Chronic Intermittent Hypoxia reveals role of the Postinspiratory Complex in swallow pattern generation

Reviewer #1 (Public Review):

Summary:
The authors were attempting to determine the extent that CIH altered swallowing motor function; specifically, the timing and probability of the activation of the larygneal and submental motor pools. The paper describes a variety of different motor patterns elicited by optogenetic activation of individual neuronal phenotypes within PiCo in a group of mice exposed to CIH. They show that there are a variety of motor patterns that emerge in CIH mice; this is apparently different than the more consistent motor patterns elicited by PiCo activation in normoxic mice (previously published).

Strengths:
The preparation is technically challenging and gives valuable information related to the role of PiCo in the pattern of motor activation involved in swallowing and its timing with phrenic activity. Genetic manipulations allow for the independent activation of the individual neuronal phenotypes of PiCo (glutamatergic, cholinergic) which is a strength.

Weaknesses:
1. The data presented are largely descriptive in terms of the effect of PiCo activation on the probability of swallowing and the pattern of motor activation changes following CIH. Comparisons made between experimental data acquired currently and those obtained in a previous cohort of animals (possibly years before) are extremely problematic, with the potential confounding influence of changing environments, genetics, and litter effects. The statistical analyses (i.e. comparing CIH with normoxic) appear insufficiently robust. Exactly how the data were compared is not described.

2. There is limited mechanistic insight into how PiCo manipulation alters the pattern and probability of motor activation. For example, does CIH alter PiCo directly, or some other component of the circuit (NTS)? Techniques that silence or activation projections to/from PiCo should be interrogated. This is required to further delineate and define the swallowing circuit, which remains enigmatic.

3. The functional significance of the altered (non-classic) patterns is unclear.

Reviewer #2 (Public Review):

Summary:
In this study, the authors investigated the role of a medullary region, named Postinspiratory Complex (PiCo), in the mediation of swallow/laryngeal behaviours, their coordination with breathing, and the possible impact on the reflex exerted by chronic intermittent hypoxia (CIH). This region is characterized by the presence of glutamatergic/cholinergic interneurons. Thus, experiments have been performed in single allelic and intersectional allelic recombinase transgenic mice to specifically excite cholinergic/glutamatergic neurons using optogenetic techniques, while recording from relevant muscles involved in swallowing and laryngeal activation. The data indicate that in anaesthetized transgenic mice exposed to CIH, the optogenetic activation of PiCo neurons triggers swallow activity characterized by variable motor patterns. In addition, these animals show an increased probability of triggering a swallow when stimulation is applied during the first part of the respiratory cycle.

They conclude that the PiCo region may be involved in the occurrence of swallow and other laryngeal behaviours. These data interestingly improve the ongoing discussion on neural pathways involved in swallow-breathing coordination, with specific attention to factors leading to disruption that may contribute to dysphagia under some pathological conditions.

The Authors' conclusions are partially justified by their data. However, it should be acknowledged that the impact of the study is to a certain extent limited by the lack of knowledge on the source of excitatory inputs to PiCo during swallowing under physiological conditions, i.e. during water-evoked swallowing. Also the connectivity between this region and the swallowing CPG, a structure not well defined, or other brain regions involved in the reflex is not known.

Strengths:
Major strengths of the manuscript:

- The methodological approach is refined and well-suited for the experimental question. The in vivo mouse preparation developed for this study takes advantage of selective optogenetic stimulation of specific cell types with the simultaneous EMG recordings from upper airway muscles involved in respiration and swallowing to assess their motor patterns. The animal model and the chronic intermittent hypoxia protocol have already been published in previous papers (Huff et al. 2022, 2023).

- The choice of the topic. Swallow disruption may contribute to the dysphagia under some pathological conditions, such as obstructive sleep apnea. Investigations aimed at exploring and clarifying neural structures involved in this behaviour as well as the connectivity underpinning muscle coordination are needed.

- This study fits in with previous works. This work is a logical extension of previous studies from this group on swallowing-breathing coordination with further advances using a mouse model for obstructive sleep apnea.

Weaknesses:
Major weaknesses of the manuscript:

- The Authors should be more cautious in concluding that the PiCo is critical for the generation of swallowing itself. It remains to demonstrate that PiCo is necessary for swallowing and laryngeal function in a more physiological situation, i.e. swallow of a bolus of water or food. It should be interesting to investigate the effects of silencing PiCo cholinergic/glutamatergic neurons on normal swallowing. In this perspective, the title should be slightly modified to avoid "swallow pattern generation" (e.g. Chronic Intermittent Hypoxia reveals the role of the Postinspiratory Complex in the mediation of normal swallow production).

- The duration of swallows evoked by optogenetic stimulation of PiCo is considerably shorter in comparison with the duration of swallows evoked by a physiological stimulus (water). This makes it hard to compare the timing and the pattern of motor response in CIH-exposed mice. In Figure 1, the trace time scale should be the same for water-triggered and PiCo-triggered swallows. In addition, it is not clear if exposure to CIH alters the ongoing respiratory activity. Is the respiratory rhythm altered by hypoxia? If a disturbed or irregular pattern of breathing is already present in CIH-exposed mice, could this alteration interfere with the swallowing behaviour?

Reviewer #3 (Public Review):

In the present study, the authors investigated the effects of CIH on the swallowing and breathing responses to PICO stimulation. Their conclusion is that glutamatergic-cholinergic neurons from PICO are not only critical for the gating of post-inspiratory and swallow activity, but also play important roles in the generation of swallow motor patterns. There are several aspects that deserve the authors' attention and comments, mainly related to the study´s conclusions.

- The authors refer to PICO as the generator of post-inspiratory rhythm. However, evidence points to this region as a modulator of post-inspiratory activity rather than a rhythmogenic site (Toor et al., 2019 - 10.1523/JNEUROSCI.0502-19.2019; Oliveira et al., 2021 - 10.1016/j.neuroscience.2021.09.015). For example, sustained activation of PICO for 10 s barely affected the vagus or laryngeal post-inspiratory activity (Huff et al., 2023 - 10.7554/eLife.86103).

- The optogenetic activation of glutamatergic and cholinergic neurons from PICO evoked submental and laryngeal responses, and CIH changed these motor responses. Therefore, the authors proposed that PICO is directly involved in swallow pattern generation and that CIH disrupts the connection between PICO and SPG (swallow pattern generator). However, the experiments of the present study did not provide evidence about connections between these two regions nor their possible disruption after CIH, or even whether PICO is part of SPG.

- CIH affects several brainstem regions which might contribute to generating abnormal motor responses to PICO stimulation. For example, Bautista et al. (1995 - 10.1152/japplphysiol.01356.2011) documented that intermittent hypoxia induces changes in the activity of laryngeal motoneurons by neural plasticity mechanisms involving serotonin.

- To support the hypothesis that PICO is directly involved in swallow pattern generation the authors should perform the inhibition of Vglut2-ChAT neurons from PICO and then evoke swallow motor responses. If swallow is abolished when the neurons from this region are inhibited, it would indicate that PICO is crucial to generate this behavior.

- In almost all the data presented, the authors observed different patterns of changes in the motor submental and laryngeal responses to PICO activation, including that animals submitted to CIH (6%) presented a "normal" motor response. However, the authors did not discuss the possible explanations and functional implications of this variability.

- In Figure 4, the authors need to present low magnification sections showing the PICO transfected neurons as well as the absence of transfection in the ventral respiratory column. The authors could also check the scale since the cAmb seems very small.

- Finally, the title does not reflect the study. The present study did not demonstrate that PICO is a swallow pattern generator.