Unilateral focal lesions in the rostrolateral medulla influence chemosensitivity and breathing measured during wakefulness, sleep, and exercise

Objectives-The rostrolateral medulla (RLM) has been identified in animals a s an important site of chemosensitivity; in humans such site(s) have not be en defined. The aim of this study was to investigate the physiological impl ications of unilateral lesions in the lower brainstem on the control of bre athing. Methods-In 15 patients breathing was measured awake at rest, asleep, during exercise, and during CO2 stimulation. The lesions were located clinically and by MRI; in nine patients they involved the RLM (RLM group), in six they were in the pens, cerebellum, or medial medulla (Non-RLM group). All RLM g roup patients, and three non-RLM group patients had ipsilateral Horner's sy ndrome. Results-Six of the RLM group had a ventilatory sensitivity to inhaled CO2 ( (V) over dot/P-ET CO2) below normal (group A: (V) over dot/P-ET CO2, mean, 0.87; range 0.3-1.4 1.min(-1)/mm Hg). It was normal in all of the non-RLM g roup (group B: (V) over dot/P-ET CO2, mean, 3.0; range, 2.6-3.9 min(-1)/mmH g). There was no significant difference in breathing between groups during relaxed wakefulness ((V) over dot, group A: 7.44 (SD 2.5) 1.min(-1); group B: 6.02 (SD 1.3) 1.min(-1); P-ET CO2, group A: 41.0 (SD 4.2) mm g; group B: 38.3 (SD2.0) mm Hg) or during exercise ((V) over dot/(V) over dotO(2): gro up A: 21 (SD 6.0) 1.min(-1)/1.min(-1); group B: 24 (SD 7.3) 1.min(-1)/1.min (-1)). During sleep, all group A had fragmented sleep compared with only on e patient in group B (group A: arousals, range 13 to > 60 events/hour); mor eover, in group A there was a high incidence of obstructive sleep apnoea as sociated with hypoxaemia. Conclusion-Patients with unilateral RLM lesions require monitoring during s leep to diagnose any sleep apnoea. The finding that unilateral RLM lesions reduce ventilatory sensitivity to inhaled CO2 is consistent with animal stu dies. The reduced chemosensitivity had a minimal effect on breathing awake at rest or during exercise.