Abolition of ventilatory response to caffeine in chemodenervated lambs

Mechanistic actions of oxygen and methylxanthines on respiratory neural control and for the treatment of neonatal apnea

Apnea remains one of the most concerning and prevalent respiratory disorders spanning all ages from infants (particularly those born preterm) to adults. Although the pathophysiological consequences of apnea are fairly well described, the neural mechanisms underlying the etiology of the different types of apnea (central, obstructive, and mixed) still remain incompletely understood. From a developmental perspective, however, research into the respiratory neural control system of immature animals has shed light on both central and peripheral neural pathways underlying apnea of prematurity (AOP), a highly prevalent respiratory disorder of preterm infants. Animal studies have also been fundamental in furthering our understanding of how clinical interventions (e.g. pharmacological and mechanical) exert their beneficial effects in the clinical treatment of apnea. Although current clinical interventions such as supplemental O2 and positive pressure respiratory support are critically important for the infant in respiratory distress, they are not fully effective and can also come with unfortunate, unintended (and long-term) side-effects. In this review, we have chosen AOP as one of the most common clinical scenarios involving apnea to highlight the mechanistic basis behind how some of the interventions could be both beneficial and also deleterious to the respiratory neural control system. We have included a section on infants with critical congenital heart diseases (CCHD), in whom apnea can be a clinical concern due to treatment with prostaglandin, and who may benefit from some of the treatments used for AOP.

Caffeine use in the neonatal intensive care unit

Caffeine is the most frequently used medication in the neonatal intensive care unit. It is used for the prevention and treatment of apnea, although this has been associated with lower incidence of bronchopulmonary dysplasia (BPD) and patent ductus arteriosus as well as intact survival at 18-21 months of life. Although neurodevelopmental advantage was no longer statistically significant at age 5 years, caffeine was associated with sustained improvement in co-ordination and less gross motor impairment than placebo. The mechanism of action of caffeine on prevention of apnea and activation of breathing seems to be through central inhibition of adenosine receptors. However, its impact on BPD and neurodevelopmental outcomes might be induced through its effects as anti-inflammatory mediator, protection of white matter, and induction of surfactant protein B. Whereas long-term studies have documented the safety of caffeine as used in current practice, further studies are clearly needed to identify optimum dosing, and time of starting and discontinuing caffeine.

Effect of caffeine on peripheral chemoreceptor activity in premature neonates: interaction with sleep stages

Caffeine is widely used for the treatment of apnea in premature neonates. However, the localization of caffeine's target site (central nervous system and/or peripheral chemoreceptors) is not well defined, especially for sleeping neonates whose sleep stages interact with respiratory control. The aim of this study was to assess the activity of the peripheral chemoreceptors in relation to sleep stages in premature neonates treated (or not) with caffeine for idiopathic apnea. Peripheral chemoreceptor activity was assessed in 22 neonates (postconceptional age of 36 +/- 1 wk with birth weights ranging from 790 to 1,910 g) by performing a 30-s hyperoxic test during active and quiet sleep. Eleven neonates received caffeine treatment (4.0 +/- 0.5 mg.kg(-1).day(-1)) and 11 served as controls. For all neonates, the decrease in minute ventilation observed during hyperoxia was greater during active than during quiet sleep. Neonates receiving caffeine showed a significantly greater decrease in ventilation during hyperoxia in both sleep stages, compared with controls (caffeine; -29.7 +/- 12.8% vs. control; -22.0 +/- 7.4%; F(1,15) = 4.6, P = 0.04). We conclude that caffeine administration increases the effectiveness of chemoreceptor activity. Because sleep stage durations were not affected by the treatment, it is likely that the decrease in apneic episodes typically observed with caffeine therapy is only related to respiratory processes and is independent of the sleep stage organization.

Effects of caffeine on carotid sinus nerve chemosensory discharge in kittens and cats

Caffeine (C) decreases apneic episodes in premature infants and is thought to stimulate breathing mainly by a central mechanism. While the methylxanthines theophylline and aminophylline are known to alter the carotid chemoreceptor activity, there are little data on C. The aim of the study was to examine the effects of C on the carotid sinus nerve discharge (CSND) in developing animals. Nine kittens 17-21 days old and six adult cats that were anesthetized and artificially ventilated were studied. They received four consecutive doses of C, each of 10 mg/kg, administered at intervals of 20 min either as intravenous bolus injection (6 kittens, 3 cats) or continuous infusion (3 kittens, 3 cats). Bolus injections of C invariably induced a prompt but transient increase in the CSND from 4.1 +/- 0.6 to 8.1 +/- 1.0 (SE) impulses/s in kittens (P = 0.01) and form 3.9 +/- 0.1 to 7.9 to 1.0 impulses/s in cats (after the first injection). This response was associated with a significant decrease in arterial blood pressure. Continuous infusion of C did not induce any early change in either CSND or blood pressure in kittens or cats. Fifteen minutes after C injection or infusion was begun, CSND values in air, 8% O2-balance N2, or 100% O2 were not significantly different from control. Haloperidol administered at the end of the experiment in four cats and four kittens significantly increased CSND and did not suppress the early response to C injection. It is concluded that caffeine administered by bolus in the kitten induces a transient stimulation of the CSND that is associated with a decrease in the arterial blood pressure and is independent of the dopaminergic mechanisms in the carotid body. The lack of sustained effect implies the main mechanism to the ventilatory stimulation by C must be central.

Carotid bodies and ventilatory response to hypoxia in aminophylline-treated piglets

Peripheral chemoreceptors may be immature in neonatal animals, exhibiting maturational changes in the perinatal period. Even though methylxanthines are respiratory stimulants, many premature neonates do not respond to them. Thus, we hypothesized that carotid body activity is necessary for aminophylline to reverse hypoxia-induced respiratory depression. We exposed 16 anesthetized newborn piglets (age 2-7 days) to hypoxia (inhalation of 12% oxygen) for 5 min. Aminophylline (15 mg/kg iv) was administered either prior to (11 piglets) or following (5 piglets) carotid body denervation (CBD). Before CBD, hypoxia elicited transient initial increases in tidal volume (from 79 +/- 4 to 99 +/- 1% of maximum, mean +/- SE), minute ventilation (from 64 +/- 5 to 93 +/- 4%), and peak phrenic electroneurogram (from 63 +/- 8 to 91 +/- 6%, all P < 0.05). This was followed by a decrease in tidal volume, minute ventilation and phrenic electroneurogram (all P < 0.05). Prior to CBD, aminophylline pretreatment prevented the decrease in all the measures of respiratory output during late hypoxia. After CBD, hypoxia induced an initial and sustained depression of ventilation (tidal volume from 100 to 33 +/- 14%; frequency from 94 +/- 4 to 42 +/- 17%; minute ventilation from 100 to 32 +/- 14%, all P < 0.05) and phrenic electroneurogram (peak phrenic from 100 to 47 +/- 18%; minute phrenic from 85 +/- 6 to 55 +/- 21%, both P < 0.05). Administration of aminophylline after CBD did not prevent the profound respiratory depression elicited by hypoxia in the chemodenervated piglets.(ABSTRACT TRUNCATED AT 250 WORDS)

Aminophylline and increased activity of peripheral chemoreceptors in newborn infants

Peripheral chemoreceptor activity was studied in nine healthy, unsedated neonates (with a mean (SD) postconceptional age of 39 (2) weeks and birth weight of 3000 (400) g) by measuring the inhibition of ventilation elicited by five breaths of 100% oxygen (Dejours technique). Changes in tidal volume, frequency, and minute ventilation were measured before and after administration of aminophylline (10 mg/kg by mouth). Before aminophylline hyperoxia induced a decrease in minute ventilation (from a mean (SE) of 825 (55) to 520 (30) ml/kg/min) as result of reduction of tidal volume (from 12 (0.3) to 8 (0.3) ml/kg). After aminophylline administration the hyperoxia induced decrease in tidal volume (from 14 (0.7) to 6 (0.3) ml/kg) and minute ventilation (from 847 (57) to 386 (21) ml/kg/min) was significantly greater than before. It is concluded that in neonates peripheral chemoreceptors are more active in the presence of aminophylline. It is speculated that aminophylline increases the activity of peripheral chemoreceptors, reducing the breakdown of cAMP, which is a crucial mediator for peripheral chemoreceptor discharge.

Ventilatory response to keto-doxapram in intact and carotid body denervated lambs

We aimed to investigate the role of the carotid bodies in the ventilatory response to keto-doxapram, and whether this response was dose-dependent; we studied two group (n = 5 per group) of awake, intact and carotid-body denervated (CBD) lambs, aged 10-15 days. At 20 min intervals, they received 0.5, 1.0, 2.5 and 5.0 m g/kg mg/kg of keto-doxapram as an intravenous bolus infusion. Plasma keto-doxapram was measured (HPLC). Ventilation was recorded via a face mask and a pneumotachograph. In intact lambs, an immediate dose-dependent increase in minute ventilation (V1) was observed. At 2 min, VI increased from baseline by 125 +/- 28, 212 +/- 49, 378 +/- 41 and 637 +/- 92 mol.kg 1.min 1 (mean +/- SE, P less than 0.01) corresponding to the foregoing incremental doses. A significant correlation was observed between the peak VI and the corresponding plasma keto-doxapram concentrations (r = 0.73, P less than 0.0003). In CBD lambs, VI increased significantly less than in intact animals. In conclusion, early ventilatory response to keto-doxapram depends mainly on intact carotid bodies, and the effect is dose-dependent.

Effects of theophylline on ventilatory response to hypoxic challenge

The respiratory and arousal responses to mild hypoxia during quiet sleep were studied using inductive plethysmography and transcutaneous gas electrodes in 11 apnoeic infants before and after the administration of oral theophylline (3 mg/kg). Theophylline changed the ventilatory response to a more biphasic pattern--that is, ventilation decreased after an initial increase. The relative ventilatory slope (defined as the decrease in transcutaneous carbon dioxide tension (PCO2) in relation to the fall in transcutaneous oxygen tension (PO2)) decreased significantly after theophylline. Four infants were roused during hypoxia before theophylline administration compared with none after treatment. Theophylline abolished the periodic breathing induced by hypoxia in one of six infants. These findings suggest that methylxanthines may not, as previously thought, enhance the respiratory drive during hypoxia.