Excitatory mechanism of veratridine on slowly adapting pulmonary stretch receptors in anesthetized rabbits

Optimal Management of Heart Failure and Chronic Obstructive Pulmonary Disease: Clinical Challenges

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common causes of breathlessness which frequently co-exist; one potentially exacerbating the other. Distinguishing between the two can be challenging due to their similar symptomatology and overlapping risk factors, but a timely and correct diagnosis is potentially lifesaving. Modern treatment for HF can substantially improve symptoms and prognosis for many patients and may have beneficial effects for patients with COPD. Conversely, while many inhaled treatments for COPD can improve symptoms and reduce exacerbations, there is conflicting evidence regarding the safety of some inhaled treatments for COPD in patients with HF. Here we explore the overlap between HF and COPD, examine the effect of one condition on the other, and address the challenges of managing patients with both conditions.

Paradoxical response of pulmonary slowly adapting units during constant pressure lung inflation

Typically, unit discharge of slowly adapting receptors (SARs) declines slowly when lung inflation pressure is constant, although in some units it increases instead-a phenomenon hereinafter referred to as creeping. These studies characterize creeping behavior observed in 62 of 137 SAR units examined in anesthetized, open-chest, and mechanically ventilated rabbits. SAR units recorded from the cervical vagus nerve were studied during 4 s of constant lung inflation at 10, 20, and 30 cmH₂O. Affected SAR units creep more quickly as inflation pressure increases. SAR units also often deactivate after creeping, i.e., their activity decreases or stops completely. Creeping likely results from encoder switching from a low discharge to a high discharge SAR, because it disappears in SAR units with multiple receptive fields after blocking a high discharge encoder in one field leaves low discharge encoders intact. The results support that encoder switching is a common mechanism operating in lung mechanosensory units.

A direct injection technique for investigation of lung sensory properties and reflex functions

NEW FINDINGS

This article reviews a unique direct injection technique that complements the more conventional right atrial injection and aerosol delivery methods to study sensory and reflex effects of the lung sensors. Used in combination with other methods, this technique should contribute to the pulmonary sensory research.

ABSTRACT

The lungs house sensory receptors (sensors) that mediate a variety of sensory and reflex responses to mechanical or chemical changes. These reflexes are mainly carried through pulmonary sympathetic and vagal afferent pathways. The chemosensors in the lung periphery are especially important in pulmonary diseases and their reflex responses have traditionally been studied either by aerosol delivery, which also activates receptors in the central airways, or by right atrial injection, which also activates receptors lying outside the lung. Thus, these techniques may confound the interpretation of sensory function. Our laboratory has developed a direct injection technique to deliver agents into the lung parenchyma, which complements the conventional techniques with some important advantages. This article reviews the technique.

Controlled Delivery of 80 mg Aerosol Furosemide Does Not Achieve Consistent Dyspnea Relief in Patients

PURPOSE

Aerosol furosemide may be an option to treat refractory dyspnea, though doses, methods of delivery, and outcomes have been variable. We hypothesized that controlled delivery of high dose aerosol furosemide would reduce variability of dyspnea relief in patients with underlying pulmonary disease.

METHODS

Seventeen patients with chronic exertional dyspnea were recruited. Patients rated recently recalled breathing discomfort on a numerical rating scale (NRS) and the multidimensional dyspnea profile (MDP). They then performed graded exercise using an arm-ergometer. The NRS was completed following each exercise grade, and the MDP was repeated after a pre-defined dyspnea threshold was reached. During separate visits, patients received either aerosol saline or 80 mg of aerosol furosemide in a randomized, double-blind, crossover design. After treatment, graded exercise to the pre-treatment level was repeated, followed by completion of the NRS and MDP. Treatment effect was defined as the difference between pre- and post-treatment NRS at end exercise, expressed in absolute terms as % Full Scale. "Responders" were defined as those showing treatment effect ≥ 20% of full scale.

RESULTS

Final analysis included 15 patients. Neither treatment produced a statistically significant change in NRS and there was no significant difference between treatments (p = 0.45). There were four "responders" and one patient whose dyspnea worsened with furosemide; two patients were responders with saline, of whom one also responded to furosemide. No adverse events were reported.

CONCLUSIONS

High dose controlled delivery aerosol furosemide was not statistically different from saline placebo at reducing exercise-induced dyspnea. However, a clinically meaningful improvement was noted in some patients.

Sensory nerves in lung and airways

Sensory nerves innervating the lung and airways play an important role in regulating various cardiopulmonary functions and maintaining homeostasis under both healthy and disease conditions. Their activities conducted by both vagal and sympathetic afferents are also responsible for eliciting important defense reflexes that protect the lung and body from potential health-hazardous effects of airborne particulates and chemical irritants. This article reviews the morphology, transduction properties, reflex functions, and respiratory sensations of these receptors, focusing primarily on recent findings derived from using new technologies such as neural immunochemistry, isolated airway-nerve preparation, cultured airway neurons, patch-clamp electrophysiology, transgenic mice, and other cellular and molecular approaches. Studies of the signal transduction of mechanosensitive afferents have revealed a new concept of sensory unit and cellular mechanism of activation, and identified additional types of sensory receptors in the lung. Chemosensitive properties of these lung afferents are further characterized by the expression of specific ligand-gated ion channels on nerve terminals, ganglion origin, and responses to the action of various inflammatory cells, mediators, and cytokines during acute and chronic airway inflammation and injuries. Increasing interest and extensive investigations have been focused on uncovering the mechanisms underlying hypersensitivity of these airway afferents, and their role in the manifestation of various symptoms under pathophysiological conditions. Several important and challenging questions regarding these sensory nerves are discussed. Searching for these answers will be a critical step in developing the translational research and effective treatments of airway diseases.

Airway Mechanosensor Behavior during Application of Positive End-Expiratory Pressure

<b><i>Background:</i></b> Positive end-expiratory pressure (PEEP) is commonly used in clinical settings. It is expected to affect the input from slowly adapting pulmonary stretch receptors (SARs), leading to altered cardiopulmonary functions. However, we know little about how SARs behave during PEEP application. <b><i>Objectives:</i></b> Our study aimed to characterize the behavior of SARs during PEEP application. <b><i>Methods:</i></b> We recorded single-unit activities from 18 SARs in the cervical vagus nerve and examined their response to an increase of PEEP from 3 to 10 cm H₂O for 20 min in anesthetized, open-chest and mechanically ventilated rabbits. <b><i>Results:</i></b> The mean activity of the units increased immediately from 35.7 to 80.5 impulses per second at the fifth breath after increasing PEEP (n = 14, p < 0.001) and then gradually returned to 56.5 impulses per second at the end of 20 min of PEEP application (p < 0.001). In the meantime, peak airway pressure increased from 9.3 to 32.7 cm H₂O, and then gradually returned to 29.4 cm H₂O (n = 18; p < 0.05) after 20 min. The remaining four units ceased firing at 34.7 s (range 10-56 s) after their initial increased activity upon 10 cm H₂O PEEP application. The unit activity resumed as the PEEP was returned to 3 cm H₂O. <b><i>Conclusions:</i></b> High PEEP stimulates SARs and SAR activity gradually returns towards the baseline via multiple mechanisms including receptor deactivation, neural habituation and mechanical adaptation. Understanding of the sensory inputs during PEEP application will assist in developing better strategies of mechanical ventilation.

Flecainide inhibits the stimulatory effect of veratridine on the response of airway mechanoreceptors to maintained inflations in rats

AIMS

the purpose of the present study was to investigate (a) whether maintained inflations result in the inhibition of slowly adapting pulmonary stretch receptor (SAR) discharge to elicit an abrupt change in receptor activity and (b) whether pretreatment with veratridine, a Na(+) channel opener, and/or flecainide, a Na(+) channel blocker, alters the responses of SAR properties to maintained inflations.

MAIN METHODS

we measured the properties of SAR activity during maintained inflations at different pressures in 31 anesthetized, artificially ventilated rats with unilateral vagotomy.

KEY FINDINGS

During maintained inflations (approximately 5, 10 and 15 cmH(2)O) for about 5s, the procedures did not produce the induction of inhibition of either 16 low-threshold SARs (firing during both inflation and deflation) or 15 high-threshold SARs (firing during inflation only). In these preparations, the excitatory responses of SARs to maintained inflations at three different pressures were markedly enhanced after administration of veratridine (50 μg/kg), but under such conditions, the inhibition of SAR discharges was not observed. In the same SAR preparations, after flecainide treatment (9 mg/kg) sufficient for the blockade of veratridine (50 μg/kg)-induced SAR stimulation, maintained inflations at higher pressures (10 and 15 cmH(2)O) greatly inhibited SAR discharges. Under these conditions, the inhibition of SAR discharges was not observed during maintained inflations at 5 cmH(2)O.

SIGNIFICANCE

These results suggest that neither low-threshold SARs nor high-threshold SARs in the rat lung are deactivated during maintained inflations at higher pressures.

Sensory nerves and airway irritability

The lung, like many other organs, is innervated by a variety of sensory nerves and by nerves of the parasympathetic and sympathetic nervous systems that regulate the function of cells within the respiratory tract. Activation of sensory nerves by both mechanical and chemical stimuli elicits a number of defensive reflexes, including cough, altered breathing pattern, and altered autonomic drive, which are important for normal lung homeostasis. However, diseases that afflict the lung are associated with altered reflexes, resulting in a variety of symptoms, including increased cough, dyspnea, airways obstruction, and bronchial hyperresponsiveness. This review summarizes the current knowledge concerning the physiological role of different sensory nerve subtypes that innervate the lung, the factors which lead to their activation, and pharmacological approaches that have been used to interrogate the function of these nerves. This information may potentially facilitate the identification of novel drug targets for the treatment of respiratory disorders such as cough, asthma, and chronic obstructive pulmonary disease.

Pathophysiology of dyspnea evaluated by breath-holding test: studies of furosemide treatment

Breath-holding is one of the most powerful methods to induce the dyspneic sensation, and the breath-holding test gives us much information on the onset and endurance of dyspnea. In conscious subjects, immediately after the start of breath-holding at functional residual capacity (FRC), there is a certain period of no particular respiratory sensation lasting for 20-30s, which is designated "no respiratory sensation period". This period is terminated by the onset of dyspnea and followed by a progressive increase in the intensity of dyspnea until the breaking point of breath-holding. The measurement of the period of no respiratory sensation provides us with information about the threshold of dyspneic sensation whereas the measurement of the total breath-holding time is a behavioral measure of the tolerable limit of dyspneic sensation. The behavioral measure of tolerable limit of dyspnea can permit the study of dyspnea even in anesthetized animals while observing escape behavior in response to airway occlusion. Inhaled furosemide causes prolongation of both the period of no respiratory sensation and total breath-holding time in conscious subjects, indicating that inhaled furosemide alleviates experimentally induced dyspnea. Alleviation of dyspnea with inhaled furosemide in conscious subjects is also consistent with the result of animal studies in which inhaled furosemide suppresses the escape behavior in the lightly anesthetized condition. The purpose of this article is to emphasize the usefulness of breath-holding test as a tool for evaluation of dyspnea. Furthermore, the possible mechanisms of alleviation of dyspnea with inhaled furosemide are highlighted.

Airway mechanoreceptor deactivation

Airway sensors play an important role in control of breathing. Recently, it was found that pulmonary slowly adapting stretch receptors (SARs) cease after a brief excitation following sodium pump blockade by ouabain. This deactivation can be explained by overexcitation. If this is true, mechanical stimulation of the SARs should also lead to a deactivation. In this study, we recorded unit activity of the SARs in anesthetized, open-chest, and mechanically ventilated rabbits and examined their responses to lung inflation at different constant pressures. Forty-seven of 137 units had a clear deactivation during the lung inflation. The deactivation threshold varied from unit to unit. For a given unit, the higher the inflation pressure, the sooner the deactivation occurs. For example, the SARs deactivated at 3.0 +/- 0.3 and 4.8 +/- 0.4 s when the lungs were inflated to constant pressures of 30 and 20 cmH(2)O, respectively (n = 25, P < 0.0001). The units usually ceased after a brief intense discharge. In some units, their activity shifted to a lower level, indicating a pacemaker switching. Our results support the notion that SARs deactivate due to overexcitation.

Transient receptor potential vanilloid receptor-1 does not contribute to slowly adapting airway receptor activation by inhaled ammonia

Inhalation of ammonia influences the activity of slowly adapting airway receptors (SARs), but the mechanism(s) is uncertain. Release of inflammatory mediators by transient receptor potential vanilloid receptor-1 (TRPV1) containing nerve endings could affect SAR response to ammonia. We examined how sensitization and subsequent desensitization of the TRPV1 by resiniferatoxin (RTX), affected the responses of SARs to inhaled ammonia. In pentobarbital-anesthetized, paralyzed and artificially ventilated rats, the left cervical vagus nerve was exposed, sectioned rostrally, and desheathed. Single fibers of SARs were identified and recorded. Two milliliters of ammonia vapor (from a 30% NH(4)OH solution) was inhaled over 20 s and responses to ammonia were measured. RTX was injected intravenously at 2 microg/Kg. Twenty minutes later, ammonia inhalation was repeated. Isoproterenol (ISO, 100 microg/kg, i.v.) was used in another set of experiments to block possible ammonia-induced bronchoconstriction. Ammonia increased tonic activity of SARs (n=10, P<0.0001), with complex changes in ventilator-related activity. SAR firing rate began to increase 2.3+/-0.2 min after RTX and returned to control levels at 13.6+/-1.4 min (n=10). By 20 min after RTX cardiovascular responses to ammonia were abolished, but effects on SAR activity were essentially unchanged. ISO did not modify the response of SARs to ammonia (n=8). These data suggest that responses of SARs to ammonia in rats do not depend on release of mediators by nerve endings containing TRPV1 and are not secondary to bronchoconstriction. However, when TRPV1 containing nerve endings were initially activated by RTX, the release of mediators may have affected SAR discharges.

The inhibitory effect of ouabain on the response of slowly adapting pulmonary stretch receptors to hyperinflation in the rabbit

The combined effects of ouabain (Na(+)-K(+) ATPase inhibitor) and hyperinflation (inflation volume=three tidal volumes) on slowly adapting pulmonary stretch receptors (SARs) were studied before and after administration of nifedipine (an L-type Ca(2+) channel blocker) and KB-R7943 (a reverse-mode Na(+)-Ca(2+) exchanger blocker) in anesthetized, artificially ventilated rabbits after bilateral vagotomy. Before ouabain administration, hyperinflation stimulated SAR activity. After 20 min of ouabain administration (30 microg/kg) the SARs increased discharge rates in normal inflation. Under these conditions, hyperinflation initially stimulated SAR activity but subsequently inhibited the activity at peak inflation. Additional administration of 60 microg/kg ouabain (total dose=90 microg/kg) caused a further stimulation of SAR activity, but 20 min later both normal inflation and hyperinflation resulted in a greater inhibition of the receptor activity. The hyperinflation-induced SAR inhibition in the presence of ouabain (30 microg/kg) was not significantly altered by administration of either nifedipine (2 and 4 mg/kg) or KB-R7943 (1 and 3 mg/kg). In another series of experiments, we further examined the combined effects of ouabain and hyperinflation in veratridine (a Na(+) channel opener, 40 microg/kg)-treated animals. After recovery from the veratridine effect on SAR activity, which vigorously stimulated the receptor activity, ouabain treatment (30 microg/kg) that silenced the receptor activity at peak inflation greatly inhibited hyperinflation-induced SAR stimulation. These results suggest that hyperinflation-induced SAR inhibition in the presence of ouabain may be related to a Na(+) overload, but not to a Ca(2+) influx via activation of L-type Ca(2+) channels, in the SAR endings.

Effects of potassium channel and Na+-Ca2+ exchange blockers on the responses of slowly adapting pulmonary stretch receptors to hyperinflation in flecainide-treated rats

1. The effects of K(+) channel blockers, such as 4-aminopyridine (4-AP) and tetraethylammonium (TEA), and a reverse-mode Na(+)-Ca(2+) exchange blocker, 2-[2-[4-(4-nitrobenzyloxyl) phenyl] ethyl] isothiourea methanesulphonate (KB-R7943), on the responses of slowly adapting pulmonary stretch receptor activity to hyperinflation (inflation volume=3 tidal volumes) were investigated in anaesthetized, artificially ventilated, unilaterally vagotomized rats after pretreatment with a Na(+) channel blocker flecainide. The administration of flecainide (9 mg kg(-1)) at a dose greater than that which abolished 50 microg kg(-1) veratridine-induced SAR stimulation also inhibited hyperinflation-induced stimulation of SARs. 2. In flecainide-treated animals, administration of 4-AP (0.7 and 2 mg kg(-1)) stimulated SAR activity during normal inflation and also caused a partial blockade of hyperinflation-induced SAR inhibition. 3. The discharges of SARs during normal inflation in flecainide-treated animals were not significantly altered by administration of either TEA (2 and 7 mg kg(-1)) or KB-R7943 (1 and 3 mg kg(-1)), but both K(+) channel and Na(+)-Ca(2+) exchange blockers partially attenuated hyperinflation-induced SAR inhibition. 4. These results suggest that hyperinflation-induced SAR inhibition in the presence of flecainide (9 mg kg(-1)) involves the activation of several K(+) conductance pathways.

Airway receptors

There are many types of afferent receptor in the airways; at least five in the larynx: pressure, drive, cold, irritant and C-fibre; and at least four in the trachea and bronchi: slowly and rapidly adapting stretch receptors (SARs and RARs), C-fibre receptors, and those in neuroepithelial bodies (NEBs). Histologically enough sensory structures have been identified to account for the various patterns of afferent activity, but most correlations are poor. For the larynx, four or more sensory structures have not definitively been identified with afferent discharges and reflex responses. For the trachea and bronchi, only SARs have been clearly identified morphologically and physiologically. The reflexes and afferent discharges from RARs and C-fibre receptors are fairly clear, some at least of the sensory terminals lie in the epithelium, but receptor complexes have not been mapped out. Nerves in NEBs have been identified, but not their local and central reflex actions.

Activation of sympathoadrenomedullary system increases pulmonary nitric oxide production in the rabbit

Nitric oxide (NO) is continuously produced in the lung and can be measured in exhaled gas of different species. To investigate a possible neuro-humoral regulation of pulmonary NO production in vivo we injected veratrine, an activator of Na(+) channels known to activate the sympathoadrenal system, in anaesthetized, mechanically ventilated and laparotomized rabbits. Exhaled NO concentration increased by 38+/-3% when plasma adrenaline rose from 12.3+/-3.1 to 49.5+/-10.7 pmol ml(-1) in response to veratrine (500 microg kg(-1), i.v.). Pretreatment with atenolol, a beta(1)-adrenoceptor antagonist (1 mg kg(-1)), or bilateral ligation of adrenal blood vessels inhibited the increase in exhaled NO in response to veratrine. Atenolol also decreased basal NO, suggesting an endogenous regulation of pulmonary NO by adrenaline. Neither phentolamine (1 mg kg(-1)), atropine (1 mg kg(-1)) nor vagotomy inhibited the veratrine-induced pulmonary NO production. These results suggest a role of the sympathoadrenal system in the regulation of pulmonary NO production.

Responses of tracheobronchial receptors to inhaled furosemide in anesthetized rats

Inhalation of furosemide, a loop diuretic, has shown favorable effects on experimentally induced cough, bronchoconstriction, and dyspnea. The effect of inhaled furosemide on tracheobronchial receptors was studied in anesthetized, spontaneously breathing rats. Single unit or pauci unit activity was recorded from the right vagus nerve. Tracheobronchial receptors were classified into slowly and rapidly adapting receptors (SARs and RARs, respectively), based on their adaptation index (AI), which was derived from the decrease in spike frequency (sf) over 2 s, expressed as a percentage of the peak firing rate. There were 43 SARs (AI </= 25%) and eight RARs (AI >/= 50%). Inhalation of furosemide (n = 29) increased the slope of airway pressure (Paw) versus sf of SARs from 8.6 to 14.8 Hz/cm H(2)O with an increase in sf at Paw = 0 cm H(2)O from 18.0 to 49.5 Hz, resulting in an upward shift of the line. Neither inhalation of vehicle (n = 9) nor intravenous injection of furosemide (n = 5) changed this relationship. In addition, inhalation of furosemide attenuated the activity of RARs. These findings indicate that SARs are sensitized and RARs desensitized by inhalation of furosemide. We discuss possible mechanisms for this, and its relevance to clinical problems of dyspnea, bronchoconstriction, and cough.

Inhaled furosemide greatly alleviates the sensation of experimentally induced dyspnea

Furosemide is known to influence the activity of vagally mediated mechanoreceptors in the airways. Because vagal afferent fibers may play an important role in modulation of the sensation of dyspnea, it is possible that inhaled furosemide may modify the sensation of dyspnea. In a double-blind, randomized, crossover study, we compared the effect of inhaled furosemide on dyspneic sensation with that of placebo. Severe dyspneic sensation was induced in 12 healthy subjects in two ways: (1) breathholding and (2) loaded breathing with a combination of inspiratory resistive load (240 cm H(2)O/L/s) and hypercapnia induced by extra mechanical dead space (0.26 L). Subjects were asked to rate their sensation of respiratory discomfort using a visual analogue scale (dyspneic VAS). Breathholding times and changes in dyspneic VAS score during a 5-min period of loaded breathing were measured after inhalation of placebo and furosemide (40 mg). Total breathholding time after inhalation of furosemide (median, 93 [interquartile range, 78 to 112]s) was prolonged compared with the total breathholding time after placebo inhalation (67 [47-74]s). We also found that respiratory discomfort during loaded breathing after inhalation of furosemide develops more slowly and is less than that observed after inhalation of placebo. Our findings indicate that inhaled furosemide greatly alleviates the sensation of dyspnea induced experimentally by breathholding and by a combination of resistive loading and hypercapnia.

Effects of ouabain and flecainide on CO(2)-induced slowly adapting pulmonary stretch receptor inhibition in the rabbit

The inhibitory effect of CO2 on slowly adapting pulmonary stretch receptors (SARs) was examined before and after administration of ouabain, a Na+-K+ ATPase inhibitor, and flecainide, a Na+ channel blocker. The experiments were performed in anesthetized, artificially ventilated rabbits after vagus nerve section. CO2 inhalation (maximal tracheal CO2 concentration ranging from 9.2 % to 10.4%) for about 60 sec decreased the receptor activity during both inflation and deflation. The magnitude of decreased SAR activity during deflation was greater than that seen during inflation. Administration of ouabain (25 microg/kg) initially stimulated SAR activities during inflation and deflation, and after 20 min, the SAR response was still kept excitatory in both inflation and deflation phases. Under these conditions, CO2 inhalation inhibited SAR activities during inflation and deflation. Flecainide treatment (3 mg/kg) that abolished veratridine (30 microg/kg)-induced SAR excitation had no significant effect on the inhibitory responses of SAR activity to CO2. These results suggest that the inhibitory effect of CO2 occurs when ouabain results in intracellular Na+ concentration ([Na+]i) increases in the SAR endings, and that CO2-induced SAR inhibition may not be related to the reduction of influx of Na+ through voltage-gated Na+ channels.