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Kent DT, Scott WC, Zealear D, Schwartz AR. Ansa cervicalis stimulation increases pharyngeal patency in patients with obstructive sleep apnea. J Appl Physiol (1985) 2021; 131:487-495. [PMID: 34197226 DOI: 10.1152/japplphysiol.00076.2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Hypoglossal nerve stimulation (HNS) is an alternative treatment option for obstructive sleep apnea (OSA) that reduces pharyngeal collapsibility, but HNS nonresponders often demonstrate continued retropalatal and lateral pharyngeal wall collapse. Recent evidence suggests that caudal pharyngeal traction with sternothyroid muscle contraction via ansa cervicalis stimulation (ACS) can also stabilize the pharynx, but the underlying mechanisms have not been elucidated. Our objective was to evaluate the effect of ACS on pharyngeal patency during expiration when the airway is most hypotonic. Eight participants with OSA underwent sustained ultrasound-guided fine-wire stimulation of the medial branch of the right hypoglossal nerve with and without transient stimulation of the branch of the ansa cervicalis nerve plexus innervating the right sternothyroid muscle during drug-induced sleep endoscopy. Airway cross-sectional area and expiratory airflow (V̇e) were measured from endoscopy video with ImageJ and pneumotachometry, respectively. ACS significantly increased retropalatal cross-sectional area (CSARP) to 211% [159-263] of unstimulated CSARP (P < 0.05). Adding ACS to HNS increased CSARP from baseline by 341% [244-439] (P < 0.05), a 180% [133-227] increase over isolated HNS (P < 0.05). ACS increased V̇e from baseline by 177% [138-217] P < 0.05). Adding ACS to HNS increased V̇e by 254% [207-301], reflecting decreases in pharyngeal collapsibility. Combining ACS with HNS increased retropalatal cross-sectional area and increased expiratory airflow, suggesting decreases in pharyngeal collapsibility. Our findings suggest that ACS exerts caudal traction on the upper airway through sternothyroid muscle contraction and that it may augment HNS efficacy in patients with OSA.NEW & NOTEWORTHY Ansa cervicalis stimulation (ACS) is a recently proposed neurostimulation mechanism for generating caudal pharyngeal traction that may benefit patients with obstructive sleep apnea. Here, we document endoscopic findings with ACS during drug-induced sleep endoscopy and additionally detail the effects of ACS on expiratory airflow, when the pharynx is known to be most hypotonic.
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Affiliation(s)
- David T Kent
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William C Scott
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David Zealear
- Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Alan R Schwartz
- Department of Otorhinolaryngology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Universidad Peruana Cayetano Heredia School of Medicine, Lima, Peru
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Neuromuscular Specializations of the Human Hypopharyngeal Muscles. Dysphagia 2020; 36:769-785. [PMID: 33159539 DOI: 10.1007/s00455-020-10212-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
The hypopharyngeal muscles in humans play a vital role in swallowing, speech, and respiration. Increasing evidence indicates that these muscles are specialized to perform life-sustaining upper aerodigestive functions. This review aims to provide current knowledge regarding the key structural, physiological, and biochemical features of the hypopharyngeal muscles, including innervation, contractile properties, histochemistry, biochemical properties, myosin heavy chain (MyHC) expression and regulation, and age-related alterations. These would clarify the unique neuromuscular specializations of the human hypopharyngeal muscles for a better understanding of the functions and pathological conditions of the pharynx and for the development of novel therapies to treat related upper airway disorders.
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Pilarski JQ, Leiter JC, Fregosi RF. Muscles of Breathing: Development, Function, and Patterns of Activation. Compr Physiol 2019; 9:1025-1080. [PMID: 31187893 DOI: 10.1002/cphy.c180008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This review is a comprehensive description of all muscles that assist lung inflation or deflation in any way. The developmental origin, anatomical orientation, mechanical action, innervation, and pattern of activation are described for each respiratory muscle fulfilling this broad definition. In addition, the circumstances in which each muscle is called upon to assist ventilation are discussed. The number of "respiratory" muscles is large, and the coordination of respiratory muscles with "nonrespiratory" muscles and in nonrespiratory activities is complex-commensurate with the diversity of activities that humans pursue, including sleep (8.27). The capacity for speech and adoption of the bipedal posture in human evolution has resulted in patterns of respiratory muscle activation that differ significantly from most other animals. A disproportionate number of respiratory muscles affect the nose, mouth, pharynx, and larynx, reflecting the vital importance of coordinated muscle activity to control upper airway patency during both wakefulness and sleep. The upright posture has freed the hands from locomotor functions, but the evolutionary history and ontogeny of forelimb muscles pervades the patterns of activation and the forces generated by these muscles during breathing. The distinction between respiratory and nonrespiratory muscles is artificial, as many "nonrespiratory" muscles can augment breathing under conditions of high ventilator demand. Understanding the ontogeny, innervation, activation patterns, and functions of respiratory muscles is clinically useful, particularly in sleep medicine. Detailed explorations of how the nervous system controls the multiple muscles required for successful completion of respiratory behaviors will continue to be a fruitful area of investigation. © 2019 American Physiological Society. Compr Physiol 9:1025-1080, 2019.
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Affiliation(s)
- Jason Q Pilarski
- Department of Biological and Dental Sciences, Idaho State University Pocatello, Idaho, USA
| | - James C Leiter
- Department of Molecular and Systems Biology, The Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire, USA
| | - Ralph F Fregosi
- Departments of Physiology and Neuroscience, The University of Arizona, Tucson, Arizona, USA
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Tran TTA, Harris BM, Pearson WG. Improvements resulting from respiratory-swallow phase training visualized in patient-specific computational analysis of swallowing mechanics. COMPUTER METHODS IN BIOMECHANICS AND BIOMEDICAL ENGINEERING-IMAGING AND VISUALIZATION 2016; 6:532-538. [PMID: 30581689 DOI: 10.1080/21681163.2016.1152567] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The aim of this study was to visualize improved swallowing mechanics resulting from respiratory-swallow phase training using patient specific computational analysis of Modified Barium Swallow (MBS) videofluoroscopic images. Imaging from a single subject showing improved MBSImP™© scores in 17 of 18 pre- to post-treatment swallows was selected for analysis. Using a semi-automated MATLAB tracker tool, a frame-by-frame annotation of 10 coordinates mapping muscle functional groups was performed during oropharyngeal swallowing. Computational analysis of coordinate shape change was executed using MorphoJ software to determine differences in swallowing mechanics associated with multiple independent variables. Canonical variant analysis indicated significant differences in mechanics associated with respiratory-swallow phase training (D=1.92,p<.0001). Vectors allowed for visualization of changes in swallowing mechanics associated with respiratory-swallow phase training. A regression of shape associated with laryngeal vestibular closure on respiratory-swallow phase training was highly significant (p<.0001) and accounted for 94.1% of the variance.
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Affiliation(s)
- Thi Tu Anh Tran
- Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
| | - Bonnie Martin Harris
- Department of Otolaryngology - Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - William G Pearson
- Department of Cellular Biology and Anatomy; Department of Otolaryngology, Medical College of Georgia, Georgia Regents University, Augusta, GA, USA
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Stuth EAE, Stucke AG, Zuperku EJ. Effects of anesthetics, sedatives, and opioids on ventilatory control. Compr Physiol 2013; 2:2281-367. [PMID: 23720250 DOI: 10.1002/cphy.c100061] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This article provides a comprehensive, up to date summary of the effects of volatile, gaseous, and intravenous anesthetics and opioid agonists on ventilatory control. Emphasis is placed on data from human studies. Further mechanistic insights are provided by in vivo and in vitro data from other mammalian species. The focus is on the effects of clinically relevant agonist concentrations and studies using pharmacological, that is, supraclinical agonist concentrations are de-emphasized or excluded.
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Affiliation(s)
- Eckehard A E Stuth
- Medical College of Wisconsin, Anesthesia Research Service, Zablocki VA Medical Center, Milwaukee, Wisconsin, USA.
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Abstract
Obstructive sleep apnea (OSA) is a common disorder characterized by repetitive collapse of the pharyngeal airway during sleep. Control of pharyngeal patency is a complex process relating primarily to basic anatomy and the activity of many pharyngeal dilator muscles. The control of these muscles is regulated by a number of processes including respiratory drive, negative pressure reflexes, and state (sleep) effects. In general, patients with OSA have an anatomically small airway the patency of which is maintained during wakefulness by reflex-driven augmented dilator muscle activation. At sleep onset, muscle activity falls, thereby compromising the upper airway. However, recent data suggest that the mechanism of OSA differs substantially among patients, with variable contributions from several physiologic characteristics including, among others: level of upper airway dilator muscle activation required to open the airway, increase in chemical drive required to recruit the pharyngeal muscles, chemical control loop gain, and arousal threshold. Thus, the cause of sleep apnea likely varies substantially between patients. Other physiologic mechanisms likely contributing to OSA pathogenesis include falling lung volume during sleep, shifts in blood volume from peripheral tissues to the neck, and airway edema. Apnea severity may progress over time, likely due to weight gain, muscle/nerve injury, aging effects on airway anatomy/collapsibility, and changes in ventilatory control stability.
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Affiliation(s)
- David P White
- Harvard Medical School and Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Kairaitis K, Verma M, Amatoury J, Wheatley JR, White DP, Amis TC. A threshold lung volume for optimal mechanical effects on upper airway airflow dynamics: studies in an anesthetized rabbit model. J Appl Physiol (1985) 2012; 112:1197-205. [DOI: 10.1152/japplphysiol.01286.2011] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Increasing lung volume improves upper airway airflow dynamics via passive mechanisms such as reducing upper airway extraluminal tissue pressures (ETP) and increasing longitudinal tension via tracheal displacement. We hypothesized a threshold lung volume for optimal mechanical effects on upper airway airflow dynamics. Seven supine, anesthetized, spontaneously breathing New Zealand White rabbits were studied. Extrathoracic pressure was altered, and lung volume change, airflow, pharyngeal pressure, ETP laterally (ETPlat) and anteriorly (ETPant), tracheal displacement, and sternohyoid muscle activity (EMG%max) monitored. Airflow dynamics were quantified via peak inspiratory airflow, flow limitation upper airway resistance, and conductance. Every 10-ml lung volume increase resulted in caudal tracheal displacement of 2.1 ± 0.4 mm (mean ± SE), decreased ETPlat by 0.7 ± 0.3 cmH2O, increased peak inspiratory airflow of 22.8 ± 2.6% baseline (all P < 0.02), and no significant change in ETPant or EMG%max. Flow limitation was present in most rabbits at baseline, and abolished 15.7 ± 10.5 ml above baseline. Every 10-ml lung volume decrease resulted in cranial tracheal displacement of 2.6 ± 0.4 mm, increased ETPant by 0.9 ± 0.2 cmH2O, ETPlat was unchanged, increased EMG%max of 11.1 ± 0.3%, and a reduction in peak inspiratory airflow of 10.8 ± 1.0%baseline (all P < 0.01). Lung volume, resistance, and conductance relationships were described by exponential functions. In conclusion, increasing lung volume displaced the trachea caudally, reduced ETP, abolished flow limitation, but had little effect on resistance or conductance, whereas decreasing lung volume resulted in cranial tracheal displacement, increased ETP and increased resistance, and reduced conductance, and flow limitation persisted despite increased muscle activity. We conclude that there is a threshold for lung volume influences on upper airway airflow dynamics.
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Affiliation(s)
- Kristina Kairaitis
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute and University of Sydney at Westmead Hospital, Westmead, New South Sales, Australia; and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Manisha Verma
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute and University of Sydney at Westmead Hospital, Westmead, New South Sales, Australia; and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Jason Amatoury
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute and University of Sydney at Westmead Hospital, Westmead, New South Sales, Australia; and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - John R. Wheatley
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute and University of Sydney at Westmead Hospital, Westmead, New South Sales, Australia; and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P. White
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute and University of Sydney at Westmead Hospital, Westmead, New South Sales, Australia; and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Terence C. Amis
- Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute and University of Sydney at Westmead Hospital, Westmead, New South Sales, Australia; and Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Brown EC, Hudson AL, Butler JE, McKenzie DK, Bilston LE, Gandevia SC. Single motor unit recordings in human geniohyoid reveal minimal respiratory activity during quiet breathing. J Appl Physiol (1985) 2011; 110:1054-9. [DOI: 10.1152/japplphysiol.00454.2010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Maintenance of airway patency during breathing involves complex interactions between pharyngeal dilator muscles. The few previous studies of geniohyoid activity using multiunit electromyography (EMG) have suggested that geniohyoid shows predominantly inspiratory phasic activity. This study aimed to quantify geniohyoid respiration-related activity with single motor unit (SMU) EMG recordings. Six healthy subjects of normal body mass index were studied. Intramuscular EMG recordings of geniohyoid activity were made with a monopolar needle with subjects in supine and seated positions. The depth of the geniohyoid was identified by ultrasound, and the electrode position was confirmed with maneuvers to isolate activity in geniohyoid and genioglossus. Activity was recorded at 85 sites in the geniohyoid during quiet breathing (45 supine and 40 seated). When subjects were supine, 33 sites (73%) showed no activity during breathing and 10 (22%) showed tonic activity. In addition, one site showed a tonic SMU with increased expiratory discharge, and one site in another subject had one unit with expiratory phasic activity. When subjects were seated, 27 sites (68%) in the geniohyoid showed no activity, 12 sites (30%) showed tonic activity that was not respiration related, and one unit at one site showed phasic expiratory activity. The average peak discharge frequency of geniohyoid motor units was 16.2 ± 3.1 impulses/s during the “geniohyoid maneuver,” which was the first part of a swallow. In contrast to previous findings, the geniohyoid shows some tonic activity but minimal respiration-related activity in healthy subjects in quiet breathing. The geniohyoid has little active role in airway stability under these conditions.
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Affiliation(s)
- Elizabeth C. Brown
- Neuroscience Research Australia and University of New South Wales, Sydney, NSW, Australia
| | - Anna L. Hudson
- Neuroscience Research Australia and University of New South Wales, Sydney, NSW, Australia
| | - Jane E. Butler
- Neuroscience Research Australia and University of New South Wales, Sydney, NSW, Australia
| | - David K. McKenzie
- Neuroscience Research Australia and University of New South Wales, Sydney, NSW, Australia
| | - Lynne E. Bilston
- Neuroscience Research Australia and University of New South Wales, Sydney, NSW, Australia
| | - Simon C. Gandevia
- Neuroscience Research Australia and University of New South Wales, Sydney, NSW, Australia
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10
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Is the pharynx a muscular hydrostat? Med Hypotheses 2010; 74:590-5. [DOI: 10.1016/j.mehy.2009.06.040] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Revised: 06/17/2009] [Accepted: 06/20/2009] [Indexed: 12/12/2022]
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Farina D, Falla D. Discharge Rate of Sternohyoid Motor Units Activated With Surface EMG Feedback. J Neurophysiol 2009; 101:624-32. [DOI: 10.1152/jn.90901.2008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We analyzed individual motor units of the sternohyoid muscle with the aim of characterizing their minimum and maximum discharge rates and their variability in discharge during voluntary contractions. Surface EMG signals were recorded with an array of eight electrodes from the sternohyoid muscle of seven healthy men (age: 30.2 ± 3.5 yr). The multichannel surface EMG signals were displayed as feedback for the subjects who identified and modulated the activity of one target motor unit in 30-s contractions during which the discharge rate was increased from minimum to maximum (ramp contraction), sustained at maximum level (sustained), or increased in brief bursts (burst). During the ramp contractions, the minimum average discharge rate over epochs of 1 s was 11.6 ± 1.5 pulses per second (pps) and the maximum 57.0 ± 5.7 pps ( P < 0.001). During the sustained contractions, the motor unit discharge rate decreased from 65.5 ± 8.4 pps at the beginning to 52.9 ± 7.6 pps at the end of the contraction ( P < 0.05). The coefficient of variation for the interspike interval during the sustained contractions was 40.2 ± 9.8% and a large percentage of discharges had instantaneous rates >50 pps (52.2 ± 12.5%) and >100 pps (8.0 ± 1.2%), with peak values >150 pps. During the burst contractions, the instantaneous discharge rate reached average maximum values of 97.6 ± 36.8 pps. The observed discharge rates and their variability are higher than those reported for limb muscles, which may be due to large synaptic input and noise received by these motor neurons.
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12
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Lam JCM, Kairaitis K, Verma M, Wheatley JR, Amis TC. Saliva production and surface tension: influences on patency of the passive upper airway. J Physiol 2008; 586:5537-47. [PMID: 18818243 DOI: 10.1113/jphysiol.2008.159822] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Pharyngeal patency is influenced by the surface tension (gamma) of the upper airway lining liquid (UAL), of which saliva is a major component. We investigated the influences of saliva production on gamma of the UAL, and upper airway re-opening and closing pressures. In 10 supine, male, anaesthetized, tracheostomised, mechanically ventilated New Zealand White rabbits, we measured re-opening and closing of the passive isolated upper airway at baseline and following graded (cumulative) doses of methacholine or atropine. Upper airway liquid volume index (UALVI) was assessed using a standardized suction procedure (secretion weight obtained per second) expressed as the natural logarithm (LnUALVI). The gamma of UAL samples were measured using the 'pull-off' force technique. Across all animals, baseline values were: LnUALVI -6.2 (-8.6 to -5.4) median (interquartile range), gamma of UAL 58.9 (56.6-59.9) mN m(-1), re-opening 8.6 (6.9-11.1) cmH(2)O, and closing pressures 3.2 (1.8-5.7) cmH(2)O. LnUALVI increased by approximately 0.17 per microg kg(-1) methacholine and decreased by approximately 0.14 per 100 microg kg(-1) atropine (both P < 0.03, linear mixed effects modelling). Surface tension was unchanged by methacholine but increased by approximately 0.6 mN m(-1) per 100 microg kg(-1) atropine (P < 0.004). When data were analysed across all animals, both re-opening and closing pressures increased as surface tension increased (by approximately 0.4 cmH(2)O mN(-1) and by approximately 0.7 cmH(2)O mN(-1), respectively; both P < 0.05). We conclude that saliva production influences upper airway mechanical properties partly via alterations in gamma of UAL. We speculate that in obstructive sleep apnoea, altered autonomic activity may reduce saliva production and increase surface tension of the upper airway lining liquid, thus increasing the likelihood of upper airway obstruction.
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Affiliation(s)
- J C M Lam
- Division of Respiratory and Critical Care Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, SAR, China
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Abstract
The geniohyoid (Genio) upper airway muscle shows phasic, inspiratory electrical activity in awake humans but no activity and lengthening in anesthetized cats. There is no information about the mechanical action of the Genio, including length and shortening, in any awake, nonanesthetized mammal during respiration (or swallowing). Therefore, we studied four canines, mean weight 28.8 kg, 1.5 days after Genio implantation with sonomicrometry transducers and bipolar electromyogram (EMG) electrodes. Awake recordings of breathing pattern, muscle length and shortening, and EMG activity were made with the animal in the right lateral decubitus position during quiet resting, CO2-stimulated breathing, inspiratory-resisted breathing (80 cmH2O. l-1. s), and airway occlusion. Genio length and activity were also measured during swallowing, when it shortened, showing a 9.31% change from resting length, and its EMG activity increased 6.44 V. During resting breathing, there was no phasic Genio EMG activity at all, and Genio showed virtually no movement during inspiration. During CO2-stimulated breathing, Genio showed minimal lengthening of only 0.07% change from resting length, whereas phasic EMG activity was still absent. During inspiratory-resisted breathing and airway occlusion, Genio showed phasic EMG activity but still lengthened. We conclude that the Genio in awake, nonanesthetized canines shows active contraction and EMG activity only during swallowing. During quiet or stimulated breathing, Genio is electrically inactive with passive lengthening. Even against resistance, Genio is electrically active but still lengthens during inspiration.
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Affiliation(s)
- M Yokoba
- Department of Critical Care, University of Calgary, Calgary, Alberta, Canada T2N 4N1
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Kirkness JP, Christenson HK, Garlick SR, Parikh R, Kairaitis K, Wheatley JR, Amis TC. Decreased surface tension of upper airway mucosal lining liquid increases upper airway patency in anaesthetised rabbits. J Physiol 2003; 547:603-11. [PMID: 12562967 PMCID: PMC2342661 DOI: 10.1113/jphysiol.2002.031013] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
The obstructive sleep apnoea syndrome (OSA) is a disorder characterised by repetitive closure and re-opening of the upper airway during sleep. Upper airway luminal patency is influenced by a number of factors including: intraluminal air pressure, upper airway dilator muscle activity, surrounding extraluminal tissue pressure, and also surface forces which can potentially act within the liquid layer lining the upper airway. The aim of the present study was to examine the role of upper airway mucosal lining liquid (UAL) surface tension (gamma) in the control of upper airway patency. Upper airway opening (PO) and closing pressures (PC) were measured in 25 adult male, supine, tracheostomised, mechanically ventilated, anaesthetised (sodium pentabarbitone), New Zealand White rabbits before (control) and after instillation of 0.5 ml of either 0.9 % saline (n = 9) or an exogenous surfactant (n = 16; Exosurf Neonatal) into the pharyngeal airway. The gamma of UAL (0.2 microl) was quantified using the 'pull-off' force technique in which gamma is measured as the force required to separate two curved silica discs bridged by the liquid sample. The gamma of UAL decreased after instillation of surfactant from 54.1 +/- 1.7 mN m-1 (control; mean +/- S.E.M.) to 49.2 +/- 2.1 mN m-1 (surfactant; P < 0.04). Compared with control, PO increased significantly (P < 0.04; paired t test, n = 9) from 6.2 +/- 0.9 to 9.6 +/- 1.2 cmH2O with saline, and decreased significantly (P < 0.05, n = 16) from 6.6 +/- 0.4 to 5.5 +/- 0.6 cmH2O with surfactant instillation. Findings tended to be similar for PC. Change in both PO and PC showed a strong positive correlation with the change in gamma of UAL (both r > 0.70, P < 0.001). In conclusion, the patency of the upper airway in rabbits is partially influenced by the gamma of UAL. These findings suggest a role for UAL surface properties in the pathophysiology of OSA.
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Affiliation(s)
- Jason P Kirkness
- Ludwig Engel Centre for Respiratory Research, Westmead Hospital and University of Sydney, New South Wales, Australia, 2145.
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Mu L, Sanders I. Neuromuscular compartments and fiber-type regionalization in the human inferior pharyngeal constrictor muscle. THE ANATOMICAL RECORD 2001; 264:367-77. [PMID: 11745092 DOI: 10.1002/ar.10020] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The inferior pharyngeal constrictor (IPC) muscle functions during swallowing, respiration, and vocalization. The most-caudal portion of the IPC is believed to be part of the functional upper esophageal sphincter (UES). We hypothesized that the caudal fibers of the human IPC may have enzyme-histochemical characteristics similar to those of the cricopharyngeus muscle, a major component of the UES. In this study, human IPC muscles obtained from autopsy were studied using Sihler's stain to examine innervation patterns, and using myofibrillar ATPase, NADH tetrazolium reductase (NADH-TR), and succinic dehydrogenase (SDH) techniques to investigate the distribution and oxidative capacity of the slow- (type I) and fast- (type II) twitch fibers in the muscle. The results showed that the human IPC consists of at least two neuromuscular compartments (NMCs): rostral and caudal. Each of the NMCs was innervated by a separate nerve branch derived from the pharyngeal branch of the vagus nerve. The rostral NMC is faster (39% type I, 61% type II) than the caudal NMC (70% type I, 30% type II). In addition, two histochemically-delineated fiber layers were identified in the human IPC: a slow inner layer (SIL) with predominantly type I fibers (66%), and a fast outer layer (FOL) with predominantly type II fibers (62%) (P < 0.01). However, the dimensions of both fiber layers and proportions of the muscle fiber types varied with the NMCs. Specifically, the ratio of the thickness of the SIL to FOL was approximately 2:1 for the caudal NMC and approximately 1:2 for the rostral NMC, respectively. In the SIL the type I fibers accounted for 84% for the caudal NMC and 69% and 44% for the lower and upper portions of the rostral NMC. In contrast, the type II fibers in the FOL accounted for 46% for the caudal NMC and 67% and 74% for the lower and upper portions of the rostral NMC, respectively (P < 0.01). The caudal NMC of the IPC shared histochemical characteristics with the cricopharyngeus muscle, in that it contained predominantly slow oxidative fibers. Overall, the caudal NMC and the SIL in the IPC had high NADH-TR and SDH activities. However, different patterns of oxidative enzyme activity were identified in both type I and type II fibers. This study provided histochemical evidence for the concept that the caudal NMC within the IPC contributes to the functional UES. In addition, the two histochemically-defined fiber layers in the IPC may be a specialized adaptation in humans to enable different upper-airway functions during respiration, swallowing, and speech.
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Affiliation(s)
- L Mu
- Grabscheid Voice Center, Department of Otolaryngology, Mount Sinai Medical Center, New York, New York 10029-6574, USA.
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16
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Beard WL, Holcombe SJ, Hinchcliff KW. Effect of a tongue-tie on upper airway mechanics during exercise following sternothyrohyoid myectomy in clinically normal horses. Am J Vet Res 2001; 62:779-82. [PMID: 11341403 DOI: 10.2460/ajvr.2001.62.779] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the effect of a tongue-tie on upper airway mechanics in clinically normal horses exercising on a treadmill following sternothyrohyoid myectomy. ANIMALS 6 Standardbreds. PROCEDURE Upper airway mechanics were measured with horses exercising on a treadmill at 5, 8, and 10 m/s 4 weeks after a sternothyrohyoid myectomy was performed. Pharyngeal and tracheal inspiratory and expiratory pressures were measured by use of transnasal pharyngeal and tracheal catheters connected to differential pressure transducers. Horses were fitted with a facemask and airflow was measured by use of a pneumotachograph. Horses underwent a standardized exercise protocol on a treadmill at 5, 8, and 10 m/s with and without a tongue-tie in a randomized cross-over design. Inspiratory and expiratory airflow, tracheal pressure, and pharyngeal pressure were measured, and inspiratory and expiratory resistances were calculated. RESULTS We were unable to detect an effect of a tongue-tie on any of the respiratory variables measured. CONCLUSIONS AND CLINICAL RELEVANCE Results indicate that a tongue-tie does not alter upper airway mechanics following sternothyrohyoid myectomy in clinically normal horses during exercise.
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Affiliation(s)
- W L Beard
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, The Ohio State University, Columbus 43210, USA
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Feroah TR, Forster HV, Pan LG, Rice T. Reciprocal activation of hypopharyngeal muscles and their effect on upper airway area. J Appl Physiol (1985) 2000; 88:611-26. [PMID: 10658029 DOI: 10.1152/jappl.2000.88.2.611] [Citation(s) in RCA: 12] [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] Open
Abstract
We examined in awake goats, 1) with intact upper airways (UAW), the effect of altering chemical drive on pharyngeal constrictors [thyropharyngeus (TP) and hypopharyngeus (HP)] and a dilator [stylopharyngeus (SP)], and 2) with an isolated UAW, the effect of activation of these muscles on supraglottic UAW (UAW(SG)) area. During eupnea in nine goats with intact UAW, the TP and HP were active during expiration, whereas the SP exhibited tonic expiratory and phasic inspiratory activity. After mechanically induced apneas (MIA), TP activity increased (263%, P < 0.02), HP activity exhibited a small, varied response, and SP activity greatly decreased (10%, P < 0.02). During resumption of respiratory effort, all goats exhibited absent/reduced airflow, and when diaphragm activity was 95% of control, TP activity remained elevated (135%) and SP activity was reduced (56%, P < 0.02). During hypercapnia, 1) TP activity decreased (P < 0.02), 2) HP response varied, and 3) SP activity increased (P < 0.02). After MIA in six goats with isolated UAW, TP activity increased 198% (P < 0.02) and UAW(SG) area (endoscopically determined) decreased (to 15% of control, P < 0.02). During recovery from MIA, a correlation was found between UAW(SG) area and the ratio of SP to TP activity. We conclude that the reciprocal activation of mechanically opposing dilator and constrictor muscles in the hypopharynx is correlated to changes in the UAW(SG) area, and an imbalance in activity of these opposing muscles can lead to UAW(SG) narrowing.
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Affiliation(s)
- T R Feroah
- Department of Physiology, Medical College of Wisconsin and Zablocki Veterans Affairs Medical Center, Milwaukee 53226, Wisconsin, USA
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Rowley JA, Williams BC, Smith PL, Schwartz AR. Neuromuscular activity and upper airway collapsibility. Mechanisms of action in the decerebrate cat. Am J Respir Crit Care Med 1997; 156:515-21. [PMID: 9279233 DOI: 10.1164/ajrccm.156.2.9607115] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
We have shown that tracheal and tongue displacement represent two basic mechanisms by which upper airway collapsibility can be altered. In this study, we investigated whether hypercapnia, which activates upper airway muscles, alters upper airway collapsibility by a mechanism similar to tracheal or tongue displacement. To answer this question, we utilized a feline isolated upper airway preparation in which maximal inspiratory airflow (Vimax), the pharyngeal critical pressure (Pcrit) and the nasal resistance (Rn) upstream to the flow-limiting site (FLS) were measured. In protocol #1, upper airway airflow dynamics were studied at two levels of trachea displacement under either hypo- or hypercapnic conditions. We found that the increase in Vimax with 1 cm of caudal tracheal displacement was attenuated by hypercapnia (44 +/- 12 ml/s versus 81 +/- 7 ml/s during hypocapnia, p = 0.048), as was the decrease in Pcrit (-2.4 +/- 1.1 cm H2O versus -5.2 +/- 1.1 cm H2O, p = 0.001). In protocol #2, we investigated the effect of transecting the cervical strap muscles and hypoglossal nerves on airflow dynamics during hypercapnia. Vimax, Pcrit, and Rn did not change after transecting either the strap muscles or the hypoglossal nerves. We conclude that the primary mechanism for changes in Pcrit during hypercapnia is similar to trachea displacement and is mediated by muscles other than the straps or tongue.
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Affiliation(s)
- J A Rowley
- Department of Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
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Diaz V, Kianicka I, Letourneau P, Praud JP. Inferior pharyngeal constrictor electromyographic activity during permeability pulmonary edema in lambs. J Appl Physiol (1985) 1996; 81:1598-604. [PMID: 8904575 DOI: 10.1152/jappl.1996.81.4.1598] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Newborn mammals exhibit an active expiratory upper airway closure during the first hours of extrauterine life. We have recently shown that permeability pulmonary edema led to active expiratory glottic closure in awake newborn lambs while hypoxia (inspired O2 fraction 8%; 15 min) did not. In the present study, we tested the hypothesis that expiratory glottic closure was accompanied by an increase in pharyngeal constrictor muscle expiratory electromyographic (EMG) activity. We studied seven awake nonsedated lambs aged 8-20 days. Airflow (facial mask + pneumotachograph), blood gases (arterial catheter), and EMG activity of both the thyroarytenoid muscle (a glottic adductor) and the inferior pharyngeal constrictor muscle were recorded before and after intravenous injection of halothane (0.05 ml/kg) to induce a permeability pulmonary edema. A central apnea (duration 15 s to 5 min) with continuous thyroarytenoid and inferior pharyngeal constrictor activity was observed within seconds after halothane injection. One lamb died despite rescuing maneuvers. An expiratory phasic thyroarytenoid and inferior pharyngeal constrictor muscle activity with simultaneous zero airflow gradually took place and, by 30 min after halothane injection, was present at each expiration in the six remaining lambs. Expiratory glottic and pharyngeal constrictor muscle EMG activity was subsequently present during the whole study period (1.5-5 h), even after correction of the initial hypoxia. Permeability lung edema was present at postmortem examination in all seven lambs. We conclude that a permeability pulmonary edema induced by intravenous halothane in non-sedated lambs enhances both glottic and pharyngeal constrictor muscle expiratory EMG. We hypothesize that expiratory contraction of the inferior pharyngeal constrictor muscle could participate in the active expiratory upper airway closure; this, in turn, might improve alveolocapillary gas exchange by increasing the end-expiratory lung volume.
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Affiliation(s)
- V Diaz
- Department of Pediatrics, Faculty of Medicine, University of Sherbrooke, Quebec, Canada
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20
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Abstract
Some reports have suggested occurrence of expiratory upper airway narrowing in patients with obstructive sleep apnea (OSA) during sleep and in awake humans during respiratory muscles relaxation. This is compatible with the hypothesis that upper airway muscles are activated during expiration. We studied five healthy volunteers and four patients with OSA in a tank respirator (Emerson; Cambridge, Mass). Supraglottic pressure (Psg) was measured with a catheter with the tip at the retroepiglottic level, tidal volume with an inductance plethysmograph and airflow with a pneumotachograph at the mouth. Diaphragmatic electromyogram was recorded with an esophageal bipolar electrode. Measurements were done at -30 cm H2O. Subjects were asked to breathe in phase with the respirator and then asked to breathe in phase with the respirator and then to relax their muscles. During muscular relaxation, there was supraglottic obstruction and flow limitation. This was observed during both inspiration and expiration. Upper airway obstruction was more severe in patients with OSA than in healthy subjects. In two healthy volunteers, fiberoptic bronchoscopy showed a wide-open oropharyngeal isthmus during active breathing that narrowed during muscular relaxation. This was true during both inspiration and expiration. We conclude that muscular relaxation is associated with upper airway narrowing and flow limitation occurring during both inspiration and expiration. We suggest that to preserve an open upper airway, airway muscles have to be activated during both inspiration and expiration.
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Affiliation(s)
- A Sanna
- Pulmonary Laboratory and Division, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Schwab RJ, Gefter WB, Hoffman EA, Gupta KB, Pack AI. Dynamic upper airway imaging during awake respiration in normal subjects and patients with sleep disordered breathing. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1993; 148:1385-400. [PMID: 8239180 DOI: 10.1164/ajrccm/148.5.1385] [Citation(s) in RCA: 286] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The effects of respiration on upper airway caliber were studied using cine computed tomography (CT) in 15 normal subjects, 14 snorer/mildly apneic subjects, and 13 patients with obstructive sleep apnea. All subjects were scanned in the supine position during awake nasal breathing. Eight-millimeter-thick axial slices were obtained at four anatomic levels from the nasopharynx to the retroglossal region every 0.4 s during a respiratory cycle. Tidal volume measured from an integrated pneumotachograph signal was correlated with slice acquisition during inspiration and expiration to generate loops comparing upper airway area and tidal volume. In all three subject groups and at all anatomic levels studied, there were significant dimensional changes in upper airway caliber during the respiratory cycle. The major findings in this investigation include: (1) the upper airway was significantly smaller in apneic than normal subjects, especially at the retropalatal low and retroglossal anatomic levels; in apneic patients the airway had an anterior-posterior configuration unlike the normal airway, which had a horizontal configuration with the major axis in the lateral direction; (2) in all three subject groups, little airway narrowing occurred in inspiration, suggesting that the action of the upper airway dilator muscles balanced the effects of negative intraluminal pressure.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- R J Schwab
- Department of Radiology, University of Pennsylvania, Philadelphia
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Vanner RG, Pryle BJ, O'Dwyer JP, Reynolds F. Upper oesophageal sphincter pressure and the intravenous induction of anaesthesia. Anaesthesia 1992; 47:371-5. [PMID: 1599058 DOI: 10.1111/j.1365-2044.1992.tb02215.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
The upper oesophageal sphincter can prevent regurgitation of oesophageal contents into the pharynx following gastrooesophageal reflux in the awake patient. Upper oesophageal sphincter pressure was recorded with a Dent sleeve after hypnosis with midazolam (n = 7) and also during the rapid intravenous induction of anaesthesia with thiopentone (n = 16) or ketamine (n = 7). Thiopentone decreased mean (SD) sphincter pressure from an awake value of 43 (19) to 9 (7) mmHg (p less than 0.001) and midazolam from 38 (25) to 7 (3) mmHg (p less than 0.02). Mean (SD) sphincter pressures before and after ketamine were not significantly different at 29 (15) and 32 (21) mmHg respectively. After suxamethonium mean (SD) sphincter pressure in all patients (n = 30) was 7 (4) mmHg. Laryngoscopy (n = 30) caused a small increase in mean (SD) sphincter pressure to 13 (10) mmHg (p less than 0.001). Thiopentone caused a rapid fall in upper oesophageal sphincter pressure which usually started before loss of consciousness. These findings have implications for the timing of cricoid pressure application.
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Affiliation(s)
- R G Vanner
- Department of Anaesthetics, St Thomas' Hospital, London
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Hisa Y, Malmgren LT, Gacek RR. Actomyosin adenosine triphosphatase activities of the cat infrahyoid muscles. Ann Otol Rhinol Laryngol 1989; 98:202-8. [PMID: 2466434 DOI: 10.1177/000348948909800308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
By use of actomyosin ATPase histochemistry, it was found that there were large differences among the three cat infrahyoid muscles (sternohyoid, sternothyroid, and thyrohyoid) with respect to their percentages of different muscle fiber types. It has been established that the individual activity patterns of the component motor units in each muscle drive the biochemical and physiologic differentiation of the muscle fibers associated with each motor unit. Therefore, the data obtained in the present investigation provide an indication of the characteristics of long-term use of each of the various types of motor units, as well as the associated differences in the physiologic capacities of the different motor unit types composing each of these infrahyoid muscles.
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Affiliation(s)
- Y Hisa
- Department of Otolaryngology, State University of New York Health Science Center, Syracuse 13210
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Saether K, Hilaire G, Monteau R. Dorsal and ventral respiratory groups of neurons in the medulla of the rat. Brain Res 1987; 419:87-96. [PMID: 3676744 DOI: 10.1016/0006-8993(87)90571-3] [Citation(s) in RCA: 131] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The aim of the present work was to identify and localize in rat the medullary neurons involved in respiration. Neural activity was recorded in ketamine-anesthetized, paralyzed and artificially ventilated rats. Active sites were marked by electrocoagulation. Neurons firing in relation to phrenic nerve activity were located between 0.5 and 2 mm lateral to the midline, extending from 0.5 mm caudal to 2 mm rostral to the posterior end of the area postrema. Two groups of respiratory neurons were found: a dorsal group located ventrolateral to the tractus solitarius and a ventral group located in the ventrolateral reticular formation close to the nucleus ambiguus. Neurons were classified as bulbospinal or laryngeal if stimulation of the spinal cord or the vagus nerve, respectively, elicited antidromic action potentials, or as propriobulbar if they were not activated. Neurons firing synchronously with lung inflation were termed pump (P) cells. The dorsal respiratory group includes inspiratory (I) bulbospinal and propriobulbar neurons, P cells, but few expiratory (E) propriobulbar neurons. The ventral respiratory group includes bulbospinal, laryngeal and propriobulbar I and E neurons. Laryngeal motoneurons project ipsilaterally whereas bulbospinal neurons project contralaterally. Cross-correlations between inspiratory bulbospinal neuronal activity and phrenic discharge suggest that bulbospinal I neurons of dorsal and ventral groups project monosynaptically to contralateral phrenic motoneurons. These results indicate a similarity of the medullary respiratory centers of rats and cats, suggesting that rats may profitably be used in studies of respiratory rhythmogenesis.
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Affiliation(s)
- K Saether
- Département de Physiologie et Neurophysiologie, Faculté des Sciences et Techniques Saint-Jérome, Marseille, France
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Davis PJ, Macefield G, Nail BS. Respiratory muscle activity during asphyxic apnoea and opisthotonus in the rabbit. RESPIRATION PHYSIOLOGY 1986; 65:285-94. [PMID: 3786968 DOI: 10.1016/0034-5687(86)90013-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The behaviour of submandibular, cervical, thoracic and abdominal respiratory muscles was examined in the pentobarbitone-urethane-anaesthetized rabbit during progressive asphyxia induced by rebreathing. During asphyxic hyperpnoea the external intercostal, interchondral and scalene inspiratory activities augmented until succeeded by the apnoeic period, in which all were inhibited with the diaphragm. Likewise, the genioglossus, sternohyoid and thyrohyoid muscles exhibited inspiratory augmentation during asphyxic hyperpnoea until the onset of apnoeic inhibition. However, late in the apnoea these muscles, together with the sternothyroid, sternomastoid and digastric muscles, generated an augmenting tonic discharge associated with an intense abdominal constriction, and with the extension of the limbs characteristic of opisthotonus. This intense tonic activity, which was never expressed by the diaphragm and thoracic inspiratory muscles, was immediately interrupted or terminated by the subsequent inspiratory efforts of gasping respiration, during which the abdominal muscles were inhibited but all the submandibular, cervical and thoracic inspiratory muscles greatly participated. The mylohyoid muscles presented augmenting expiratory activity during asphyxic hyperpnoea which declined during the apnoea. These muscles, however, did not exhibit the intense tonic discharge expressed by the expiratory abdominal and inspiratory submandibular and cervical muscles in late apnoea and were not active in gasping.
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St John WM, Bledsoe TA. Comparison of respiratory-related trigeminal, hypoglossal and phrenic activities. RESPIRATION PHYSIOLOGY 1985; 62:61-78. [PMID: 4070836 DOI: 10.1016/0034-5687(85)90050-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
In decerebrate, paralyzed and vagotomized cats, we recorded activities of hypoglossal and phrenic nerves and of the mylohyoid branch of the trigeminal nerve. At normocapnia, a respiratory-modulated trigeminal discharge could be discerned in most cats. This discharge was characterized by a diminution of activity during neural inspiration and a peak in expiration. In hypercapnia or hypoxia, peak activity increased and its time of occurrence moved to late inspiration. Augmentations of peak trigeminal, hypoglossal and phrenic activities were proportional. Peak trigeminal and hypoglossal activities increased more than phrenic following administrations of protriptyline, strychnine and, in some cats, cyanide or doxapram. Peak trigeminal activity fell more than phrenic after diazepam. Pentobarbital or halothane reduced peak hypoglossal, but not trigeminal, activity more than phrenic. However, after these anesthetics, trigeminal activity became restricted to the inspiratory-expiratory junction. We conclude that trigeminal and hypoglossal activities are more dependent upon processes within the reticular formation than is the bulbospinal-phrenic system. Central and peripheral chemoreceptor influences are distributed equivalently upon trigeminal, hypoglossal and phrenic motoneurons.
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