We analyzed snoring noise from 10 nonapneic heavy snorers and nine patients with obstructive sleep apnea (OSA). Sound was recorded simultaneously through two microphones, one attached to the manubrium sterni and one suspended in the air 15 cm from the patient's head. Signals were stored on magnetic tape, digitized, and displayed in the time and frequency domains. Most of the power of snoring noise was below 2,000 Hz, and the peak power was usually below 500 Hz. When snores were generated during nose-only breathing (nasal snores), the sound spectrum was made up of a series of discrete, sharp peaks, with a fundamental note and harmonics similar to the spectrum of voiced sounds. When snores were generated during breathing through nose and mouth (oronasal snores), the spectra showed a mixture of sharp peaks and broad-band white noise. Patients with apnea showed a sequence of snores with spectral characteristics that varied markedly through an apnea-respiration cycle. The first postapneic snore consisted mainly of broad-band white noise with relatively more power at higher frequencies, so that the ratio of power above 800 Hz to power below 800 Hz could be used to separate snorers from patients with OSA. Other breaths in the cycle resembled oronasal or nasal snores in nonapneic subjects. Characteristics of the noise give information about the possible mechanism of sound generation and thus about the behavior of the pharynx during snoring. Quality of snoring sound may help to separate patients with obstructive apnea from those with simple snoring.

The vasculature of one lung of unanesthetized spontaneously breathing decerebrate cats was isolated and congested with blood. Such pulmonary vascular congestion (PVC) consistently resulted in a shallow tachypnea associated with expiratory activation of the diaphragm and thyroarytenoid muscles, signifying augmented expiratory braking. With progressive increases in pulmonary vascular pressure, tachypnea and expiratory braking increased progressively and ultimately obscured phasic activity in the diaphragm and thyroarytenoid. Thus the apnea caused by PVC constitutes not an arrest of neural respiratory activity but rather a continuous activation of thoracic inspiratory and laryngeal adductor muscles. When capsaicin, a neurotoxin that activates nonmyelinated afferents, was injected into the pulmonary artery of the isolated lung, it produced changes in timing and distribution of respiratory motor output that resembled those with PVC but were more abrupt in onset. Capsaicin, applied perineurally to the cervical vagi, preferentially blocked the conduction of nonmyelinated afferent fibers. This procedure, which produced little degradation in Hering-Breuer reflexes, eliminated tachypnea and expiratory braking caused by PVC or capsaicin injection. The results indicate that activation of pulmonary vagal afferent fibers of C or A-delta category in unanesthetized cats reflexly modifies the respiratory motor output in a way that resembles the human response to PVC or pulmonary embolism. This is a brain stem reflex.

BackgroundPandemic type A (H1N1) influenza arose in early 2009, probably in Mexico and the United States, and reappeared in North America in September for seven more months. An amino acid substitution in the hemagglutinin (HA), D222G, has been reported in a significant proportion of patients with a severe and fatal outcome. We studied the prevalence of HA222 substitutions in patients in Mexico during the second wave and its association with clinical outcome and pathogenicity in a mouse model.MethodsThe nucleotide sequences of hemagglutinin (HA) from viruses collected from 77 patients were determined including 50 severe and fatal cases and 27 ambulatory cases. Deep sequencing was done on 5 samples from severe or fatal cases in order to determine the quasispecies proportion. Weight loss and mortality due to infection with cultured influenza viruses were analyzed in a mouse model.ResultsViruses from 14 out of 50 hospitalized patients (28%) had a non aspartic acid residue at the HA 222 position (nD222), while all 27 ambulatory patients had D222 (p = 0.0014). G222 was detected as sole species or in coexistence with N222 and D222 in 12 patients with severe disease including 8 who died. N222 in coexistence with D222 was detected in 1 patient who died and co-occurrence of A222 and V222, together with D222, was detected in another patient who died. The patients with a nD222 residue had higher mortality (71.4%), compared to the group with only D222 (22.2%, p = 0.0008). Four of the 14 viruses from hospitalized patients were cultured and intranasally infected into mice. Two viruses with G222 were lethal while a third virus, with G222, caused only mild illness in mice similar to the fourth virus that contained D222.ConclusionsWe confirm the elevated incidence of HA222 (H1N1)pdm09 variants in severe disease and mortality. Both clinical and mouse infection data support the idea that nD222 mutations contribute to increased severity of disease but additional determinants in disease outcome may be present.

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