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T h o r a x

1 9 8 9 ; 4 4 : 4 1 9 - 4 2 1

How many manoeuvres s h o u l d b e d o n e

t o measure

m a x i m a l i n s p i r a t o r y m o u t h pressure

i n

p a t i e n t s w i t h

c h r o n i c

a i r f l o w

o b s t r u c t i o n ?

J

A

F I Z ,

J M MONTSERRAT

C

PICADO, V PLAZA, A AGUSTI VIDAL

F r o m t h e S e r v e i d e P n e u m o l o g i a, H o s p i t a l

C l i n i c ,

B a r c e l o n a , S p a i n

ABSTRACT To d e t e r m i n e

t h e n u m b e r o f

m a x i m a l m o u t h

pressure

manoeuvres

n e e d e d t o

o b t a i n a

r e p r o d u c i b l e v a l u e o f

m a x i m a l i n s p i r a t o r y

m o u t h pressure ( M I P ) ,

we

s t u d i e d

4 4

p a t i e n t s

w i t h

c h r o n i c

a i r f l o w o b s t r u c t i o n ,

w i t h a

mean

( S D )

r e d i c t e d

F E V y

v a l u e

o f

5 3 - 9

( 2 5 ) ,

who

were

c l i n i c a l l y

s t a b l e .

M a x i m a l

i n s p i r a t o r y m o u t h pressure was d e t e r m i n e d

w i t h

an

a n a e r o i d manometer

d u r i n g

m a x i m a l

i n s p i r a t o r y

e f f o r t s i n

a

q u a s i

s t a t i c

c o n d i t i o n

a t

r e s i d u a l

v o l u m e .

A l l

p a t i e n t s

p e r f o r m e d

2 0

c o n s e c u t i v e

m a x i m a l i n s p i r a t o r y m o u t h manoeuvres,

e a c h one

s e p a r a t e d b y

3 0 - 4 0

s e c o n d s . T h e

mean

( S D )

v a l u e s o f

MIP

v a r i e d f r o m

7 1

5

( 2 5 - 5 )

cm

H20

a t t h e

f i r s t m e a s u r e m e n t

t o

8 0 - 1

( 2 7 )

cm

H20

a t t h e

l a s t

m e a s u r e m e n t . M a x i m a l v a l u e s o f

MIP

were

u s u a l l y

a c h i e v e d a f t e r

n i n e d e t e r m i n a t i o n s .

I t

i s

c o n c l u d e d

t h a t t o o b t a i n a

r e p r o d u c i b l e

MIP

v a l u e

i n

p a t i e n t s

w i t h

c h r o n i c a i r f l o w o b s t r u c t i o n

wh o

a r e u n t r a i n e d a n d

u n e x p e r i e n c e d

i n s u c h

manoeuvres a

minimum

o f

n i n e

t e c h n i c a l l y

a c c e p t a b l e

m a x i m a l

m o u t h

pressure

manoeuvres s h o u l d b e

p e r f o r m e d .

I n t r o d u c t i o n

M e t h o d s

T h e m e a s u r e m e n t

o f m a x i m a l

i n s p i r a t o r y p r e s s u r e

g e n e r a t e d

a t

t h e

m o u t h

( M I P )

i s

a n

a c c e p t e d

n o n -

i n v a s i v e c l i n i c a l

m e t h o d f o r

e v a l u a t i n g

t h e

s t r e n g t h

o f

r e s p i r a t o r y m u s c l e s .

T h e r e

i s ,

h o w e v e r ,

w i d e v a r i a t i o n

i n

r e f e r e n c e n o r m a l

v a l u e s ,

p r o b a b l y

i n

p a r t

d u e

t o

a

l e a r n i n g

e f f e c t . I n

a

p r e v i o u s

s t u d y

w e e v a l u a t e d t h e

l e a r n i n g e f f e c t

i n

1 0

h e a l t h y

p e o p l e a n d f o u n d t h a t

t h e

m e a n ( S E M ) f o r

MIP

i n c r e a s e d

f r o m

1 3 8

( 7 - 8 )

t o 1 5 8

( 4

9 0 )

cm

H 2 0

w h e n

r e p e t i t i v e

s t u d i e s

o f

m u s c u l a r

s t r e n g t h

a r e

c a r r i e d

o u t t h r e e

t i m e s ,

o n e

d a y

a

w e e k ,

f o r s i x c o n s e c u t i v e

w e e k s . 6

A l t h o u g h

MIP

m e a s u r e -

m e n t

h a s

g a i n e d

a n e s t a b l i s h e d

p l a c e

i n t h e

m a n a g e -

m e n t

o f

p a t i e n t s

w i t h

c h r o n i c

a i r f l o w

o b s t r u c t i o n , 7 8

i t

i s

n o t c l e a r h o w

many

m a n o e u v r e s

s h o u l d

b e c a r r i e d

o u t

t o

a c h i e v e

a

m a x i m a l

M I P .

We

h a v e

a n a l y s e d

2 0


MIP

m e a s u r e m e n t s

i n 4 4

p a t i e n t s

w i t h

c h r o n i c

a i r f l o w

o b s t r u c t i o n

t o d e t e r m i n e

t h e

m i n i m a l

n u m b e r

o f

MIP m a n o e u v r e s

n e c e s s a r y

t o o b t a i n

a

m a x i m a l

v a l u e

f o r

M I P .

A d d r e s s f o r

r e p r i n t

r e q u e s t s :

Dr

J

M

M o n t s e r r a t ,

C a n a l S e r v e i d e

P n e u m o l o g i a ,

H o s p i t a l C l i n i c , C / V i l l a r r o e l 1 7 0 ,

B a r c e l o n a

0 8 0 3 6 ,

S p a i n .

A c c e p t e d 1 0 F e b r u a r y

1 9 8 9

We

s t u d i e d

4 4

p a t i e n t s

w i t h

c h r o n i c

a i r f l o w o b s t r u c -

t i o n

( 3 4

m a l e

a n d

1 0

f e m a l e )

a t t e n d i n g

o u r

c h e s t

c l i n i c .

T h e m e a n

( S D )

a g e w a s 5 5 * 5 ( 1 1 - 3 ) y e a r s .

T h e

p a t i e n t s

s e l e c t e d h a d

c l i n i c a l a n d f u n c t i o n a l

e v i d e n c e o f

c h r o n i c

a i r f l o w

l i m i t a t i o n

a n d

w e r e c l i n i c a l l y s t a b l e a t

t h e t i m e o f t h e

s t u d y . T h e s p i r o m e t r i c v a l u e s

( m e a n

( S D ) , e x p r e s s e d

a s

p e r c e n t a g e s

o f t h e n o r m a l

v a l u e s 9 )

w e r e :

F E V ,

5 3 - 9 ( 2 5 ) , f o r c e d v i t a l c a p a c i t y ( F V C ) 6 6 5

( 1 7 )

a n d

F E V , / F V C

r a t i o 5 0 6 ( 1 5 ) . None

h a d

b e e n

t r a i n e d o r h a d c a r r i e d o u t

m a x i m a l

m o u t h p r e s s u r e

m a n o e u v r e s b e f o r e . P a t i e n t s w i t h c o e x i s t i n g

d i s e a s e s

w e r e

e x c l u d e d .

M a x i m a l i n s p i r a t o r y

m o u t h p r e s s u r e

w a s o b t a i n e d

w i t h

a n a n a e r o i d m a n o m e t e r

( i n s p i r a -

t o r y

f o r c e m e t e r ,

m o d e l

4 1 0 1 ,

B o e h r i n g e r L a b o r a -

t o r i e s ,

W y n n e w o o d ,

P e n n s y l v a n i a )

d u r i n g

m a x i m a l


e f f o r t s

i n

a q u a s i

s t a t i c c o n d i t i o n a t

r e s i d u a l v o l u m e ( R V ) . T h e

m a n o m e t e r r a n g e w a s

±

1 5 0 cm

H20 w i t h a n a c c u r a c y

±

3 . I t w a s

c a l i b r a t e d

a g a i n s t

a w a t e r c o l u m n

s y s t e m

e v e r y

t w o

w e e k s

d u r i n g

t h e

s t u d y

a n d

w a s l i n e a r f r o m

-

1 0

t o

a t

l e a s t 8 0

cm

H 2 0 .

A l l

d e t e r m i n a t i o n s

w e r e

p e r f o r m e d

b y

t h e s a m e

p h y s i c i a n

( J A F ) .

E a c h

p a t i e n t

r e c e i v e d

e x a c t l y

t h e s a m e i n s t r u c t i o n s . T h e

p a t i e n t s

i n s p i r e d

t h r o u g h

a

m o u t h p i e c e

w i t h a s m a l l l e a k

( 1 5

mm

d i a m e t e r )

t o

p r e v e n t

t h e

u s e o f b u c c i n a t o r m u s c l e s .

I f

c l o s e

i n s p e c t i o n

s h o w e d

a i r

l e a k a g e

a r o u n d

t h e

l i p s

4 1 9

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F i z , M o n t s e r r a t , P i c a d o , P l a z a , A g u s t i -

V i d a l

M a x i m c a l

i n s p i r a t o r Y

pressure

measurements

( m e a n s

w i t h

SEM)

f o r t h e

2 0

manoeuv res.

1

2 3 4 5

6

7

8

9 10

11 1 2 1 3 14

15

16 17 1 8 19 20

N o o f


t h i s

manoeuvre was

r e j e c t e d .

A l l

p a t i e n t s p e r f o r m e d

2 0

c o n s e c u t i v e m a x i m a l


m o u t h man

oeuvres, s e p a r a t e d b y 3 0 -

4 0

s e c o n d s .

R e s u l t s

are

e x p r e s s e d

a s

means w i t h

SD

o r

SE M

i n

p a r e n t h e s e s

Two

way

a n a l y s i s

o f

variance a n d

S c h e f f e s

t e s t

were

u s e d t o

compare

r e s u l t s .

R e s u l t s

T h e mean (SEM) MIP v a l u e s o b t a i n e d

i n

t h e 2 0

manoeuvres

are s h o w n

i n

t h e f i g u r e .

T h e

mean

( S D )

v a l u e s o f MIP v a r i e d f r o m 7 1 5 ( 2 5 ) cm

H , O

a t

t h e

f i r s t

d e t e r m i n a t i o n t o 8 0

( 2 7 )

cm

H2O a t

t h e l a s t

measurement. M a x i m a l

v a l u e s o f

MIP

were u s u a l l y

a c h i e v e d

a t

t h e n i n t h or t e n t h

d e t e r m i n a t i o n .

T h e r e

were s i g n i f i c a n t

i n t r a s u b j e c t

d i f f e r e n c e s ( t w o way

a n a l y s i s

o f

variance,

F

=

2

9 9 ,

p

<

0 - 0 5 )

a n d

s i g n i f i c a n t d i f f e r e n c e s b e t w e e n t h e h i g h e s t

v a l u e

( t h e

2 0 t h

d e t e r m i n a t i o n )

a n d

t h e

f i r s t

e i g h t


( S c h e f f e s t e s t ) .

T h e d i f f e r e n c e b e t w e e n

t h e

n i n t h

a n d

t h e t w e n t i e t h


were

n o t

s i g n i f i c a n t .

D i s c u s s i o n

T h e

n e e d

t o q u a n t i f y t h e p e r f o r m a n c e

o f

t h e r e s -

p i r a t o r y m u s c l e s h a s

b e e n

h i g h l i g h t e d b y r e c e n t

s t u d i e s

on

m u s c l e

f a t i g u e a n d

m u s c l e t r a i n i n g . -

T h e r e i s g e n e r a l agreement

t h a t

f o r c l i n i c a l

purposes

MIP

i s t h e measure

o f

c h o i c e

of

muscle

s t r e n g t h . )

A l t h o u g h

some

d a t a

are

a v a i l a b l e on n o r m a l

m a x i m a l

i n s p i r a t o r y pressure,

e s p e c i a l l y

a t

r e s i d u a l v o l u m e

( R V ) , '

l i t t l e w o r k h a s b e e n

d o n e

on t h e

e f f e c t

o f

l e a r n i n g

on

MIP

d e t e r m i n a t i o n s . We m e a s u r e d

MIP

a t

R V ,

f o l l o w i n g

t h e

r e c o m m e n d a t i o n s o f s e v e r a l

a u t h o r s . 4

Our

r e s u l t s

show t h a t

a minimum

o f

nine

t e c h n i c a l l y a c c e p t a b l e

manoeuvres o f m a x i m a l

mouth

pressure

manoeuvres are

necessary

t o o b t a i n

a

r e p r o d u c i b l e

MIP i n

u n t r a i n e d

a n d

u n e x p e r i e n c e d

p a t i e n t s

w i t h c h r o n i c

a i r f l o w

o b s t r u c t i o n .

Our

con-

c l u s i o n s d i f f e r

f r o m t h o s e

o f

B l a c k e t

a l ,

wh o

s t u d i e d

n o r m a l v a l u e s

o f MI P i n 1 2 0

p a t i e n t s .

T h e y

t e s t e d

t h e

e f f e c t

o f

l e a r n i n g

i n

o n l y

s i x i n d i v i d u a l s over

t h r e e


d a y s

a n d

f o u n d no

s i g n i f i c a n t

d i f f e r e n c e s

b e t w e e n t h e

mean

v a l u e s on

t h e

f i r s t

d a y

a n d

on

t h e

s e c o n d a n d

t h i r d

d a y s

The

h i g h e s t

v a l u e

f o r

MIP

on

t h e t h i r d

d a y

was l e s s

t h a n

10

g r e a t e r

t h a n t h e v a l u e

on

t h e f i r s t

d a y

in

t h r e e

s u b j e c t s

a n d

was

u n c h a n g e d

or

l o w e r

in

t h e o t h e r t h r e e

s u b j e c t s .

B l a c k e t

a c o n c l u d e d

t h a t t h e s h or t

t e r m

l e a r n i n g

e f f e c t i s

s l i g h t .

The l i m i t e d

number o f

s u b j e c t s

a n d manoeuvres

u s e d t o

a n a l y s e

t h e

l e a r n i n g

e f f e c t

may e x p l a i n

t h e

d i s c r e p a n c y

b e -

tween

t h e s e

r e s u l t s

a n d ours.

R i n g q u i s t

e t

a l 4

s t u d i e d

n o r m a l

v a l u e s o f

MIP

u s i n g

10

or more

measurements

o f

M I P ,

a n d

r e p o r t e d

h i g h e r

maximal

pressures

t h a n

B l a c k

e t

a l

a n d

L e e c h e t

a l , S

who

u s e d

o n l y

two

a n d

t h r e e

measurements

r e s p e c t i v e l y

t o d e t e r m i n e

t h e i r

4 2 0

P r e s s u r e

( c m

H , O )

8 5

8 4

8 3

8 2

8 1

8 0

7 9

7 8

7 7

7 6

7 5

7 4

7 3

7 2

7 1

7 0









8/10/2019 Thorax-1989-Fiz-419-21.pdf


How

m a n y m a n o e u v r e s

t o

m e a s u r e

m a x i m a l i n s p i r a t o r y m o u t h p r e s s u r e i n c h r o n i c

a i r f l o w

o b s t r u c t i o n ?

n o r m a l

v a l u e s . T h i s s u g g e s t s

t h a t t h e l e a r n i n g e f f e c t i s

i m p o r t a n t i f m a x i m a l a n d r e p r o d u c i b l e

MIP

m e a s u r e m e n t s a r e t o b e o b t a i n e d .

We

h a d n o s e r i o u s

p r o b l e m s i n

c a r r y i n g

o u t

r e p e a t e d

m e a s u r e m e n t s o f

M I P ,

a n d o n l y

t w o

p a t i e n t s

w e r e

u n a b l e

t o p e r f o r m

t h e 2 0

m a n o e u v r e s ,

t h o u g h

s o m e

p a t i e n t s

w e r e

e x h a u s t e d

a t

t h e

e n d

o f

t h e

2 0 .

N i n e

m a n o e u v r e s ,

h o w e v e r ,

w e r e w e l l

t o l e r a t e d b y

a l m o s t a l l

t h e

p a t i e n t s .

R e f e r e n c e s

B l a c k

L F ,

H y a t t

R E .

M a x i m a l

i n s p i r a t o r y p r e s s u r e s :

n o r m a l

v a l u e s a n d r e l a t i o n s h i p

t o

a g e

a n d

s e x .

Am R e v

R e s p i r

D i s

1 9 6 9 ; 9 9 : 6 9 6 - 7 0 2 .

2 S m y t h R J C h a p m a n KR,

R e b u c k

A . M a x i m a l

i n -

s p i r a t o r y

a n d e x p i r a t o r y

p r e s s u r e s

i n

a d o l e s c e n t s .

N o r m a l v a l u e s . C h e s t 1 9 8 4 ; 8 6 : 5 6 8 - 7 2 .

3

G a u l t i e r

C ,

Z i n m a n R .

M a x i m a l

s t a t i c

p r e s s u r e s

i n

h e a l t h y

c h i l d r e n .

R e s p i r

P h y s i o l

1 9 8 3 ; 5 1 : 4 6 - 6 1 .

4

R i n g q v i s t

T .

T h e

v e n t i l a t o r y

c a p a c i t y

i n

h e a l t h y s u b j e c t s :

a n

a n a l y s i s

o f

c a u s a l f a c t o r s w i t h

s p e c i a l

r e f e r e n c e

t o

t h e

r e s p i r a t o r y

f o r c e s . S c a n d

J

C l i n I n v e s t

1 9 6 6 ; 1 8

( s u p p l ) : 8 7 - 9 3 .

5

L e e c h

J A ,

G h e z z o

H ,

S t e v e n s

D ,

B e c k l a k e MR .

R e s -

p i r a t o r y p r e s s u r e s

a n d f u n c t i o n

i n

y o u n g

a d u l t s .

Am

R e v R e s p i r

D i s

1 9 8 3 ; 1 2 8 : 1 7 - 2 3 .

6

F i z

J A ,

M o n t s e r r a t

J M ,

P i c a d o

C , A g u s t i - V i d a l

A .

P r e s i o n i n s p i r a t o r i a

m a x i m a e s t a t i c a ( P I M ) .

R e l a c i o n e s

e n t r e

l a s p r e s i o n e s p i c o - m e s e t a

y e f e c t o

a p r e n d i z a j e . A r c h i v o s

B r o n c o n e u m o l o g i a 1 9 8 7 ; 2 3 :

2 5 3 - 5 .

7 R o c h e s t e r D F , A r o r a N S .

D e t e r m i na n t s o f m a x i m a l

i n s p i r a t o r y p r e s s u r e i n c h r o n i c o b s t r u c t i v e p u l m o n a r y

d i s e a s e .

Am

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m o n a r y d i s e a s e ( C O P D ) . B u l l E u r

P h y s i o p a t h o l R e s p i r

1 9 7 9 ; 1 5 : 9 5 1 - 7 5 .

9 R o c a

J , S a n c h i s

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1 9 8 6 ; 2 2 : 2 1 7 - 2 4 .

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t h e

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J Med 1 9 8 5 ; 3 1 3 : 1 4 5 0 - 6 .

1 1 R o c h e s t e r DR, B r a u n

NMT,

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S . D i a p h r a g m a t i c

e n e r g y e x p e n d i t u r e

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1 9 7 7 ; 6 3 : 2 2 3 - 3 2 .

1 2

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F a t i g u e ,

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C h e s t 1 9 8 2 ; 8 2 : 7 6 1 - 6 .

1 4 C l a u s e n J L .

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s u r e s .

I n : J J

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e d . P u l m o n a r y f u n c t i o n t e s t i n g :

g u i d e l i n e s

a n d

c o n t r o v e r s i e s . N ew Y o r k : A c a d e m i c

P r e s s , 1 9 8 2 : 1 8 7 - 9 1 .

4 2 1









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doi: 10.1136/thx.44.5.419 1989 44: 419-421Thorax

J A Fiz, J M Montserrat, C Picado, et al. obstruction?patients with chronic airflowinspiratory mouth pressure inbe done to measure maximalHow many manoeuvres should

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