Irregularities and power law distributions in the breathing pattern in preterm and term infants

Unlike olderchildren, young infants are prone to develop unstable respiratorypatterns, suggesting important differences in their control ofbreathing. We examined the irregular breathing pattern in infants bymeasuring the time interval between breaths ("interbreathinterval"; IBI) assessed from abdominal movement during 2 h of sleepin 25 preterm infants at a postconceptional age of 40.5 ± 5.2 (SD) wk and in 14 term healthy infants at a postnatal age of 8.2 ± 4 wk. In 10 infants we performed longitudinal measurements on twooccasions. We developed a threshold algorithm for the detection of abreath so that an IBI included an apneic period and potentially someperiods of insufficient tidal breathing excursions (hypopneas). Theprobability density distribution (P) of IBIs follows a power law,P(IBI)~IBI,with the exponent  providing a statistical measurement of the relative risk of insufficient breathing. With maturation,  increased from 2.62 ± 0.4 at 41.2 ± 3.6 wk to 3.22 ± 0.4 at47.3 ± 6.4 wk postconceptional age, indicating a decrease in longhypopneas (for paired data P = 0.002). The statisticalproperties of IBI were well reproduced in a model of the respiratoryoscillator on the basis of two hypotheses:1) tonic neural inputs to the respiratory oscillator are noisy; and2) the noise explores a criticalregion where IBI diverges with decreasing tonic inputs. Accordingly,maturation of infant respiratory control can be explained by the tonicinputs moving away from this critical region. We conclude thatbreathing irregularities in infants can be characterized by , whichprovides a link between clinically accessible data and theneurophysiology of the respiratory oscillator.

     

Spectral characteristics of airway opening and chest wall tidal flows in spontaneously breathing preterm infants.

We compared the harmonic content of tidal flows measured simultaneously at the mouth and chest wall in spontaneously breathing very low birth weight infants (n = 16, 1,114 +/- 230 g, gestation age: 28 +/- 2 wk). Airway opening flows were measured via face mask-pneumotachograph (P-tach), whereas chest wall flows were derived from respiratory inductance plethysmography (RIP) excursions. Next, for each, we computed two spectral shape indexes: 1) harmonic distortion (k(d); k(d,P-tach) and k(d,RIP), respectively) defines the extent to which flows deviated from a single sine wave, and 2) the exponent of the power law (s; s(P-tach) and s(RIP), respectively), describing the spectral energy vs. frequency. P-tach and RIP flow spectra exhibited similar power law functional forms consistently in all infants. Also, mouth [s(P-tach) = 3.73 +/- 0.23% (95% confidence interval), k(d,P-tach) = 38.8 +/- 4.6%] and chest wall (s(RIP) = 3.51 +/- 0.30%, k(d,RIP) = 42.8 +/- 4.8%) indexes were similar and highly correlated (s(RIP) = 1.17 x s(P-tach) + 0.85; r(2) = 0.81; k(d,RIP) = 0.90 x k(d,P-tach) + 8.0; r(2) = 0.76). The corresponding time to peak tidal expiratory flow-to-expiratory time ratio (0.62 +/- 0.08) was higher than reported in older infants. The obtained s and k(d) values are similar to those reported in older and/or larger chronic lung disease infants, yet appreciably lower than for 1-mo-old healthy infants of closer age and/or size; this indicated increased complexity of tidal flows in very low birth weight babies. Importantly, we found equivalent flow spectral data from mouth and chest wall tidal flows. The latter are desirable because they avoid face mask artificial effects, including leaks around it, they do not interfere with ventilatory support delivery, and they may facilitate longer measurements that are useful in control of breathing assessment.     

Measuring equipment for bedside diagnosis of respiratory function in spontaneously breathing newborn infants

Equipment was developed for bedside lung function testing in the newborn using the simultaneous measurement of air flow rate, tidal volume, and esophageal pressure changes as a measure of transpulmonary pressure. The equipment has a number of advantages for the investigation of very low birthweight infants. A flow-through technique was used to eliminate the dead space of the face mask and a very thin micro-tipped catheter permits ready measurement of esophageal pressure. With this equipment, long-term measurements are also possible in oxygen-dependent newborns and the air-tightness of the mask can be monitored continuously. Long-time measurements in neonates are a prerequisite for standardizing the measuring conditions and adapting the duration of the measurement to the variability of the signals, especially in newborn with an irregular pattern of breathing.     

Vagal-dependent nonlinear variability in the respiratory pattern of anesthetized, spontaneously breathing rats

Physiological rhythms, including respiration, exhibit endogenous variability associated with health, and deviations from this are associated with disease. Specific changes in the linear and nonlinear sources of breathing variability have not been investigated. In this study, we used information theory-based techniques, combined with surrogate data testing, to quantify and characterize the vagal-dependent nonlinear pattern variability in urethane-anesthetized, spontaneously breathing adult rats. Surrogate data sets preserved the amplitude distribution and linear correlations of the original data set, but nonlinear correlation structure in the data was removed. Differences in mutual information and sample entropy between original and surrogate data sets indicated the presence of deterministic nonlinear or stochastic non-Gaussian variability. With vagi intact (n = 11), the respiratory cycle exhibited significant nonlinear behavior in templates of points separated by time delays ranging from one sample to one cycle length. After vagotomy (n = 6), even though nonlinear variability was reduced significantly, nonlinear properties were still evident at various time delays. Nonlinear deterministic variability did not change further after subsequent bilateral microinjection of MK-801, an N-methyl-D-aspartate receptor antagonist, in the K?lliker-Fuse nuclei. Reversing the sequence (n = 5), blocking N-methyl-D-aspartate receptors bilaterally in the dorsolateral pons significantly decreased nonlinear variability in the respiratory pattern, even with the vagi intact, and subsequent vagotomy did not change nonlinear variability. Thus both vagal and dorsolateral pontine influences contribute to nonlinear respiratory pattern variability. Furthermore, breathing dynamics of the intact system are mutually dependent on vagal and pontine sources of nonlinear complexity. Understanding the structure and modulation of variability provides insight into disease effects on respiratory patterning.     

Arousal pattern following central and obstructive breathing abnormalities in infants and children

McNamara, Frances, Faiq G. Issa, and Colin E. Sullivan.Arousal pattern following central and obstructive breathing abnormalities in infants and children. J. Appl.Physiol. 81(6): 2651-2657, 1996.We analyzed thepolysomnographic records of 15 children and 20 infants with obstructivesleep apnea (OSA) to examine the interaction between central andobstructive breathing abnormalities and arousal from sleep. Eachpatient was matched for age with an infant or child who had no OSA. Wefound that the majority of respiratory events in infants and childrenwas not terminated with arousal. In children, arousals terminated 39.3 ± 7.2% of respiratory events during quiet sleep and 37.8 ± 7.2% of events during active (rapid-eye-movement) sleep. In infants,arousals terminated 7.9 ± 1.0% of events during quiet sleep and7.9 ± 1.2% of events during active sleep. In both infants andchildren, however, respiratory-related arousals occurred more frequently after obstructive apneas and hypopneas than after central events. Spontaneous arousals occurred in all patients with OSA duringquiet and active sleep. The frequency of spontaneous arousals was notdifferent between children with OSA and their matched controls. Duringactive sleep, however, infants with OSA had significantly fewerspontaneous arousals than did control infants. We conclude that arousalis not an important mechanism in the termination of respiratory eventsin infants and children and that electroencephalographic criteria arenot essential to determine the clinical severity of OSA in thepediatric population.

     

Lung function and breathing pattern in subjects developing high altitude pulmonary edema

Introduction

The purpose of the study was to comprehensively evaluate physiologic changes associated with development of high altitude pulmonary edema (HAPE). We tested whether changes in pulmonary function and breathing pattern would herald clinically overt HAPE at an early stage.

Methods

In 18 mountaineers, spirometry, diffusing capacity, nitrogen washout, nocturnal ventilation and pulse oximetry were recorded at 490 m and during 3 days after rapid ascent to 4559 m. Findings were compared among subjects developing HAPE and those remaining well (controls).

Results

In 8 subjects subsequently developing radiographically documented HAPE at 4559 m, median FVC declined to 82% of low altitude baseline while closing volume increased to 164% of baseline (P<0.05, both instances). In 10 controls, FVC decreased slightly (to 93% baseline, P<0.05) but significantly less than in subjects with HAPE and closing volume remained unchanged. Sniff nasal pressure was reduced in both subjects with and without subsequent HAPE. During nights at 4559 m, mean nocturnal oxygen saturation dropped to lower values while minute ventilation, the number of periodic breathing cycles and heart rate were higher (60%; 8.6 L/min; 97 cycles/h; 94 beats/min, respectively) in subjects subsequently developing HAPE than in controls (73%; 5.1 L/min; 48 cycles/h; 79 beats/min; P<0.05 vs. HAPE, all instances).

Conclusion

The results comprehensively represent the pattern of physiologic alterations that precede overt HAPE. The changes in lung function are consistent with reduced lung compliance and impaired gas exchange. Pronounced nocturnal hypoxemia, ventilatory control instability and sympathetic stimulation are further signs of subsequent overt HAPE.

Registration

ClinicalTrials.gov identifier: {"type":"clinical-trial","attrs":{"text":"NCT00274430","term_id":"NCT00274430"}}NCT00274430     

Lung volumes, chest wall configuration, and pattern of breathing in microgravity

We studied the changes in functional residual capacity (FRC), thoracoabdominal volume (Vw), and chest wall configuration in five normal subjects seated in an aircraft flying parabolic trajectories resulting in 20-s periods of microgravity. We measured vital capacity (VC), inspiratory capacity, and tidal volume by integrating airflow at the mouth and changes in rib cage and abdominal volume (delta Vrc and delta Vab, respectively, where delta Vrc + delta Vab = delta Vw) using induction plethysmography. During microgravity (0 Gz) FRC decreased by 413 +/- 70 (SE) ml and VC by 0.37 liter. The decrease in Vw did not differ from that in FRC and was entirely the result of reduction of Vab, the Vrc showing no significant change. During tidal breathing the abdominal contribution (delta Vab/delta Vw) increased from 0.39 +/- 0.08 at 1 Gz to 0.57 +/- 0.08 at 0 Gz. During brief periods of hypergravity (approximately 1.8 Gz) all changes were opposite in sign and relatively smaller. Limited data during "roller coaster" flight patterns suggested that, in contrast to configurational changes, the temporal pattern of breathing was uninfluenced by changes in Gz. We conclude that at the onset of weightlessness there are substantial changes in lung volume and thoracoabdominal configuration. Abdominal contribution to tidal excursions increases but the temporal pattern of breathing is unchanged.     

Metabolic and respiratory effects of flow-resistive loading in preterm infants

Oxygen consumption (VO2) was measured during hypoventilation induced by moderate-sized flow-resistive loading in 12 preterm infants, and the results were compared with those obtained under basal conditions immediately before and after the loaded run, each of which lasted for 7-10 min. Loading was performed with a continuous flow-resistive load (inspiratory and expiratory), which was approximately threefold greater in magnitude than the intrinsic resistance of preterm infants. VO2, minute ventilation (VE), transcutaneous oxygen tension (PtCO2), and transcutaneous carbon dioxide tension (PtcCO2) were continuously monitored. Results revealed that VE decreased significantly with loading, from 336 +/- 103 to 231 +/- 58 (SD) ml.min-1.kg-1 (P less than 0.001), while returning to basal levels of 342 +/- 59 ml.min-1.kg-1 after discontinuation of the load. VO2 decreased from 7.2 +/- 1.2 to 5.9 +/- 0.9 ml.min-1.kg-1 with loading (P less than 0.001) and returned to 7.2 +/- 1.2 ml.min-1.kg-1 at the second basal measurement. PtcCO2 remained unchanged with loading, and PtcCO2 only increased from 39 +/- 8 to 41 +/- 9 Torr (P less than 0.05) with loading, while returning to 40 +/- 9 Torr at the second basal measurement. Results indicate a decrease in the metabolic rate and ventilation with loading, with relatively little increase in PtcCO2. These data can explain prior observations that minimal disturbances in oxygen and carbon dioxide tensions occur with hypoventilation during flow-resistive loading in neonates, although the precise mechanism for this reduction remains to be determined.     

Influence of breathing pattern on functional residual capacity in sleeping newborn infants

The present study was designed to assess the influence of breathing pattern on the variations of functional residual capacity during sleep in newborn infants. Functional residual capacity was measured by the He-dilution method. Neurophysiologic criteria were used to identify sleep states. Movements of chest and abdomen were monitored. Twenty-six healthy newborn infants were studied. Sixteen were premature and 10 were at term. Functional residual capacity did not change in relation to changes in sleep states. In active sleep it was 1.48 +/- 0.07 ml/cm compared with 1.50 +/- 0.06 ml/cm in quiet sleep. Functional residual capacity decreased when rib cage and abdomen moved out-of-phase with a value of 1.38 +/- 0.09 ml/cm as compared to 1.56 +/- 0.09 ml/cm when in phase (P less than 0.01), in the 7 infants who displayed these two opposite patterns.     

Airway anesthesia effects on hypercapnic breathing pattern in humans

Minute ventilation (VE) and breathing pattern during an abrupt increase in fractional CO2 were compared in 10 normal subjects before and after airway anesthesia. Subjects breathed 7% CO2-93% O2 for 5 min before and after inhaling aerosolized lidocaine. As a result of airway anesthesia, VE and tidal volume (VT) were greater during hypercapnia, but there was no effect on inspiratory time (TI). Therefore, airway anesthesia produced an increase in mean inspiratory flow (VT/TI) during hypercapnia. The increase in VT/TI was compatible with an increase in neuromuscular output. There was no effect of airway anesthesia on the inspiratory timing ratio or the shape and position of the curve relating VT and TI. We also compared airway resistance (Raw), thoracic gas volume, forced vital capacity, forced expired volume at 1s, and maximum midexpiratory flow rate before and after airway anesthesia. A small (0.18 cmH2O X l-1 X s) decrease in Raw occurred after airway anesthesia that did not correlate with the effect of airway anesthesia on VT/TI. We conclude that airway receptors accessible to airway anesthesia play a role in hypercapnic VE.     

Effects of increase in body temperature on the breathing pattern in premature infants

This study was designed to determine the effects of a mild increase in body temperature within the physiological range (0.8 degrees C) in healthy premature infants. Seven unsedated premature infants (38.4 wk +/- 1.5 postconceptional age) were monitored polygraphically during "morning naps" in an incubator under two different environmental temperatures: (1) normothermia with the incubator temperature set at 25 degrees C and the rectal temperature equal to 36.9 degrees C +/- 0.1; (2) hyperthermia with the incubator temperature set at 35 degrees C and the rectal temperature equal to 37.7 degrees C +/- 0.15. Respiratory frequency and heart rate, respiratory events, i.e., central and obstructive apnea, and periodic breathing with and without apneic oscillations were tabulated. Results for respiratory events were expressed as (1) indices of the total number of respiratory events, and of specific respiratory events per hour of total, quiet and active sleep times; (2) duration of total and specific respiratory events expressed as a percentage of total sleep, quiet and active sleep times. Respiratory frequency and heart rate were significantly increased by hyperthermia (P less than 0.05). Hyperthermia did not significantly modify the indices or the duration of central and obstructive apnea. But the indices and the duration of periodic breathing with and without apneic oscillations were significantly increased by hyperthermia during active sleep (P less than 0.05) but not during quiet sleep. The present study shows that a mild increase in body temperature within the physiological range in premature infants enhances the instability of the breathing pattern during active sleep.     

Effects of negative upper airway pressure on pattern of breathing in sleeping infants

Negative upper airway (UAW) pressure inhibits diaphragm inspiratory activity in animals, but there is no direct evidence of this reflex in humans. Also, little is known regarding reflex latency or effects of varying time of stimulation during the breathing cycle. We studied effects of UAW negative pressure on inspiratory airflow and respiratory timing in seven tracheostomized infants during quiet sleep with a face mask and syringe used to produce UAW suction without changing lower airway pressure. Suction trials lasted 2-3 s. During UAW suction, mean and peak inspiratory airflow as well as tidal volume was markedly reduced (16-68%) regardless of whether stimulation occurred in inspiration or expiration. Reflex latency was 42 +/- 3 ms. When suction was applied during inspiration or late expiration, the inspiration and the following expiration were shortened. In contrast, suction applied during midexpiration prolonged expiration and tended to prolong inspiration. The changes in flow, tidal volume, and timing indicate a marked inhibitory effect of UAW suction on thoracic inspiratory muscles. Such a reflex mechanism may function in preventing pharyngeal collapse by inspiratory suction pressure.     

A respiratory sensory reflex in response to CO2 inhibits breathing in preterm infants.

Traditionally, the increase in ventilation occurring after approximately 4 s of CO2 inhalation in preterm infants has been attributed to an action at the peripheral chemoreceptors. However, on a few occasions, we have observed a short apnea (2-3 s) in response to 3-5% CO2 in these infants. To test the hypothesis that this apnea reflects a respiratory sensory reflex to CO2, we gave nine preterm infants [birth wt 1.5 +/- 0.1 (SE) kg, gestational age 31 +/- 1 wk] 7-8% CO2 while they breathed 21% O2. To study the dose-response relationship, we also gave 2, 4, 6, and 8% CO2 to another group of seven preterm infants (birth wt 1.5 +/- 0.1 kg, gestational age 31 +/- 1 wk). In the first group of infants, minute ventilation during 21% O2 breathing (0.232 +/- 0.022 l.min-1.kg-1) decreased after CO2 administration (0.140 +/- 0.022, P < 0.01) and increased with CO2 removal (0.380 +/- 0.054, P < 0.05). This decrease in ventilation was related to an apnea (12 +/- 2.6 s) occurring 7.7 +/- 0.8 s after the beginning of CO2 inhalation. There was no significant change in tidal volume. In the second group of infants, minute ventilation increased during administration of 2, 4, and 6% CO2 but decreased during 8% CO2 because of the presence of an apnea. These findings suggest that inhalation of a high concentration of CO2 (> 6%) inhibits breathing through a respiratory sensory reflex, as described in adult cats (H. A. Boushey and P. S. Richardson. J. Physiol. Lond. 228: 181-191, 1973).(ABSTRACT TRUNCATED AT 250 WORDS)     

Plasma and urine amino acid pattern in preterm infants on enteral nutrition: impact of gestational age

Plasma and urine amino acids were determined by ion-exchange chromatography in 80 healthy preterm infants divided into three groups: (1) 23 0/7–28 0/7, (2) 28 1/7–32 0/7 and (3) 32 1/7–35 0/7 weeks of gestation. Samples were collected from days 5 to 57 of life, when infants were exclusively orally fed. Infants with evidence of underlying diseases were excluded. Concentrations of most plasma amino acids increased with gestational and maturational age; urinary excretion followed an opposite course. Few amino acids depended on postnatal age. Plasma amino acids did not correlate inversely to their counterparts in urine indicating that plasma amino acids do not simply reflect kidney function. Some amino acids in blood and urine were linked to nutrient intake and body weight. Our data clearly indicate the heterogeneity of the preterm cohort; therefore, gestational age-matched reference values have to be used for diagnostic purposes in preterm infants.