Non-nutritive swallowing and respiration coordination in full-term newborn lambs

Respiratory activity of the cricopharyngeus muscle in the neonatal period

While phasic electrical activity of the cricopharyngeus muscle (EAcp)-the main component of the upper esophageal sphincter-occurs with inspiration and forceful expiration in adults, no such data is available for newborns. In addition, the effect of nasal respiratory support commonly used in newborns is unknown. We aimed to describe the phasic respiratory EAcp and to assess the potential effect of nasal CPAP (nCPAP, 6 cmH₂O) or high-flow nasal cannula (HFNC, 7 L/min) in newborn lambs during 6-h recordings. Phasic EAcp was present in 11/17 lambs, including in 32 % (25, 81) [(median (Q1, Q3)] of respiratory cycles in wakefulness, 40 % (27, 70) in NREM sleep, and 10 % (0, 23) in REM sleep. In addition, EAcp was observed only during post-inspiration and/or expiration. Nasal CPAP or HFNC assessed in 7 of the 17 lambs did not have any effect. We conclude that phasic respiratory EAcp occurs in post-inspiration and expiration in newborn lambs.

Effects of reflux laryngitis on non-nutritive swallowing in newborn lambs

Reflux laryngitis in infants may be involved not only in laryngeal disorders, but also in disorders of cardiorespiratory control through its impact on laryngeal function. Our objective was to study the effect of reflux laryngitis on non-nutritive swallowing (NNS) and NNS-breathing coordination. Two groups of six newborn lambs, randomized into laryngitis and control groups, were surgically instrumented for recording states of alertness, swallowing and cardiorespiratory variables without sedation. A mild to moderate reflux laryngitis was induced in lambs from the experimental group. A significant decrease in the number of NNS bursts and apneas was observed in the laryngitis group in active sleep (p=0.03). In addition, lower heart and respiratory rates, as well as prolonged apnea duration (p<0.0001) were observed. No physiologically significant alterations in NNS-breathing coordination were observed in the laryngitis group. We conclude that a mild to moderate reflux laryngitis alters NNS burst frequency and autonomous control of cardiac activity and respiration in lambs.

Neural control of the upper airway: integrative physiological mechanisms and relevance for sleep disordered breathing

The various neural mechanisms affecting the control of the upper airway muscles are discussed in this review, with particular emphasis on structure-function relationships and integrative physiological motor-control processes. Particular foci of attention include the respiratory function of the upper airway muscles, and the various reflex mechanisms underlying their control, specifically the reflex responses to changes in airway pressure, reflexes from pulmonary receptors, chemoreceptor and baroreceptor reflexes, and postural effects on upper airway motor control. This article also addresses the determinants of upper airway collapsibility and the influence of neural drive to the upper airway muscles, and the influence of common drugs such as ethanol, sedative hypnotics, and opioids on upper airway motor control. In addition to an examination of these basic physiological mechanisms, consideration is given throughout this review as to how these mechanisms relate to integrative function in the intact normal upper airway in wakefulness and sleep, and how they may be involved in the pathogenesis of clinical problems such obstructive sleep apnea hypopnea.

Effects of postnatal environmental tobacco smoke on non-nutritive swallowing-breathing coordination in newborn lambs

While prenatal environmental tobacco smoke (ETS) exposure is a well-known risk factor for sudden infant death syndrome, the effect of postnatal ETS exposure is less clear. The objective of this study was to investigate the effect of postnatal ETS exposure on non-nutritive swallowing (NNS) and NNS-breathing coordination, which are crucial to prevent aspiration related-cardiorespiratory events. Eighteen newborn lambs (6 per group) were randomly exposed to either 10 cigarettes/day, 20 cigarettes/day or room air for 15 days. Lambs were instrumented for recording states of alertness, swallowing, electrocardiogram and breathing; recordings were performed in non-sedated lambs at the end of ETS exposure. Urinary cotinine/creatinine ratio confirmed relevant real-life exposure. Postnatal ETS exposure had no effect on NNS frequency but tended to decrease inspiratory NNS (p=0.07) during quiet sleep. No effect on respiratory or heart rate (p>0.6), apnea index (p=0.2) or sleep states (p=0.3) was observed. In conclusion, postnatal ETS exposure in lambs had only mild effects on NNS-breathing coordination.

Effects of nasal continuous positive-airway pressure on nutritive swallowing in lambs

Current knowledge suggests that, to be successful, oral feeding in preterm infants should be initiated as soon as possible, often at an age where immature respiration still requires ventilatory support in the form of nasal continuous positive airway pressure (nCPAP). While some neonatologist teams claim great success with initiation of oral feeding in immature infants with nCPAP, others strictly wait for this ventilatory support to be no longer necessary before any attempt at oral feeding, fearing laryngeal penetration and tracheal aspiration. Therefore, the aim of the present study was to provide a first assessment of the effect of various levels of nCPAP on bottle-feeding in a neonatal ovine model, including feeding safety, feeding efficiency, and nutritive swallowing-breathing coordination. Eight lambs born at term were surgically instrumented 48 h after birth to collect recordings of electrical activity of laryngeal constrictor muscle, electrocardiography, and arterial blood gases. Two days after surgery, lambs were bottle-fed under five randomized nCPAP conditions, including without any nCPAP or nasal mask and nCPAP of 0, 4, 7, and 10 cmH(2)O. Results revealed that application of nCPAP in the full-term lamb had no deleterious effect on feeding safety and efficiency or on nutritive swallowing-breathing coordination. The present study provides a first and unique insight on the effect of nCPAP on oral feeding, demonstrating its safety in newborn lambs born at term. These results open the way for further research in preterm lambs to better mimic the problems encountered in neonatology.

Effects of simulated reflux laryngitis on laryngeal chemoreflexes in newborn lambs

It has been suggested that reflux laryngitis (RL) is involved in apneas-bradycardias of the newborn. The aim of the present study was to develop a unique RL model in newborn lambs to test the hypothesis that RL enhances the cardiorespiratory components of the laryngeal chemoreflexes (LCR) in the neonatal period. Gastric juice surrogate (2 ml of normal saline solution with HCl pH 2 + pepsin 300 U/ml) (RL group, n = 6) or normal saline (control group, n = 6) was repeatedly injected onto the posterior aspect of the larynx, 3 times a day for 6 consecutive days, via a retrograde catheter introduced into the cervical esophagus. Lambs instilled with gastric juice surrogate presented clinical signs of RL, as well as moderate laryngitis on histological observation. Laryngeal chemoreflexes were thereafter induced during sleep by injection of 0.5 ml of HCl (pH 2), ewe's milk, distilled water or saline into the laryngeal vestibule via a chronic, transcutaneous supraglottal catheter. Overall, RL led to a significantly greater respiratory inhibition compared with the control group during LCR, including longer apnea duration ( P = 0.01), lower minimal respiratory rate ( P = 0.002), and a more prominent decrease in arterial hemoglobin saturation (SpO2) ( P = 0.03). No effects were observed on cardiac variables. In conclusion, 1) our unique neonatal ovine model presents clinical and histological characteristics of RL; and 2) the presence of RL in newborn lambs increases the respiratory inhibition observed with LCR, at times leading to severe apneas and desaturations.

Effects of postnatal smoke exposure on laryngeal chemoreflexes in newborn lambs

Laryngeal chemoreflexes (LCR), which are elicited by the contact of liquids such as gastric refluxate with laryngeal mucosa, may trigger some cases of sudden infant death syndrome. Indeed, while LCR in mature mammals consist of protective responses, previous animal data have shown that LCR in immature newborns can include laryngospasm, apnea, bradycardia, and desaturation. The present study was aimed at testing the hypothesis that postnatal exposure to cigarette smoke is responsible for enhancing cardiorespiratory inhibition observed with LCR. Eight lambs were exposed to cigarette smoke (20 cigarettes/day) over 16 days and compared with seven control lambs. Urinary cotinine/creatinine ratio was measured at a level relevant to previously published levels in infants. On days 15 and 16, 0.5 ml of HCl (pH 2), milk, distilled water, or saline was injected onto the larynx via a chronic supraglottal catheter during sleep. Results showed that exposure to cigarette smoke enhanced respiratory inhibition (P < 0.05) and tended to enhance cardiac inhibition and decrease swallowing and arousal during LCR (P < 0.1). Overall, these results were observed independently of the state of alertness and the experimental solution tested. In conclusion, 16-day postnatal exposure to cigarette smoke increases cardiorespiratory inhibition and decreases protective mechanisms during LCR in nonsedated full-term lambs.

Origins of the inhibiting effects of nasal CPAP on nonnutritive swallowing in newborn lambs

The present study investigated the mechanism by which continuous positive airway pressure (CPAP) suppresses nonnutritive swallowing (NNS) during quiet sleep (QS) in newborn lambs. Eighteen full-term lambs were chronically instrumented and evenly distributed into three separate groups to determine the extent to which modulation of NNS may be attributed to stimulation of upper airway and/or bronchopulmonary mechanoreceptors. Six lambs were tracheotomized, six other lambs underwent a two-step bilateral intrathoracic vagotomy, and the remaining six lambs underwent chronic laryngotracheal separation (isolated upper airway group). Forty-eight hours after surgery, each nonsedated lamb underwent polysomnographic recordings on three consecutive days. States of alertness, NNS and respiratory movements were recorded. Results demonstrate that a CPAP of 6 cmH2O inhibited NNS during QS while administered directly on the lower airways and that bivagotomy prevented this inhibition. However, application of CPAP on the upper airways only also inhibited NNS during QS. Finally, the application of a CPAP of 6 cmH2O had no systematic effect on NNS-breathing coordination (assessed by the respiratory phase preceding and following NNS). In conclusion, our results suggest that bronchopulmonary receptors are implicated in the inhibiting effects of nasal CPAP of 6 cmH2O on NNS in all our experimental conditions, whereas upper airway receptors are only implicated in certain conditions.

Arousal has no effect on non-nutritive breathing-swallowing coordination during the first year of human life

Although the brainstem plays an important role in breathing-swallowing coordination (BSC), the role of suprabulbar structures is ill defined. Given the known decrease in global cerebral activity during sleep, the sleep-wake paradigm was used to elucidate suprabulbar influences. Non-nutritive BSC of 10 healthy human infants was monitored longitudinally during wakefulness and sleep from birth to 1 year of age. Time-locked recordings of submental muscle activity, nasal airflow, and thyroid acoustics enabled the categorization of swallows depending on the preceding and following respiratory phase. In contrast to the change in the overall pattern of BSC with age, and despite well-known marked postnatal cortical development over this time, no arousal-related differences were seen during the first year of life. This most likely reflects complete brainstem control of non-nutritive BSC in infants.

Respiratory-swallowing interactions during sleep in premature infants at term

Non-nutritive swallowing occurs frequently during sleep in infants and is vital for fluid clearance and airway protection. Swallowing has also been shown to be associated with prolonged apnea in some clinical populations. What is not known is whether swallowing contributes to apnea or may instead help resolve these clinically significant events. We studied the temporal relationships between swallowing, respiratory pauses and arousal in six preterm infants at term using multi-channel polysomnography and a pharyngeal pressure transducer. Results revealed that swallows occurred more frequently during respiratory pauses and arousal than during control periods. They did not trigger the respiratory pause, however, as most swallows (66%) occurred after respiratory pause onset and were often tightly linked to arousal from sleep. Swallows not associated with respiratory pauses (other than the respiratory inhibition to accommodate swallowing) and arousal occurred consistently during the expiratory phase of the breathing cycle. Results suggest that swallowing and associated arousal serve an airway protective role during sleep and medically stable preterm infants exhibit the mature pattern of respiratory-swallowing coordination by the time they reach term.

Effects of hypoxia and hypercapnia on nonnutritive swallowing in newborn lambs

The aim of the present study was to investigate the effect of hypercapnia and hypoxia on apnea and nonnutritive swallowing (NNS) frequency, as well as on the coordination between NNS and phases of the respiratory cycle in newborn lambs, while taking into account the potential effects of states of alertness. Six lambs were chronically instrumented for recording electroencephalogram, eye movements, diaphragm and thyroarytenoid muscle (a glottal adductor) activity, nasal airflow, and electrocardiogram. Polysomnographic recordings were performed in nonsedated lambs exposed to air (control), 10% O(2), and 5% CO(2) in a random order at 3, 4, and 5 days of age. Although hypercapnia decreased apnea frequency in wakefulness and active sleep (P = 0.002 vs. air and hypoxia), hypoxia had no significant effect on apnea. In addition, although hypercapnia increased NNS frequency during wakefulness and quiet sleep (P < 0.005 vs. air and hypoxia), hypoxia tended to decrease NNS frequency. Finally, only hypercapnia altered NNS-breathing coordination by increasing NNS at the transition from inspiration to expiration (ie-type NNS; P < 0.001 vs. air and hypoxia). In conclusion, whereas hypercapnia increases overall NNS frequency by specifically increasing ie-type NNS, hypoxia has the inverse tendency. Results were identical in all three states of alertness.

The development of descending projections from the brainstem to the spinal cord in the fetal sheep

Background

Although the fetal sheep is a favoured model for studying the ontogeny of physiological control systems, there are no descriptions of the timing of arrival of the projections of supraspinal origin that regulate somatic and visceral function. In the early development of birds and mammals, spontaneous motor activity is generated within spinal circuits, but as development proceeds, a distinct change occurs in spontaneous motor patterns that is dependent on the presence of intact, descending inputs to the spinal cord. In the fetal sheep, this change occurs at approximately 65 days gestation (G65), so we therefore hypothesised that spinally-projecting axons from the neurons responsible for transforming fetal behaviour must arrive at the spinal cord level shortly before G65. Accordingly we aimed to identify the brainstem neurons that send projections to the spinal cord in the mature sheep fetus at G140 (term = G147) with retrograde tracing, and thus to establish whether any projections from the brainstem were absent from the spinal cord at G55, an age prior to the marked change in fetal motor activity has occurred.

Results

At G140, CTB labelled cells were found within and around nuclei in the reticular formation of the medulla and pons, within the vestibular nucleus, raphe complex, red nucleus, and the nucleus of the solitary tract. This pattern of labelling is similar to that previously reported in other species. The distribution of CTB labelled neurons in the G55 fetus was similar to that of the G140 fetus.

Conclusion

The brainstem nuclei that contain neurons which project axons to the spinal cord in the fetal sheep are the same as in other mammalian species. All projections present in the mature fetus at G140 have already arrived at the spinal cord by approximately one third of the way through gestation. The demonstration that the neurons responsible for transforming fetal behaviour in early ontogeny have already reached the spinal cord by G55, an age well before the change in motor behaviour occurs, suggests that the projections do not become fully functional until well after their arrival at the spinal cord.

Postnatal maturation of laryngeal chemoreflexes in the preterm lamb

Laryngeal chemoreflexes (LCR) are triggered by the contact of liquids with the laryngeal mucosa. In the mature organism, LCR trigger lower airway protective responses (coughing, effective swallowing, and arousal) to prevent aspiration. General belief holds that LCR are responsible for apnea and bradycardia in the newborn mammal, including humans. Our laboratory has recently shown that LCR in full-term lambs are consistently analogous to the mature LCR reported in adult mammals, without significant apneas and bradycardias (St-Hilaire M, Nsegbe E, Gagnon-Gervais K, Samson N, Moreau-Bussiere F, Fortier PH, and Praud J-P. J Appl Physiol 98: 2197-2203, 2005). The aim of the present study was to assess LCR in nonsedated, newborn preterm lambs born at 132 days of gestation (term = 147 days). The preterm lambs were instrumented for recording glottal adductor electromyogram, electroencephalogram, eye movements, heart rate, respiration, and oximetry. A chronic supraglottal catheter was used for injecting 0.5 ml of saline, distilled water, and HCl (pH 2) during quiet sleep, active sleep, and wakefulness on postnatal days 7 (D7) and 14 (D14). Laryngeal stimulation by water or HCl on D7 induced significant apneas, bradycardia, and desaturation, which, at times, appeared potentially life-threatening. No significant apneas, bradycardias, or desaturation were observed on D14. No consistent effects of sleep state could be shown in the present study. In conclusion, laryngeal stimulation by liquids triggers potentially dangerous LCR in preterm lambs on D7, but not on D14. It is proposed that maturation of the LCR between D7 and D14 is partly involved in the disappearance of apneas/bradycardias of prematurity with postnatal age.

The early impact of feeding on infant breathing-swallowing coordination

This longitudinal study assessed the coordination of nutritive and non-nutritive swallowing with breathing in 10 healthy term infants from birth to 1 year of age. Swallows were classified into five respiratory-phase categories: mid-inspiration (II), mid-expiration (EE), inspiratory-expiratory cusp (IE), expiratory-inspiratory cusp (EI), and mid-pause (P). Breathing-swallowing coordination differed markedly between the two swallowing conditions, especially between 2 weeks and 2 months. Significant condition effects were found in up to four respiratory-phase categories (II, IE, EI, and P). The condition effect was minimal from 9 months with only IE swallow proportions differing between conditions. These data suggest a 'critical period' in infantile neural response to oropharyngeal stimulation during feeding and that the impact of this on infants with neurological and/or respiratory disorders should be further investigated.

Effect of nasal continuous or intermittent positive airway pressure on nonnutritive swallowing in the newborn lamb

The present study was aimed at investigating the effects of nasal continuous positive airway pressure (nCPAP; 6 cmH2O) or intermittent positive pressure ventilation (nIPPV; 10/4 cmH2O) on nonnutritive swallowing (NNS) and on the coordination between NNS and phases of the respiratory cycle, while taking into account the potential effects of states of alertness. Twelve full-term lambs were chronically instrumented at 48 h after birth for polysomnographic recordings, including NNS, diaphragm electromyographic activity, respiratory movements, pulse oximetry, and states of alertness. Studies in control conditions, with nCPAP and nIPPV, were performed in random order in nonsedated lambs at 4, 5, and 6 days of life. Results demonstrate that nCPAP significantly decreased overall NNS frequency, more specifically isolated NNS during quiet sleep and bursts of NNS in active sleep. In comparison, the effects of nIPPV on NNS frequency were more variable, with an inhibition of NNS only in wakefulness and an increase in isolated NNS frequency in active sleep. In addition, neither nCPAP nor nIPPV disrupted the coordination between NNS and phases of the respiratory cycle. In conclusion, nCPAP inhibits NNS occurrence in newborn lambs. Clinical relevance of this novel finding is related to the importance of NNS for clearing the upper airways from secretions and gastric content frequently regurgitated in the neonatal period.

Upper airways and neonatal respiration

The upper airways exert an important influence on breathing from the fetal period onward. This review focuses on recent results obtained in the newborn, particularly on laryngeal function in the lamb. Cumulated data can be summarized as follows. Firstly, upper airway closure, either at the pharyngeal or laryngeal level, is now known to occur during central apneas. By maintaining a high apneic lung volume throughout central apneas, active laryngeal closure decreases the magnitude of post-apneic desaturation. Secondly, reflexes originating from laryngeal mucosal receptors, such as laryngeal chemoreflexes and non-nutritive swallowing, are of crucial importance within the context of preterm birth, postnatal maturation, neonatal apneas and apparent life-threatening events/sudden infant death syndrome. While laryngeal chemoreflexes appear to be mature and confer an efficient protection against aspiration in the full-term healthy newborn, they can be responsible for prolonged apneas and bradycardias in the immature preterm newborn. In regard to non-nutritive swallowing, the absence of swallowing activity during apneas in periodic breathing during quiet sleep as well as the presence of bursts of swallows with apneas in active sleep remain to be explained. Forthcoming studies will have to further delineate the impact of common clinical conditions, such as cigarette smoke exposure and/or viral respiratory infection on laryngeal chemoreflexes and non-nutritive swallowing. Better knowledge on the importance of the upper airways in neonatal respiration will ultimately aid in designing clinical applications for the understanding and treatment of severe, pathological respiratory conditions of the newborn.

C-fiber blockade influence on non-nutritive swallowing in full-term lambs

Systemic C-fiber blockade (CFB) has been reported to inhibit induced swallowing in adult guinea pigs. The aim of this study was to investigate the effects of CFB on spontaneous, non-nutritive swallowing (NNS) frequency and NNS-respiration coordination in the neonatal period. Seven CFB lambs and seven control lambs aged 2+/-1 days were chronically instrumented for recording electroencephalogram, eye movements, diaphragm EMG, thyroarytenoid muscle EMG, nasal airflow and electrocardiogram. Polysomnographic recordings were performed in non-sedated lambs, using radiotelemetry transmission. CFB lambs spent more time in active sleep than controls (p=0.02). Frequency of non-nutritive swallowing was not different in CFB and control lambs, whatever the state of alertness. In addition, CFB did not disrupt the overall respiratory-swallowing coordination, inspiratory-related NNS being the most frequent and expiratory-related NNS the least in both CFB and control lambs. Further analyses revealed that CFB had no effect on baseline respiratory and heart rate, and apnea and sigh frequency, whatever the state of alertness. Our results suggest that, in the neonatal period, C-fibers are not involved in NNS frequency and have no influence on the overall respiratory-swallowing coordination.

Laryngeal chemoreflexes induced by acid, water, and saline in nonsedated newborn lambs during quiet sleep

Laryngeal chemoreflexes (LCR) are triggered by the contact of assorted liquids with the laryngeal mucosa. In the neonatal period, the immature LCR consist primarily of apnea and bradycardia, which at times can be life threatening. The aim of this study was to assess LCR induction in nonsedated, newborn full-term lambs by several acid solutions, compared with distilled water and saline. Twelve lambs were instrumented for recording of glottal adductor and diaphragm EMG, EEG, eye movements, heart rate, systemic arterial pressure, and respiratory movements. LCR were induced during quiet sleep by the injection (0.5 ml) of saline, distilled water or two acid solutions (HCl and citric acid, pH 2, diluted in either water or saline). A chronic supraglottal catheter was used to inject the solutions in a random order. Distilled water and acid solutions did not induce any significant decrease in heart rate or respiratory rate. However, significant lower airway protective responses (swallowing, cough, and arousal) were observed after distilled water and especially acid solution administration. In conclusion, LCR in full-term lambs, particularly with acid solutions, are merely characterized by lower airway protective responses resembling mature LCR reported in adult mammals.

Nonnutritive swallowing and respiration relationships in preterm lambs

The aim of the present study was to assess the effects of the different states of alertness on 1) nonnutritive swallowing (NNS) frequency, 2) the relationship between NNS and the respiratory cycle, and 3) the association of NNS with spontaneous apneas. Recordings of sleep states, diaphragm and laryngeal constrictor electrical activity, nasal flow, electrocardiogram, respiratory inductance plethysmography, and pulse oximetry were obtained from six preterm lambs without sedation. Analysis of 2,468 NNS showed that 1) NNS frequency was higher during quiet wakefulness and active sleep (AS) than in quiet sleep; 2) in all states of alertness, a greater number of NNS (38%) were preceded and followed by an inspiration; 3) although NNS and central apneas were rarely coincidental, AS appeared to favor their association; and 4) most obstructive apneas occurred in AS and were coincidental with bursts of NNS. Compared with results in full-term lambs, premature birth does not modify the NNS-respiratory coordination. However, AS in preterm lambs is characterized by a higher association of NNS bursts with obstructive apneas.

Influence of sleep state on frequency of swallowing, apnea, and arousal in human infants

Apnea and arousal are modulated with sleep stage, and swallowing may interfere with respiratory rhythm in infants. We hypothesized that swallowing itself would display interaction with sleep state. Concurrent polysomnography and measurement of swallowing allowed time-matched analysis of 3,092 swallows, 482 apneas, and 771 arousals in 17 infants aged 1-34 wk. The mean rates of swallowing, apnea, and arousal were significantly different, being 23.3 +/- 8.5, 9.4 +/- 8.8, and 15.5 +/- 10.6 h(-1), respectively (P < 0.001 ANOVA). Swallows occurred before 25.2 +/- 7.9% and during 74.8 +/- 6.3% of apneas and before 39.8 +/- 6.0% and during 60.2 +/- 6.0% of arousals. The frequencies of apneas and arousals were both strongly influenced by sleep state (active sleep > indeterminate > quiet sleep, P < 0.001), whether or not the events coincided with swallowing, but swallowing rate showed minimal independent interaction with sleep state. Interactions between swallowing and sleep state were predominantly influenced by the coincidence of swallowing with apnea or arousal.