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Development of Ventilatory Response to Transient Hypercapnia and Hypercapnic Hypoxia in Term Infants

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Development of Ventilatory Response to Transient Hypercapnia and Hypercapnic Hypoxia in Term Infants 0031-3998/04/5502-0302 PEDIATRIC RESEARCH Vol. 55, No. 2, 2004 Copyright © 2004 International Pediatric Research Foundation, Inc. Printed in U.S.A. Development of Ventilatory Response to Transient Hypercapnia and Hypercapnic Hypoxia in Term Infants SIGNE SØVIK AND KRISTIN LOSSIUS Department of Physiology, Institute of Basic Medical Sciences, University of Oslo, NO-0317 Oslo [S.S.], and Section of Neonatology, Department of Pediatrics, Rikshospitalet, NO–0027 Oslo [K.L.], Norway ABSTRACT Whereas peripheral chemoreceptor oxygen sensitivity in- was unchanged for hypoxia. Response magnitude was unchanged creases markedly after birth, previous studies of ventilatory for hypercapnia, but increased for the two hypoxic stimuli. In responses to CO2 in term infants have shown no postnatal conclusion, an interaction between the effects of hypercapnia and development. However, the hypercapnic challenges applied have hypoxia on ventilatory response rate emerged between postnatal usually been long-term, which meant that the effect of central d 2 and wk 8 in term infants. Concomitantly, stimulus-response chemoreceptors dominated. Oscillatory breathing, apneas, and time to hypercapnic stimuli declined markedly. The development sighs cause transient PCO2 changes, probably primarily stimulat- of a prompt response to transient hypercapnia may be important ing peripheral chemoreceptors. We wanted to assess whether the for infant respiratory stability. (Pediatr Res 55: 302–309, 2004) immediate ventilatory responses to step changes in inspired CO2 and O2 in term infants undergo postnatal developmental changes. Twenty-six healthy term infants were studied during natural Abbreviations sleep 2 d and 8 wk postnatally. Ventilatory responses to a FiCO2, fraction of inspired carbon dioxide randomized sequence of 15 s hypercapnia (3% CO2), hypoxia fR, respiratory rate ϩ (15% O2), and hypercapnic hypoxia (3% CO2 15% O2) were PaCO2, partial pressure of arterial carbon dioxide recorded breath-by-breath using a pneumotachometer. Response VT, tidal volume rate, stimulus-response time, and response magnitude were ana- V˙ E, minute ventilation ˙ lyzed with ANOVA after coherent averaging. Response rate VE 45, integrated ventilatory response for 45 s after the onset increased with age by 30% (hypercapnia), 318% (hypoxia), and of a 15-s stimulus 302% (hypercapnic hypoxia). Response rate during hypercapnic V˙ Emedian, median value of ventilation in the period Ϯ5s hypoxia exceeded rate during hypercapnia plus rate during hyp- from the end of a 15-s stimulus oxia in wk 8, but not on d 2. Time to half-maximum response V˙ Emax, maximum value of ventilation during a response, decreased by 3.4 s with age for the two hypercapnic stimuli but determined after signal filtering Peripheral and central chemoreceptors are crucial for the (9). Preterm infants displayed an age-related increase in precise control of respiration. The carotid, aortic, and central steady-state CO2 sensitivity (10, 11), whereas term infants chemoreceptors are functional even in fetal life (1, 2), but the showed no such postnatal development (12, 13). Dynamic CO2 transition to continuous breathing calls for rapid adjustments. sensitivity was unchanged during the first month in neonatal The marked increase in arterial PO2 at birth brings about a lambs (8, 14), whereas in piglets the relative contribution of corresponding resetting of carotid and aortic chemoreceptor O2 peripheral chemoreceptors to CO2 stimulation increased post- sensitivity, which takes place during the first postnatal days natally (15). and weeks (1, 3–5). In contrast, studies of postnatal CO 2 Ultimately, the combined effects of PCO2, arterial PO2, and chemosensitivity show divergent results. Steady-state CO2 sen- pH determine the level of ventilation. Nonlinear interaction sitivity increased after birth in some (6–8) but not all species between PCO2 and PO2, i.e. increased CO2 chemosensitivity at increasing levels of hypoxia, has been described in carotid and Received October 15, 2002; accepted August 7, 2003. aortic nerve recordings (7, 8, 16) and in ventilatory responses Correspondence: Signe Søvik. M.D., Department of Anesthesiology, Aker University in animals (17, 18) and adult humans (19). Whether interaction Hospital, Trondheimsveien 235, NO-0514 Oslo, Norway; e-mail: [email protected] between PCO2 and PO2 is present at birth and whether it Funded by the University of Oslo, Norway, with no extramural financial support. increases postnatally differs from one species to another (7, 16, DOI: 10.1203/01.PDR.0000106316.40213.DB 20). 302 INFANT VENTILATORY CO2–O2 RESPONSES 303 ˙ There have been few studies of infant respiratory control fR,VT, and VE were calculated for each breath cycle from a during transient hypercapnia, and to our knowledge, the hy- pneumotachograph connected to the mask (23). Beat-by-beat percapnic-hypoxic ventilatory interaction has not been as- heart rate was determined online from a three-lead ECG. sessed in term infants. These are areas of interest because a Continuous measurements of CO2 and O2 immediately in front fast-feedback system to maintain PaCO2 level is crucial for of the infants’ nostrils were obtained by infrared spectroscopy respiratory stability. Infants display a variety of oscillatory and paramagnetic method, respectively (Artema Multigas breathing patterns, sighs, and apneas, which produce marked Monitor MM201, Sundbyberg, Sweden; sampling rate 150 but transient changes in PaCO2. Observed stimulus–response mL/min), and end-tidal values were estimated for each breath. times indicate that the effect of peripheral chemoreceptors must Timed gas valve status was stored together with the physio- dominate over that of central chemoreceptors in these situa- logic data. tions (17, 21). The maturation of infant respiratory oscillations Data selection. Epochs of quiet sleep were selected on the after a spontaneous sigh has been linked to peripheral chemo- basis of behavioral criteria. We discarded stimulation periods receptor development (22), and it has been proposed that the in which pneumotachograph recordings indicated that mask emerging CO2–O2 interaction at the peripheral chemoreceptor leakage had occurred, or in which a sigh occurred during the level underlies the postnatal increase in hypoxic sensitivity 20 s preceding stimulation. (16). Gas analysis measurements were inspected to ensure that We hypothesized that the peripheral chemoreceptors in inspired oxygen during hypoxic stimulation did not exceed healthy term infants undergo a postnatal increase in CO2 15% and that FiCO2 during hypercapnic stimulation did not fall sensitivity, resulting in changes in the time course of ventila- below 3%. This would happen if peak inspiratory flow ex- tory responses to step increases in PCO2. Secondly, we hypoth- ceeded the flow of test gas, resulting in dilution of the stimulus esized that during simultaneous exposure, effects of hypercap- with room air. Some accepted responses included a single nia and hypoxia on ventilation would interact, and that such breath cycle (an exaggerated breath or a sigh) in which such interaction could develop postnatally. dilution did occur, but only test gas was inhaled in the ensuing breath cycles. Ventilatory response categories. For each experiment and METHODS test gas type, each ventilatory response was categorized as being 1) smooth, with a gradual rise and fall, 2) spiked, i.e. a Subjects. Twenty-six randomly selected infants (16 girls) smooth response with one or two exaggerated breaths at its were studied at 2 d and 8 wk postnatally. Inclusion criteria maximum phase, or 3) sighlike, in which the breathing pattern were healthy infant, birth weight Ն 2500 g, Apgar scores Ն 8 seemed unaffected until a sudden sigh was elicited. at 1 and 5 min, spontaneous vaginal delivery to term, and Quantitative analysis. Ventilatory and end-tidal gas data uncomplicated pregnancy. Exclusion criteria were any chronic were converted to 5-Hz time series, and recordings in a time maternal illness and alcohol or illicit drug abuse. Median birth window from 50 s before to 150 s after the onset of each weight was 3482 g (range, 2940–4390), gestational age was 39 accepted stimulation period were aligned so that the onset of wk 6 d (range, 38 wk 0 d–41 wk 2 d), and maternal age was stimulus coincided before averaging. Time 0 was taken as the 30.2 y (range, 22.3–41.3 y). Fourteen women were nonsmok- beginning of the first inspiration after a switch to test gas. Յ ˙ ers, seven women smoked 5 cigarettes/d, and five women Coherently averaged VE,VT, and fR responses and the smoked 10–20 cigarettes/d. Regional Ethics Committee ap- course of end-tidal CO2 and O2 values were calculated for each proval and written informed consent from parents were ob- infant, age, and type of test gas. The averaged ventilatory tained, and mothers were often present during experiments. responses were analyzed in a virtual instrument programmed in Procedures. Full details of this method of assessing chemo- LabVIEW 5.0 (National Instruments Corp., Austin, TX, receptor reflexes in infants have been published previously U.S.A.), as described previously (24). For illustration purposes, ˙ (23). The infants were studied during a daytime nap in a crib, the coherently averaged VE,VT, and fR response of the entire sleeping in the supine position. Inspiratory gases were supplied group was also calculated for each stimulus–age combination through a lightweight, handheld face mask. Instantaneous (Figs. 1 and 2). switching between
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