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1 Laboratoire de Physiopathologie Respiratoire (Unité Propre de Recherche de l'Enseignement Supérieur, Equipe d'Accueil 2201), Institut Jean Roche, Faculté de Médecine, Université de la Méditerranée, Marseille, France
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Abstract |
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(Received 26 April 2005;
accepted after revision 17 June 2005;
first published online 23 June 2005)
Corresponding author Y. Jammes: Laboratoire de Physiopathologie Respiratoire (UPRES EA 2201), Faculté de Médecine, Boulevard Pierre Dramard, 13916 cedex 20, Marseille, France. Email: jammes.y{at}jean-roche.university-mrs.fr
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Introduction |
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Pneumothorax is a disease of the pleura, which suppresses the normal negative pressure and often necessitates a therapeutic action involving a continuous pleural aspiration, the two situations activating mechanosensitive nerve endings. Pleural effusion is another disease, often associated with pleural fluid acidosis, due to the synthesis of lactic acid, and local release of inflammatory mediators (Sahn, 1983). The pleural mesothelial cells play a key role by secreting such different metabolites as lactic acid and inflammatory substances (Potts et al. 1978; Lo et al. 1987; Hott et al. 1994; Kroegel & Antony, 1997), which could activate chemosensitive nerve endings. Thus, sensory endings in the pleural layers should be submitted in pathological circumstances to both mechanical and chemical stimulations.
Anatomical studies reveal that the parietal costal pleura and the peripheral part of the diaphragmatic pleura are innervated by the internal intercostal nerves whereas the central portion of the diaphragmatic pleura is innervated by the phrenic nerves (Chrétien, 1983; Peng & Wang, 2004). The neurohistological study of internal intercostal nerves by Duron & Marlot (1980) showed in cats that the afferent fibres, which degenerate after the ablation of the spinal ganglia, constitute 18–24% of the total nerve population, depending on the intercostal space. These authors also found that the number of non-myelinated fibres was higher in the internal intercostal nerves than in external intercostal ones. They attributed these differences to the existence of a cutaneous contingent in the internal intercostal nerve but they also hypothesized that a certain number of these fibres may go to the pleura. Neurohistological and neurohistochemical studies have also demonstrated the existence of an autonomic innervation of both the visceral and parietal pleura of various mammals, including man (Amenta et al. 1982; Artico et al. 1998). The catecholaminergic innervation prevails in the rat parietal pleura (Artico et al. 1998), but cholinergic nerves are also present (Amenta et al. 1982). In the parietal pleura, the sensory nerve endings terminate in corpuscular endings (Golgi-Mazzoni type) and mostly in free nerve endings (Dubreuil & Beaudrimont, 1950; cited by Chrétien, 1983).
We found only one electrophysiological study on the receptive properties of afferent fibres from the pleura in rabbits (Wedekind, 1997). This study was limited to an in vitro protocol on isolated portions of mediastinal and pericardial pleura and the tendinous centre of the diaphragm, all these portions being innervated by the phrenic nerve. The author tested the response of phrenic afferents to locally applied punctuate mechanical stimulation (von Frey hairs) and chemicals represented by capsaicin and an inflammatory mixture combining the effects of bradykinin, serotonin, histamine and prostaglandin E2 (PGE2) (Kessler et al. 1992). The response to lactic acid, commonly present in pleural effusion, was not tested. Wedekind identified group III (thin myelinated) and group IV (non-myelinated) fibres which showed slowly adapting response to mechanical stimulation. Some of these afferents were activated by capsaicin (21% of the units tested), but the inflammatory mixture constituted the most efficient stimulus for 82% of the afferent fibres challenged. Wedekind concluded that ‘the rabbit pleura appears as a tissue mainly innervated by multimodal mechano- and chemosensitive afferent units’ (Wedekind, 1997). However, this study did not entirely discard the possibility that the test agents had also activated nerve endings in the diaphragm muscle itself, which are also very sensitive to the chemicals tested by Wedekind (Kaufman et al. 1982; Graham et al. 1986; Jammes et al. 1986; Hussein et al. 1990; Jammes & Balzamo, 1992; Hoheisel et al. 2004).
The aim of the present study was to identify, in internal intercostal nerves, afferent activities responding to local mechanical and/or chemical stimulation of the parietal pleura. We destroyed the muscle fibres in these intercostal spaces, leaving intact the pleural layer, in order to avoid the activation of muscle afferents by the test agents.
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Methods |
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The animal experiments were performed in accordance with national guidelines and the experiments conformed with the requirements of the ethics committee of Jean Roche Institut.
Sixteen adult rabbits (body weight = 2.3–3.1 kg) were used. They were anaesthetized by an injection of ethyl-carbamate, 1 g kg–1 (Urethane, Coopération Pharmaceutique Française, France) in the marginal ear vein. The external jugular vein was cannulated to continue anaesthesia by subsequent injections and to perfuse the animals with saline containing adrenalin (0.3 µg kg–1 h–1), allowing maintenance of the systolic blood pressure in the range 100–130 mmHg after thoracotomy. A tracheotomy was performed and the animals were ventilated at constant volume (10 ml kg–1) and frequency (30 min–1) with a Harvard volumetric pump. They inhaled a gas mixture containing 30% oxygen. End-tidal O2 and CO2 fractions were, respectively, measured with rapid pyrolytic (Gauthier, France) and infrared gas analysers (Godart, Netherlands). A heating pad allowed maintenance of the rectal temperature in the range 37–38°C. The animals were neuromuscularly blocked at hourly intervals by I.V. injections of pancuronium bromide (Pavulon®, Organon Technika, France, 0.4 mg kg–1). The left carotid artery was catheterized for measurements of blood pressure and heart rate, with an electromanometer (Gould Statham P23Db, Hato Rey, PR, USA), and for blood gas analyses (Radiometer ABL 330, Copenhagen).
Throughout and after the operative procedure, the adequacy of the level of anaesthesia was judged from the changes in blood pressure, heart rate and pupil size, the changes in these variables governing the injection of supplementary doses of ethyl-carbamate. At the end of the experiments, the rabbits were killed by an I.V. injection of a hyperosmolar potassium chloride solution.
Recordings of internal intercostal afferent activities
Figure 1 schematizes the experimental set-up used to record the afferent activities and analyse their discharge.
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First, on one side, the thoracic muscles covering the 5th to 10th intercostal spaces, such as the pectoralis major and minor, and serratus anterior, were dissected and removed. We carefully removed the external and internal intercostal muscles in one selected space, leaving the parietal pleura intact, by using an operating microscope (x 40, OPM 11 Zeiss, Germany). A pair of small steel hooks were implanted into the upper rib making up the intercostal space, in the vicinity of the sternum. The hooks were connected to a Grass S8800 stimulator delivering rectangular pulses through an isolation unit. As described by De Troyer & Legrand (1995), the internal intercostal nerve was dissected and freed from surrounding tissues over at least 3 cm, and its proximal portion was cut at the mid-axillary level. To record activity from the intercostal afferents, the distal nerve ending was divided into several filament bundles on a 6 mm x 6 mm bakelite nerve support covered by warm paraffin oil, by using the operating microscope (x 40, OPM 11 Zeiss, Germany). In each nerve, one to three bundles were placed sequentially on a monopolar tungsten electrode. The nerve activity was referred to a nearby ground electrode, amplified (x 50 000–100 000) and filtered (30 Hz to 10 kHz) by a differential amplifier.
Prior to testing the response of the selected afferent units to different test agents, the compound evoked action potential was recorded in the whole nerve bundle to identify the different afferent populations with respect to their conduction velocities. Thus, the raw nerve signal was displayed on a storage oscilloscope (DSO 400, Gould, France) to average the action potentials evoked by the stimulation of the distal nerve with single shocks (0.1 or 1 ms-long rectangular pulses, supramaximal) delivered by the Grass S8800 stimulator throughout an isolation unit. We measured the conduction time and calculated the conduction velocity of the different nerve populations taking into consideration the interelectrode distance, which varied from 2.0 to 2.8 cm.
To identify selective afferent activities from multiunit recordings, the raw nerve signal was displayed on a two-channel window discriminator built in our laboratory, which allowed the simultaneous analysis of two afferent populations with positive and negative polarities. The output of these discriminators provided noise-free tracings (discriminated units) which were counted by two frequency meters at 1-s intervals (fimpulses, expressed in s–1) and then displayed on the chart recorder. The positive and negative discriminated units were counted and recorded on separate tracings. Due to the small size of the action potentials of the thin afferent fibres in each filament bundle, the window discriminators allowed us to select two to three units with the same polarity in each afferent population, i.e. four to six units with positive and negative polarities per filament bundle. In eight nerve bundles (4 animals), it was possible to record and count single action potentials which had the highest conduction velocity (10.8–14 m s–1) and thus the largest diameters (Fig. 2).
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The following sessions were performed for each selected filament bundle. (1) Measurements of the conduction velocities of all units in a selected bundle. (2) Measurement of the conduction velocity of discriminated units. (3) Response of discriminated units to mechanical stimulation (touch stimulus): a small piece of gauze (10 mm x 20 mm) soaked in buffered isotonic saline (NaCl 0.9%; pH 7.0) was placed for a 10-s period close to the internal thoracic wall at the level of the studied intercostal space. This also constituted a sham chemical test. In four rabbits, a strain gauge (Narco Bio-Systems, Detroit, MI, USA), linear from 0 to 30 g, was used to measure the force produced during the gauze application against the thoracic pleura. A steel hook was fixed in the upper rib making up the space, in the vicinity of the sternum, and connected to the strain gauge with a nylon cable. The force was measured perpendicularly to the thoracic wall. (4) Response to acid: a piece of gauze soaked in lactic acid solution (0.04 M; pH 4.7) was positioned for a 10-s period at the same thoracic level. In three rabbits, we also compared the response of nerve afferents to 0.02 M and 0.04 M lactic acid solutions. (5) At the end of experiment, response to the application of a piece of gauze soaked in an inflammatory mixture consisting of bradykinine–5-HT–histamine–PGE2, at 10–5M concentration (pH 6.7) (Kessler et al. 1992; Wedekind, 1997). The contact of the pleura with the inflammatory mixture was maintained for a 10-s or most often a 30-s period. In five filament bundles, we also tested the afferent response to a lower concentration (10–8M) of inflammatory mediators. (6) Response to a buffered capsaicin solution (10–5M; pH 7.0) applied for several minutes. (7) In three rabbits (5 filaments bundles), the effects of the inflammatory mixture were tested 2 min after the beginning of capsaicin application.
All the chemical solutions were stored at 37°C in a thermostatic water bath before soaking the pieces of gauze. Fifteen minutes lapsed between applying two successive test agents.
On the same hemithorax only one internal intercostal nerve (7th or 8th space) was studied due to the long lasting effects of capsaicin, which also diffused on the pleura covering the adjacent spaces.
In six rabbits, a contralateral internal intercostal nerve was also studied and the battery of test agents repeated on each filament bundle.
Statistical analysis
The baseline value of the afferent fibre activity was averaged for a 1-min period prior to applying each test agent and expressed as the mean ±S.E.M. Then, the significant changes in the afferent activity induced by each test agent were determined with respect to the corresponding averaged baseline value using analysis of variance for repeated measures followed by the Student-Newman-Keuls post hoc test to indicate the direction and magnitude of the variations between the different conditions. Data processing was carried out on absolute values of impulse frequency (fimpulses) using the software program SigmaStat (SPSS Inc., Chicago, IL, USA).
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Conduction velocities of afferent fibres
Recordings of the compound action potentials evoked in the whole nerve trunk by distal stimulation showed different conduction velocities corresponding to large myelinated (45–88 m s–1) fibres, small myelinated fibres (mean value: 11.2 ± 1.5 m s–1) (pulse shock duration = 0.1 ms), and also unmyelinated fibres (1.2 ± 0.1 m s–1) (pulse shock duration = 1.0–1.5 ms). The large myelinated fibres probably corresponded to motor fibres and afferents from the muscle spindles and Golgi tendon organs in intercostal muscles. However, after we had destroyed the muscle layers, the maximal conduction velocity of the discriminated units, having a spontaneous background afferent discharge, was 14 m s–1 and most units had very low conduction velocities (less than 2.8 m s–1). It must be pointed out that the test agents used in our protocol of parietal pleural stimulation were unable to elicit afferent activities having rapid conduction velocities. These observations concerned the destruction of the intercostal muscles, suppressing the muscle afferents in the selected bundles.
A total of 154 discriminated units were examined.
The mean background afferent discharge of small size potentials (2–3 in each filament bundle) was 3.8 ± 0.9 s–1 (i.e. 1.2–1.9 s–1 for a single unit). Their conduction velocity was low (0.5–2.8 m s–1).
The spontaneous discharge of units having the largest potentials (maximally two units in most of bundles and one in eight of them) was less than 0.5 s–1 and their conduction velocity ranged from 5 to 14 m s–1.
Response to test agents
The response to LA was tested in 142 discriminated units, to a pure mechanical stimulus (warmed buffered saline solution) in 131 units, to the inflammatory mixture in 110 units, and to capsaicin in 114 units.
Response to pure mechanical pleural stimulation (Figs 2, 3B and 5B and C). One hundred and twenty-seven (i.e. 97%) of the 131 tested units were immediately activated when the gauze piece soaked in buffered isotonic saline were applied with differing force. Figure 2A shows that the baseline activity of single units (two examples) increased in parallel with the rise of force applied to the thoracic wall and that there was a very slow adaptation of the discharge rate throughout the 10-s period of contact. Figure 2B indicates that there is a linear relationship between the discharge rate of units and the force applied to the thoracic wall, the lowest force levels corresponding to simple touch stimulation. This was also noted in multiunit recordings (Figs 3B and 5B). When there was a prolonged contact of the gauze piece with the pleural space, i.e. in the cases of the inflammatory mixture (Figs 3B and 5C) and capsaicin (Fig. 5C), the mechanosensitive units adapted and their activation totally disappeared in less than 20 s. In some cases (Fig. 5C), the afferent nerve discharge displayed a rhythmic pattern in phase with the frequency of the ventilatory pump. This may represent a periodic mechanical stimulus of pleural afferents due to the gauze motion in phase with lung inflation. Among these mechanosensitive units, only 38/131 (29%) solely responded to touch and thus were purely mechanosensitive. However, 92/131 units (70%) were also activated by several chemical agents (lactic acid, the inflammatory mixture, and capsaicin) and were regarded as multimodal receptors. As shown in Figs 2, 3B and 5B and C, mechanosensitive units had often the largest action potential amplitude and the fastest conduction velocity (11.0 ± 1.3 m s–1). The maximal global discharge rate of multiunits in response to gauze application considerably varied among the tests (14 to 78 s–1; mean = 30.0 ± 8.0 s–1). However, the strength of the mechanical stimulation was not standardized. In four rabbits, we measured the force produced by local gauze application against the thoracic wall. The values of force elicited by touching ranged from 9 to 17 g, corresponding to a pressure of 4.5–8.5 g cm–2 (area of the gauze = 2 cm2), i.e. 4.5–8.5 cmH2O.
Response to lactic acid (Fig. 3C). Sixty-nine (49%) of the 142 tested units were activated after applying the gauze soaked in LA solution. The gauze was maintained close to the pleura for a 10-s period. The latency for a 20% increase in discharge rate was 27 ± 3 s, i.e. the response to LA began after the gauze was removed and persisted for a further 2–4-min period. The maximal discharge rate measured in response to 0.04 M LA was 15.8 ± 1.4 s–1 and thus lower than the maximal response to mechanical stimulation. Among the 69 units responding to LA, 15 units (21.7%) did not respond to the mechanical stimulation, and thus were considered purely chemosensitive. In six filament bundles, the response to 0.04 M and 0.02 M LA solutions was tested. In these units, the maximal discharge rate to 0.02 M and 0.04 M LA was 8.2 ± 2.0 s–1 and 16.9 ± 1.8 s–1, respectively.
Response to the inflammatory mixture (Figs 4 and 5C). Fifty-nine (50%) of 118 tested units were activated after applying the inflammatory mixture at a concentration of 10–5M. We noted that the inflammatory mixture must be maintained in contact with the pleura for 30 s to elicit any measurable activation of the afferents. The latency of the response, as well as the magnitude of the maximal activation, greatly varied among the bundles: a 20% increase in discharge rate occurred within 12–80 s and the maximal discharge rate was 28.1 ± 6.0 s–1. The recovery of the background discharge rate needed several minutes after the removal of the gauze with the inflammatory mixture. A few (8/59, i.e. 13.6%) of the afferent units activated by the inflammatory mixture did not respond to the mechanical stimulation. In five filament bundles (16 units), we also tested a solution of inflammatory mediators at a lower concentration (10–8M). This test agent was never effective in activating these units.
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Twenty units were studied during three successive sessions: (1) activation by the inflammatory mixture; (2) activation by capsaicin after the background discharge rate had been recovered or was reduced; (3) further application of the inflammatory mixture during continuous application of capsaicin. Figure 5C shows that during capsaicin treatment, although the background discharge rate was low, a further application of the inflammatory mixture did not elicit any afferent response.
In all cases, the application of the gauze (whether soaked in the lactic acid solution, the inflammatory mixture, or capsaicin) also transiently activated mechanosensitive afferents (Figs 3C and 5C).
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Discussion |
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Most of our data confirm the observations by Wedekind (1997) in the phrenic nerve, which innervates the diaphragmatic pleura. Indeed, we also identified mechano- and chemosensitive units and mostly multimodal receptors in the parietal pleura covering the chest wall. However, Wedekind did not examine the response to lactic acid, a chemical often present in pleural effusion, and he was not able to discard the possibility that some afferents may arise from the diaphragmatic muscle itself. Indeed, the inflammatory mediators, lactate and capsaicin tested by Wedekind are also powerful stimuli for the group III–IV afferents in the diaphragm (Graham et al. 1986; Jammes et al. 1986; Hussein et al. 1990; Jammes & Balzamo, 1992).
Mechanosensitive afferents were activated by stretching the thoracic pleura at the level of intercostal spaces in which the muscles had been removed. This surgical preparation avoided the recording of muscle afferents. Using the strain gauge to measure the displacement of the thorax during the gauze application revealed first that pleural afferents were activated by a wide range of mechanical stimulations varying from a simple touch (1 g, i.e. around 0.5 cmH2O) to a relatively high stretch of the thoracic wall (30 g corresponded to 15 cmH2O). In most of these cases, the absolute pressure developed (4.5–8.5 cmH2O) was in the range of the pleural pressure measured in rabbits breathing spontaneously with intact chest wall, and anaesthetized with the same agent (Badier et al. 1989). However, we were only able to mimic positive pressure changes in the pleural cavity. This situation solely occurs in rare circumstances, such as cough, forced expiration, pneumothorax and surgical pleuroscopy. Thus, there is a major difference between our experimental protocol and the natural condition where pleural nerve endings are normally exposed to a negative (subatmospheric) pressure. We cannot conclude that these mechanosensitive pleural afferents may be activated during spontaneous breathing movements before performing further experiments reproducing a negative pressure.
The normal pleural fluid contains a low level of lactate dehydrogenase (half that found in the serum) (Miserocchi & Agostoni, 1971; Sahn, 1983). This probably explains why lactic acidosis frequently occurs in pleural effusions. In humans, the concentration of lactic acid in pleural effusions varied from 8 to 54 mmol l–1, i.e. 0.008–0.054 M (Potts et al. 1978; Brook, 1980; Riley, 1985). Thus, in our study the 0.02 M and 0.04 M lactic acid solutions were in the range of lactic acid levels measured in pleural diseases.
The release of inflammatory mediators is documented in the experimental kaolin-induced pleurisy in rats (Hori et al. 1988). In this experimental model, the histamine concentration in pleural fluid went up to 3 x 10–6M, that of kinins to 3 x 10–9M, and of PGE2 to 6 x 10–10M. Indeed, the pleural mesothelial cells release PGE2 (Hott et al. 1994; Harada et al. 1996) and other inflammatory mediators including the interleukins (Kroegel & Antony, 1997). It was already suspected by Costa et al. (2002) that kinin generation could activate the sensory nerves innervating the pleura. In our study, only the 10–5M and not the 10–8M concentration of inflammatory mediators was effective in activating pleural afferents. Such a high concentration of inflammatory substances has been used already by Wedekind (1997) to activate pleural afferents and by Kessler et al. (1992) to stimulate cutaneous afferents. This concentration was higher than that measured in kaolin-induced pleurisy by Hori et al. (1988) (10–6–10–8M) but their experimental model of pleurisy needed 5 h to develop whereas in our study the direct application of the mixture of inflammatory substances against the thoracic pleura was limited to a 3-min period. Thus, we suppose that our protocol should necessitate a higher concentration to rapidly activate nerve afferents.
The effects of capsaicin on unmyelinated afferents in the vagus nerve (Coleridge et al. 1965; Kaufman et al. 1982; Solway & Leff, 1991; Marantz et al. 2001; Kollarik et al. 2003; Lee et al. 2003) and also the limb muscle (Dousset et al. 2004; Hoheisel et al. 2004) and the diaphragmatic afferents (Hussein et al. 1990) are well documented. In all the aforementioned studies capsaicin was injected into the general circulation at lower concentrations (10–7–10–8M) than in our study (10–5M). Indeed, we choose to reproduce the protocol by Wedekind (1997) who directly applied the capsaicin solution to the isolated diaphragm preparation. Capsaicin action on afferents is regarded as involving an initial excitation, which leads to a transmitter release, followed by desensitization after a prolonged exposure, the latter mostly resulting from the diffusion of the drug and its direct effect on the nerve fibres (Solway & Leff, 1991; Holzer, 1998; Blackshaw et al. 2000). Desensitization of the C-fibre pleural afferents seems to occur with the high capsaicin concentration (10–5M) used in the present study because we reported a marked depression or a suppression of the nerve response to a further chemical stimulation under capsaicin application. Based on these observations, we may suppose that a large proportion (57%) of internal intercostal afferents, which were initially either activated (41/65) or inhibited (24/65) by capsaicin and then became unresponsive to inflammatory mediators, were unmyelinated fibres. This is consistent with our observation that the majority of the discriminated units in each filament bundle (3–5/6 units) had a rather low (0.5–2.8 m s–1) conduction velocity. The treatment of rats with capsaicin resulted in an inhibition of the leucocyte migration in a model of pleurisy (Costa et al. 2002), suggesting that the activation of the sensory nerves in the pleura may contribute to a neurogenic inflammatory mechanism.
Like Wedekind (1997), we denominated the pleural afferents as ‘groups III and IV’ fibres in the limb and respiratory muscles. However, this nerve classification is specific to the somatic nervous system and our study, like the study by Wedekind, cannot discard the possibility that sensory neurones in the vegetative system may also innervate the parietal pleura, their afferent fibres going with the somatic afferents in intercostal nerves. In such a case the afferents here recorded should be A
and C fibres and not III and IV ones. This hypothesis is supported by some data indicating the existence of a rich sympathetic innervation of the parietal pleura (Amenta et al. 1982; Artico et al. 1998).
These electrophysiological data have provided physiological evidence in support of the existence of pleural afferents activated by mechanical and/or chemical stimuli which are encountered in pleural diseases. It is now crucial to study the ventilatory, bronchomotor and cardiovascular responses to the activation of these pleural afferents and to explore their projections on the cortical areas involved in the sensation of thoracic pain.
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