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Original Research: Sleep Disorders |

Substance P and Neurokinin 1 Receptors as Potential Therapeutic Targets in Children With OSASubstance P and Tonsil Proliferation in OSA FREE TO VIEW

David Gozal, MD, FCCP; Jinkwan Kim, PhD; Rakesh Bhattacharjee, MD; Julie L. Goldman, MD; Leila Kheirandish-Gozal, MD
Author and Funding Information

From the Section of Sleep Medicine (Drs Gozal, Kim, Bhattacharjee, and Kheirandish-Gozal), Department of Pediatrics, Pritzker School of Medicine, Biological Sciences Division, The University of Chicago, Chicago, IL; and the Department of Surgery (Dr Goldman), Division of Otolaryngology, University of Louisville, Louisville, KY.

Correspondence to: Leila Kheirandish-Gozal, MD, Section of Sleep Medicine, Department of Pediatrics, Pritzker School of Medicine, The University of Chicago, 5841 S Maryland Ave/MC2117, Chicago, IL 60637-1470; e-mail: lgozal@peds.bsd.uchicago.edu


Funding/Support: This study was supported in part by the Herbert T. Abelson Endowed Chair in Pediatrics.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(5):1039-1045. doi:10.1378/chest.13-2026
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Background:  Increased substance P (SP) levels and abundant expression of neurokinin (NK) 1 receptor in adenotonsillar tissues of children with OSA but not recurrent tonsillar infection (RI) suggest that NK1 antagonists could be useful in treating OSA.

Methods:  The effects of SP and the NK1 antagonist GR-82334 were examined on mixed cell cultures prepared from dissociated tonsils harvested intraoperatively from children with OSA and RI. Proliferation was assessed by [3H]-thymidine or 5-ethynyl-2′-deoxyuridine incorporation, and inflammatory cytokine production (tumor necrosis factor [TNF]-α, IL-6, IL-1β) was assessed in supernatants by enzyme-linked immunosorbent assay.

Results:  SP elicited dose-dependent increases in tonsillar cell proliferation in mixed cell cultures from children with OSA but not with RI (P < .0001). The NK1 antagonist exhibited dose-dependent reductions in cellular proliferative rates in OSA-derived cell cultures but not in RI-derived mixed cell cultures (P < .00001). SP treatment was associated with increased TNF-α and IL-6 production, and GR-82334 abrogated SP effects, as well as reduced basal cytokine release (P < .0001).

Conclusions:  SP pathways appear to underlie intrinsic proliferative and inflammatory signaling pathways in tonsillar tissues from children with OSA but not with RI. Selective disruption of these pathways may provide nonsurgical alternatives for prevention and treatment of pediatric OSA.

Figures in this Article

OSA is a highly prevalent condition affecting 2% to 3% of the general pediatric population between the ages of 1 and 8 years and is characterized by recurrent episodes of increased upper airway resistance or collapse with attendant alterations in oxygenation, alveolar ventilation, and sleep integrity.1,2 Adenotonsillar hypertrophy is by far the major pathophysiologic contributor to OSA in children,2 and adenotonsillectomy (T&A) remains the first line of treatment of children with OSA, even if the curative efficacy of this procedure has been questioned.3,4 If not treated in a timely and effective manner, OSA can lead to substantial morbidities affecting cognitive, behavioral, cardiovascular, and metabolic systems.510

An improved understanding of the mechanisms mediating upper airway lymphoid tissue proliferation has emerged and provided clear evidence that the inflammatory cellular substrate in children with OSA and in children with recurrent tonsillar infection (RI) markedly differs.1113 These differences ultimately led to the initial development and validation of nonsurgical alternatives for treatment of mild pediatric OSA,14 and these approaches have now been repeatedly demonstrated as effective both in vitro15,16 and in randomized controlled trials.1719 However, we also identified that early-life infections with respiratory viruses such as respiratory syncytial virus may lead to increased nerve growth factor expression in tonsils of children with OSA; nerve growth factor is a precursor for increased substance P (SP) levels in these tissues.20,21 We further postulated that increased concentrations of SP and its cognate receptor in tonsils of children with OSA may account for the increased cellular proliferation.

One of the SP receptors, tachykinin neurokinin (NK) 1 receptor, often referred to as NK1 receptor, is a member of family 1 (rhodopsin-like) of G protein-coupled receptors22 and consists of 407 amino acid residues spanning more than seven hydrophobic transmembrane domains with three extracellular and three intracellular loops, an amino terminus, and a cytoplasmic carboxy terminus. The development of a large array of selective NK1 antagonists prompted us to examine the potential validity of SP as a major promoter of upper airway lymphadenoid tissue proliferation and the use of NK1 blockers in pediatric OSA.23,24

Subjects

The study was approved by the University of Louisville Human Research Committee (protocol 587.02A), and informed consent was obtained from the legal caregiver with assent obtained from children aged ≥ 7 years. Consecutive children who underwent tonsillectomy for OSA or RI were identified before surgery and recruited into the study. Overnight polysomnography was performed using standard methods that have been published in detail elsewhere.25 OSA was considered to be present when the obstructive apnea-hypopnea index (AHI) was ≥ 5/h of total sleep time (TST) in the context of habitual snoring in otherwise healthy children without any chronic disorders requiring treatment with medications or with any known genetic or craniofacial syndromes. Children with RI were selected based on a history of at least five tonsillar infections requiring administration of an antibiotic course over a period of < 6 months, as well as the absence of any symptoms suggestive of OSA, using a previously validated questionnaire highly sensitive and specific for ruling out sleep-disordered breathing in children, and polysomnographic findings showing an AHI < 1 event/h of TST.26

Cell Culture

Surgically removed tonsils from children with OSA and RI were immediately placed in ice-cold phosphate-buffered saline (PBS) with added antibiotics, as previously described.27 Sample processing was initiated within 30 min under aseptic conditions. Briefly, tonsils were washed thoroughly with PBS, manually dissected into Petri dishes, and gently ground with a syringe plunger through a 70-μ mesh screen to obtain a mixed cell suspension through mechanical dissociation. RBCs were removed by lysis buffer. Cell viability of all specimens was determined by trypan blue exclusion. Specimens with a viability of < 75% were discarded. Cells cultures were established in standard Roswell Park Memorial Institute 1640 medium supplemented with 10% heat-inactivated fetal bovine serum plus antibiotics, which included streptomycin, fungisone, gentamycin, and penicillin, to prevent bacterial and fungal contamination. Mixed cell suspensions were transferred onto 96-round bottom-well plates at a concentration of 1 × 106 cells/well. Cells were cultured in a 5% CO2 incubator at 37°C for 72 h. Cells were also cultured using 24-well plates to determine proinflammatory cytokine levels. Cultures were also exposed to SP or to the NK1 antagonist GR-82334 (Tocris Bioscience), with control conditions corresponding to the addition of the diluent alone. SP was added to the medium 24 h after plating to achieve final concentrations ranging from 10−3 M to 10−13 M. For GR-82334, initial experiments using concentrations of 10−3 M to 10−13 M were conducted in mixed cell cultures from four children with OSA to define the optimal dose of the drug, which was retained as 10−6 M. This concentration was then used for all subsequent experiments.

Proliferation Assay

Cells were incubated for the final 18 to 20 h of the 72-h culture with 0.0185 MBq (0.5 μCi) [3H]-thymidine in complete medium (General Electric Healthcare Life Sciences). Cells were then harvested onto glass-fiber filters with a cell harvester, and radioactivity was measured in a liquid scintillation counter. Alternatively, we used a nonradioactive kit for assessment of cell proliferation (Click-iT EdU Cell Proliferation Assay; Life Technologies Corp), which uses a modified nucleoside, 5-ethynyl-2′-deoxyuridine (EdU), that is incorporated during DNA synthesis.

All experimental conditions were performed in triplicate, and either [3H]-thymidine uptake or EdU-based kit results were expressed as the average of the three wells for each subject. Since the findings were similar across proliferation assays, results were merged for presentation purposes.

Immunohistochemistry

Coronal sections (40 μm) of tonsils were initially incubated in 1X citrate buffer (Laboratory Vision Corp) at 95°C for 45 min, washed several times in PBS, and blocked with a PBS/0.4% Triton X-100/0.5% Tyramide Signal Amplification (TSA) (Life Technologies Corp) blocking reagent/10% normal horse serum for 1 h. Sections were then serially incubated with a rabbit antihuman NK1 antibody (1:750; Thermo Fisher Scientific Inc) at 4°C for 24 h and then washed in PBS six times for 5 min each wash. Sections were incubated at room temperature for 1 h in horse antimouse biotinylated antibody (1:400; Vector Laboratories Inc) in a PBS/0.4% TSA blocking reagent/10% horse serum solution and then with streptavidin-horseradish peroxidase diluted 1:100 in PBS/0.5% TSA blocking reagent. Subsequently, the sections were incubated with TSA fluorescein reagents diluted 1:50 in amplification diluent (PerkinElmer Inc) for 2 min. Sections were then washed and mounted onto glass slides. Negative control subjects were prepared by either omitting the primary or the secondary antibody. Sections were prepared from tonsils from subjects with OSA or with RI (n = 5 from each group), and were visualized using a fluorescent microscope by an investigator who was blinded to the sample source.

Cytokine Assays

Concentrations of IL-1β, tumor necrosis factor (TNF)-α, and IL-6 were measured using commercially available enzyme-linked immunosorbent assay kits (R&D Systems Inc) from the supernatants of mixed tonsillar-cell cultures incubated in 24-well flat-bottom plates in complete Roswell Park Memorial Institute medium supplemented with 10% fetal bovine serum in the presence of SP (10−6 M), GR-82334 (10−6 M), or both compounds, or in their absence. Supernatants were collected after 48 h and stored at −80°C until assay. The concentrations of cytokines in the supernatants were normalized to the number of cells plated, and expressed as pg/106 cells. For all assays, calibration curves were performed in duplicate for each experiment.

Data Analysis

All data were expressed as mean plus or minus SE unless stated otherwise. Statistical analyses were performed using SPSS software, version 21.0 (IBM). All P values reported are two-tailed with statistical significance set at < .05.

A total of 82 children out of 154 prospectively identified and scheduled to undergo T&A agreed to participate and completed the study. Sixty-three children with a clinically based diagnosis of OSA did not fulfill polysomnographic criteria for OSA, and of the children with RI, nine had AHI > 1/h TST on polysomnography. The demographic characteristics and major overnight polysomnographic findings for the participants are shown in Table 1. Of note, tissue availability restricted the overall number of experimental conditions possible for every participant, such that the number of subjects included in each experiment varied and is indicated, as appropriate.

Table Graphic Jump Location
Table 1 —Demographic and Polysomnographic Characteristics in 49 Children With OSA Undergoing Adenotonsillectomy

Data given as mean ± SE unless otherwise indicated. AHI = obstructive apnea-hypopnea index; RI = recurrent tonsillar infection; Sao2 = oxygen saturation; TST = total sleep time.

Of the 82 collected samples, only four could not be processed because trypan blue exclusion tests revealed excessive cell death in the cell culture plates (> 25%). These four samples required a more prolonged delay between surgical removal and laboratory processing (> 1 h), which may account for the high cell-death rate. As in previous studies,13,27 basal proliferative rates based on [3H]-thymidine or EdU incorporation were higher for OSA-derived tonsil cultures than those from children with RI (n = 38 for OSA and n = 36 for RI, P < .0001).

Imuunohistochemical assessments of tonsils for NK1 expression showed remarkably higher immunoreactivity in tonsils from five children with OSA when compared with five matched children with RI, particularly in germinal centers (Fig 1). Accordingly, we first assessed the effect of SP on basal proliferation. Figure 2 shows the responses to incremental doses of SP on [3H]-thymidine/EdU incorporation in both OSA- and RI-derived mixed-cell tonsil cultures. SP increased cellular proliferation rates and exhibited dose-dependent responses in OSA-derived tonsils but not in RI-derived tonsils (OSA vs RI: P < .05; n = 12/group). From these experiments, a 10−6 M SP concentration was retained for subsequent experiments with the NK1 blocker.

Figure Jump LinkFigure 1. A-C, Representative microscopic images of tonsillar tissues in a child with OSA (A) and an age-matched child with recurrent tonsillar infection (RI) (B) (magnification × 20). Expression of neurokinin-1 receptor, shown as red fluorescent immunoreactivity, is particularly abundant in OSA, and more specifically in the germinal center (C) (magnification × 40). Similar findings emerged in the tonsils of five children with OSA and five with RI.Grahic Jump Location
Figure Jump LinkFigure 2. Effects of increases in substance P (SP) concentrations on tonsillar cellular proliferation in children with OSA (open box plots) and children with RI (hatched box plots) in a mixed-cell culture system (n = 12/group). Dose-dependent increases in proliferative rates emerged in OSA (P < .001) but not in RI. B = basal. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location

Addition of GR-82334 at 10−6 M to the mixed-cell culture system elicited dose-dependent reductions in cell proliferation in OSA-derived tonsils but not in RI-derived tonsillar tissues (OSA vs RI: P < .05; n = 14/group) (Fig 3). Furthermore, GR-82334 blocked SP-induced increases in cellular proliferative rates in tonsil cultures harvested from OSA cases (Fig 3).

Figure Jump LinkFigure 3. Adenotonsillar cell proliferative responses to 1 × 10−6 M SP, 1 × 10−6 M GR-82334, or both, in children with OSA (open box plots) and in children with RI (hatched box plots) in a mixed-cell culture system. See Figure 1 and 2 legends for expansion of abbreviations.Grahic Jump Location

Basal release of IL-1β, TNF-α, and IL-6 to the cell culture supernatants was increased in tonsillar cultures from children with OSA when compared with RI, and IL-1β and TNF-α concentrations in effluent medium were further increased after addition of SP at 10−6 M (P < .01), an effect that was overall absent in children with RI, except for mild increases in IL-1β (n = 13 for OSA group and n = 10 for RI group) (fig 4). Addition of GR-82334 induced significant reductions in proinflammatory IL-1β and TNF-α cytokine production (P < .01, n = 10 for OSA and n = 8 for RI) (fig 4), but did not affect IL-6 release (P > .05).

Figure Jump LinkFigure 4. Concentrations of IL-1 β , TNF-α , and IL-6 in the supernatants of tonsillar cell cultures from children with OSA (filled columns) and children with RI (hatched columns) in basal conditions after stimulation with SP (1 × 10−6 M), after stimulation with SP but in the presence of effective concentrations of GR-82334 (1 × 10−6 M), or both SP and GR-82334. SP increased production of IL-1 β and TNF-α , but not IL-6, in OSA tonsillar mixed cell cultures. This effect was blocked by addition of GR-82334, which further reduced the concentrations of these cytokines when given alone. TNF 5 tumor necrosis factor. See Figure 1 and 2 legends for expansion of other abbreviations.Grahic Jump Location

The present study revealed that addition of SP to a dissociated mixed-cell culture system of tonsils derived from children with OSA induced increased dose-dependent proliferative responses and release of pro-inflammatory cytokines, and that these responses did not occur in tonsils surgically extracted from children with RI. Furthermore, treatment with a selective NK1 antagonist markedly reduced proliferation and also was accompanied by reductions in the production and release of the pro-inflammatory cytokines IL-1β and TNF-α, but not IL-6. These findings not only support the concept that the pathways underlying tonsillar proliferation in children with OSA and RI are quite different, but also that development of SP-NK1 adenotonsillar tissue-targeted delivery systems may reduce the severity of sleep-disordered breathing in children.

Before we examine potential implications of the present experiments, a few selected technical and methodologic issues deserve comment. First, the children included in the present study were not objectively examined and tested for the presence of allergic rhinitis or asthma. However, the prevalence of these two conditions as reported by the parents was, overall, similar in the OSA and RI groups (Table 1). Furthermore, due to the a priori exclusionary criteria, none of the children was receiving any topical or systemic medications at the time of the T&A. We should remark, however, that both allergic symptoms and asthma are very prevalent in children with OSA,2831 and, in fact, treatment of OSA has been shown to improve the severity of asthma in children with persistent and severe asthma.32 Furthermore, SP-related pathways have been closely implicated in both allergies and asthma22,33,34 such that expanded exploration of the potentiating effect of blocking this pathway in children with OSA and, for example, asthma, emerges as an attractive option for future studies. Indeed, the mixed tonsil-tissue cell culture system we previously developed and used herein should enable a convenient technical approach to explore such aims and further determine selective neuroimmune interactions.27,35 However, we cannot infer from current experiments the potential associations between the response to SP and tonsillar size in individual cases, or on the magnitude of putative inhibition by NK1 antagonists among children with different tonsillar sizes or disease severities. Second, we did not examine which cell type subsets within the tonsils were specifically targeted by alterations in SP bioavailability. Based on our previous studies showing that T-cell lymphocytes are preferentially proliferative and proinflammatory in pediatric OSA,13 it is possible that these cells account for the major effects associated with manipulation of the SP-NK1 pathway in the current experiments. This is certainly likely considering the major role played by SP and other tachykinins in the modulation of the immune system,36 whereby T lymphocytes can produce SP and also express NK1 receptors.3739

The possibility that SP antagonists may serve as a treatment strategy aiming to reduce adenotonsillar size in pediatric OSA was initially raised after increased levels of SP were found.20 It is likely that some of the beneficial effects of topical corticosteroids and anti-leukotrienes in reducing the size of the tissues in children with OSA1719 may reflect, at least in part, the intermediate effects of these agents on the SP-NK1 system or vice versa.4042 Thus, it would be important to ascertain whether addition of these antiinflammatory agents, such as topical corticosteroids and leukotriene receptor inhibitors, to NK1 antagonists will additively or synergistically enhance the potential beneficial effects of these agents.

As mentioned, tonsils from children with OSA display increased proliferative rates as well as increased proinflammatory cytokine production,13,43 and treatment with topical corticosteroids such as fluticasone furoate leads to reduced IL-6 levels in those tissues.44 Increased SP levels have been associated with enhanced release from inflammatory cells of proinflammatory cytokines such as IL-1β, IL-6, and TNF-α.4548 Our findings revealed a dichotomous response of tonsillar tissues to SP-NK1 pharmacologic perturbations, namely that the tissues from children with OSA displayed IL-1β and TNF-α prominent responses (but not Il-6 responses), while the tissues obtained from children with RI did not emerge as responsive. These findings further reinforce the concept of neuroimmunomodulatory mechanisms, possibly triggered by early viral infections, playing a major role in pediatric OSA, while such is not likely the case in RI.20

In summary, tonsils obtained from children with OSA undergoing T&A display SP- and NK1-dependent alterations in cellular proliferative rates and in pro-inflammatory cytokine production. Our findings provide initial support to future exploration of SP and NK1 pathways as therapeutic targets aiming to elicit the involution of the lymphadenoid tissue hypertrophy and hyperplasia that underlie OSA in children.

Author contributions: Dr Gozal had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Dr Gozal: contributed to conceptual design of the project, data analysis, drafting the manuscript, and review and approval of the final manuscript and served as principal author.

Dr Kim: contributed to the experiments in this study, data analysis, drafting components of the manuscript, and review and approval of the final manuscript.

Dr Bhattacharjee: contributed to recruiting subjects, analyzing a portion of the sleep studies, and review and approval of the final manuscript.

Dr Goldman: contributed to recruiting subjects, performing all surgical procedures, and review and approval of the final manuscript.

Dr Kheirandish-Gozal: contributed to conceptual design, recruiting subjects, scoring sleep studies, data analysis, drafting early portions of the manuscript, and review and approval of the final manuscript.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Role of sponsors: The sponsor had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.

Other contributions: We thank the parents of all children for their willingness to participate.

AHI

apnea hypopnea index

EdU

ethynyl-2′-deoxyuridine

NK

neurokinin

PBS

phosphate-buffered saline

RI

recurrent tonsillar infection

SP

substance P

T&A

adenotonsillectomy

TNF

tumor necrosis factor

TSA

Tyramide Signal Amplification

TST

total sleep time

Kheirandish-Gozal L, Gozal D. Sleep Disordered Breathing in Children.1st ed. New York, NY: Springer Science; 2012.
 
Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714-e755. [CrossRef] [PubMed]
 
Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med. 2010;182(5):676-683. [CrossRef] [PubMed]
 
Marcus CL, Moore RH, Rosen CL, et al; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376. [CrossRef] [PubMed]
 
Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3 pt 1):616-620. [CrossRef] [PubMed]
 
Gozal D, Kheirandish-Gozal L. Neurocognitive and behavioral morbidity in children with sleep disorders. Curr Opin Pulm Med. 2007;13(6):505-509. [CrossRef] [PubMed]
 
Gozal D, Kheirandish-Gozal L, Serpero LD, Sans Capdevila O, Dayyat E. Obstructive sleep apnea and endothelial function in school-aged nonobese children: effect of adenotonsillectomy. Circulation. 2007;116(20):2307-2314. [CrossRef] [PubMed]
 
Amin R, Somers VK, McConnell K, et al. Activity-adjusted 24-hour ambulatory blood pressure and cardiac remodeling in children with sleep disordered breathing. Hypertension. 2008;51(1):84-91. [CrossRef] [PubMed]
 
Horne RS, Yang JS, Walter LM, et al. Elevated blood pressure during sleep and wake in children with sleep-disordered breathing. Pediatrics. 2011;128(1):e85-e92. [CrossRef] [PubMed]
 
Gozal D, Capdevila OS, Kheirandish-Gozal L. Metabolic alterations and systemic inflammation in obstructive sleep apnea among nonobese and obese prepubertal children. Am J Respir Crit Care Med. 2008;177(10):1142-1149. [CrossRef] [PubMed]
 
Goldbart AD, Goldman JL, Li RC, Brittian KR, Tauman R, Gozal D. Differential expression of cysteinyl leukotriene receptors 1 and 2 in tonsils of children with obstructive sleep apnea syndrome or recurrent infection. Chest. 2004;126(1):13-18. [CrossRef] [PubMed]
 
Goldbart AD, Veling MC, Goldman JL, Li RC, Brittian KR, Gozal D. Glucocorticoid receptor subunit expression in adenotonsillar tissue of children with obstructive sleep apnea. Pediatr Res. 2005;57(2):232-236. [CrossRef] [PubMed]
 
Kim J, Bhattacharjee R, Dayyat E, et al. Increased cellular proliferation and inflammatory cytokines in tonsils derived from children with obstructive sleep apnea. Pediatr Res. 2009;66(4):423-428. [CrossRef] [PubMed]
 
Kheirandish-Gozal L, Kim J, Goldbart AD, Gozal D. Novel pharmacological approaches for treatment of obstructive sleep apnea in children. Expert Opin Investig Drugs. 2013;22(1):71-85. [CrossRef] [PubMed]
 
Dayyat E, Serpero LD, Kheirandish-Gozal L, et al. Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009;135(5):1142-1149. [CrossRef] [PubMed]
 
Kheirandish-Gozal L, Serpero LD, Dayyat E, et al. Corticosteroids suppress in vitro tonsillar proliferation in children with obstructive sleep apnoea. Eur Respir J. 2009;33(5):1077-1084. [CrossRef] [PubMed]
 
Kheirandish-Gozal L, Gozal D. Intranasal budesonide treatment for children with mild obstructive sleep apnea syndrome. Pediatrics. 2008;122(1):e149-e155. [CrossRef] [PubMed]
 
Goldbart AD, Goldman JL, Veling MC, Gozal D. Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005;172(3):364-370. [CrossRef] [PubMed]
 
Goldbart AD, Greenberg-Dotan S, Tal A. Montelukast for children with obstructive sleep apnea: a double-blind, placebo-controlled study. Pediatrics. 2012;130(3):e575-e580. [CrossRef] [PubMed]
 
Goldbart AD, Mager E, Veling MC, et al. Neurotrophins and tonsillar hypertrophy in children with obstructive sleep apnea. Pediatr Res. 2007;62(4):489-494. [CrossRef] [PubMed]
 
Snow A, Dayyat E, Montgomery-Downs HE, Kheirandish-Gozal L, Gozal D. Pediatric obstructive sleep apnea: a potential late consequence of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. 2009;44(12):1186-1191. [CrossRef] [PubMed]
 
Ramalho R, Soares R, Couto N, Moreira A. Tachykinin receptors antagonism for asthma: a systematic review. BMC Pulm Med. 2011;11:41. [CrossRef] [PubMed]
 
Alvaro G, Di Fabio R. Neurokinin 1 receptor antagonists—current prospects. Curr Opin Drug Discov Devel. 2007;10(5):613-621. [PubMed]
 
Huang SC, Korlipara VL. Neurokinin-1 receptor antagonists: a comprehensive patent survey. Expert Opin Ther Pat. 2010;20(8):1019-1045. [CrossRef] [PubMed]
 
Montgomery-Downs HE, O’Brien LM, Gulliver TE, Gozal D. Polysomnographic characteristics in normal preschool and early school-aged children. Pediatrics. 2006;117(3):741-753. [CrossRef] [PubMed]
 
Spruyt K, Gozal D. Screening of pediatric sleep-disordered breathing: a proposed unbiased discriminative set of questions using clinical severity scales. Chest. 2012;142(6):1508-1515. [CrossRef] [PubMed]
 
Serpero LD, Kheirandish-Gozal L, Dayyat E, Goldman JL, Kim J, Gozal D. A mixed cell culture model for assessment of proliferation in tonsillar tissues from children with obstructive sleep apnea or recurrent tonsillitis. Laryngoscope. 2009;119(5):1005-1010. [CrossRef] [PubMed]
 
McColley SA, Carroll JL, Curtis S, Loughlin GM, Sampson HA. High prevalence of allergic sensitization in children with habitual snoring and obstructive sleep apnea. Chest. 1997;111(1):170-173. [CrossRef] [PubMed]
 
Lu LR, Peat JK, Sullivan CE. Snoring in preschool children: prevalence and association with nocturnal cough and asthma. Chest. 2003;124(2):587-593. [CrossRef] [PubMed]
 
Ng DK, Chan CH, Hwang GY, Chow PY, Kwok KL. A review of the roles of allergic rhinitis in childhood obstructive sleep apnea syndrome. Allergy Asthma Proc. 2006;27(3):240-242. [CrossRef] [PubMed]
 
Ishman SL, Smith DF, Benke JR, Nguyen MT, Lin SY. The prevalence of sleepiness and the risk of sleep-disordered breathing in children with positive allergy test. Int Forum Allergy Rhinol. 2012;2(2):139-143. [CrossRef] [PubMed]
 
Kheirandish-Gozal L, Dayyat EA, Eid NS, Morton RL, Gozal D. Obstructive sleep apnea in poorly controlled asthmatic children: effect of adenotonsillectomy. Pediatr Pulmonol. 2011;46(9):913-918. [CrossRef] [PubMed]
 
De Swert KO, Joos GF. Extending the understanding of sensory neuropeptides. Eur J Pharmacol. 2006;533(1-3):171-181. [CrossRef] [PubMed]
 
Groneberg DA, Harrison S, Dinh QT, Geppetti P, Fischer A. Tachykinins in the respiratory tract. Curr Drug Targets. 2006;7(8):1005-1010. [CrossRef] [PubMed]
 
Nakanishi M, Furuno T. Molecular basis of neuroimmune interaction in an in vitro coculture approach. Cell Mol Immunol. 2008;5(4):249-259. [CrossRef] [PubMed]
 
Bost KL. Tachykinin-mediated modulation of the immune response. Front Biosci. 2004;9:3331-3332. [CrossRef] [PubMed]
 
Ikeda Y, Takei H, Matsumoto C, et al. Administration of substance P during a primary immune response amplifies the secondary immune response via a long-lasting effect on CD8+ T lymphocytes. Arch Dermatol Res. 2007;299(7):345-351. [CrossRef] [PubMed]
 
Katsanos GS, Anogeianaki A, Orso C, et al. Impact of substance P on cellular immunity. J Biol Regul Homeost Agents. 2008;22(2):93-98. [PubMed]
 
Beinborn M, Blum A, Hang L, et al. TGF-beta regulates T-cell neurokinin-1 receptor internalization and function. Proc Natl Acad Sci U S A. 2010;107(9):4293-4298. [CrossRef] [PubMed]
 
Li M, Shang YX. Inhaled corticosteroids inhibit substance P receptor expression in asthmatic rat airway smooth muscle cells. BMC Pulm Med. 2012;12:79. [CrossRef] [PubMed]
 
Schäper C, Noga O, Koch B, et al. Anti-inflammatory properties of montelukast, a leukotriene receptor antagonist in patients with asthma and nasal polyposis. J Investig Allergol Clin Immunol. 2011;21(1):51-58. [PubMed]
 
Wei B, Shang YX, Li M, Zhang H. Effect of montelukast on the expression of neurokinin-1 receptor in young asthmatic rats with airway remodeling [in Chinese]. Zhongguo Dang Dai Er Ke Za Zhi. 2013;15(4):298-301. [PubMed]
 
Komorowska A, Komorowski J, Banasik M, Lewkowicz P, Tchórzewski H. Cytokines locally produced by lymphocytes removed from the hypertrophic nasopharyngeal and palatine tonsils. Int J Pediatr Otorhinolaryngol. 2005;69(7):937-941. [CrossRef] [PubMed]
 
Esteitie R, Emani J, Sharma S, Suskind DL, Baroody FM. Effect of fluticasone furoate on interleukin 6 secretion from adenoid tissues in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2011;137(6):576-582. [CrossRef] [PubMed]
 
Cuesta MC, Quintero L, Pons H, Suarez-Roca H. Substance P and calcitonin gene-related peptide increase IL-1 beta, IL-6 and TNF alpha secretion from human peripheral blood mononuclear cells. Neurochem Int. 2002;40(4):301-306. [CrossRef] [PubMed]
 
Delgado AV, McManus AT, Chambers JP. Production of tumor necrosis factor-alpha, interleukin 1-beta, interleukin 2, and interleukin 6 by rat leukocyte subpopulations after exposure to substance P. Neuropeptides. 2003;37(6):355-361. [CrossRef] [PubMed]
 
Joachim RA, Sagach V, Quarcoo D, Dinh T, Arck PC, Klapp BF. Upregulation of tumor necrosis factor-alpha by stress and substance p in a murine model of allergic airway inflammation. Neuroimmunomodulation. 2006;13(1):43-50. [CrossRef] [PubMed]
 
Cunin P, Caillon A, Corvaisier M, et al. The tachykinins substance P and hemokinin-1 favor the generation of human memory Th17 cells by inducing IL-1β, IL-23, and TNF-like 1A expression by monocytes. J Immunol. 2011;186(7):4175-4182. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1. A-C, Representative microscopic images of tonsillar tissues in a child with OSA (A) and an age-matched child with recurrent tonsillar infection (RI) (B) (magnification × 20). Expression of neurokinin-1 receptor, shown as red fluorescent immunoreactivity, is particularly abundant in OSA, and more specifically in the germinal center (C) (magnification × 40). Similar findings emerged in the tonsils of five children with OSA and five with RI.Grahic Jump Location
Figure Jump LinkFigure 2. Effects of increases in substance P (SP) concentrations on tonsillar cellular proliferation in children with OSA (open box plots) and children with RI (hatched box plots) in a mixed-cell culture system (n = 12/group). Dose-dependent increases in proliferative rates emerged in OSA (P < .001) but not in RI. B = basal. See Figure 1 legend for expansion of other abbreviation.Grahic Jump Location
Figure Jump LinkFigure 3. Adenotonsillar cell proliferative responses to 1 × 10−6 M SP, 1 × 10−6 M GR-82334, or both, in children with OSA (open box plots) and in children with RI (hatched box plots) in a mixed-cell culture system. See Figure 1 and 2 legends for expansion of abbreviations.Grahic Jump Location
Figure Jump LinkFigure 4. Concentrations of IL-1 β , TNF-α , and IL-6 in the supernatants of tonsillar cell cultures from children with OSA (filled columns) and children with RI (hatched columns) in basal conditions after stimulation with SP (1 × 10−6 M), after stimulation with SP but in the presence of effective concentrations of GR-82334 (1 × 10−6 M), or both SP and GR-82334. SP increased production of IL-1 β and TNF-α , but not IL-6, in OSA tonsillar mixed cell cultures. This effect was blocked by addition of GR-82334, which further reduced the concentrations of these cytokines when given alone. TNF 5 tumor necrosis factor. See Figure 1 and 2 legends for expansion of other abbreviations.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1 —Demographic and Polysomnographic Characteristics in 49 Children With OSA Undergoing Adenotonsillectomy

Data given as mean ± SE unless otherwise indicated. AHI = obstructive apnea-hypopnea index; RI = recurrent tonsillar infection; Sao2 = oxygen saturation; TST = total sleep time.

References

Kheirandish-Gozal L, Gozal D. Sleep Disordered Breathing in Children.1st ed. New York, NY: Springer Science; 2012.
 
Marcus CL, Brooks LJ, Draper KA, et al; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012;130(3):e714-e755. [CrossRef] [PubMed]
 
Bhattacharjee R, Kheirandish-Gozal L, Spruyt K, et al. Adenotonsillectomy outcomes in treatment of obstructive sleep apnea in children: a multicenter retrospective study. Am J Respir Crit Care Med. 2010;182(5):676-683. [CrossRef] [PubMed]
 
Marcus CL, Moore RH, Rosen CL, et al; Childhood Adenotonsillectomy Trial (CHAT). A randomized trial of adenotonsillectomy for childhood sleep apnea. N Engl J Med. 2013;368(25):2366-2376. [CrossRef] [PubMed]
 
Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102(3 pt 1):616-620. [CrossRef] [PubMed]
 
Gozal D, Kheirandish-Gozal L. Neurocognitive and behavioral morbidity in children with sleep disorders. Curr Opin Pulm Med. 2007;13(6):505-509. [CrossRef] [PubMed]
 
Gozal D, Kheirandish-Gozal L, Serpero LD, Sans Capdevila O, Dayyat E. Obstructive sleep apnea and endothelial function in school-aged nonobese children: effect of adenotonsillectomy. Circulation. 2007;116(20):2307-2314. [CrossRef] [PubMed]
 
Amin R, Somers VK, McConnell K, et al. Activity-adjusted 24-hour ambulatory blood pressure and cardiac remodeling in children with sleep disordered breathing. Hypertension. 2008;51(1):84-91. [CrossRef] [PubMed]
 
Horne RS, Yang JS, Walter LM, et al. Elevated blood pressure during sleep and wake in children with sleep-disordered breathing. Pediatrics. 2011;128(1):e85-e92. [CrossRef] [PubMed]
 
Gozal D, Capdevila OS, Kheirandish-Gozal L. Metabolic alterations and systemic inflammation in obstructive sleep apnea among nonobese and obese prepubertal children. Am J Respir Crit Care Med. 2008;177(10):1142-1149. [CrossRef] [PubMed]
 
Goldbart AD, Goldman JL, Li RC, Brittian KR, Tauman R, Gozal D. Differential expression of cysteinyl leukotriene receptors 1 and 2 in tonsils of children with obstructive sleep apnea syndrome or recurrent infection. Chest. 2004;126(1):13-18. [CrossRef] [PubMed]
 
Goldbart AD, Veling MC, Goldman JL, Li RC, Brittian KR, Gozal D. Glucocorticoid receptor subunit expression in adenotonsillar tissue of children with obstructive sleep apnea. Pediatr Res. 2005;57(2):232-236. [CrossRef] [PubMed]
 
Kim J, Bhattacharjee R, Dayyat E, et al. Increased cellular proliferation and inflammatory cytokines in tonsils derived from children with obstructive sleep apnea. Pediatr Res. 2009;66(4):423-428. [CrossRef] [PubMed]
 
Kheirandish-Gozal L, Kim J, Goldbart AD, Gozal D. Novel pharmacological approaches for treatment of obstructive sleep apnea in children. Expert Opin Investig Drugs. 2013;22(1):71-85. [CrossRef] [PubMed]
 
Dayyat E, Serpero LD, Kheirandish-Gozal L, et al. Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009;135(5):1142-1149. [CrossRef] [PubMed]
 
Kheirandish-Gozal L, Serpero LD, Dayyat E, et al. Corticosteroids suppress in vitro tonsillar proliferation in children with obstructive sleep apnoea. Eur Respir J. 2009;33(5):1077-1084. [CrossRef] [PubMed]
 
Kheirandish-Gozal L, Gozal D. Intranasal budesonide treatment for children with mild obstructive sleep apnea syndrome. Pediatrics. 2008;122(1):e149-e155. [CrossRef] [PubMed]
 
Goldbart AD, Goldman JL, Veling MC, Gozal D. Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005;172(3):364-370. [CrossRef] [PubMed]
 
Goldbart AD, Greenberg-Dotan S, Tal A. Montelukast for children with obstructive sleep apnea: a double-blind, placebo-controlled study. Pediatrics. 2012;130(3):e575-e580. [CrossRef] [PubMed]
 
Goldbart AD, Mager E, Veling MC, et al. Neurotrophins and tonsillar hypertrophy in children with obstructive sleep apnea. Pediatr Res. 2007;62(4):489-494. [CrossRef] [PubMed]
 
Snow A, Dayyat E, Montgomery-Downs HE, Kheirandish-Gozal L, Gozal D. Pediatric obstructive sleep apnea: a potential late consequence of respiratory syncytial virus bronchiolitis. Pediatr Pulmonol. 2009;44(12):1186-1191. [CrossRef] [PubMed]
 
Ramalho R, Soares R, Couto N, Moreira A. Tachykinin receptors antagonism for asthma: a systematic review. BMC Pulm Med. 2011;11:41. [CrossRef] [PubMed]
 
Alvaro G, Di Fabio R. Neurokinin 1 receptor antagonists—current prospects. Curr Opin Drug Discov Devel. 2007;10(5):613-621. [PubMed]
 
Huang SC, Korlipara VL. Neurokinin-1 receptor antagonists: a comprehensive patent survey. Expert Opin Ther Pat. 2010;20(8):1019-1045. [CrossRef] [PubMed]
 
Montgomery-Downs HE, O’Brien LM, Gulliver TE, Gozal D. Polysomnographic characteristics in normal preschool and early school-aged children. Pediatrics. 2006;117(3):741-753. [CrossRef] [PubMed]
 
Spruyt K, Gozal D. Screening of pediatric sleep-disordered breathing: a proposed unbiased discriminative set of questions using clinical severity scales. Chest. 2012;142(6):1508-1515. [CrossRef] [PubMed]
 
Serpero LD, Kheirandish-Gozal L, Dayyat E, Goldman JL, Kim J, Gozal D. A mixed cell culture model for assessment of proliferation in tonsillar tissues from children with obstructive sleep apnea or recurrent tonsillitis. Laryngoscope. 2009;119(5):1005-1010. [CrossRef] [PubMed]
 
McColley SA, Carroll JL, Curtis S, Loughlin GM, Sampson HA. High prevalence of allergic sensitization in children with habitual snoring and obstructive sleep apnea. Chest. 1997;111(1):170-173. [CrossRef] [PubMed]
 
Lu LR, Peat JK, Sullivan CE. Snoring in preschool children: prevalence and association with nocturnal cough and asthma. Chest. 2003;124(2):587-593. [CrossRef] [PubMed]
 
Ng DK, Chan CH, Hwang GY, Chow PY, Kwok KL. A review of the roles of allergic rhinitis in childhood obstructive sleep apnea syndrome. Allergy Asthma Proc. 2006;27(3):240-242. [CrossRef] [PubMed]
 
Ishman SL, Smith DF, Benke JR, Nguyen MT, Lin SY. The prevalence of sleepiness and the risk of sleep-disordered breathing in children with positive allergy test. Int Forum Allergy Rhinol. 2012;2(2):139-143. [CrossRef] [PubMed]
 
Kheirandish-Gozal L, Dayyat EA, Eid NS, Morton RL, Gozal D. Obstructive sleep apnea in poorly controlled asthmatic children: effect of adenotonsillectomy. Pediatr Pulmonol. 2011;46(9):913-918. [CrossRef] [PubMed]
 
De Swert KO, Joos GF. Extending the understanding of sensory neuropeptides. Eur J Pharmacol. 2006;533(1-3):171-181. [CrossRef] [PubMed]
 
Groneberg DA, Harrison S, Dinh QT, Geppetti P, Fischer A. Tachykinins in the respiratory tract. Curr Drug Targets. 2006;7(8):1005-1010. [CrossRef] [PubMed]
 
Nakanishi M, Furuno T. Molecular basis of neuroimmune interaction in an in vitro coculture approach. Cell Mol Immunol. 2008;5(4):249-259. [CrossRef] [PubMed]
 
Bost KL. Tachykinin-mediated modulation of the immune response. Front Biosci. 2004;9:3331-3332. [CrossRef] [PubMed]
 
Ikeda Y, Takei H, Matsumoto C, et al. Administration of substance P during a primary immune response amplifies the secondary immune response via a long-lasting effect on CD8+ T lymphocytes. Arch Dermatol Res. 2007;299(7):345-351. [CrossRef] [PubMed]
 
Katsanos GS, Anogeianaki A, Orso C, et al. Impact of substance P on cellular immunity. J Biol Regul Homeost Agents. 2008;22(2):93-98. [PubMed]
 
Beinborn M, Blum A, Hang L, et al. TGF-beta regulates T-cell neurokinin-1 receptor internalization and function. Proc Natl Acad Sci U S A. 2010;107(9):4293-4298. [CrossRef] [PubMed]
 
Li M, Shang YX. Inhaled corticosteroids inhibit substance P receptor expression in asthmatic rat airway smooth muscle cells. BMC Pulm Med. 2012;12:79. [CrossRef] [PubMed]
 
Schäper C, Noga O, Koch B, et al. Anti-inflammatory properties of montelukast, a leukotriene receptor antagonist in patients with asthma and nasal polyposis. J Investig Allergol Clin Immunol. 2011;21(1):51-58. [PubMed]
 
Wei B, Shang YX, Li M, Zhang H. Effect of montelukast on the expression of neurokinin-1 receptor in young asthmatic rats with airway remodeling [in Chinese]. Zhongguo Dang Dai Er Ke Za Zhi. 2013;15(4):298-301. [PubMed]
 
Komorowska A, Komorowski J, Banasik M, Lewkowicz P, Tchórzewski H. Cytokines locally produced by lymphocytes removed from the hypertrophic nasopharyngeal and palatine tonsils. Int J Pediatr Otorhinolaryngol. 2005;69(7):937-941. [CrossRef] [PubMed]
 
Esteitie R, Emani J, Sharma S, Suskind DL, Baroody FM. Effect of fluticasone furoate on interleukin 6 secretion from adenoid tissues in children with obstructive sleep apnea. Arch Otolaryngol Head Neck Surg. 2011;137(6):576-582. [CrossRef] [PubMed]
 
Cuesta MC, Quintero L, Pons H, Suarez-Roca H. Substance P and calcitonin gene-related peptide increase IL-1 beta, IL-6 and TNF alpha secretion from human peripheral blood mononuclear cells. Neurochem Int. 2002;40(4):301-306. [CrossRef] [PubMed]
 
Delgado AV, McManus AT, Chambers JP. Production of tumor necrosis factor-alpha, interleukin 1-beta, interleukin 2, and interleukin 6 by rat leukocyte subpopulations after exposure to substance P. Neuropeptides. 2003;37(6):355-361. [CrossRef] [PubMed]
 
Joachim RA, Sagach V, Quarcoo D, Dinh T, Arck PC, Klapp BF. Upregulation of tumor necrosis factor-alpha by stress and substance p in a murine model of allergic airway inflammation. Neuroimmunomodulation. 2006;13(1):43-50. [CrossRef] [PubMed]
 
Cunin P, Caillon A, Corvaisier M, et al. The tachykinins substance P and hemokinin-1 favor the generation of human memory Th17 cells by inducing IL-1β, IL-23, and TNF-like 1A expression by monocytes. J Immunol. 2011;186(7):4175-4182. [CrossRef] [PubMed]
 
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