Intraoperative Pontine Infarction: A Hidden Challenge

Apneusis, or apneustic respirations, is characterized by an abnormal breathing pattern involving gasping and the inability to fully expire. A loss of gag reflex and other cranial nerve deficits are also often accompanied with these respiratory changes. In neurological intensive care units (NICUs), these respiratory and airway changes are not uncommon and have been well documented (Lee et al. 1976). These clinical changes are often associated with pontine trauma as it is the core pneumotaxic center in the brain stem. We describe the airway management of a patient with an acute, occult pontine infarct status post craniectomy and cervical laminectomy for decompression of known Chiari malformation in the postanesthesia care unit (PACU).

Pontile regulation of ventilatory activity in the adult rat

Our purpose was to characterize the pontile components of the brain stem ventilatory control system in rats. This study was precipitated by reports that this pontile component might differ fundamentally from that of other species. Efferent activity of the phrenic nerve was recorded in anesthetized, vagotomized, paralyzed, and ventilated adult rats. As in other species, electrical stimulations of the rostral pons caused premature terminations and/or onsets of phrenic activity in eupnea. Electrolytic lesions of rostrolateral pons resulted in apneusis, characterized by significant prolongations of the phrenic burst. Some effective lesions were in the region of the nucleus parabrachialis medialis and the Kolliker-Fuse nucleus, the site of the pneumotaxic center. Other lesions resulting in apneusis were ventral to the pneumotaxic center. As in cats, lesions in the caudal pontile reticular formation caused the duration of the apneustic neural inspiration to return toward that of eupnea. Again, as in other species, gradual alterations from eupnea to gasping in the rat were recorded during hypoxia, which was induced by ventilation with carbon monoxide. We conclude that the brain stem respiratory control system is similarly organized in rats and other mammalian species. These results have implications for contemporary hypotheses concerning the neurogenesis of ventilatory activity.

Genesis of rhythmic respiratory activity in pons independent of medulla

We hypothesized that rhythmic respiratory-related activity could be generated in pons independent of medullary mechanisms. In decerebrate, cerebellectomized, vagotomized, paralyzed, and ventilated cats, we recorded efferent activities of the phrenic nerve and mylohyoid branch of the trigeminal nerve. Following transections of the brain stem at the pontomedullary junction, the phrenic and trigeminal nerves discharged with independent rhythms. Spontaneous trigeminal discharges eventually ceased but were reestablished after strychnine, doxapram, and/or protriptyline were administered. In some animals having no spontaneous trigeminal discharges after transection, these discharges appeared, with a rhythm different from the phrenic, following administration of these agents. In other cats having no transections between pons and medulla, these pharmacological agents induced trigeminal and phrenic discharges after kainic acid had been injected into the entire dorsal and ventral medullary respiratory nuclei. Phrenic and trigeminal discharges were linked, indicating survival of bulbospinal neurons or presence of pontospinal units. We conclude that rhythms, similar to respiratory rhythm, can occur by mechanisms in isolated pons. Such mechanisms are hypothesized to be within the pneumotaxic center and may underlie the neurogenesis of eupnea.