yawning is constrained to a thermal window of ambient temperature provides unique and compelling support in favor of this theory. Heretofore, no existing alternative hypothesis of yawning can explain these results, which have important implications for understanding the potential functional role of this behavior, both physiologically and socially, in humans and other animals. In discussion we stress the broader applications of this work in clinical settings, and counter the various criticisms of this theory.

Pathological yawning as an ictal seizure manifestation in the elderly

Excessive yawning has been reported in the peri-ictal period preceding or following seizures. We describe an exceptional case of an elderly man with impairment of consciousness and paroxysmal excessive yawning. We hypothesise that this can be regarded as an autonomic seizure originating from diencephalic/brainstem structures, manifesting with yawning as an ictal phenomenon.

Human paranasal sinuses and selective brain cooling: a ventilation system activated by yawning?

The function of the paranasal sinuses has been a controversial subject since the time of Galen, with many different theories advanced about their biological significance. For one, the paranasal sinuses have been regarded as warmers of respiratory air, when in actuality these structures appear to function in cooling the blood. In fact, human paranasal sinuses have been shown to have higher volumes in individuals living in warmer climates, and thus may be considered radiators of the brain. The literature suggests that the transfer of cool venous blood from the paranasal sinuses to the dura mater may provide a mechanism for the convection process of cooling produced by the evaporation of mucus within human sinuses. In turn, the dura mater may transmit these temperature changes, initiated by the cool venous blood from the heat-dissipating surfaces of the sinuses, to the cerebrospinal fluid compartments. Furthermore, it has recently been demonstrated in cadaveric dissections that the thin bony posterior wall of the maxillary sinus serves as an origin for both medial and lateral pterygoid muscle segments, an anatomic finding that had been previously underappreciated in the literature. The present authors hypothesize that the thin posterior wall of the maxillary sinus may flex during yawning, operating like a bellows pump, actively ventilating the sinus system, and thus facilitating brain cooling. Such a powered ventilation system has not previously been described in humans, although an analogous system has been reported in birds.

Pandiculation: nature's way of maintaining the functional integrity of the myofascial system?

Pandiculation is the involuntary stretching of the soft tissues, which occurs in most animal species and is associated with transitions between cyclic biological behaviors, especially the sleep-wake rhythm (Walusinski, 2006). Yawning is considered a special case of pandiculation that affects the musculature of the mouth, respiratory system and upper spine (Baenninger, 1997). When, as often happens, yawning occurs simultaneously with pandiculation in other body regions (Bertolini and Gessa, 1981; Lehmann, 1979; Urba-Holmgren et al., 1977) the combined behavior is referred to as the stretch-yawning syndrome (SYS). SYS has been associated with the arousal function, as it seems to reset the central nervous system to the waking state after a period of sleep and prepare the animal to respond to environmental stimuli (Walusinski, 2006). This paper explores the hypothesis that the SYS might also have an auto-regulatory role regarding the locomotor system: to maintain the animal's ability to express coordinated and integrated movement by regularly restoring and resetting the structural and functional equilibrium of the myofascial system. It is now recognized that the myofascial system is integrative, linking body parts, as the force of a muscle is transmitted via the fascial structures well beyond the tendonous attachments of the muscle itself (Huijing and Jaspers, 2005). It is argued here that pandiculation might preserve the integrative role of the myofascial system by (a) developing and maintaining appropriate physiological fascial interconnections and (b) modulating the pre-stress state of the myofascial system by regularly activating the tonic musculature. The ideas presented here initially arose from clinical observations during the practice of a manual therapy called Muscular Repositioning (MR) (Bertolucci, 2008; Bertolucci and Kozasa, 2010a; Bertolucci, 2010b). These observations were supplemented by a review of the literature on the subject. A possible link between MR and SYS is presented: The neural reflexes characteristically evoked through MR are reminiscent of SYS, which both suggests that MR might stimulate parts of the SYS reaction, and also points to one of MR's possible mechanisms of action.

The functional relationship between yawning and vigilance

BACKGROUND

Although yawning is a ubiquitous and phylogenetically old phenomenon, its origin and purpose remain unclear. The study aimed at testing the widely held hypothesis that yawning is triggered by drowsiness and brings about a reversal or suspension of the process of falling asleep.

METHODS

Subjects complaining of excessive sleepiness were spontaneously yawning while trying to stay awake in a quiet and darkened room. Changes in their electroencephalogram (EEG) and heart rate variability (HRV) associated with yawning were compared to changes associated with isolated voluntary body movements. Special care was taken to remove eye blink- and movement-artefacts from the recorded signals.

RESULTS

Yawns were preceded and followed by a significantly greater delta activity in EEG than movements (p< or =0.008). After yawning, alpha rhythms were attenuated, decelerated, and shifted towards central brain regions (p< or =0.01), whereas after movements, they were attenuated and accelerated (p<0.02). A significant transient increase of HRV occurred after the onset of yawning and movements, which was followed by a significant slow decrease peaking 17s after onset (p<0.0001). No difference in HRV changes was found between yawns and movements.

CONCLUSIONS

Yawning occurred during periods with increased drowsiness and sleep pressure, but was not followed by a measurable increase of the arousal level of the brain. It was neither triggered nor followed by a specific autonomic activation. Our results therefore confirm that yawns occur due to sleepiness, but do not provide evidence for an arousing effect of yawning.

Yawning as a Brain Cooling Mechanism: Nasal Breathing and Forehead Cooling Diminish the Incidence of Contagious Yawning

We conducted two experiments that implicate yawning as a thermoregulatory mechanism. The first experiment demonstrates that different patterns of breathing influence susceptibility to contagious yawning. When participants were not directed how to breathe or were instructed to breathe orally (inhaling and exhaling through their mouth), the incidence of contagious yawning in response to seeing videotapes of people yawning was about 48%. When instructed to breathe nasally (inhaling and exhaling through their nose), no participants exhibited contagious yawning. In a second experiment, applying temperature packs to the forehead also influenced the incidence of contagious yawning. When participants held a warm pack (460C) or a pack at room temperature to their forehead while watching people yawn, contagious yawning occurred 41% of the time. When participants held a cold pack (40C) to their forehead, contagious yawning dropped to 9%. These findings suggest that yawning has an adaptive/functional component that it is not merely the derivative of selection for other forms of behavior.

Pathological yawning as a presenting symptom of brain stem ischaemia in two patients

Two cases of brain stem stroke involving the upper pons and the ponto-mesencephalic junction presented with transient excessive pathological yawning, associated with gait ataxia and in one subject with upper limb and facial hemiparesis. A causal relation is hypothesised between the brain stem lesion and pathological yawning, possibly related to denervation hypersensitivity of a putative brain stem yawn centre. Excessive yawning may herald brain stem ischaemia.

Does yawning represent a transient arousal-shift during intravenous induction of general anesthesia?

Although yawning occurs frequently during the IV induction of general anesthesia, the significance of this response remains unknown. In this study, we induced 30 surgical patients with 4 mg/kg thiopental IV, and 30 patients with 2 mg/kg propofol IV. Thereafter, the occurrence of yawning was continuously assessed, as the only clinical end-point, for 1 min. The electroencephalographic bispectral index was monitored throughout the observation period. The criterion for an arousal response was a transient increase during a continuing decrease in the bispectral index value. On the basis of this criterion, the sensitivity and specificity of the yawning response as an arousal sign were 77% and 80%, respectively. If a patient exhibited a yawning response, the chance of arousal was 84% (positive predictive value). With no yawning response, the chance of nonarousal was 71% (negative predictive value). According to simple logistic regression, the yawning response was predictive of a transient arousal-shift with an odds ratio of 13.5 (95% confidence interval: 3.8-48; P < 0.001). The occurrence of a yawning response during IV induction may be a clinical indicator of a transient arousal-shift during progressive loss of consciousness.

IMPLICATIONS

Yawning elicited by IV anesthetic induction was related to a transient increase during the continuing decrease in the electroencephalographic bispectral index value (sensitivity and specificity, 77% and 80%, respectively). This type of yawning may be a clinical indicator of a transient arousal-shift during progressive loss of consciousness.

Stereotyped yawning responses induced by electrical and chemical stimulation of paraventricular nucleus of the rat

Yawning was evoked by electrical or chemical stimulation in the paraventricular nucleus (PVN) of anesthetized, spontaneously breathing rats. To evaluate physiological aspects of yawning, we monitored polygraphic measures as follows; a coordinated motor pattern of yawning was assessed by monitoring breathing [intercostal electromyogram (EMG)], mouth opening (digastric EMG), and stretching of the trunk (back EMG). We also recorded blood pressure (BP), heart rate, and the electrocorticogram (ECoG) to evaluate autonomic function and arousal responses during yawning. A stereotyped yawning response was reproducibly evoked by electrical stimulation or microinjection of -glutamate or NOC-7, a nitric oxide (NO)-releasing compound, into the PVN. The stereotyped yawning response consisted of two sequential events, an initial response represented a depressor response and an arousal shift in the ECoG to lower voltage and faster rhythms. These initial changes were followed by a yawning behavior characterized by a single large inspiration with mouth opening and stretching of the trunk. A similar sequence of events occurred during spontaneous yawning; a fall in BP and ECoG arousal preceded a yawning behavior. An increase in the frequency of spontaneous yawns was also observed after microinjection of -glutamate or NOC-7 into the PVN. Intravenous administration of NG-monomethyl--arginine, an inhibitor of nitric oxide synthase (NOS), prevented the stereotyped yawning response evoked by chemical stimulation of the PVN. Histological examination revealed that effective sites for the yawning responses were located in the medial part of the rostral PVN, the site of parvocellular and magnocellular neurons. NADPH-diaphorase histochemistry showed the existence of NOS-containing cells in yawning-evoked sites of the PVN. In summary, the sequential events of yawning may be generated by NOS-containing parvocellular neurons in the medial part of the rostral PVN projecting to the lower brain stem.

Pathophysiologic basis for vasodepressor syncope

The current knowledge regarding the pathophysiologic basis of the vasodepressor response was reviewed. The balance of evidence indicates that the mechanoreceptor hypothesis seems unlikely to be the sole afferent alteration that leads to the vasodepressor response. Alternative afferent mechanisms should include neurohumoral mediated sympathoinhibition triggered by opioid mechanisms as well as impaired endothelial and NO responses to orthostatic stress in susceptible individuals. It is possible that impaired cardiovagal and sympathetic outflow control of arterial baroreceptors is enhanced by the aforementioned mechanisms. The role of central sympathoinhibition and vagal excitation triggered directly from pathways within the temporal lobe or triggered by alterations in regional cerebral blood flow should be considered as potential alternative mechanisms. Efferent autonomic outflow during vasodepressor syncope include sympathetic neural outflow withdrawal in addition to activation of parasympathetic outflow to the heart and abdominal viscera. Further human research is needed to understand the underlying mechanisms that result in the described neural and vascular responses.