A brainstem circuit controls cough-like airway defensive behaviors in mice

Reviewer #1 (Public review):

Summary:

The study by Xu and colleagues provides a useful study of brainstem circuits involved in evoked respiratory reflexes that they define to be cough or cough-like in nature. The study is conducted in mice which has the benefit of allowing for the use of modern transgenic tools, although many of the experiments end up using viral vector-based approaches that could be deployed in any species. The disadvantage of the mouse model is understanding the true identity of the respiratory event that is defined as cough. This limitation requires careful interrogation in order to understand the biology of the circuit under investigation. In this respect, the authors provide an incomplete description of a putative cough pathway linking the caudal spinal trigeminal nucleus with the ventral respiratory group. Neurons assigned as CaMKII+ with putative inputs from the paratrigeminal nucleus are central to this circuit, although the evidence for each of these claims is relatively weak or non-existent. Overall, the study employs interesting methods but limitations in methods and details of methods reduce interpretation of the study outcomes.

Strengths:

The use of modern methods to investigate brainstem circuits involved in an essential respiratory reflex.

Weaknesses:

(1) The most significant issue that needs careful consideration is the exact respiratory response, which is called a cough. The authors show a trace from their plethysmography recordings and superimpose the 3 phases of cough (inspiration, compression, expiration) with confidence, yet the parameters used to delineate these phases are unclear. Of more concern, an identical respiratory trace was reported recently as a sneeze in Jiang et al Cell 2024 (PMID 39243765). Comparing Figure 1 in the Xu study with Figure 5 in the Jiang study, it is impossible to see any difference in the respiratory trace that would allow the assignment of one as cough and the other as sneeze. The audio signals also look remarkably similar and the purported cough signal in the Jiang study is quite different. Gannot et al Nat Neurosci 2024 (PMID 38977887) seems to agree with Xu in the identity of a cough signal, but Li et al Cell 2021 (PMID 34133943) again labels these as sneezes. One of the older studies that tried to classify respiratory signals in mice (Chen et al PlosONE 2013) labeled the Jiang cough trace as a deep inspiration, while sneeze looks different again. To add further confusion, Zhang et al AJP 2017 (PMID 28228416 ) provide yet another respiratory plethysmography trace that they define as a cough, and label responses discussed above as expiration reflexes. This begs the question - who, if anyone, is correct? Interpreting the circuits underlying these peculiar mouse responses depends on accuracy in defining the response in the first instance.

(2) The involvement of the causal nSp5 in cough is an unexpected finding. Some understanding of if and how vagal afferent inputs reach this location would help strengthen the manuscript. The authors claim in the discussion that the nucleus of the solitary tract is not the source of inputs, but rather they may arise from the paratrigeminal nucleus (although no data is presented to support this claim). This could fit with the known jugular vagal afferent pathway, which is embryologically distinct and terminates in trigeminal regions, rather than the NTS. But if this is correct, what does this finding then say about the purported involvement of NTS neurons in cough in mice, for example, the recent study by Gannot et al Nat Neurosci where Tac1-expressing NTS neurons were integral for what they call cough in mice? Xu and colleagues are encouraged to resolve their input circuitry so that we can better understand the pathway under investigation and how it relates to the NTS pathway. Related to this, and the issues differentiating cough-like responses from sneeze, the authors will need to consider how to differentiate their cough-like circuitry from the sneeze pathway from the caudal nSp5 to the cVRG as reported by Li et al Cell 2021. It seems highly possible that the two groups are studying the same circuitry, yet the interpretation is confounded by an inability to agree on the identity of the evoked response.

(3) Injection volumes and titres for AAV transductions are not stated anywhere. The methods (line 484) indicate that different volumes were used for different purposes, but nowhere is this information stated properly. Looking at representative images suggests that volumes were very large, with most of the brainstem often transduced. As single slices are only ever shown it becomes a concern as to how extensive transductions truly are. The authors need to provide complete maps of viral transduction so that readers can understand exactly what regions could contribute to responses, thereby confounding interpretation.

(4) The authors do not provide any data to explore the impacts of manipulations on basal breathing. This is important as impacts on the respiratory patterning will likely have profound effects on evoked responses that are not related to the specific pathway under investigation. For example, in Figure 2b. breathing looks to be severely compromised in the TKO animals and disrupted in the M4 DREADD animals. Figure 3 also shows the effects of optical stimulation on breathing patterns, which appear like apnea with several breakthrough augmented breaths (some labeled as cough?), although hard to see properly in the traces provided. Figure 5, one would expect VRG inhibition to have impacts on breathing, and the traces supplied appear to suggest this is the case. Please include data showing breathing effects and consider how these may confound your study interpretation.

Reviewer #2 (Public review):

Summary:

This study employs a combination of state-of-the-art experimental approaches in mice to identify components of the brainstem circuits involved in the cough reflex in a freely behaving mouse model. The cough reflex is an important respiratory airway defense mechanism, and there has been longstanding interest in defining the neural circuits involved in the mammalian brainstem. Consistent with other recent studies, the present results provide multiple lines of evidence indicating that mice are a suitable model for studying neural mechanisms generating cough behavior. The main novel finding of this study is the authors' results indicating that the caudal spinal trigeminal nucleus (SP5C) nucleus plays a role in generating cough-like behaviors in response to inhaled tussigen. The supporting data presented for this role includes the authors' findings that: (1) neural activity in the SP5C is strongly correlated with tussigen-evoked cough-like behaviors, (2) impairing synaptic outputs or chemogenetic inhibition of SP5C neurons effectively abolished these cough-like reflexes, (3) optogenetically activating a specific subpopulation of excitatory neurons in the SP5C triggers cough-like behaviors, (4) SP5C neurons project monosynaptically to ventral medullary regions containing respiratory circuits that exhibit cough-related neural activity, and (5) specific activation of the SP5C-ventral respiratory circuitry induces robust cough-like behavior without tussive stimuli. This study will be valuable to respiratory neurobiologists studying mechanosensory control of breathing in mammals.

Strengths:

(1) The authors developed an experimental paradigm in mice that combines whole-body plethysmography (WBP), audio, and video tracking to assess breathing and putative cough-like behaviors in conscious animals.

(2) The mouse model enables optogenetic, chemogenetic, virus-based circuit tracing and manipulation, and in vivo fiber photometry to analyze neural activity and define circuity in the medulla-producing cough-like behavior.

(3) Multiple lines of evidence from these experimental approaches support the conclusion that the SP5C nucleus plays a role in the respiratory reflex behaviors studied in mice, but there is uncertainty that these behaviors are definitively cough.

Weaknesses:

(1) This paper lacks essential quantitative details about the number of animals studied explicitly for many of the experimental paradigms presented and for statistical analyses as well as to verify replication of the neuroanatomical data presented.

(2) The authors' evidence is incomplete that the reflex behavior produced in their mouse model is definitively cough, limiting functional interpretation of the putative circuit identified and requiring more thorough experimental interrogation of the behavior studied.

(3) The medullary circuit described conveys afferent sensorimotor signals to downstream respiratory circuits to coordinate cough-like motor behavior, but how the circuits that typically mediate the cough reflex, which involve airway-related vagal sensory neurons, operate in conjunction or parallel with the SP5C circuit described has not been determined, which is a significant gap in understanding how the present results fit into the neural control of the cough reflex.

Reviewer #3 (Public review):

Summary:

The authors have submitted a comprehensive manuscript on the production and central pathways that they propose mediate cough-like behaviors in a TRAP2 transgenic mouse model. While the central pathway data are good, there is significant uncertainty regarding the identity of the presumptive cough-like behavior that has been produced in their model which reduces enthusiasm for the manuscript.

Strengths:

(1) The use of the TRAP2 model in the investigation of coughing is strong.

(2) The implication of SP5 in the production of coughing in response to ammonia inhalation is a novel finding. Further, this area can be activated by AAV-CaMKII to induce coughing in the absence of coincident afferent activation is an important observation.

Weaknesses:

(1) A fundamental aspect of this investigation is the unequivocal identification of the behavior that has been evoked. In this case, the authors have not established that they are actually studying cough. The evidence that they present (especially Figure 1 - Supplement 1) clearly shows that the citric acid (2nd example), capsaicin (2nd example), and ammonia (2nd example) box flows lack a large inspiratory component which is a requirement of cough. The referenced behaviors appear to be expulsion/inspiration which is not cough. The only way these behaviors could be cough is if the conventional polarity of presentation of the flow signals are reversed. However, inspection of the flows during breathing strongly indicates that inspiration is down in your records. Again, this makes these behaviors expulsion/inspiration.

An additional issue is that there are compression phases marked when the flow is occurring. The compression phase is a period of no flow so this is not accurate. There also is no evidence that the mouse has a compression phase at all. In cough flow records in humans, the compression phase can clearly be seen when it happens but not all coughs have one. You must show that a compression phase happens according to the actual description of what this segment of cough actually is.

It may be that you are evoking behaviors that primarily occur in the mouse. As such, they would be novel airway protective behaviors that are worthy of description and study. Ironically, another manuscript in the journal Cell (Jiang et al, 2024, Cell 187:5981-5997) shows similar box flow polarities as your own and clear cough airflows (Fig. 5B). However, they also show other airflow patterns that resemble what you call cough (Figure 5A) but they call them sneeze. Those airflows are expulsion/inspiration and are clearly not sneezing as the expulsion in this behavior also is preceded not followed by inspiration.

The definitive manuscript on cough in the mouse is Zhang et al Am J Physiol Reg Integr Comp 312:R718-R726, 2017. In this manuscript, Figure 2 clearly shows both box pressures and intrapleural pressures during airway protective behaviors in the awake mouse. Note that both cough and a behavior known as expiration reflex were recorded. The key element here is that the cough elicited a tri-phasic box flow. The last excursion was associated with a sound. When compared to the pressure it is clear that this last flow excursion is mechanical chest wall recoil from residual volume. The fact that this segment of the flow record was associated with sound strongly suggests that the vocal folds were adducting at the time to "brake" the chest wall recoil. In other words, the airway resistance went up to slow inspiratory airflow as the chest returned to its resting position. As such, this observation suggests that the chest wall mechanics of cough in the mouse are different than that of larger animals.

(2) Roger Shannon and coworkers have published a number of papers on the detailed brainstem circuits that are responsible for coughing. I recommend that the authors assimilate this knowledge in the context of their results.