Effect of transnasal insufflation on sleep disordered breathing in acute stroke: a preliminary study.

BACKGROUND AND PURPOSE: Sleep disordered breathing (SDB) is frequent in acute stroke patients and is associated with early neurologic worsening and poor outcome. Although continuous positive airway pressure (CPAP) effectively treats SDB, compliance is low. The objective of the present study was to assess the tolerance and the efficacy of a continuous high-flow-rate air administered through an open nasal cannula (transnasal insufflation, TNI), a less-intrusive method, to treat SDB in acute stroke patients. METHODS: Ten patients (age, 56.8 ± 10.7 years), with SDB ranging from moderate to severe (apnea-hypopnea index, AHI, >15/h of sleep) and on a standard sleep study at a mean of 4.8 ± 3.7 days after ischemic stroke (range, 1-15 days), were selected. The night after, they underwent a second sleep study while receiving TNI (18 L/min). RESULTS: TNI was well tolerated by all patients. For the entire group, TNI decreased the AHI from 40.4 ± 25.7 to 30.8 ± 25.7/h (p = 0.001) and the oxygen desaturation index >3% from 40.7 ± 28.4 to 31 ± 22.5/h (p = 0.02). All participants except one showed a decrease in AHI. The percentage of slow-wave sleep significantly increased with TNI from 16.7 ± 8.2% to 22.3 ± 7.4% (p = 0.01). There was also a trend toward a reduction in markers of sleep disruption (number of awakenings, arousal index). CONCLUSIONS: TNI improves SDB indices, and possibly sleep parameters, in stroke patients. Although these changes are modest, our findings suggest that TNI is a viable treatment alternative to CPAP in patients with SDB in the acute phase of ischemic stroke.

Ambient particulate air pollution from vehicles promotes lipid peroxidation and inflammatory responses in rat lung

Oxidative stress plays a major role in the pathogenesis of particle-dependent lung injury. Ambient particle levels from vehicles have not been previously shown to cause oxidative stress to the lungs. The present study was conducted to a) determine whether short-term exposure to ambient levels of particulate air pollution from vehicles elicits inflammatory responses and lipid peroxidation in rat lungs, and b) determine if intermittent short-term exposures (every 4 days) induce some degree of tolerance. Three-month-old male Wistar rats were exposed to ambient particulate matter (PM) from vehicles (N = 30) for 6 or 20 continuous hours, or for intermittent (5 h) periods during 20 h for 4 consecutive days or to filtered air (PM <10 µm; N = 30). Rats continuously breathing polluted air for 20 h (P-20) showed a significant increase in the total number of leukocytes in bronchoalveolar lavage compared to control (C-20: 2.61 x 105 ± 0.51;P-20: 5.01 x 105 ± 0.81; P < 0.05) and in lipid peroxidation ([MDA] nmol/mg protein: C-20: 0.148 ± 0.01; P-20: 0.226 ± 0.02; P < 0.05). Shorter exposure (6 h) and intermittent 5-h exposures over a period of 4 days did not cause significant changes in leukocytes. Lipid damage resulting from 20-h exposure to particulate air pollution did not cause a significant increase in lung water content. These data suggest oxidative stress as one of the mechanisms responsible for the acute adverse respiratory effects of particles, and suggest that short-term inhalation of ambient particulate air pollution from street with high automobile traffic represents a biological hazard.

The breathing pattern and the ventilatory response to aquatic and aerial hypoxia and hypercarbia in the frog Pipa carvalhoi

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Regulation of breathing and body temperature of a burrowing rodent during hypoxic-hypercapnia

Burrowing mammals usually have low respiratory sensitivity to hypoxia and hypercapnia. However, the interaction between ventilation (V), metabolism and body temperature (Tb) during hypoxic-hypercapnia has never been addressed. We tested the hypothesis that Clyomys bishopi, a burrowing rodent of the Brazilian cerrado, shows a small ventilatory response to hypoxic-hypercapnia, accompanied by a marked drop in Tb and metabolism. V, Tb and O-2 consumption (VO2) of C. bishopi were measured during exposure to air, hypoxia (10% and 7% O-2), hypercapnia (3% and 5% CO2) and hypoxic-hypercapnia (10% O-2 + 3% CO2). Hypoxia of 7% but not 10%, caused a significant increase in V, and a significant drop in Tb. Both hypoxic levels decreased VO2 and 7% O-2 significantly increased V/VO2. Hypercapnia of 5%, but not 3%, elicited a significant increase in V, although no significant change in Tb, VO2 or V/VO2 was detected. A combination of 10% O-2 and 3% CO2 had minor effects on V and Tb, while VO2 decreased and V/VO2 tended to increase. We conclude that C. bishopi has a low sensitivity not only to hypoxia and hypercapnia, but also to hypoxic-hypercapnia, manifested by a biphasic ventilatory response, a drop in metabolism and a tendency to increase V/VO2. The effect of hypoxic-hypercapnia was the summation of the hypoxia and hypercapnia effects, with respiratory responses tending to have hypercapnic patterns while metabolic responses, hypoxic patterns. (C) 2004 Elsevier B.V. All rights reserved.

Effects of temperature and hypercapnia on ventilation and breathing pattern in the lizard Uromastyx aegyptius microlepis

In most reptiles, the ventilatory response to hypercapnia consists of large increases in tidal volume (V-T), whereas the effects on breathing frequency (f(R)) are more variable. The increased V-T seems to arise from direct inhibition of pulmonary stretch receptors. Most reptiles also exhibit a transitory increase in ventilation upon removal of CO2 and this post-hypercapnic hyperpnea may consist of changes in both V-T and f(R). While it is well established that increased body temperature augments the ventilatory response to hypercapnia, the effects of temperature on the post-hypercapnic hyperpnea is less described. In the present study, we characterise the ventilatory response of the agamid lizard Uromastyx aegyptius to hypercapnia and upon the return to air at 25 and 35 degreesC. At both temperatures, hypercapnia caused large increases in V-T and small reductions in f(R), that were most pronounced at the higher temperature. The post-hypercapnic hyperpnea, which mainly consisted of increased fR, was numerically larger at 35 compared to 25 degreesC. However, when expressed as a proportion of the levels of ventilation reached during steady-state hypercapnia, the post-hypercapnic hyperpnea was largest at 25 degreesC. Some individuals exhibited buccal pumping where each expiratory thoracic breath was followed by numerous small forced inhalations caused by contractions of the buccal cavity. This breathing pattern was most pronounced during severe hypercapnia and particularly evident during the post-hypercapnic hyperpnea. (C) 2002 Published by Elsevier B.V.

Role of the post-hepatic septum on breathing during locomotion in Tupinambis merianae (Reptilia : Teiidae)

Tupinambis merianae increased minute ventilation by increasing both tidal volume and breathing frequency during sustained locomotion at 0.17 m s(-1). Animals in which the post-hepatic septum (PHS) had been surgically removed were not able to increase tidal volume during locomotion. Tegus without PHS compensated, in part, by increasing breathing frequency above the levels observed for tegus with intact PHS, but minute ventilation remained less than in the control animals. The rate of oxygen consumption and the air convection requirement, however, were not significantly different between animals with and without PHS, nor at the tested speeds was endurance affected by the removal of the PHS. These data suggest that the PHS facilitates ventilation by acting as a mechanical barrier, preventing the viscera from moving cranially during physical exertion.

Locus coeruleus noradrenergic neurons and CO2 drive to breathing

The Locus coeruleus (LC) has been suggested as a CO2 chemoreceptor site in mammals. In the present study, we assessed the role of LC noradrenergic neurons in the cardiorespiratory and thermal responses to hypercapnia. To selectively destroy LC noradrenergic neurons, we administered 6-hydroxydopamine (6-OHDA) bilaterally into the LC of male Wistar rats. Control animals had vehicle (ascorbic acid) injected (sham group) into the LC. Pulmonary ventilation (plethysmograph), mean arterial pressure (MAP), heart rate (HR), and body core temperature (T-c, data loggers) were measured followed by 60 min of hypercapnic exposure (7% CO2 in air). To verify the correct placement and effectiveness of the chemical lesions, tyrosine hydroxylase immunoreactivity was performed. Hypercapnia caused an increase in pulmonary ventilation in all groups, which resulted from increases in respiratory frequency and tidal volume (V-T) in sham-operated and 6-OHDA-lesioned groups. The hypercapnic ventilatory response was significantly decreased in 6-OHDA-lesioned rats compared with sham group. This difference was due to a decreased V-T in 6-OHDA rats. LC chemical lesion or hypercapnia did not affect MAP, HR, and T-c. Thus, we conclude that LC noradrenergic neurons modulate hypercapnic ventilatory response but play no role in cardiovascular and thermal regulation under resting conditions.

The breathing pattern and the ventilatory response to aquatic and aerial hypoxia and hypercarbia in the frog Pipa carvalhoi

Anuran amphibians are known to exhibit an intermittent pattern of pulmonary ventilation and to exhibit an increased ventilatory response to hypoxia and hypercarbia. However, only a few species have been studied to date. The aquatic frog Pipa carvalhoi inhabits lakes, ponds and marshes that are rich in nutrients but low in O-2. There are no studies of the respiratory pattern of this species and its ventilation during hypoxia or hypercarbia. Accordingly, the aim of the present study was to characterize the breathing pattern and the ventilatory response to aquatic and aerial hypoxia and hypercarbia in this species. With this purpose, pulmonary ventilation (V-1) was directly measured by the pneumotachograph method during normocapnic normoxia to determine the basal respiratory pattern and during aerial and aquatic hypercarbia (5% CO2) and hypoxia (5% O-2). Our data demonstrate that P. carvalhoi exhibits a periodic breathing pattern composed of single events (single breaths) of pulmonary ventilation separated by periods of apnea. The animals had an enhanced V-1 during aerial hypoxia, but not during aquatic hypoxia. This increase was strictly the result of an increase in the breathing frequency. A pronounced increase in V-1 was observed if the animals were simultaneously exposed to aerial and aquatic hypercarbia, whereas small or no ventilatory responses were observed during separately administered aerial or aquatic hypercarbia. P. carvalhoi primarily inhabits an aquatic environment. Nevertheless, it does not respond to low O-2 levels in water, although it does so in air. The observed ventilatory responses to hypercarbia may indicate that this species is similar to other anurans in possessing central chemoreceptors. (C) 2012 Elsevier Inc. All rights reserved.

Diaphragmatic Breathing Training Program Improves Abdominal Motion During Natural Breathing in Patients With Chronic Obstructive Pulmonary Disease: A Randomized Controlled Trial

Yamaguti WP, Claudino RC, Neto AP, Chammas MC, Gomes AC, Salge TM, Moriya HT, Cukier A, Carvalho CR. Diaphragmatic breathing training program improves abdominal motion during natural breathing in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Arch Phys Med Rehabil 2012;93:571-7. Objective: To investigate the effects of a diaphragmatic breathing training program (DBTP) on thoracoabdominal motion and functional capacity in patients with chronic obstructive pulmonary disease. Design: A prospective, randomized controlled trial. Setting: Academic medical center. Participants: Subjects (N=30; forced expiratory volume in Is, 4270 +/- 13% predicted) were randomly allocated to either a training group (TG) or a control group (CG). Interventions: Subjects in the TG completed a 4-week supervised DBTP (3 individualized weekly sessions), while those in the CG received their usual care. Main Outcome Measures: Effectiveness was assessed by amplitude of the rib cage to abdominal motion ratio (RC/ABD ratio) (primary outcome) and diaphragmatic mobility (secondary outcome). The RC/ABD ratio was measured using respiratory inductive plethysmography during voluntary diaphragmatic breathing and natural breathing. Diaphragmatic mobility was measured by ultrasonography. A 6-minute walk test and health-related quality of life were also evaluated. Results: Immediately after the 4-week DBTP, the TG showed a greater abdominal motion during natural breathing quantified by a reduction in the RC/ABD ratio when compared with the CG (F=8.66; P<.001). Abdominal motion during voluntary diaphragmatic breathing after the intervention was also greater in the TG than in the CG (F=4.11; P<.05). The TG showed greater diaphragmatic mobility after the 4-week DBTP than did the CG (F=15.08; P<.001). An improvement in the 6-minute walk test and in health-related quality of life was also observed in the TG. Conclusions: DBTP for patients with chronic obstructive pulmonary disease induced increased diaphragm participation during natural breathing, resulting in an improvement in functional capacity.

Subcutaneous oxygen pressure in spontaneously breathing lean and obese volunteers: a pilot study

BACKGROUND: Oxidative killing is the primary defense against surgical pathogens; risk of infection is inversely related to tissue oxygenation. Subcutaneous tissue oxygenation in obese patients is significantly less than in lean patients during general anesthesia. However, it remains unknown whether reduced intraoperative tissue oxygenation in obese patients results from obesity per se or from a combination of anesthesia and surgery. In a pilot study, we tested the hypothesis that tissue oxygenation is reduced in spontaneously breathing, unanesthetized obese volunteers. METHODS: Seven lean volunteers with a body mass index (BMI) of 22 +/- 2 kg/m(2) were compared to seven volunteers with a BMI of 46 +/- 4 kg/m(2). Volunteers were subjected to the following oxygen challenges: (1) room air; (2) 2 l/min oxygen via nasal prongs, (3) 6 l/min oxygen through a rebreathing face mask; (4) oxygen as needed to achieve an arterial oxygen pressure (arterial pO(2)) of 200 mmHg; and (5) oxygen as needed to achieve an arterial pO(2) of 300 mmHg. The oxygen challenges were randomized. Arterial pO(2) was measured with a continuous intraarterial blood gas analyzer (Paratrend 7); deltoid subcutaneous tissue oxygenation was measured with a polarographic microoxygen sensor (Licox). RESULTS: Subcutaneous tissue oxygenation was similar in lean and obese volunteers: (1) room air, 52 +/- 10 vs 58 +/- 8 mmHg; (2) 2 l/min, 77 +/- 25 vs 79 +/- 24 mmHg; (3) 6 l/min, 125 +/- 43 vs 121 +/- 25 mmHg; (4) arterial pO(2) = 200 mmHg, 115 +/- 42 vs 144 +/- 23 mmHg; (5) arterial pO(2) = 300 mmHg, 145 +/- 41 vs 154 +/- 32 mmHg. CONCLUSION: In this pilot study, we could not identify significant differences in deltoid subcutaneous tissue oxygen pressure between lean and morbidly obese volunteers.

Air bells of water spiders are an extended phenotype modified in response to gas composition

The water spider Argyroneta aquatica (Clerck) is the only spider that spends its whole life under water. Water spiders keep an air bubble around their body for breathing and build under-water air bells, which they use for shelter and raising offspring, digesting and consuming prey, moulting, depositing eggs and sperm, and copulating. It is unclear whether these bells are an important oxygen reservoir for breathing under water, or whether they serve mainly to create water-free space for feeding and reproduction. In this study, we manipulated the composition of the gas inside the bell of female water spiders to test whether they monitor the quality of this gas, and replenish oxygen if required. We exchanged the entire gas in the bell either with pure O(2), pure CO(2), or with ambient air as control, and monitored behavioural responses. The test spiders surfaced and replenished air more often in the CO(2) treatment than in the O(2) treatment, and they increased bell building behaviour. In addition to active oxygen regulation, they monitored and adjusted the bells by adding silk. These results show that water spiders use the air bell as an oxygen reservoir, and that it functions as an external lung, which renders it essential for living under water permanently. A. aquatica is the only animal that collects, transports, and stores air, and monitors its property for breathing, which is an adaptive response of a terrestrial animal to the colonization of an aquatic habitat. J. Exp. Zool. 307A:549-555, 2007. (c) 2007 Wiley-Liss, Inc.

Air pollution during pregnancy and lung function in newborns: a birth cohort study

Post-natal exposure to air pollution is associated with diminished lung growth during school age. The current authors aimed to determine whether pre-natal exposure to air pollution is associated with lung function changes in the newborn. In a prospective birth cohort of 241 healthy term-born neonates, tidal breathing, lung volume, ventilation inhomogeneity and exhaled nitric oxide (eNO) were measured during unsedated sleep at age 5 weeks. Maternal exposure to particles with a 50% cut-off aerodynamic diameter of 10 microm (PM(10)), nitrogen dioxide (NO(2)) and ozone (O(3)), and distance to major roads were estimated during pregnancy. The association between these exposures and lung function was assessed using linear regression. Minute ventilation was higher in infants with higher pre-natal PM(10) exposure (24.9 mL x min(-1) per microg x m(-3) PM(10)). The eNO was increased in infants with higher pre-natal NO(2) exposure (0.98 ppb per microg x m(-3) NO(2)). Post-natal exposure to air pollution did not modify these findings. No association was found for pre-natal exposure to O(3) and lung function parameters. The present results suggest that pre-natal exposure to air pollution might be associated with higher respiratory need and airway inflammation in newborns. Such alterations during early lung development may be important regarding long-term respiratory morbidity.

Airliner cabin air quality exposure assessment

The airliner cabin environment and its effects on occupant health have not been fully characterized. This dissertation is: (1) A review of airliner environmental control systems (ECSs) that modulate the ventilation, temperature, relative humidity (RH), and barometric pressure (PB) of the cabin environment---variables related to occupant comfort and health. (2) A review and assessment of the methods and findings of key cabin air quality (CAQ) investigations. Several significant deficiencies impede the drawing of inferences about CAQ, e.g., lack of detail about investigative methods, differences in methods between investigations, limited assessment of CAQ variables, small sample sizes, and technological deficiencies of data collection. (3) A comprehensive evaluation of the methods used in the subsequent NIOSH-FAA Airliner CAQ Exposure Assessment Feasibility Study (STUDY) in which this author participated. A number of problems were identified which limit the usefulness of the data. (4) An analysis of the reliable 10-flight STUDY data. Univariate and multivariate methods applied to CO2 (a surrogate for air contaminants), temperature, RH, and PB, in association with percent passenger load, ventilation system, flight duration, airliner body type, and measurement location within the cabin, revealed neither the measured values nor their variability exceeded established health-based exposure limits. Regression analyses suggest CO2, temperature, and RH were affected by percent passenger load. In-flight measurements of CO2 and RH were relatively independent of ventilation system type or flight duration. Cabin temperature was associated with percent passenger load, ventilation system type, and flight duration. (5) A synthesis of the implications of the airliner ECS and cabin O2 environment on occupant health. A model was developed to predict consequences of the airliner cabin pressure altitude 8,000 ft limit and resulting model-estimated PO2 on cardiopulmonary status. Based on the PB, altitude, and environmental data derived from the 10 STUDY flights, the predicted PaO2 of adults with COPD, or elderly adults with or without COPD, breathing ambient cabin air could be < 55 mm Hg (SaO2 < 88%). Reduction in cabin PB found in the STUDY flights could aggravate various medical conditions and require the use of in-flight supplemental O2. ^

Neuroimaging of cerebral activations and deactivations associated with hypercapnia and hunger for air

There are defined medullary, mesencephalic, hypothalamic, and thalamic functions in regulation of respiration, but knowledge of cortical control and the elements subserving the consciousness of breathlessness and air hunger is limited. In nine young adults, air hunger was produced acutely by CO2 inhalation. Comparisons were made with inhalation of a N2/O2 gas mixture with the same apparatus, and also with paced breathing, and with eyes closed rest. A network of activations in pons, midbrain (mesencephalic tegmentum, parabrachial nucleus, and periaqueductal gray), hypothalamus, limbic and paralimbic areas (amygdala and periamygdalar region) cingulate, parahippocampal and fusiform gyrus, and anterior insula were seen along with caudate nuclei and pulvinar activations. Strong deactivations were seen in dorsal cingulate, posterior cingulate, and prefrontal cortex. The striking response of limbic and paralimbic regions points to these structures having a singular role in the affective sequelae entrained by disturbance of basic respiratory control whereby a process of which we are normally unaware becomes a salient element of consciousness. These activations and deactivations include phylogenetically ancient areas of allocortex and transitional cortex that together with the amygdalar/periamygdalar region may subserve functions of emotional representation and regulation of breathing.

Brain responses associated with consciousness of breathlessness (air hunger)

Little is known about the physiological mechanisms subserving the experience of air hunger and the affective control of breathing in humans. Acute hunger for air after inhalation of CO2 was studied in nine healthy volunteers with positron emission tomography. Subjective breathlessness was manipulated while end-tidal CO2- was held constant. Subjects experienced a significantly greater sense of air hunger breathing through a face mask than through a mouthpiece. The statistical contrast between the two conditions delineated a distributed network of primarily limbic/paralimbic brain regions, including multiple foci in dorsal anterior and middle cingulate gyrus, insula/claustrum, amygdala/periamygdala, lingual and middle temporal gyrus, hypothalamus, pulvinar, and midbrain. This pattern of activations was confirmed by a correlational analysis with breathlessness ratings. The commonality of regions of mesencephalon, diencephalon and limbic/paralimbic areas involved in primal emotions engendered by the basic vegetative systems including hunger for air, thirst, hunger, pain, micturition, and sleep, is discussed with particular reference to the cingulate gyrus. A theory that the phylogenetic origin of consciousness came from primal emotions engendered by immediate threat to the existence of the organism is discussed along with an alternative hypothesis by Edelman that primary awareness emerged with processes of ongoing perceptual categorization giving rise to a scene [Edelman, G. M. (1992) Bright Air, Brilliant Fire (Penguin, London)].