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Ghali MGZ. Phrenic motoneurons: output elements of a highly organized intraspinal network. J Neurophysiol 2018; 119:1057-1070. [DOI: 10.1152/jn.00705.2015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
pontomedullary respiratory network generates the respiratory pattern and relays it to bulbar and spinal respiratory motor outputs. The phrenic motor system controlling diaphragm contraction receives and processes descending commands to produce orderly, synchronous, and cycle-to-cycle-reproducible spatiotemporal firing. Multiple investigators have studied phrenic motoneurons (PhMNs) in an attempt to shed light on local mechanisms underlying phrenic pattern formation. I and colleagues (Marchenko V, Ghali MG, Rogers RF. Am J Physiol Regul Integr Comp Physiol 308: R916–R926, 2015.) recorded PhMNs in unanesthetized, decerebrate rats and related their activity to simultaneous phrenic nerve (PhN) activity by creating a time-frequency representation of PhMN-PhN power and coherence. On the basis of their temporal firing patterns and relationship to PhN activity, we categorized PhMNs into three classes, each of which emerges as a result of intrinsic biophysical and network properties and organizes the orderly contraction of diaphragm motor fibers. For example, early inspiratory diaphragmatic activation by the early coherent burst generated by high-frequency PhMNs may be necessary to prime it to overcome its initial inertia. We have also demonstrated the existence of a prominent role for local intraspinal inhibitory mechanisms in shaping phrenic pattern formation. The objective of this review is to relate and synthesize recent findings with those of previous studies with the aim of demonstrating that the phrenic nucleus is a region of active local processing, rather than a passive relay of descending inputs.
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Affiliation(s)
- Michael George Zaki Ghali
- Department of Neurobiology and Anatomy, Drexel University College of Medicine, Philadelphia, Pennsylvania
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Fast oscillations during gasping and other non-eupneic respiratory behaviors: Clues to central pattern generation. Respir Physiol Neurobiol 2013; 187:176-82. [PMID: 23545119 DOI: 10.1016/j.resp.2013.03.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Revised: 03/18/2013] [Accepted: 03/21/2013] [Indexed: 11/20/2022]
Abstract
The mammalian nervous system exhibits fast synchronous oscillations, which are especially prominent in respiratory-related nerve discharges. In the phrenic nerve, they include high- (HFO), medium- (MFO), and low-frequency (LFO) oscillations. Because motoneurons firing at HFO-related frequencies had never been recorded, an epiphenomenological mechanism for their existence had been posited. We have recently recorded phrenic motoneurons firing at HFO-related frequencies in unanesthetized decerebrate rats and showed that they exhibit dynamic coherence with the phrenic nerve, validating synchronous motoneuronal discharge as a mechanism underlying the generation of HFO. In so doing, we have helped validate the conclusions of previous studies by us and other investigators who have used changes in fast respiratory oscillations to make inferences about central respiratory pattern generation. Here, we seek to review changes occurring in fast synchronous oscillations during non-eupneic respiratory behaviors, with special emphasis on gasping, and the inferences that can be drawn from these dynamics regarding respiratory pattern formation.
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Haxhija EQ, Yang H, Spencer AU, Koga H, Sun X, Teitelbaum DH. Modulation of mouse intestinal epithelial cell turnover in the absence of angiotensin converting enzyme. Am J Physiol Gastrointest Liver Physiol 2008; 295:G88-G98. [PMID: 18483182 PMCID: PMC2494725 DOI: 10.1152/ajpgi.00589.2007] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Angiotensin converting enzyme (ACE) has been shown to be involved in regulation of apoptosis in nonintestinal tissues. This study examined the role of ACE in the modulation of intestinal adaptation utilizing ACE knockout mice (ACE-/-). A 60% small bowel resection (SBR) was used, since this model results in a significant increase in intestinal epithelial cell (EC) apoptosis as well as proliferation. Baseline villus height, crypt depth, and intestinal EC proliferation were higher, and EC apoptosis rates were lower in ACE-/- compared with ACE+/+ mice. After SBR, EC apoptosis rates remained significantly lower in ACE-/- compared with ACE+/+ mice. Furthermore, villus height and crypt depth after SBR continued to be higher in ACE-/- mice. The finding of a lower bax-to-bcl-2 protein ratio in ACE-/- mice may account for reduced EC apoptotic rates after SBR in ACE-/- compared with ACE+/+ mice. The baseline higher rate of EC proliferation in ACE-/- compared with ACE+/+ mice may be due to an increase in the expression of several EC growth factor receptors. In conclusion, ACE appears to have an important role in the modulation of intestinal EC apoptosis and proliferation and suggests that the presence of ACE in the intestinal epithelium has a critical role in guiding epithelial cell adaptive response.
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Affiliation(s)
- Emir Q. Haxhija
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, and C. S. Mott Children's Hospital, Ann Arbor, Michigan; and Department of Pediatric Surgery, Medical University Graz, Graz, Austria
| | - Hua Yang
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, and C. S. Mott Children's Hospital, Ann Arbor, Michigan; and Department of Pediatric Surgery, Medical University Graz, Graz, Austria
| | - Ariel U. Spencer
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, and C. S. Mott Children's Hospital, Ann Arbor, Michigan; and Department of Pediatric Surgery, Medical University Graz, Graz, Austria
| | - Hiroyuki Koga
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, and C. S. Mott Children's Hospital, Ann Arbor, Michigan; and Department of Pediatric Surgery, Medical University Graz, Graz, Austria
| | - Xiaoyi Sun
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, and C. S. Mott Children's Hospital, Ann Arbor, Michigan; and Department of Pediatric Surgery, Medical University Graz, Graz, Austria
| | - Daniel H. Teitelbaum
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Medical School, and C. S. Mott Children's Hospital, Ann Arbor, Michigan; and Department of Pediatric Surgery, Medical University Graz, Graz, Austria
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Warren KA, Solomon IC. Glutamatergic Neurotransmission is Not Essential for, but Plays a Modulatory Role in, the Production of Gasping in Arterially-Perfused Adult Rat. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2008; 605:423-7. [DOI: 10.1007/978-0-387-73693-8_74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Marchenko V, Rogers RF. Temperature and state dependence of dynamic phrenic oscillations in the decerebrate juvenile rat. Am J Physiol Regul Integr Comp Physiol 2007; 293:R2323-35. [PMID: 17913868 DOI: 10.1152/ajpregu.00472.2007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The aim of the present study was to determine characteristics of fast oscillations in the juvenile rat phrenic nerve (Ph) and to establish their temperature and state dependence. Two different age-matched decerebrate, baro- and chemodenervated rat preparations, in vivo and in situ arterially perfused models, were used to examine three systemic properties: 1) generation and dynamics of fast oscillations in Ph activity (both preparations), 2) responses to anoxia (both preparations), and 3) the effects of temperature on fast oscillations (in situ only). Both juvenile preparations generated power and coherence in two major bands analogous to adult medium- and high-frequency oscillations (HFO) at frequencies that increased with temperature but were lower than in adults. At < 28°C, however, Ph oscillations were confined primarily to one low-frequency band (20–45 Hz). During sustained anoxia, both preparations produced stereotypical state changes from eupnea to hyperpnea to transition bursting (a behavior present only in vivo during incomplete ischemia) to gasping. Thus the juvenile rat produces a sequential pattern of responses to anoxia that are intermediate forms between those produced by neonates and those produced by adults. Time-frequency analysis determined that fast oscillations demonstrated dynamics over the course of the inspiratory burst and a state dependence similar to that of adults in vivo in which hyperpnea (and transition) bursts are associated with increases in HFO, while gasping contains no HFO. Our results confirm that both the fast oscillations in Ph activity and the coherence between Ph pairs produced by the juvenile rat are profoundly state- and temperature-dependent.
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Affiliation(s)
- Vitaliy Marchenko
- Dept. of Electrical and Computer Engineering, Univ. of Delaware, Newark, DE 19716, USA
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Berger AJ, Sebe J. Developmental effects of ketamine on inspiratory hypoglossal nerve activity studied in vivo and in vitro. Respir Physiol Neurobiol 2007; 157:206-14. [PMID: 17267296 DOI: 10.1016/j.resp.2007.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2006] [Revised: 01/03/2007] [Accepted: 01/04/2007] [Indexed: 11/13/2022]
Abstract
The effects of the anesthetic ketamine on properties of inspiratory bursts (I-bursts) in mouse hypoglossal nerve activity were studied in vivo and in vitro. In urethane anesthetized mice we observed rhythmic I-phase activity in only one of eight pups at P9 days. In contrast in older mice rhythmic I-phase hypoglossal activity was almost always observed. Ketamine caused a reduction in I-burst frequency and an increase in peak integrated hypoglossal nerve activity in all three age groups studied (P10-P13, P15-P20 and adult mice). In these mice I-phase oscillations, due to hypoglossal motoneurons firing clusters of action potentials at a particular frequency, were observed in control and after ketamine. Ketamine did not change the frequency of the dominant spectral peak determined from power spectra examined from 0 to 200 Hz. The effects of ketamine were also studied in vitro in the mouse rhythmic medullary slice preparation. Ketamine reduced hypoglossal I-burst frequency and I-burst peak integrated amplitude. Oscillations were observed in I-phase activity, and as in the in vivo studies ketamine did not shift the dominant spectral peak frequency. These results demonstrate that in vivo and in vitro ketamine results in significant changes in I-burst frequency and peak integrated hypoglossal nerve activity, but changes in the oscillation frequency are minimal.
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Affiliation(s)
- Albert J Berger
- Department of Physiology and Biophysics, School of Medicine, University of Washington, Box 357290, Seattle, WA 98195-7290, USA.
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Marchenko V, Rogers RF. Time-frequency coherence analysis of phrenic and hypoglossal activity in the decerebrate rat during eupnea, hyperpnea, and gasping. Am J Physiol Regul Integr Comp Physiol 2006; 291:R1430-42. [PMID: 16825419 DOI: 10.1152/ajpregu.00218.2006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Fast respiratory rhythms include medium- (MFO) and high-frequency oscillations (HFO), which are much faster than the fundamental breathing rhythm. According to previous studies, HFO is characterized by high coherence (Coh) in phrenic (Ph) nerve activity, thereby providing a means of distinguishing between these two types of oscillations. Changes in Coh between the Ph and hypoglossal (XII) nerves during the transition from normal eupnic breathing to gasping have not been characterized. Experiments were performed on nine unanesthetized, chemo- and barodenervated, decerebrate adult rats, in which sustained asphyxia elicited hyperpnea and gasping. A gated time-frequency Coh analysis was developed and applied to whole Ph and medial XII nerve recordings. The results showed dynamic Ph-Ph Coh during eupnea, including MFO and HFO. XII-XII Coh during eupnea was broadband and included four distinct peaks, with low-frequency Coh dominating the epochs preceding the onset of Ph activity. During gasping, only MFO-peaks were present in Ph-Ph Coh. Bilateral XII activity showed a significant reduction in Coh and a shift toward lower frequencies during gasping. In contrast, contralateral Ph-XII Coh progressively increased during state changes from eupnea to gasping, a tendency mirrored in the startup part of the Ph activity. These data suggest significant hypoxia/hypercapnia-induced alterations in synchronization between respiratory outputs during the transition from eupnea to gasping, reflecting a reconfiguration of the respiratory network and/or alterations in the circuitry associated with the motor pools, including dynamic coupling between outputs.
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Affiliation(s)
- Vitaliy Marchenko
- Dept. of Electrical and Computer Engineering, Univ. of Delaware, Newark, DE 19716, USA
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Marchenko V, Rogers RF. Selective loss of high-frequency oscillations in phrenic and hypoglossal activity in the decerebrate rat during gasping. Am J Physiol Regul Integr Comp Physiol 2006; 291:R1414-29. [PMID: 16825420 DOI: 10.1152/ajpregu.00217.2006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Respiratory motor outputs contain medium-(MFO) and high-frequency oscillations (HFO) that are much faster than the fundamental breathing rhythm. However, the associated changes in power spectral characteristics of the major respiratory outputs in unanesthetized animals during the transition from normal eupneic breathing to hypoxic gasping have not been well characterized. Experiments were performed on nine unanesthetized, chemo- and barodenervated, decerebrate adult rats, in which asphyxia elicited hyperpnea, followed by apnea and gasping. A gated fast Fourier transform (FFT) analysis and a novel time-frequency representation (TFR) analysis were developed and applied to whole phrenic and to medial branch hypoglossal nerve recordings. Our results revealed one MFO and one HFO peak in the phrenic output during eupnea, where HFO was prominent in the first two-thirds of the burst and MFO was prominent in the latter two-thirds of the burst. The hypoglossal activity contained broadband power distribution with several distinct peaks. During gasping, two high-amplitude MFO peaks were present in phrenic activity, and this state was characterized by a conspicuous loss in HFO power. Hypoglossal activity showed a significant reduction in power and a shift in its distribution toward lower frequencies during gasping. TFR analysis of phrenic activity revealed the increasing importance of an initial low-frequency “start-up” burst that grew in relative intensity as hypoxic conditions persisted. Significant changes in MFO and HFO rhythm generation during the transition from eupnea to gasping presumably reflect a reconfiguration of the respiratory network and/or alterations in signal processing by the circuitry associated with the two motor pools.
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Affiliation(s)
- Vitaliy Marchenko
- Dept. of Electrical and Computer Engineering, Univ. of Delaware, Newark, DE 19716, USA
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Rodman JR, Harris MB, Rudkin AH, St-John WM, Leiter JC. Gap junction blockade does not alter eupnea or gasping in the juvenile rat. Respir Physiol Neurobiol 2006; 152:51-60. [PMID: 16159713 DOI: 10.1016/j.resp.2005.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2004] [Revised: 06/07/2005] [Accepted: 06/08/2005] [Indexed: 11/26/2022]
Abstract
The role of gap junctions in the brainstem respiratory control system is ambiguous. In the present study, we used juvenile rats to determine whether blocking gap junctions altered eupnea or gasping in the in situ, arterially perfused rat preparation. Blockade of gap junctions with 100 microM carbenoxolone or 300 microM octanol did not produce any consistent changes in the timing or amplitude of integrated phrenic discharge or in the peak frequency in the power spectrum of phrenic nerve discharge during eupnea or ischemic gasping beyond those changes seen in time-control animals. These findings do not rule out a role for gap junctions in the expression of eupnea or gasping, but they do demonstrate that these intermembrane channels are not obligatory for either rhythm to occur.
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Affiliation(s)
- Joshua R Rodman
- Department of Physiology, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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Harris MB, St-John WM. Phasic pulmonary stretch receptor feedback modulates both eupnea and gasping in an in situ rat preparation. Am J Physiol Regul Integr Comp Physiol 2005; 289:R450-R455. [PMID: 15831763 DOI: 10.1152/ajpregu.00750.2004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The perfused in situ juvenile rat preparation produces patterns of phrenic discharge comparable to eupnea and gasping in vivo. These ventilatory patterns differ in multiple aspects, including most prominently the rate of rise of inspiratory activity. Although we have recently demonstrated that both eupnea and gasping are similarly modulated by a Hering-Breuer expiratory-promoting reflex to tonic pulmonary stretch, it has generally been assumed that gasping was unresponsive to afferent stimuli from pulmonary stretch receptors. In the present study, we recorded eupneic and gasplike efferent activity of the phrenic nerve in the in situ juvenile rat perfused brain stem preparation, with and without phrenic-triggered phasic pulmonary inflation. We tested the hypothesis that phasic pulmonary inflation produces reflex responses in situ akin to those in vivo and that both eupnea and gasping are similarly modulated by phasic pulmonary stretch. In eupnea, we found that phasic pulmonary inflation decreases inspiratory burst duration and the period of expiration, thus increasing burst frequency of the phrenic neurogram. Phasic pulmonary inflation also decreases the duration of expiration and increases the burst frequency during gasping. Bilateral vagotomy eliminated these changes. We conclude that the neural substrate mediating the Hering-Breuer reflex is retained in the in situ preparation and that the brain stem circuitry generating the respiratory patterns respond to phasic activation of pulmonary stretch receptors in both eupnea and gasping. These findings support the homology of eupneic phrenic discharge patterns in the reduced in situ preparation and eupnea in vivo and disprove the common supposition that gasping is insensitive to vagal afferent feedback from pulmonary stretch receptor mechanisms.
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Affiliation(s)
- Michael B Harris
- Institute of Arctic Biology, Irving I, University of Alaska-Fairbanks, Fairbanks, AK 99775-7000, USA.
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Abstract
During eupnoea, rhythmic motor activities of the hypoglossal, vagal and phrenic nerves are linked temporally. The inspiratory discharges of the hypoglossal and vagus motor neurones commence before the onset of the phrenic burst. The vagus nerve also discharges in expiration. Upon exposure to hypocapnia or hypothermia, the hypoglossal discharge became uncoupled from that of the phrenic nerve. This uncoupling was evidenced by variable times of onset of hypoglossal discharge before or after the onset of phrenic discharge, extra bursts of hypoglossal activity in neural expiration, or complete absence of any hypoglossal discharge during a respiratory cycle. No such changes were found for vagal discharge, which remained linked to the phrenic bursts. Intracellular recordings in the hypoglossal nucleus revealed that all changes in hypoglossal discharge were due to neuronal depolarization. These results add support to the conclusion that the brainstem control of respiratory-modulated hypoglossal activity differs from control of phrenic and vagal activity. These findings have implications for any studies in which activity of the hypoglossal nerve is used as the sole index of neural inspiration. Indeed, our results establish that hypoglossal discharge alone is an equivocal index of the pattern of overall ventilatory activity and that this is accentuated by hypercapnia and hypothermia.
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Affiliation(s)
- Walter M St-John
- Department of Physiology, Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03756, USA.
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Zhou P, Streutker C, Borojevic R, Wang Y, Croitoru K. IL-10 modulates intestinal damage and epithelial cell apoptosis in T cell-mediated enteropathy. Am J Physiol Gastrointest Liver Physiol 2004; 287:G599-604. [PMID: 15331352 DOI: 10.1152/ajpgi.00063.2004] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In vivo T cell activation by anti-CD3 monoclonal antibody (mAb) results in intestinal damage characterized by loss of villi and epithelial cell apoptosis. The role of the increased interleukin (IL)-10 released during this process is not clear. We assessed the effects of IL-10 on T cell-induced mucosal damage in vivo using IL-10-deficient C57BL/6 [IL-10 knockout (KO)] mice. IL-10 KO and wild-type C57BL/6 mice were injected with anti-CD3 mAb and observed for diarrhea. Changes in serum cytokine levels were measured by ELISA. Histological changes and epithelial cell apoptosis were analyzed on hematoxylin- and eosin-stained tissue sections. Fas expression on intestinal epithelial cells was assessed by flow cytometry analysis of freshly isolated intestinal epithelial cells. Anti-CD3-treated IL-10 KO mice developed more severe diarrhea, a greater loss of intestinal villi, and an increase in the numbers of apoptotic cells in the crypt epithelium. This difference in IL-10 KO mice was associated with an increase in serum tumor necrosis factor-alpha and interferon-gamma levels and with an increase in Fas expression on fresh, isolated, small intestinal epithelial cells. In addition, the enhanced intestinal tissue damage induced by anti-CD3 in IL-10 KO mice was significantly diminished by treatment with recombinant murine IL-10. Therefore, the lack of IL-10 allowed for an increased T cell-induced intestinal tissue damage, and this was associated with an increase in T cell cytokine release and an increase in epithelial cell Fas expression.
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Affiliation(s)
- Pengfei Zhou
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada L8N 3Z5
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Harris MB, St -John WM. Tonic pulmonary stretch receptor feedback modulates both eupnea and gasping in an in situ rat preparation. Am J Physiol Regul Integr Comp Physiol 2003; 285:R215-21. [PMID: 12623772 DOI: 10.1152/ajpregu.00112.2003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The perfused in situ juvenile rat preparation produces phrenic discharge patterns comparable to eupnea and gasping in vivo. These ventilatory patterns of eupnea and gasping differ in multiple aspects, including most prominently the rate of rise of inspiratory activity. Because gasping, but not eupnea, appeared similar after vagotomy in spontaneous breathing preparations, it has been assumed that gasping was unresponsive to afferent stimuli from pulmonary stretch receptors. In the present study, efferent activity of the phrenic nerve was recorded during eupnea and gasping in the in situ juvenile rat preparation. Gasping was induced in hypoxic-hypercapnia or ischemia. An increase in the pressure of tonic lung inflation from 1 to 10 cmH2O caused a prolongation of the duration between phrenic bursts in both eupnea or gasping. Bilateral vagotomy eliminated these changes. We conclude that the neural substrate mediating the Hering-Breuer reflex is retained in the in situ preparation and that the brain stem circuitry generating the respiratory patterns responds to tonic activation of pulmonary stretch receptors in a similar manner in eupnea and gasping. These findings support the homology of eupnea-like phrenic discharge patterns in the reduced in situ preparation and eupnea in vivo and disprove the common supposition that gasping is insensitive to vagal afferent feedback from pulmonary stretch receptor mechanisms.
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Affiliation(s)
- Michael B Harris
- Dept. of Physiology, Dartmouth College, Borwell Bldg., Dartmouth Hitchcock Medical Center, One Medical Center Dr., Lebanon, NH 03756, USA.
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