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SUMMARY________________________________________________________
A method for determining maximal respiratory pressures is described. The test was
easy to perform; reproducible results were obtained, and no complications were en-
countered in the 120 subjects studied. The normal range of values for the maximal in-
spiratory (Pr max) and expiratory (PE max) pressures in males and females from 20 to
74 years of age was determined. There was no significant regression of Pr max or PE max
with age in subjects younger than 55 years. In subjects older than 55, PE max in males
and females and Pr max in females decreased with age. The application of the method
is illustrated by the results obtained in 2 patients with neuromuscular disease.
after a maximal expiration. The pressures measured tient 1 was a 52-year-old man who complained
were maintained for at least one second. The de- of dyspnea on exertion. Physical examination
terminations were repeated until two technically revealed widespread muscle fasiculations and
satisfactory measurements were recorded; the
higher value was used in subsequent calculations. atrophy of muscles of the tongue. Electromy-
ography demonstrated evidence of lower motor
RESULTS neuron disease with fibrillation potentials in
The relationship of age to PI max and PE both upper extremities. The clinical diagnosis
max in males and females is shown in figures was amyotrophic lateral sclerosis. Patient 2
2 and 3. Regression equations calculated from was a 68-year-old man who complained of
these data are listed in table 1. The slope of the dyspnea and difficulty in chewing and swallow-
regression lines was significant for PI max and ing. Physical examination revealed weakness of
PE max in both males and females. A parabolic the bulbar and extremity muscles. Electro-
regression line was also determined for the myography showed evidence of a neuromuscu-
same four groups, but this did not result in lar transmission defect in the intercostal,
less residual variance than that obtained from peripheral, and masseter muscles. The clinical
the linear regression in any group. Because diagnosis was myasthenia gravis. Results of
there appeared to be a breaking point in the pulmonary function tests in these patients are
data at approximately 55 years, the subjects shown in table 3. The studies reveal little
were divided into two age groups-those 55 abnormality in the commonly used tests ex-
and older and those younger than 55. There
was no significant regression of PI max or PE
max with age in either males or females
younger than 55 years. In subjects older than
55, there was significant regression of PE max in
males and females and of PI max in females.
Because of the small number of subjects older
than 75, prediction of the range of normal
values for the maximal pressures was limited
to ages 20 to 74 (table 2). Where regression
with age was not significant, the subjects were
treated as one group and the mean plus-minus
2 standard deviation (SD) was calculated. In
the groups in which significant regression with
age was demonstrated, the values represent the
regression prediction plus-minus 2syx (syx =
residual SD about the regression line) .
The average value for the individual coeffi-
cients of variation for duplicate determinations
at one time was 9 per cent in both females and
males for Pr max and PE max. Four females
and 2 m ales were tested in the same manner on
three consecutive days. There was no signifi-
cant difference between the mean values for
the pressures on the first day compared with
the second and third days. The highest value
for Pr max and for PE max on the third day
was less than 10 per cent greater than the
value on the first day in 3 subjects and was
unchanged or lower in 3 subjects, which sug-
gests that the short-term learning effect is FIG. 1. Instrument used in this study, showing
slight. inspiratory pressure (0 em to -160 em H.O) and
expiratory pressure (0 em to 300 em H,O) gauges,
Maximal respiratory pressures were measured which are alternately connect ed to cylinder by
in 2 patients with neuromuscular disease. Pa- three-way stopcock.
698 BLACK AND HYATT
A A A A .a.;:: 300
280
... .. - .
240
'-
~
200
~ ~
~
~ tJ
160 f- .:
(..) '-
....
(/)~
c:t
~
~ ~ 1201
(/)
(/) }-
Ill
'- 80 f-
~
~
~ 40
tJ
~
~ 0
~ ::=:-160
.......
tJ
-40
..
.~.... ~
~ ~
-80
.. ....
tJ
,.. ...
~ ~
;.
...
~ -120
~
-160
10 20 30 40 50 60 70 80 90
Age, years
FIG. 2. Effect of age on maximal respiratory pressures in 60 normal males. Triangles and
squares indicate values beyond limits of gauges.
cept for the decrease in maximal breathing by the present method. Hyatt found that this
capacity. The maximal pressures were markedly method provided results similar to those of
decreased in both patients. another method for measuring respiratory mus-
cle strength. He recorded intraesophageal
DISCUSSION pressures from a balloon placed in the lower
The effect of lung volume on maximal static third of the esophagus during cough at differ-
pressures has been previously described (1-3). ent lung volumes in 9 normal subjects and
Cook and associates (2) and Ringqvist (3) compared the pressures with those obtained by
found that the highest maximal expiratory the present method at the same lung volumes.
pressures were obtained at lung volumes The mean value for the cough pressures, un-
greater than 70 per cent of TLC and the corrected for lung retractive force, was 203 em
highest maximal inspiratory pressures were ob- H,O; the mean value for PE max by the present
tained at volumes less than 40 per cent to 50 method was 204 em H.O.
per cent of TLC. By initiating the measure- Measurements of the maximal pressures
ment of PE max from TLC and that of Pr should be more reproducible at the lung vol-
max from RV, the highest maximal pressures umes chosen in the present study than meas-
for the respiratory system should be recorded Hyatt, R. E.: Unpublished data.
MAXIMAL RESPIRATORY PRESSURES 699
240
\,.
Ill
......
200
~
... ...
.... ..
~ 160
(/)~
~
t:l
~
::J
-~
120
(/) ~
(/)
~
~ 80
t:t
t- 40
~
~
......
~ 0
~
~ ~ -40
.
.'". ... . ... . . . .
.
C)
......
-~ ~
.. .. ...
......
-80
~ ~
..!:::
-120
10 20 30 40 50 60 70 80 90
Age, years
urements at other lung volumes because it has an extensive series of measurements in each
been shown that the change in maximal pres- subject whereas in this study only two tech-
sure for a given change in lung volume is nically satisfactory measurements were used.
small at these selected volumes compared with Linear regression of PI max on age was
those elsewhere in the TLC (2, 3). The average noted in both males and females, but the re-
coefficient of variation for duplicate measure- gression was not significant in subjects younger
ments of 9 per cent, which is similar to results than 55 in either group or in males older
obtained in repeated testing of other muscle than 55. Ringqvist (3) demonstrated a linear
groups (3, 4), is in agreement with this. It is regression of PI max with age but did not di-
important to note that the short-term learning vide the subjects into subgroups. He found a
effect was not great, because such learning, if parabolic regression of PE max with age in
significant, could influence the results obtained males and a similar but not significant tendency
in repeated testing in patients with muscular in females. Although the residual variance in
weakness. our data does not decrease with a parabolic
The values for PE max and PI max in fe- regression, it does appear likely that a curvilin-
males were 65 per cent to 70 per cent of those ear regression exists for PE max. The regres-
obtained in males; this is in agreement with sions for the males in our study may be af-
previous reports (2, 3). The actual values for fected to some extent by the fact that the
the maximal pressures in different age groups maximal pressure range of the gauges used
are similar to those reported by Cook and as- was plus 300 em to minus 160 em H.O.
sociates (2) and are 10 em to 20 em H.O less Gauges for recording higher pressures are
than those reported by Ringqvist (3). This available, but the present ones are adequate
difference may be related to Ringqvist's use of for use in clinical studies.
700 BLACK AND HYATT
TABLE 2
NORMAL VALUES FOR MAXIMAL RESPIRATORY PRESSURES
Pressure*
(cmHO)
Age
(yr)
healthy subjects: An analysis of causal fac- and Olsen, A. M.: Exertional dyspnea: A
tors with special reference to the respiratory primary complaint in unusual cases of pro-
forces, Scand. J. Clin. Lab. Invest., 1966, gressive muscular atrophy and amyotrophic
18 (Supplement 88, p. 1). lateral sclerosis, Ann. Intern. Med., 1957,
(4) Tornvall, G.: Assessment of physical capabili- 46, 119.
ties: With special reference to the evalua- (6) Gillam, P. M. S., Heaf, P. J. D., Kaufman, L.,
tion of maximal voluntary isometric muscle and Lucas, B. G. B.: Respiration in dys-
strength and maximal working capacity: trophia myotonica, Thorax, 1964, 19, 112.
An experimental study on civilian and mili- (7) Byrd, R. B., and Hyatt, R. E.: Maximal res-
tary subject groups, Acta Physiol. Scand., piratory pressures in chronic obstructive
1963,58 (Supplement 201, p. 1). lung disease, Amer. Rev. Resp. Dis., 1968,
(5) Miller, R. D., Mulder, D. W., Fowler, W. S., 98,848.