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CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
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physiologists Every component of breathing the lifelong automatic cycling of inspiration, the transmission of coordinated nerve impulses to and from the respiratory muscles, the translation of systemic in uences such as acidosis to the neuromuscular apparatus of the diaphragm is under neural control Moreover, respiratory failure is one of the most disastrous disturbances of neurologic function in comatose states and in neuromuscular diseases such as myasthenia gravis, Guillain-Barre syndrome, amyotrophic lateral sclerosis, muscular dystrophy, and poliomyelitis The major part of the treatment of these disorders consists of measures that assist respiration (mechanical ventilators) Finally, death or brain death is now virtually de ned in terms of the ability of the nervous system to sustain respiration, a reversion to ancient methods of determining the cessation of all vital forces A full understanding of respiration requires knowledge of the mechanical and physiologic workings of the lungs as organs of gas exchange; but here we limit our remarks to the nervous system control of breathing Neurologists should be familiar with the alterations of respiration caused by diseases in different parts of the nervous system, the effects of respiratory failure on the brain, and the rationale that underlies modern methods of treatment
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The Central Respiratory Motor Mechanisms
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It has been known for more than a century that breathing is controlled mainly by the lower brainstem, and that each half of the
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brainstem is capable of producing an independent respiratory rhythm In patients with poliomyelitis, for example, the occurrence of respiratory failure was associated with lesions in the ventrolateral tegmentum of the medulla (Feldman, Cohen) Until recently, thinking on this subject was dominated by Lumsden s scheme of the breathing patterns that resulted from sectioning the brainstem of cats at various levels He postulated the existence of several centers in the pontine tegmentum, each corresponding to an abnormal breathing pattern a pneumotaxic center, an apneustic center, and a medullary gasping center This scheme proves to be oversimpli ed when viewed in the light of modern physiologic experiments It appears that neurons in several discrete regions discharge with each breath and, together, generate the respiratory rhythm In other words, these sites do not function in isolation, as individual oscillators, but interact with one another to generate the perpetual respiratory cycle and they each contain both inspiratory and expiratory components Three paired groups of respiratory nuclei are oriented more or less in columns in the pontine and medullary tegmentum (Fig 26-7) They comprise (1) a ventral respiratory group (referred to as VRG), extending from the lower to the upper ventral medulla, in the region of the nucleus retroambiguus; (2) a dorsal medullary respiratory group (DRG), located dorsal to the obex and immediately ventromedial to the nucleus of the tractus solitarius (NTS); and (3) two clusters of cells in the dorsolateral pons in the region of the parabrachial nucleus From electrical stimulation experiments, it appears that paired neurons in the dorsal pons may act as
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N ambiguus Pre-Botzinger Rostral VRG Caudal DRG N ambiguus Rostral VRG IX, X Figure 26-7 The location of the main centers of respiratory control in the brainstem as currently envisioned from animal experiments and limited human pathology There are three paired groups of nuclei: A The dorsal respiratory group (DRG), containing mainly inspiratory neurons, located in the ventrolateral subnucleus of the nucleus of the tractus solitarius; B A ventral respiratory group (VRG), situated near the nucleus ambiguus and containing in its caudal part neurons that re predominantly during expiration and in its rostral part neurons that are synchronous with inspiration the latter structure merges rostrally with the Botzinger complex, which is located just behind the facial nucleus and contains neurons that are active mostly during expiration; C A pontine pair of nuclei (PRG), one of which res in the transition between inspiration and expiration and the other between expiration and inspiration The intrinsic rhythmicity of the entire system probably depends on interactions between all these regions, but the pre-Botzinger area in the rostral ventromedial medulla may play a special role in generating the respiratory rhythm (Adapted by permission from Duf n et al) XII DRG N tractus solitarius
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