Autonomic and metabolic effects of OSA in childhood obesity

This study investigates the effects of exposure to intermittent hypoxia on cardiovascular autonomic control and metabolic function in obese children with obstructive sleep apnea (OSA). Each subject underwent: (1) a polysomnography; (2) morning fasting blood samples and a subsequent FSIVGTT; (3) noninvasive measurement of respiration, arterial blood pressure, and heart rate during supine and standing postures. Assessment of adiposity was performed using a DEXA scan. From these measurements, we deduced the pertinent sleep parameters, Bergman minimal model parameters and the parameters characterizing a minimal model of cardiovascular variability. Results suggest that intermittent hypoxia in OSA contributes independently to insulin resistance and autonomic dysfunction in overweight children.

Sickle cell disease: selected aspects of pathophysiology

Sickle cell disease (SCD), a genetically-determined pathology due to an amino acid substitution (i.e., valine for glutamic acid) on the beta-chain of hemoglobin, is characterized by abnormal blood rheology and periods of painful vascular occlusive crises. Sickle cell trait (SCT) is a typically benign variant in which only one beta chain is affected by the mutation. Although both SCD and SCT have been the subject of numerous studies, information related to neurological function and transfusion therapy is still incomplete: an overview of these areas is presented. An initial section provides pertinent background information on the pathology and clinical significance of these diseases. The roles of three factors in the clinical manifestations of the diseases are then discussed: hypoxia, autonomic nervous system regulation and blood rheology. The possibility of a causal relationship between these three factors and sudden death is also examined. It is concluded that further studies in these specific areas are warranted. It is anticipated that the outcome of such research is likely to provide valuable insights into the pathophysiology of SCD and SCT and will lead to improved clinical management and enhanced quality of life.

"Optimal" application of ventilatory assist in Cheyne-Stokes respiration: a simulation study

Although a variety of ventilator therapies have been employed to treat Cheyne-Stokes respiration (CSR), these modalities do not completely eliminate CSR. As well, most current strategies require that ventilatory assist be provided continuously. We used a computer model of the respiratory control system to determine whether a ventilatory assist strategy could be found that would substantially reduce the severity of CSR while minimizing the application of positive airway pressure. We assessed the effects of different levels of ventilatory assist applied during breaths that fell below selected hypopneic thresholds. These could be applied during the descending, ascending, or both phases of the CSR cycle. We found that ventilatory augmentation equal to 30-40% of eupneic drive, applied whenever ventilation fell below 70% of the eupneic level during the ascending or descending-and-ascending phases of CSR led to the greatest regularization of breathing with minimal ventilator intervention. Application of ventilatory assist during the descending phase produced little effect.

Cardiac autonomic control in obstructive sleep apnea: effects of long-term CPAP therapy

To determine how long-term treatment with continuous positive airway pressure (CPAP) affects cardiac autonomic function, we measured R-R interval (RRI), respiration, and blood pressure in 13 awake patients with moderate-to-severe obstructive sleep apnea (OSA) in both supine and standing postures, before and after 3 to 9 mo of home therapy. Using visual feedback, the subjects controlled their respiration to track a randomized breathing pattern. From the RRI spectrum, we computed high-frequency power and the ratio of low-frequency to high-frequency power (LHR). To correct for differences in breathing, the average transfer gain relating respiration to RRI changes (G(RSA)) and the modified low-frequency to high-frequency ratio (MLHR) were also derived. CPAP therapy did not change the conventional spectral indices of heart rate variability (HRV). However, G(RSA) increased with average nightly CPAP use in supine (p < 0.01) and standing (p < 0.03) postures, whereas MLHR decreased with CPAP compliance during standing (p < 0.03). Supine mean heart rate decreased with compliance (p < 0.03). None of the estimated parameters was correlated with duration of therapy when actual CPAP use was not taken into account. These results suggest that CPAP treatment improves vagal heart rate control in patients with OSA and that the degree of improvement varies directly with compliance level.

Spectral analysis of heart rate variability and respiration during sleep in cocaine-exposed neonates

This study's objective was to examine the autonomic control of heart rate and respiration during the neonatal period in human infants with prenatal exposure to cocaine. Four-hour daytime recordings of the electrocardiogram (ECG) were obtained from 15 cocaine-exposed and 13 non-exposed full-term neonates at 2 weeks of age during quiet sleep (QS) and active sleep (AS). For each 1-min epoch of sleep, the power spectrum of the R-R intervals was computed from the ECG to obtain the total power (0-2 Hz), and spectral power in the high-frequency (HFP, 0.3-2 Hz), mid-frequency (MFP, 0.1-0.2 Hz), and low-frequency (LFP, 0.03-0.1 Hz) bands. Respiration was also monitored and processed using similar spectral analysis procedures. Cocaine-exposed neonates showed enhanced heart rate variability reflected by an increase in spectral power across all frequency bands. Spectral power in LFP and MFP was higher in cocaine-exposed neonates during both sleep states, but only in HFP during QS. There were no respiratory patterning differences between the groups to account for these findings. The index of sympathovagal balance (LFP + MFP)/HFP, showed no differences between the groups. We conclude that infants exposed to cocaine in utero show differences in the modulation of heart rate reflecting an increase in both vagal and sympathetic influences.

Nonlinear dynamics of heart rate variability in cocaine-exposed neonates during sleep

The aim of this study was to determine the effects of prenatal cocaine exposure (PCE) on the dynamics of heart rate variability in full-term neonates during sleep. R-R interval (RRI) time series from 9 infants with PCE and 12 controls during periods of stable quiet sleep and active sleep were analyzed using autoregressive modeling and nonlinear dynamics. There were no differences between the two groups in spectral power distribution, approximate entropy, correlation dimension, and nonlinear predictability. However, application of surrogate data analysis to these measures revealed a significant degree of nonlinear RRI dynamics in all subjects. A parametric model, consisting of a nonlinear delayed-feedback system with stochastic noise as the perturbing input, was employed to estimate the relative contributions of linear and nonlinear deterministic dynamics in the data. Both infant groups showed similar proportional contributions in linear, nonlinear, and stochastic dynamics. However, approximate entropy, correlation dimension, and nonlinear prediction error were all decreased in active versus quiet sleep; in addition, the parametric model revealed a doubling of the linear component and a halving of the nonlinear contribution to overall heart rate variability. Spectral analysis indicated a shift in relative power toward lower frequencies. We conclude that 1) RRI dynamics in infants with PCE and normal controls are similar; and 2) in both groups, sympathetic dominance during active sleep produces primarily periodic low-frequency oscillations in RRI, whereas in quiet sleep vagal modulation leads to RRI fluctuations that are broadband and dynamically more complex.

Determinants of ventilatory instability and variability

This paper reviews the major mechanisms that can give rise to various forms of variability in the ventilatory pattern. First, an elevated controller gain, coupled with the presence of delays and response lags in the chemoreflex loops, can lead to instability in feedback control and give rise to periodic breathing. This form of ventilatory stability can be assessed quantitatively by employing the concept of 'loop gain'. Several different methods of estimating loop gain from steady state or dynamic respiratory measurements are discussed. An inherently stable respiratory control system can also exhibit periodic behavior due to the influence of primary fluctuations in sleep-wake state and other physiological variables, such as cardiac output and cerebral blood flow. Self-sustained, irregular ventilatory fluctuations may be generated by nonlinear dynamic interactions between various components of the respiratory control system, such as the lung vagal afferents and the respiratory pattern generator, or through the propagation of stochastic disturbances around the chemoreflex loops.

Spectral indices of cardiac autonomic function in obstructive sleep apnea

Spectral analysis of heart rate variability (HRV) is useful as a noninvasive means of assessing autonomic function in patients with obstructive sleep apnea (OSA). However, standard spectral measures, such as the ratio of low-frequency to high-frequency power (LHR) and normalized high-frequency power (NHFP), can be confounded by the abnormal breathing patterns that occur during sleep. To circumvent this limitation, we employed an autoregressive modeling approach to partition the RR time-series into a component that is correlated with respiration and a respiration-independent component. From these components, we derived two new spectral indices: the modified LHR (MLHR) and the average gain relating respiration to RR changes (GRSA). Six normals and seven OSA patients were studied in relaxed wakefulness and stage 2 sleep; during sleep, the OSA patients were studied without and with continuous positive airway pressure (CPAP) therapy. All four spectral indices showed significant differences between OSA patients and normals in both wakefulness and sleep, although the changes in MLHR and GRSA were substantially larger and less variable: MLHR (p < 0.0003) and GRSA (p < 0.0001) vs. LHR (p < 0.005) and NHFP (p < 0.004). However, in the OSA subjects, LHR and NHFP were unchanged by CPAP. By contrast, CPAP produced a highly significant increase in GRSA (p < 0.0004), as well as a decrease in MLHR (p < 0.03). Thus, by compensating for the effects of breathing pattern differences, MLHR and GRSA unmasked the effects of CPAP therapy, which has been shown in previous studies to reduce sympathetic activity and increase vagal cardiac modulation.

Fuzzy assessment of sleep-disordered breathing during continuous positive airway pressure therapy

We propose a new method of quantifying sleep-disordered breathing (SDB) for the purpose of automating continuous positive airway pressure (CPAP) titration. Our algorithm, based on fuzzy logic, emulates the less-than-crisp kind of decision-making generally employed at the human level. Three input variables were first derived on a breath-by-breath basis from respiratory airflow measurements. These were: (1) the relative duration of inspiratory flow limitation in each breath; (2) the degree of hypopnea relative to the past 15 breaths; and (3) the intensity of snoring. Using these descriptors as inputs, our fuzzy inference algorithm produced a "severity index" (SI) quantifying the degree of SDB. Severity index was determined in CPAP titration procedures conducted on one normal snorer and 12 patients with moderate-to-severe obstructive sleep apnea. SI computed over the last 6 minutes of each CPAP level was compared against other more-conventional indices of SDB, such as total pulmonary resistance (RL), the number of apneas and hypopneas (NAH), and the number of arousals (NAr). In all but one of the subjects, the correlation coefficients for SI vs each of RL, NAH, and NAr were significantly different from zero, but not different from each other. The group correlation coefficients for SI vs RL, NAH, and NAr were 0.89, 0.86, and 0.87, respectively, demonstrating that SI accurately quantifies SDB. SI collapses multiple features of the airflow pattern into a single index and, therefore, may be useful as a "feedback" variable for the automatic control of CPAP therapy.

Within-night variation in respiratory effort preceding apnea termination and EEG delta power in sleep apnea

We studied the within-night variability of the maximum esophageal pressure deflection before apnea termination (DPmax) in nine patients with severe obstructive sleep apnea as an index of the arousal threshold and the mean electroencephalogram (EEG) delta power for each 30 s as an index of the timing of sleep cycles. Periodicity in the time variation of delta power and DPmax was analyzed by determining their power spectral density and their relationship determined by cross correlation. DPmax and delta power varied cyclically and in phase with a major periodicity (major peak in power spectral density) of 117.6 +/- 8.8 (SE) min. The correlation between the values of DPmax and delta power was significant (P < 0.001) in each subject (mean r = 0.47 +/- 0.03), and the coherence between DPmax and delta power at their dominant frequency was high. Within cycles of non-rapid-eye-movement sleep, DPmax and delta power increased, reaching peak values on average at or after midcycle. These findings suggest that the arousal threshold to airway occlusion in patients with obstructive sleep apnea varies cyclically during the night synchronous to the underlying cycles of sleep.

Ventilatory dynamics of transient arousal in patients with obstructive sleep apnea

The hyperpnea that accompanies arousal at the end of obstructive apnea is believed to be due to the progressive build-up in chemical drive during the apnea and a state-related decrease in upper airway resistance. We postulated the existence of a third component: a state-related transient increase in neural drive to the ventilatory pump muscles. To quantify this contribution, we measured the ventilatory response to arousal (VRA) in eight patients with obstructive sleep apnea (OSA) during continuous positive airway pressure (CPAP) therapy, applied at individually titrated levels. CPAP application reduced total pulmonary resistance (RL) to approximately normal levels, stabilizing ventilation and sleep state. Transient arousal from stage 2 sleep was induced using 5-sec tones (60-90 dB). Mean inspiratory flow increased above control on the second and third post-arousal breaths (P < 0.05), with a peak increase of 7.8 +/- 2.9 L/min while the accompanying changes in RL were significant. The time-course of VRA measured in three normal subjects under CPAP was similar to that observed in the OSA patients. However, elimination of CPAP prolonged the VRA time-course. Taken together, these findings demonstrate that: (1) during arousal, the increase in state-related neural respiratory drive is short-lived but not substantial; and (2) the resulting VRA time-course is shaped by the dynamics of the upper airway response to arousal.

Estimation of cardiorespiratory transfer under spontaneous breathing conditions: a theoretical study

Using simulated noisy sequences of respiration and heart rate, we assessed the accuracy of the respiratory sinus arrhythmia transfer function (RSATF) estimation under three kinds of spontaneous breathing patterns: regular or tidal breathing, periodic breathing with apnea, and broadband breathing. Estimation employing the cross-power and autopower spectra of the simulated data produced RSATF estimates that were generally more variable than those computed with an autoregressive modeling approach. Variability and bias errors in the RSATF estimates became larger as respiratory bandwidth decreased when the breathing pattern changed from broadband to periodic to regular breathing. However, between frequencies of 0.1 and 0.3 Hz, these errors fell within 12% in all breathing patterns. Error in the RSATF estimates was only slightly increased, with reductions in data length to as low as 90 s. The results suggest the feasibility of obtaining accurate estimates of RSATF between 0.1 and 0.8 Hz from a wide variety of conditions, such as in different sleep-wake states where voluntary control of breathing is not possible and the ventilatory pattern may vary substantially.

Estimation of chemoreflex loop gain using pseudorandom binary CO2 stimulation

We have developed a method for deriving estimates of the chemoreflex control loop gain (LG) from the ventilatory response to inhaled CO2, modulated between 0% and 5% in the form of a pseudorandom binary sequence. The corresponding changes in alveolar (and thus, arterial) CO2 result from two components: 1) the direct effect of breath-to-breath changes in inhaled CO2 and 2) the chemoreflex-mediated changes in ventilation. LG between 0.01 and 0.03 Hz, the frequency range pertinent to periodic breathing, was estimated by computationally delineating the first component from the overall ventilatory response. The method was tested against simulated and experimental data. In both cases, we found strong correlations between our predictions and LG magnitude estimates derived by other methods. However, LG phase estimates were considerably more variable when compared to model predictions based on small-signal analysis. We propose that our method, which uses data from a single test procedure lasting < 10 min, may be more useful than traditional tests of chemoresponsiveness for the quantitative assessment of respiratory control stability during changes in sleep-wake state.

Modeling the interaction between arousal and chemical drive in sleep-disordered breathing

We have measured the ventilatory response to acoustically induced arousal in normal subjects and patients with obstructive sleep apnea syndrome (OSAS). The arousal responses are similar in magnitude and time-course over the first 3 breaths, but in OSAS the subsequent response declines much more rapidly. Incorporation of these empirical findings into an existing model of sleep-disordered breathing allows an improved characterization of state-chemoreflex interactions. The shorter time-course of the arousal response in OSAS promotes greater ventilatory and state instability at low-to-intermediate levels of CO2 gain.

Transduction dynamics of intrapulmonary CO2 receptors

We have developed a functional model for quantitatively characterizing the transduction dynamics of the intrapulmonary CO2 receptors (IPC) in the snake lung. The model was based on experiments in which the neural discharges of several IPCs were recorded in response to abrupt step changes in CO2 concentration. Initial attempts to model the transduction dynamics linearly proved inadequate, although the linear model captured gross features such as rate sensitivity and the existence of two time constants in the adaptation time-course. However, with the incorporation of two static nonlinear features, namely, thresholding and preferential directionality of the rate-sensitive component, it was possible to account for over 80% of the total variation in the data. The model produced accurate predictions of IPC responses to other inputs, such as pseudorandom binary changes in CO2. The model also allows the prediction of IPC discharge in spontaneous breathing given measurements of lung CO2 concentration, and may serve as a starting point for further studies of transduction mechanisms at the cellular level.

Ventilatory dynamics during transient arousal from NREM sleep: implications for respiratory control stability

The polysomnographic and ventilatory patterns of nine normal adults were measured during non-rapid-eye-movement (NREM) stage 2 sleep before and after repeated administrations of a tone (40-72 dB) lasting 5 s. The ventilatory response to arousal (VRA) was determined in data sections showing electrocortical arousal following the start of the tone. Mean inspiratory flow and tidal volume increased significantly above control levels in the first seven breaths after the start of arousal, with peak increases (64.2% > control) occurring on the second breath. Breath-to-breath occlusion pressure 100 ms after the start of inspiration showed significant increases only on the second and third postarousal breaths, whereas upper airway resistance declined immediately and remained below control for > or = 7 consecutive breaths. These results suggest that the first breath and latter portion of the VRA are determined more by upper airway dynamics than by changes in the neural drive to breathe. Computer model simulations comparing different VRA time courses show that sustained periodic apnea is more likely to occur when the fall in the postarousal increase in ventilation is more abrupt.

Dynamics of periodic breathing and arousal during sleep at extreme altitude

To determine whether nocturnal periodic breathing (PB) at altitude is due primarily to unstable control of ventilation or the inability to maintain stable sleep states, we performed visual and computer analyses of the electroencephalographic and respiratory records of healthy volunteers at simulated altitudes of 4572, 6100 and 7620 m. Transient arousals were associated with < 52% of the apneas identified; thus, the PB cycle was not always associated with transient arousal. Following the termination of oxygen breathing, the reinitiation of PB was not dependent on the occurrence of arousal as the primary event. The transition from apnea to breathing preceded the appearance of arousal by approximately 1 to 4 sec. Ventilatory drive in the breaths immediately following arousal was significantly larger than corresponding control breaths, matched for SaO2. Our findings suggest that altitude-induced PB is unlikely to result from primary fluctuations in state. Arousals promote the development of PB with apnea and help to sustain these episodes, but are not necessary for their initiation.

Estimation of dynamic chemoresponsiveness in wakefulness and non-rapid-eye-movement sleep

We developed a method for quantifying dynamic chemoresponsiveness on the basis of the ventilatory response to pseudorandom binary CO2 stimulation. The dynamic chemoreflex gain (GD) and effective time delay (TDeff) relating breath-to-breath fluctuations in alveolar PCO2 to ventilation were evaluated at frequencies between 0 and 0.05 Hz. Application of the method to simulated "data" showed that estimation errors in GD and TDeff were most likely to be minimized in the range of 0.01-0.03 Hz, corresponding to periodicities of 30-100 s. Estimation of TDeff was generally more susceptible to error than that of GD because of the limited time resolution of the breath-by-breath measurements. In eight awake normal adults, we compared estimates of GD derived from the pseudorandom binary CO2 stimulation test with peripheral and central hypercapnic sensitivities deduced from single-breath and Read rebreathing measurements in the same subject. GD at 0.02 Hz was highly correlated with peripheral hypercapnic sensitivity but poorly correlated with central hypercapnic sensitivity, underscoring the importance of the peripheral chemoreflexes in mediating ventilatory responses to phasic stimuli. Application of the procedure to a different group of 10 healthy volunteers during wakefulness and stage 2 sleep showed decreases in GD in 8 subjects but increases in 2 subjects. However, for the group as a whole, GD and TDeff did not change significantly between wakefulness and sleep. The proposed method may provide information more pertinent to periodic breathing than traditional CO2 response tests do, since the chemoreflex responses to phasic variations in blood gases are likely to be important in determining ventilatory control during sleep.

Change in the peripheral CO2 chemoreflex from rest to exercise

A single-breath CO2 test of peripheral chemosensitivity has recently been described, and elaborated based on model simulations. This study was designed to measure the peripheral CO2 chemoreflex at rest and during heavy exercise to see if carotid chemosensitivity to CO2 increased. Ten healthy, adult males performed an incremental exercise test to determine their ventilatory anaerobic threshold (VAT), and 20 minutes of steady-state exercise at a pre-determined power output above VAT. Arterialized venous blood was obtained during each minute of incremental exercise to verify development of metabolic acidosis. Carotid chemosensitivity was tested repeatedly at rest and in steady-state exercise by the ventilatory response to a single breath of 13% CO2 in air. The peripheral chemoreflex for CO2 for the group of subjects doubled from rest to exercise (mean 0.096 l.s-1.kPa-1) with all subjects showing an increase. We conclude that the gain of the carotid CO2 chemoreflex increases from rest to exercise at work above the VAT.

Ventilatory response to randomly modulated hypercapnia and hypoxia in humans

We have developed a new method for characterizing the ventilatory response to combined hypercapnia and hypoxia (HCVR-HVR) based on the results of a single test procedure. The method is designed to evoke both hypercapnic and hypoxic responses simultaneously and to enable quantification of their static and dynamic features using an estimation algorithm based on the prediction error method. In six healthy subjects, we measured HCVR-HVR by modulating the CO2 and O2 content of the inhaled mixture in the form of two statistically independent random sequences. A two-component dynamic model was found to provide an adequate description of the stimulation-response data sets. The model consisted of a CO2 subsystem and a CO2-O2 subsystem in which a multiplicative interaction between hypercapnia and hypoxia was assumed. The steady-state gains were 2.08 +/- 0.68 (SD) 1.min-1.Torr-1 for the CO2 subsystem and 0.10 +/- 0.05 l.min-1.Torr-1 for the CO2-O2 subsystem, and the corresponding time constants were 116.7 +/- 32.3 and 19.0 +/- 4.4 s, respectively. Our results suggest that the hypercapnic component of HCVR-HVR is mediated primarily by the central chemoreceptors, whereas the interaction component is mediated largely by the peripheral chemoreceptors.

Optimal ventilatory patterns in periodic breathing

The goal of this study was to determine whether periodic breathing (PB), which is highly prevalent during sleep at high altitudes, imposes physiological penalties on the respiratory system in the absence of any accompanying disease. Using a computer model of respiratory gas exchange, we compared the effects of a variety of PB patterns on the chemical and mechanical costs of breathing to those resulting from regular tidal breathing. Although PB produced considerable fluctuation in arterial blood gas tensions, for the same cycle-averaged ventilation, higher arterial oxygen saturation and lower arterial carbon dioxide levels were achieved. This result can be explained by the fact that the combination of large breaths and apnea in PB leads to a substantial reduction in dead space ventilation. At the same time, the savings in mechanical cost achieved by the respiratory muscles during apnea partially offset the increase during the breathing phase. Consequently, the "pressure cost," a criterion based on mean inspiratory pressure, was elevated only slightly, although the average work rate of breathing increased significantly. We found that, at extreme altitudes, PB patterns with clusters of 2 to 4 large breaths that alternate with apnea produce the highest arterial oxygenation levels and lowest pressure costs. The common occurrence of PB patterns with closely similar features has been reported in sleeping healthy sojourners at extreme altitudes. Taken together, these findings suggest that PB favors a reduction in the oxygen demands of the respiratory muscles and therefore may not be as detrimental as it is generally believed to be.

Optimal application of high-frequency ventilation in infants: a theoretical study

A recent multicenter study of preterm infants concluded that high-frequency ventilation (HFV) applied at 15 Hz, in comparison with conventional mechanical ventilation (CMV), did not lead to reduced incidence of barotrauma, contrary to previous expectations. The primary goal of the present theoretical study was to determine whether computed estimates of lung pressures during HFV and CMV are consistent with these findings. An existing theoretical model of lung mechanics and gas transport in HFV was modified for applicability to neonates. New features, such as expiratory flow limitation and pulmonary air leak, were also incorporated. Simulations with the model were conducted assuming combinations of frequency and tidal volume that maintained a constant level of eucapnia. We found that peak alveolar pressures and the magnitude of alveolar pressure swings resulting from HFV at 15 Hz were in general comparable to those produced by CMV in healthy neonates and infants with bronchopulmonary dysplasia; peak alveolar pressures in the latter group tended to be higher with HFV than in CMV. Application of HFV at 15 Hz was even less advantageous than CMV when pulmonary air leak was also present in the infants with bronchopulmonary dysplasia. However, the model predicted the existence of an optimal range of frequencies between 2 and 4 Hz in which alveolar pressure swings and peak alveolar pressures could be minimized, and in some cases, reduced below the levels produced by CMV.

Sleep-induced periodic breathing and apnea: a theoretical study

To elucidate the mechanisms that lead to sleep-disordered breathing, we have developed a mathematical model that allows for dynamic interactions among the chemical control of respiration, changes in sleep-waking state, and changes in upper airway patency. The increase in steady-state arterial PCO2 accompanying sleep is shown to be inversely related to the ventilatory response to CO2. Chemical control of respiration becomes less stable during the light stage of sleep, despite a reduction in chemoresponsiveness, due to a concomitant increase in "plant gain" (i.e., responsiveness of blood gases to ventilatory changes). The withdrawal of the "wakefulness drive" during sleep onset represents a strong perturbation to respiratory control: higher magnitudes and rates of withdrawal of this drive favor instability. These results may account for the higher incidence of periodic breathing observed during light sleep and sleep onset. Periodic ventilation can also result from repetitive alternations between sleep onset and arousal. The potential for instability is further compounded if the possibility of upper airway occlusion is also included. In systems with high controller gains, instability is mediated primarily through chemoreflex overcompensation. However, in systems with depressed chemoresponsiveness, rapid sleep onset and large blood gas fluctuations trigger repetitive episodes of arousal and hyperpnea alternating with apneas that may or may not be obstructive. Between these extremes, more complex patterns can arise from the interaction between chemoreflex-mediated oscillations of shorter-cycle-duration (approximately 36 s) and longer-wavelength (approximately 60-80 s) state-driven oscillations.

A model-based evaluation of the single-breath CO2 ventilatory response test

The accuracy of the single-breath CO2 inhalation test as a method for determining peripheral chemoreflex gain (Gp) is evaluated through computer simulations using a mathematical model of the closed-loop respiratory control system. Estimates of Gp (G'p) are based on "corrected" changes in end-tidal PCO2, because the uncorrected end-tidal values do not accurately reflect changes in alveolar PCO2. The influence of the central chemoreflex on G'p is generally less than 10% but can become disproportionally more significant as the relative contribution of the peripheral chemoreflex diminishes. G'p tends to overestimate Gp with the inclusion of peripheral chemoreceptor rate sensitivity, but this effect is offset by the time constant for adaptation. The spontaneous variability of breathing can seriously impair the resolution of G'p. Averaging of G'p deduced from individual single-breath tests can lead to erroneous estimates of Gp even when a large number of repetitions are performed. This problem can be minimized by first ensemble averaging the data from individual single-breath tests and, then, computing G'p from the resulting mean changes.

Estimation of peripheral chemoreflex gain from spontaneous sigh responses

A method is proposed for quantifying the responsiveness of the peripheral chemoreflex loop to CO2 by utilizing the natural fluctuations in ventilation and end-tidal PCO2 which occur subsequent to the appearance of spontaneous sighs. The advantage of this method lies in its simplicity and noninvasiveness: the need for administering inhaled mixtures with high CO2 content is eliminated. Using autoregressive moving-average (ARMA) analysis, we demonstrate that post-sigh responses can be adequately described by a simple chemoreflex model that contains first-order dynamics and a pure time delay. The effective gain of this model is shown to reflect peripheral chemosensitivity closely when the estimation procedure is applied to 'data' obtained from computer simulations of the respiratory control system. Although central chemosensitivity affects the absolute values of effective gain, the slope of the linear correlation between effective and peripheral gains remains unchanged. Application of the procedure to spontaneously breathing anesthetized dogs shows that, in every case, effective gain increased with the induction of hypoxia, which is known to enhance peripheral chemosensitivity.

Lung pressures and gas transport during high-frequency airway and chest wall oscillation

The major goal of this study was to compare gas exchange, tidal volume (VT), and dynamic lung pressures resulting from high-frequency airway oscillation (HFAO) with the corresponding effects in high-frequency chest wall oscillation (HFCWO). Eight anesthetized paralyzed dogs were maintained eucapnic with HFAO and HFCWO at frequencies ranging from 1 to 16 Hz in the former and 0.5 to 8 Hz in the latter. Tracheal (delta Ptr) and esophageal (delta Pes) pressure swings, VT, and arterial blood gases were measured in addition to respiratory impedance and static pressure-volume curves. Mean positive pressure (25-30 cmH2O) in the chest cuff associated with HFCWO generation decreased lung volume by approximately 200 ml and increased pulmonary impedance significantly. Aside from this decrease in functional residual capacity (FRC), no change in lung volume occurred as a result of dynamic factors during the course of HFCWO application. With HFAO, a small degree of hyperinflation occurred only at 16 Hz. Arterial PO2 decreased by 5 Torr on average during HFCWO. VT decreased with increasing frequency in both cases, but VT during HFCWO was smaller over the range of frequencies compared with HFAO. delta Pes and delta Ptr between 1 and 8 Hz were lower than the corresponding pressure swings obtained with conventional mechanical ventilation (CMV) applied at 0.25 Hz. delta Pes was minimized at 1 Hz during HFCWO; however, delta Ptr decreased continuously with decreasing frequency and, below 2 Hz, became progressively smaller than the corresponding values obtained with HFAO and CMV.

Minimization of lung pressure swings during high-frequency ventilation: a model

The goal of this theoretical study was to develop a simple computational model for determining the lung pressure excursions that accompany the maintenance of adequate gas transport through high-frequency airway oscillations applied via the trachea (HFAO) and by transthoracic means (HFTO). Respiratory mechanics and gas transport parameters estimated from the preceding companion study (J. Appl. Physiol. 67: 985-992, 1989) were used in the model for computing tracheal, alveolar, pleural, and transpulmonary pressure swings. Comparison of model predictions with corresponding data obtained in dogs showed close agreement. The specification of eucapnia as a constraint led to results that were significantly different from previous findings which had assumed constant airflow. We used the model to identify "quasi-optimal" strategies for HFAO and HFTO application in which all pressure excursions were kept below the corresponding levels produced by conventional mechanical ventilation operating at 15 breaths/min. The model suggests the application of both HFAO and HFTO at frequencies substantially lower than the settings commonly employed in high-frequency ventilation. Application of HFAO at frequencies ranging from 1 to 4 Hz is recommended, whereas for HFTO the quasi-optimal range lies between 1 and 1.7 Hz. In patients with chronic obstructive pulmonary disease, pressure costs during HFAO or HFTO are minimized in the vicinity of 1 Hz.

Effects of high-frequency chest wall oscillation on respiratory control in humans

We studied the spontaneous breathing patterns of 10 normal adult volunteers during high-frequency chest wall oscillation (HFCWO), accomplished by inflating and deflating a vest worn around each subject's thorax at 2.5 Hz. Tidal volumes generated by HFCWO averaged 100 ml. Mean vest pressure was maintained at approximately 35 cm H2O throughout each experiment, even when HFCWO was not applied. During HFCWO, subjects were instructed occasionally to exhale deeply to obtain end-tidal samples representative of PACO2. HFCWO increased the breath-to-breath variability of spontaneous respiration in all subjects, prolonging expiratory pauses and producing short apneas in some cases. PACO2 decreased significantly (p less than 0.05). The effects on minute ventilation, tidal volume, and inspiratory and expiratory durations remained variable across subjects, even when differences in PACO2 between control and HFCWO states were reduced through inhalation of a low CO2 mixture. None of the changes were statistically significant, although average expiratory duration increased by 29%. Ventilatory responses to CO2 with and without HFCWO were also measured. Normocapnic (PACO2 = 40 mm Hg) ventilatory drive increased significantly (p less than 0.05) in six subjects (Type 1 response) and decreased substantially in the others (Type 2 response); with hypercapnia, the changes in drive were attenuated in both groups. Consequently, CO2 sensitivity decreased in Type 1 subjects and increased in Type 2 subjects. A simple analysis based on this result shows that with HFCWO, Type 2 subjects breathing air will tend to have a lower spontaneous minute ventilation and become hypercapnic. Type 1 subjects will become hypocapnic, but minute ventilation may be higher or lower than control.(ABSTRACT TRUNCATED AT 250 WORDS)

Simulation of gas transport due to cardiogenic oscillations

We simulated gas transport due to cardiogenic oscillations (CO) using a model developed to quantify the gas mixing due to high-frequency ventilation (16). The basic components of the model are 1) gas mixing by augmented transport, 2) symmetrical lung morphometry, and 3) a Lagrangian (moving) reference frame. The theoretical predictions of the model are in general agreement with published experimental studies that have examined the effect of CO on the nitrogen concentration obtained by intrapulmonary gas sampling and the effect of CO on regional and total anatomical dead space. Further, the model predicts that augmentation of gas transport due to CO is less, nearer to the alveolar regions of the lung, and that the effect of CO during normal tidal breathing is negligible, but that CO may contribute up to approximately 10% of the alveolar ventilation in patients with severe hypoventilation. The agreement between experimental and theoretical results suggests that it may not be necessary to invoke gas transport mechanisms specific to an asymmetrical bronchial tree to explain the major proportion of gas transport due to CO.

Gas mixing during high-frequency ventilation: an improved model

A model for gas transport during high-frequency ventilation incorporating recently derived empirical forms for the effective diffusivity in oscillatory gas flow through a symmetrical branching network is proposed. The model accounts for the movement of gas among airways with changing cross-sectional area by using a moving-reference-frame analysis. The analysis technique incorporates the convective purging of the bias flow at the airway opening. The model predicts that although the cycle-averaged CO2 elimination rate (VCO2) depends most strongly on the product of frequency and tidal volume (VT), VT has an effect on its own, a finding consistent with published observations. This "VT effect" is due primarily to the oscillatory movement of gas from more central regions into peripheral regions where large cross-sectional areas promote efficient CO2 transport by molecular diffusion. Although the VT effect exists independent of the presence of a bias flow, placing the bias flow near the main carina can enhance the VT effect substantially. As VT is increased to values in the range of ordinary tidal breaths, VCO2 predicted by the model achieves close agreement with VCO2 deduced from conventional gas exchange theory.

Intra-airway gas mixing during high-frequency ventilation

We examined the intra-airway gas transport mediated by high-frequency oscillations (HFO) in 10 nonintubated healthy volunteers using a method based on comparisons of single-breath N2-washout curves obtained after various durations of breath hold or high-frequency oscillations. With a mathematical analysis based on Fick's law of diffusion we computed the local transport parameter, effective diffusivity, during oscillations of frequency 2-24 Hz and tidal volume 10-120 ml and during breath hold alone. Local effective diffusivity increased with both oscillatory frequency and tidal volume at all levels in the tracheobronchial tree; the enhancing effect of tidal volume on local effective diffusivity was more pronounced than that of frequency so that effective diffusivity was greater with larger tidal volume at fixed frequency-tidal volume product (f . VT). The greatest enhancement of gas mixing within the lung during HFO (over breath hold) was seen in the central airways. In previous studies examining CO2 removal rate during HFO (J. Clin. Invest. 68: 1475, 1981), we found that CO2 output was also greater with larger tidal volume at fixed f . VT, and we attributed this to an end constraint imposed by a fresh gas bias flow. Results of the current study, performed without a bias flow, indicate that bias flow end constraint does not solely account for the observed dependence of CO2 output on frequency and tidal volume.

Factors inducing periodic breathing in humans: a general model

A general model is developed to account for all kinds of periodic breathing (PB) resulting from instability in respiratory control: in normals during sleep and on acute exposure to high altitude, in sleeping infants, and in patients with cardiovascular or neurologic lesions. It is found that in almost every case the ventilatory oscillation is mediated predominantly by the peripheral controller. System stability is decreased by hypoxia, hypercapnia, increased lung washout times, prolonged lung-chemoreceptor delays, and high controller sensitivity. Stability is enhanced by large lung CO2 and O2 storage volumes but little affected by body tissue stores. Using our own measurements of lung-ear delays, the model predicts that the mean cycle time of PB decreases from about 30 s at sea level to 20 s at 14,000 ft, in excellent agreement with data from other studies. Allometric scaling of the relevant parameters also shows close agreement between model predictions and data obtained on infants.

Detection of red and green flashes: evidence for cancellation and facilitation

Green and red flashes of light will differentially stimulate the middle- and long-wavelength sensitive cones. Interaction of cone signals was studied by measuring increment thresholds for combinations of green and red flashes on a yellow adapting field. When the yellow adapting field was at 10.000 trolands (td), green and red incremental flashes (1 degree, 200-msec duration) produced cancellation when presented simultaneously and facilitation when presented sequentially. A green incremental flash (1.15 degrees, 200 msec, 5000-td adaptation field) and red decremental flash, or vice versa, produced facilitation when presented simultaneously. The results can be explained by color-differencing, opponent-mechanisms. The cancellation effect for the simultaneous incremental flashes largely disappeared when the flashes were exposed briefly (10 msec) or reduced in size (0.04 degrees). It is unlikely that the stimuli were exclusively detected by achromatic, luminance channels, as suggested by previous work, since observers could partially distinguish the hue of threshold flashes of 570- and 590-nm light (0.04 degrees, 10 msec) on a bright yellow field.