Abstracts
Background:
The maximum static respiratory pressures, namely the maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), reflect the strength of the respiratory muscles. These measures are simple, non-invasive, and have established diagnostic and prognostic value. This study is the first to examine the maximum respiratory pressures within the Brazilian population according to the recommendations proposed by the American Thoracic Society and European Respiratory Society (ATS/ERS) and the Brazilian Thoracic Association (SBPT).
Objective:
To establish reference equations, mean values, and lower limits of normality for MIP and MEP for each age group and sex, as recommended by the ATS/ERS and SBPT.
Method:
We recruited 134 Brazilians living in Belo Horizonte, MG, Brazil, aged 20-89 years, with a normal pulmonary function test and a body mass index within the normal range. We used a digital manometer that operationalized the variable maximum average pressure (MIP/MEP). At least five tests were performed for both MIP and MEP to take into account a possible learning effect.
Results:
We evaluated 74 women and 60 men. The equations were as follows: MIP=63.27-0.55
(age)+17.96 (gender)+0.58 (weight), r2 2. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
of
34% and MEP= - 61.41+2.29 (age) - 0.03(age22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
)+33.72 (gender)+1.40 (waist), r2
2. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
of 49%.
Conclusion:
In clinical practice, these equations could be used to calculate the predicted values of MIP and MEP for the Brazilian population.
maximum respiratory pressures; reference values; rehabilitation; physical therapy; MIP; MEP
Contextualização:
A medida das pressões respiratórias estáticas máximas (pressão inspiratória (PImáx) e pressão expiratória máxima (PEmáx)) refletem a força dos músculos respiratórios. Essas medidas são simples, não invasivas e têm valores diagnóstico e prognóstico estabelecidos. Este é o primeiro estudo que avaliou pressões respiratórias máximas com a população brasileira realizado de acordo com as recomendações propostas pela American Thoracic Society e European Respiratory Society (ATS/ERS) e pela Sociedade Brasileira de Pneumologia e Tisiologia (SBPT).
Objetivo:
Estabelecer equações de referência, valores médios e limites inferiores de normalidade para a PImáx e a PEmáx para cada faixa etária e gênero, conforme as recomendações da ATS/ERS e da SBPT.
Método:
Foram recrutados 134 brasileiros residentes em Belo Horizonte, MG, Brazil, com idade entre 20-89 anos, com prova de função pulmonar e índice de massa corporal dentro da normalidade. Foi utilizado um manovacuômetro digital que operacionalizou a variável pressão média máxima. Para a PImáx e a PEmáx, foram realizadas, pelo menos, cinco manobras, considerando o efeito aprendizado.
Resultados:
Foram avaliados 74 mulheres e 60 homens. As equações propostas foram:
PImáx=63,27-0,55 (idade)+17,96 (sexo)+0,58 (peso), r22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
=34% e PEmáx=-61,41+2,29 (idade)-0,03 (idade22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
)+33,72 (sexo)+1,40 (cintura), r22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
=49%.
Conclusão:
As equações resultantes deste estudo poderão ser utilizadas na prática clínica para cálculo de valores preditos para PImáx e PEmáx na população brasileira.
pressão respiratória máxima; valores de referência; reabilitação; fisioterapia; PImáx; PEmáx
Introduction
The maximum static respiratory pressures (MRPs), namely the maximum inspiratory (MIP)
and expiratory pressure (MEP), reflect the strength of the respiratory muscles11. Nava S, Ambrosino N, Crotti P, Fracchia C, Rampulla C. Recruitment of
some respiratory muscles during three maximal inspiratory manoeuvres. Thorax.
1993;48(7):702-7.http://dx.doi.org/10.1136/thx.48.7.702. PMid:8153917
http://dx.doi.org/10.1136/thx.48.7.702...
2. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
-
33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.. As these measures are simple, non-invasive,
and have diagnostic and prognostic value, several authors have established reference
values for populations of diverse ethnicities44. Black LF, Hyatt RE. Maximal respiratory pressures: normal values and
relationship to age and sex. Am Rev Respir Dis. 1969;99(5):696-702. PMid:5772056.
5. Bruschi C, Cerveri I, Zoia MC, Fanfulla F, Fiorentini M, Casali L,
etal. Reference values of maximal respiratory mouth pressures: a population-based
study. Am Rev Respir Dis. 1992;146(3):790-3.http://dx.doi.org/10.1164/
ajrccm/146.3.790. PMid:1519865
http://dx.doi.org/10.1164/ ajrccm/146.3....
6. Johan A, Chan CC, Chia HP, Chan OY, Wang YT. Maximal respiratory
pressures in adult Chinese, Malays and Indians. Eur Respir J.
1997;10(12):2825-8.http://dx.doi.org/10.118 3/09031936.97.10122825. PMid:9493668
http://dx.doi.org/10.118 3/09031936.97.1...
7. Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth
pressures (PIMAX) in healthy subjects-what is the lower limit of normal? Respir Med.
2000;94(7):689-93.http://dx.doi.org/10.1053/rmed.2000.0802.
PMid:10926341
http://dx.doi.org/10.1053/rmed.2000.0802...
8. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
-
99. Gopalakrishna A, Vaishali K, Prem V, Aaron P. Normative values for
maximal respiratory pressures in an Indian Mangalore population: A cross-sectional
pilot study. Lung India. 2011;28(4):247-52.http://dx.doi.org/10.4103/09702113.85684.
PMid:22084536
http://dx.doi.org/10.4103/09702113.85684...
.
There is large inter-subject variability in MRP values. The biological characteristics
of populations, measurement technique, and equipment used all contribute to this
variability77. Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth
pressures (PIMAX) in healthy subjects-what is the lower limit of normal? Respir Med.
2000;94(7):689-93.http://dx.doi.org/10.1053/rmed.2000.0802.
PMid:10926341
http://dx.doi.org/10.1053/rmed.2000.0802...
8. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
9. Gopalakrishna A, Vaishali K, Prem V, Aaron P. Normative values for
maximal respiratory pressures in an Indian Mangalore population: A cross-sectional
pilot study. Lung India. 2011;28(4):247-52.http://dx.doi.org/10.4103/09702113.85684.
PMid:22084536
http://dx.doi.org/10.4103/09702113.85684...
10. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325.
11. McConnell AK, Copestake AJ. Maximum static respiratory pressures in
healthy elderly men and women: issues of reproducibility and interpretation.
Respiration. 1999;66(3):251-8.http://dx.doi.org/10.1159/000029386.
PMid:10364742
http://dx.doi.org/10.1159/000029386...
12. Neder JA, Andreoni S, Lerario MC, Nery LE. Reference values for lung
function tests. II. Maximal respiratory pressures and voluntary ventilation. Braz J
Med Biol Res. 1999;32(6):719-27. PMid:10412550.
-
1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. The variation in MRPs and the need to
standardize evaluation procedures has led the American Thoracic Society,
European Respiratory Society (ATS/ERS)22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
and the Brazilian ThoracicAssociation (Sociedade Brasileira de Pneumologia
e Tisiologia -SBPT)33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65. to publish guidelines for
the testing of respiratory muscles, including the performance of MRP measurements.
For testing, International and Brazilian recommendations suggest the use of a diver's type mouthpiece; the presence of a drain hole approximately 2 mm in internal diameter; the performance of the test by an experienced operator, who must stimulate the subject to perform a MIP against an occluded airway and a MEP against an occluded area near or within residual volume (RV) and within total lung capacity (TLC), respectively; adopting a sitting posture; instruction prior to the maneuver and encouragement during the maneuver; prevention of air leaks around the mouthpiece, directing the subject to hold the cheeks with the hands during expiratory pressure and to press the lips tightly around the mouthpiece; and, recording the maximum mean pressure (MMP).
ATS/ERS2 2. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
stresses the importance of using digital
instruments to ensure the validity of the measurements used to determine MMP (maximum
mean pressure sustained for 1 second). International2
2. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
and Brazilian3 3. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.guidelines have similar
recommendations, although there are points on which they differ, such as the use of a
nose clip (SBPT recommendation) and the maximum number of tests for each measurement.
SBPT3 3. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.recommends a maximum of five tests and
considers the learning effect of the repeated measurements, allowing the performance of
more tests if the last value was the highest.
In Brazil, after publication of the guidelines, two studies were published proposing
reference values for MRPs88. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
,
1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. The methodological recommendations proposed
by the scientific societies were not satisfied in their entirety in either study22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
,
33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65..
In this context, the aim of this study was to establish MRP reference values,
considering the ATS/ ERS22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
and SBPT33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65. recommendations, for a sample of adults in a
population from Belo Horizonte, MG, Brazil.
Method
Sample
Sample size calculation was performed according to Simões et al.'s study1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. A level of statistical significance of 5%, a
power of 90% and 20% estimated effect were adopted for the calculations1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
,
1414. Gordis L. Epidemiology. 3rd ed. Philadelphia: Elsevier Science;
2004. . Effect size (Cohen d) was based on
calculations of the differences between the mean MIP and MEP in men and women for
each age group, as used in Simões et al.'s study1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
, yielding a sample size of 117 individuals. Subsequently, the required
number of individuals of each gender in each age group was estimated so that the
sample would be representative, based on analysis of the Brazilian Institute of
Geography and Statistics (Instituto Brasileiro de Geografia e Estatística -IBGE) -
2010 census for the population of Belo Horizonte, MG, Brazil1515. Instituto Brasileiro de Geografia e Estatística -IBGE. Sinopse e
resultados do Censo 2010. 2012. Disponível em:
http:/www.censo2010.ibge.gov.br/sinopse/webservice/default.php?cod1=31&cod2=3
http:/www.censo2010.ibge.gov.br/sinopse/...
.
The non-probabilistic sample consisted of volunteers of both genders, selected from
the community by personal invitation, telephone call, or electronic communication,
who fulfilled all of the study's inclusion criteria. The inclusion criteria were as
follows: healthy adults between 20 and 89 years, with spirometric parameters within
the limits predicted for the Brazilian population16
16. Pereira CA, Sato T, Rodrigues SC. New reference values for forced
spirometry in white adults in Brazil. J Bras Pneumol.
2007;33(4):397-406.http://dx.doi.org/10.1590/S180637132007000400008.
PMid:17982531
http://dx.doi.org/10.1590/S1806371320070...
and body mass index (BMI) within the normal range (18.5 Kg/m22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
≤BMI≤29.9 Kg/m22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
)1717. Associação Brasileira para o Estudo da Obesidade e Síndrome
Metabólica - ABESO. Diretrizes brasileiras de obesidade. 3ª ed. São Paulo: AC
Farmacêutica; 2009. . The exclusion criteria were
as follows: history of current smoking; exposure to occupational environmental risk;
reported history of neuromuscular, respiratory, and/or heart disease; cognitive
impairment (in participants aged over 60 years); fever in the previous three weeks
and/or cold and/or sinus infection in the week before the test; use of drugs such as
oral steroids, central nervous system depressants, barbiturates, and/or muscle
relaxants; exhaustive exercise in the 48 hours preceding the test; absence of dental
elements; limiting muscle pain in the upper limbs; resting blood pressure (BP)
greater than or equal to 160/110 mmHg18 18. Sociedade Brasileira de Cardiologia. VI Diretrizes Brasileiras de
Hipertensão. Arq Bras Cardiol. 2010;95(1, Supl 1):1-51. and/or
hemoglobin saturation (SpO2) less than 90% and/or heart rate (HR) greater
than 85% of maximum heart rate before execution of the maneuvers; and inability to
understand and/or perform the procedures in the research protocol. The test was
interrupted if there were reports of respiratory and/or muscular discomfort during
performance.
The study was approved by the Ethics Committee of the Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, MG, Brazil (CAAC Protocol 0425.0.203.000-10), and all participants signed the terms of free and informed consent.
Measuring instruments
Digital Manometer
A digital manometer (NEPEB-LabCare/UFMG) was used to measure MRP1919. Ferreira JL, Pereira NC, Oliveira Júnior M, Vasconcelos FH, Parreira
VF, Tierra-Criollo CJ. Maximum respiratory pressure measuring system: calibration and
evaluation of uncertainty. Control Autom. 2010;21(6):588-97.
,
2020. Montemezzo D, Vieira DS, Tierra-Criollo CJ, Britto RR, Velloso M,
Parreira VF. Influence of 4 interfaces in the assessment of maximal respiratory
pressures. Respir Care. 2012;57(3):392-8.http://dx.doi.org/10.4187/respcare.01078.
PMid:22005049
http://dx.doi.org/10.4187/respcare.01078...
, in which the pressures were measured by
pressure transducers with an operating range of 500 cmH2O1919. Ferreira JL, Pereira NC, Oliveira Júnior M, Vasconcelos FH, Parreira
VF, Tierra-Criollo CJ. Maximum respiratory pressure measuring system: calibration and
evaluation of uncertainty. Control Autom. 2010;21(6):588-97. . A diver's mouthpiece with a 2 mm diameter
hole and nose clip were used to measure MRP22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
,
33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.
,
2121. Evans JA, Whitelaw WA. The assessment of maximal respiratory mouth
pressures in adults. Respir Care. 2009;54(10):1348-59.
PMid:19796415.. The manometer was calibrated every six
months, as established by Ferreira et al.1919. Ferreira JL, Pereira NC, Oliveira Júnior M, Vasconcelos FH, Parreira
VF, Tierra-Criollo CJ. Maximum respiratory pressure measuring system: calibration and
evaluation of uncertainty. Control Autom. 2010;21(6):588-97. .
Spirometer
Vitalograph (Vitalograph 2120, Ennis, Ireland) and
Pony (Pony FX
(r)
, Cosmed, Rome, Italy) were used, and acceptability and
reproducibility criteria were adopted according to SBPT standards2222. Pereira CAC. Espirometria. In: Sociedade Brasileira de Pneumologia e
Tisiologia. Diretrizes para testes de função pulmonar. J Pneumol. 2002;28(Supl
3):S1-82. . Spirometric data were derived from the forced
vital capacity (FVC) maneuver and interpreted in accordance with the values predicted
by Pereira et al.1616. Pereira CA, Sato T, Rodrigues SC. New reference values for forced
spirometry in white adults in Brazil. J Bras Pneumol.
2007;33(4):397-406.http://dx.doi.org/10.1590/S180637132007000400008.
PMid:17982531
http://dx.doi.org/10.1590/S1806371320070...
.
Electrical bioimpedance
Quantum III BIA - 101Q RJL-101 (Detroit, USA) equipment was used for
the measurement of lean and fat mass. The instrument was a quadrupole model with
digital display, as per recommendations2323. Kyle UG, Bosaeus I, De Lorenzo AD, Deurenberg P, Elia M, Gómez JM,
et al, and the Composition of the ESPEN Working Group. Bioelectrical impedance
analysis-part I: review of principles and methods. Clin Nutr.
2004;23(5):1226-43.http://dx.doi.org/10.1016/j. clnu.2004.06.004.
PMid:15380917
http://dx.doi.org/10.1016/j. clnu.2004.0...
.
Mechanical scale, portable digital scale and stadiometer
A Filizola analog scale (Filizola Ind. Ltda, São Paulo, Brazil) was used to measure weight and height. The scale was coupled to a stadiometer with resolutions of 100 g and 0.5 cm, which was calibrated prior to each measurement. A 100 g resolution portable digital scale (Life Electronic Scale, Geratherm (r) , Germany) and a 0.1 cm resolution portable stadiometer (Alturexata, Belo Horizonte, Brazil) were used for evaluations conducted outside the University. To evaluate the reliability of the scale measures, the weight of ten volunteers was measured on the two scales at random. No significant difference was observed between the data obtained on the two scales (67.22±10.2 Kg versus 66.86±10.0 Kg, p=0.14, intraclass correlation coefficient 0.99). These data were used to calculate BMI.
Waist circumference and waist-hip ratio
An anthropometric tape measure (metric) consisting of an inelastic material was used. The standing position was adopted with arms at the volunteer's sides, feet together, and relaxed abdomen1717. Associação Brasileira para o Estudo da Obesidade e Síndrome Metabólica - ABESO. Diretrizes brasileiras de obesidade. 3ª ed. São Paulo: AC Farmacêutica; 2009. . The waist circumference measurement was taken by firmly applying the tape in the trunk region between the lower edge of the last rib and the upper edge of the iliac crest1717. Associação Brasileira para o Estudo da Obesidade e Síndrome Metabólica - ABESO. Diretrizes brasileiras de obesidade. 3ª ed. São Paulo: AC Farmacêutica; 2009. . Hip measurement was performed by applying the tape firmly to the maximum posterior extension of the buttocks1717. Associação Brasileira para o Estudo da Obesidade e Síndrome Metabólica - ABESO. Diretrizes brasileiras de obesidade. 3ª ed. São Paulo: AC Farmacêutica; 2009. .
Fitness
Volunteers were asked about their level of physical activity and professional
occupation to classify them as active or sedentary, as recommended by the American
College of Sports Medicine (ACSM)2424. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et
al. Physical activity and public health: updated recommendation for adults from the
American College of Sports Medicine and the American Heart Association. Med Sci
Sports Exerc. 2007;39(8):1423-34.http://dx.doi. org/10.1249/mss.0b013e3180616b27.
PMid:17762377
http://dx.doi.
org/10....
: active
(weekly caloric expenditure above 450 MET-min/week) or sedentary (below 450 MET-min/
week), ascertained by self-report2525. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ,
et al. Compendium of physical activities: an update of activity codes and MET
intensities. Med Sci Sports Exerc. 2000;32(9, Suppl):S498-504.http://dx.doi.
org/10.1097/00005768-200009001-00009. PMid:10993420
http://dx.doi.
org/10....
.
Procedures
The initial evaluation included the following data: personal data; measuring weight,
height, and waist and hip circumferences; vital data -PA (Littman Classic,
St. Paul, USA stethoscope and Tycos, NY, USA
sphygmomanometer); HR and SpO2 (Nonim, USA pulse
oximeter); and physical fitness by self-report2424. Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et
al. Physical activity and public health: updated recommendation for adults from the
American College of Sports Medicine and the American Heart Association. Med Sci
Sports Exerc. 2007;39(8):1423-34.http://dx.doi. org/10.1249/mss.0b013e3180616b27.
PMid:17762377
http://dx.doi.
org/10....
,
2525. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz AM, Strath SJ,
et al. Compendium of physical activities: an update of activity codes and MET
intensities. Med Sci Sports Exerc. 2000;32(9, Suppl):S498-504.http://dx.doi.
org/10.1097/00005768-200009001-00009. PMid:10993420
http://dx.doi.
org/10....
. The Mini Mental State Exam was also
applied for elderly volunteers and a cutoff of 23/24 adopted2626. Brucki SM, Nitrini R, Caramelli P, Bertolucci PH, Okamoto IH.
[Suggestions for utilization of the mini-mental state examination in Brazil]. Arq
Neuropsiquiatr. 2003;61(3B):777-81.http://dx.doi.org/10.1590/S0004282X2003000500014.
PMid:14595482
http://dx.doi.org/10.1590/S0004282X20030...
. Electrical bioimpedance was then measured, after which the
volunteers were offered a standardized food intake.
The pulmonary function test was then performed. Later, after standing for at least 10 minutes, the subjects' MRP measurement was taken randomly (electronic randomization). All procedures were performed on a single visit and by a single evaluator.
For MRP measurements (i.e. MMP), the subjects remained in a sitting position with
legs and trunks supported, with instructions and a demonstration being given prior to
the tests22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
,
33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.. All MRP measurements were performed using
the nose clip33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.. To measure MIP, the
participants performed two to three breaths at functional residual capacity (FRC)
level and then were requested to perform an expiration to RV, indicating that time by
elevating the participant's own hand33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.. At this
point, the participant was encouraged to generate maximal inspiratory pressure, and
simultaneously, the examiner proceeded to close the occlusion orifice and give a
standardized verbal command33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.
,
2020. Montemezzo D, Vieira DS, Tierra-Criollo CJ, Britto RR, Velloso M,
Parreira VF. Influence of 4 interfaces in the assessment of maximal respiratory
pressures. Respir Care. 2012;57(3):392-8.http://dx.doi.org/10.4187/respcare.01078.
PMid:22005049
http://dx.doi.org/10.4187/respcare.01078...
.
The same procedure was performed to measure MEP, except for the final verbal
instruction, which was to request an inspiration to TLC, followed by encouragement to
perform maximal expiratory pressure22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
,
33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.
,
2020. Montemezzo D, Vieira DS, Tierra-Criollo CJ, Britto RR, Velloso M,
Parreira VF. Influence of 4 interfaces in the assessment of maximal respiratory
pressures. Respir Care. 2012;57(3):392-8.http://dx.doi.org/10.4187/respcare.01078.
PMid:22005049
http://dx.doi.org/10.4187/respcare.01078...
. To measure MEP, the researcher pressed the
cheeks of the volunteers to prevent air leakage22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
.
The minimum operating time was 1.5 seconds so that the maximum sustained pressure
could be observed for 1 second22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
. All subjects
underwent at least five repetitions of each test, with a 1-minute interval between
them. The pressure measurement was considered complete when the participant performed
three acceptable maneuvers (no air leaks between the lips and/or nose clip and at
least 1.5 second duration)22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
,
3 3. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.and when, of these tests, there were three
reproducible ones (one with variation less than or equal to 10% and the other with a
variation of no more than 20% with pressure of higher value)22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
,
33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.. The largest measure could not be the last
test because of a potential learning effect33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65..
The highest MMP value was selected22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
.
Data reduction
The MRPs were operationalized by Manovac software version 4.1, using
the MMP variable2020. Montemezzo D, Vieira DS, Tierra-Criollo CJ, Britto RR, Velloso M,
Parreira VF. Influence of 4 interfaces in the assessment of maximal respiratory
pressures. Respir Care. 2012;57(3):392-8.http://dx.doi.org/10.4187/respcare.01078.
PMid:22005049
http://dx.doi.org/10.4187/respcare.01078...
,
2121. Evans JA, Whitelaw WA. The assessment of maximal respiratory mouth
pressures in adults. Respir Care. 2009;54(10):1348-59.
PMid:19796415.
,
2727.Hamnegård CH, Wragg S, Kyroussis D, Aquilina R, Moxham J, Green M.
Portable measurement of maximum mouth pressures. Eur Respir J.
1994;7(2):398-401.http://dx.doi.or g/10.1183/09031936.94.07020398.
PMid:8162993
http://dx.doi.or
g/10....
. The formula LLN = value predicted by the
regression equation formula -(1.645 x standard error of the estimate) was used to
obtain the lower limit of normality (LLN)33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65..
Statistical analysis
Descriptive data statistical analysis (means and dispersions) was performed, and the
normal distribution and homogeneity of variance of the variables were ascertained
using the Lilliefors and Cochran & Bartletti tests, respectively. Once the nature
of responses was established in their parametric or non-parametric condition
(Pearson, Spearman, and Kendall), a correlation matrix was established of the
independent variables (i.e. gender, age, height, weight, BMI, waist circumference,
waist-hip ratio, and physical activity level) between each pair of these variables
and with the measured responses (i.e. MIP, MEP). Using the backward stepwise
system, non-significant independent variables (p>0.05) were disregarded,
noting the continued determination capacity (r22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
) of the model. After the explanatory effects of each model were defined,
they were tested for each of their quadratic effects as well as for possible
interactions. All analyses were processed using the Statistical Package for
Social Sciences program (SPSS 15.0, Chicago, IL, USA)
and the Statistical Analysis System (SAS 12.0, Carey, NC,
USA).
Results
One hundred sixty-four individuals were initially evaluated. Of these individuals, 20
were not included because they were obese (BMI above 30 Kg/m22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
), and two were excluded due to being underweight (BMI below 18.5
Kg/m22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
). Eight subjects were excluded due to
obstructive or restrictive disorders being identified during pulmonary function testing.
The final sample consisted of 134 volunteers. All volunteers completed the proposed
protocol. The mean age was 47±18 years for women and 43±16 years for men. The final
sample comprised 51% sedentary women and 39% sedentary men. The percentage of body mass
was evaluated in a subgroup of individuals (n=64), verifying that the men had a mean
lean body mass percentage of 72.8±4.7 Kg and the women of 64.4±5.0 Kg. Participants
presented the following spirometric data: forced vital capacity (FVC): women=94.1±10.9%
of predicted value and men 92.5±10.0% of predicted value; forced expiratory volume in 1
second (FEV1): women=93.8±11.2% of predicted value and men=92.4±9.5%
predicted value); and FEV1/FVC ratio (%): women=81.5±5.7 and men=81.6±4.7.
Table 1 shows the anthropometric and demographic characteristics of the volunteers distributed by gender across five age subgroups.
Table 2 presents the mean MRP values with their coefficients of variation. The mean MIP and MEP values were 24% and 33% lower in women than in men, respectively.
Table 3 shows the prediction equations for the
MRPs. The following variables in each MIP regression equation were considered: age
(p<0.0001), gender (p=0.0047) and weight (p=0.0245), explaining 34% of MIP variation;
and for MEP: gender (p=0.0004), age2 2. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
(p=0.0071),
age (p=0.0516), waist circumference (p=0.0125), explaining 49% of MEP variation.
Discussion
To our knowledge, this work was the first Brazilian study to establish MRP reference
values as set forth in the methodological recommendations proposed by ATS/ERS22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
and by the SBPT3
3. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.that used digital equipment, which provides highly accurate and valid measures.
This study was conducted with the aim of building prediction models for MRPs in a sample
of the adult population of Belo Horizonte, MG, Brazil according to the methodological
recommendations of ATS/ERS2 2. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
and SBPT33. Souza RB. Pressões respiratórias estáticas máximas. J Pneumol.
2002;28(Supl 3):S155-65.. The issue of the existence of several benchmarks
for MIP measures was confirmed in a recently published systematic review2828. Sclauser Pessoa IMB, Franco Parreira V, Fregonezi GAF, Sheel AW,
Chung F, Reid WD. Reference values for maximal inspiratory pressure: a systematic
review. Can Respir J. 2014;21(1):43-50. PMid:24137574. , in which the low methodological quality of the
existing articles was noted, contributing to an appreciation of the difficulty, in
research and especially in clinical situations, of choosing an appropriate prediction
equation.
One reason for the variability in MRP values is a lack of methodological standardization
among studies. After the ATS/ERS publication2 2. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
on
methodological recommendations for MRP testing, two Brazilian studies were
published88. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
,
13 13. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
that did not fully comply with the
recommendations, the main deviation being the non-use of a digital instrument that would
enable the operationalization of MMP. It is known that valid measures provide correct
interpretations of the respiratory muscle strength rates, which are essential for the
diagnosis of respiratory muscle weakness. All Brazilian studies have used an analog
manometer, compromising measurement accuracy. This study therefore has the
advantage/originality of building prediction equations from MRPs created from a digital
manometer.
In studies on benchmarks, the premise that the sample must be healthy and representative
of the population for which the study was conducted is valid. This definition has been
ignored in certain studies88. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
,
13 13. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
in terms of the absence of a report on a
pulmonary function test8 8. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
and the fact that the
sample consisted entirely of sedentary individuals1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. In contrast to all other studies on reference values, this study took the
additional care to apply the Mini Mental State Exam for elderly subjects (i.e. over 60
years) to verify the absence of cognitive impairment, as the test was volitional and
could have been affected by the understanding, cooperation, and coordination of the
individual22. American Thoracic Society/European Respiratory Society. ATS/ERS
Statement on respiratory muscle testing. Am J Respir Crit Care Med.
2002;166(4):518-624.http://dx.doi. org/10.1164/rccm.166.4.518.
PMid:12186831
http://dx.doi. org/10.1164/rccm.166.4.51...
.
In addition to a lack of procedural standardization, variability in reference values may
also be explained by the influence of individual (biological) factors involved in the
study sample2929. Carpenter MA, Tockman MS, Hutchinson RG, Davis CE, Heiss G.
Demographic and anthropometric correlates of maximum inspiratory pressure: The
Atherosclerosis Risk in Communities Study. Am J Respir Crit Care Med.
1999;159(2):415-22.http://dx.doi.org/10.1164/ ajrccm.159.2.9708076.
PMid:9927352
http://dx.doi.org/10.1164/ ajrccm.159.2....
. In this study, it was found that
when analyzed by gender, the mean MRP values showed significant variation between
subjects in the same age group (26 to 37% of MIP, Table
2). A high coefficient of variation was also reported in studies by Hautmann
et al.7 7. Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth
pressures (PIMAX) in healthy subjects-what is the lower limit of normal? Respir Med.
2000;94(7):689-93.http://dx.doi.org/10.1053/rmed.2000.0802.
PMid:10926341
http://dx.doi.org/10.1053/rmed.2000.0802...
and Enright et al.30 30. Enright PL, Kronmal RA, Manolio TA, Schenker MB, Hyatt RE.
Respiratory muscle strength in the elderly. Correlates and reference values.
Cardiovascular Health Study Research Group. Am J Respir Crit Care Med. 1994;149(2 Pt
1):430-8.http://dx.doi.org/10.1164/ajrccm.149.2.8306041.
PMid:8306041
http://dx.doi.org/10.1164/ajrccm.149.2.8...
(25 to 27% and 32 to 39%, respectively). Such variations could be
attributed to the degree of motivation and cooperation of the volunteer55. Bruschi C, Cerveri I, Zoia MC, Fanfulla F, Fiorentini M, Casali L,
etal. Reference values of maximal respiratory mouth pressures: a population-based
study. Am Rev Respir Dis. 1992;146(3):790-3.http://dx.doi.org/10.1164/
ajrccm/146.3.790. PMid:1519865
http://dx.doi.org/10.1164/ ajrccm/146.3....
; to the value of the elastic recoil pressure of
the respiratory system55. Bruschi C, Cerveri I, Zoia MC, Fanfulla F, Fiorentini M, Casali L,
etal. Reference values of maximal respiratory mouth pressures: a population-based
study. Am Rev Respir Dis. 1992;146(3):790-3.http://dx.doi.org/10.1164/
ajrccm/146.3.790. PMid:1519865
http://dx.doi.org/10.1164/ ajrccm/146.3....
; coordination during the
test10 10. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325. and the degree of individual activation
of musculature during the test1010. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325. ; the intrinsic
differences of individual muscles77. Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth
pressures (PIMAX) in healthy subjects-what is the lower limit of normal? Respir Med.
2000;94(7):689-93.http://dx.doi.org/10.1053/rmed.2000.0802.
PMid:10926341
http://dx.doi.org/10.1053/rmed.2000.0802...
, such as speed
of muscle contraction11. Nava S, Ambrosino N, Crotti P, Fracchia C, Rampulla C. Recruitment of
some respiratory muscles during three maximal inspiratory manoeuvres. Thorax.
1993;48(7):702-7.http://dx.doi.org/10.1136/thx.48.7.702. PMid:8153917
http://dx.doi.org/10.1136/thx.48.7.702...
; and genetic and
environmental factors55. Bruschi C, Cerveri I, Zoia MC, Fanfulla F, Fiorentini M, Casali L,
etal. Reference values of maximal respiratory mouth pressures: a population-based
study. Am Rev Respir Dis. 1992;146(3):790-3.http://dx.doi.org/10.1164/
ajrccm/146.3.790. PMid:1519865
http://dx.doi.org/10.1164/ ajrccm/146.3....
.
Surprisingly high MEP values were observed in men aged 50 to 59 when compared to lower age groups. Importantly, there were a significant number of active and motivated individuals tested in this age group. These subjects met all inclusion criteria, so there was no justification for their exclusion from the analysis.
All studies on reference values evaluate the predictive power of physical
characteristics on MRPs, and there appears to be a weak association between them, as
evidenced by the low coefficients of determination. There is no consensus on the
influence of certain individual factors (e.g. height, weight, age) on the MRPs of men
and women. Height has been found to be a positive predictor3131. Wilson SH, Cooke NT, Edwards RH, Spiro SG. Predicted normal values
for maximal respiratory pressures in caucasian adults and children. Thorax.
1984;39(7):535-8.http://dx.doi. org/10.1136/thx.39.7.535.
PMid:6463933
http://dx.doi. org/10.1136/thx.39.7.535...
, a negative one99. Gopalakrishna A, Vaishali K, Prem V, Aaron P. Normative values for
maximal respiratory pressures in an Indian Mangalore population: A cross-sectional
pilot study. Lung India. 2011;28(4):247-52.http://dx.doi.org/10.4103/09702113.85684.
PMid:22084536
http://dx.doi.org/10.4103/09702113.85684...
,
3232. Harik-Khan RI, Wise RA, Fozard JL; The Baltimore Longitudinal Study
of Aging. Determinants of maximal inspiratory pressure. Am J Respir Crit Care Med.
1998;158(5 Pt 1):1459-64.http://dx.doi.org/10.1164/ ajrccm.158.5.9712006.
PMid:9817693
http://dx.doi.org/10.1164/ ajrccm.158.5....
, or not a predictor of MIP in women88. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
,
1212. Neder JA, Andreoni S, Lerario MC, Nery LE. Reference values for lung
function tests. II. Maximal respiratory pressures and voluntary ventilation. Braz J
Med Biol Res. 1999;32(6):719-27. PMid:10412550.
,
13 13. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
and a negative predictor in men66. Johan A, Chan CC, Chia HP, Chan OY, Wang YT. Maximal respiratory
pressures in adult Chinese, Malays and Indians. Eur Respir J.
1997;10(12):2825-8.http://dx.doi.org/10.118 3/09031936.97.10122825. PMid:9493668
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.
There is consensus that gender is the best predictor of MRPs44. Black LF, Hyatt RE. Maximal respiratory pressures: normal values and
relationship to age and sex. Am Rev Respir Dis. 1969;99(5):696-702. PMid:5772056.
,
77. Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth
pressures (PIMAX) in healthy subjects-what is the lower limit of normal? Respir Med.
2000;94(7):689-93.http://dx.doi.org/10.1053/rmed.2000.0802.
PMid:10926341
http://dx.doi.org/10.1053/rmed.2000.0802...
,
88. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
,
1010. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325.
,
1111. McConnell AK, Copestake AJ. Maximum static respiratory pressures in
healthy elderly men and women: issues of reproducibility and interpretation.
Respiration. 1999;66(3):251-8.http://dx.doi.org/10.1159/000029386.
PMid:10364742
http://dx.doi.org/10.1159/000029386...
. Values for MIP and MEP were, on average, 24%
and 33% higher in men compared to women, which is consistent with the study by Simões et
al.1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. Some authors claim that respiratory
muscles behave like skeletal muscles1010. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325.
,
1212. Neder JA, Andreoni S, Lerario MC, Nery LE. Reference values for lung
function tests. II. Maximal respiratory pressures and voluntary ventilation. Braz J
Med Biol Res. 1999;32(6):719-27. PMid:10412550.
,
3030. Enright PL, Kronmal RA, Manolio TA, Schenker MB, Hyatt RE.
Respiratory muscle strength in the elderly. Correlates and reference values.
Cardiovascular Health Study Research Group. Am J Respir Crit Care Med. 1994;149(2 Pt
1):430-8.http://dx.doi.org/10.1164/ajrccm.149.2.8306041.
PMid:8306041
http://dx.doi.org/10.1164/ajrccm.149.2.8...
,
3333. Wilmore JH. Alterations in strength, body composition and
anthropometric measurements consequent to a 10-week weight training program. Med Sci
Sports. 1974;6(2):133-8. PMid:4461973., so strength is proportional to the sectional
area of the muscle3434. Ikai M, Fukunaga T. Calculation of muscle strength per unit
cross-sectional area of human muscle by means of ultrasonic measurement. Int Z Angew
Physiol. 1968;26(1):26-32. PMid:5700894. . In this study, analysis of
body composition was performed in 64 individuals of both genders, and it was found that
the mean lean body mass percentage (i.e. muscle) was higher in men, one possible
explanation for the difference in MRP between genders.
The results of this study showed that age significantly influenced MRP, being a negative
predictor, which was consistent with the three previous Brazilian studies88. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
,
1212. Neder JA, Andreoni S, Lerario MC, Nery LE. Reference values for lung
function tests. II. Maximal respiratory pressures and voluntary ventilation. Braz J
Med Biol Res. 1999;32(6):719-27. PMid:10412550.
,
1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. The effect of age on MRPs in both genders is
still questionable44. Black LF, Hyatt RE. Maximal respiratory pressures: normal values and
relationship to age and sex. Am Rev Respir Dis. 1969;99(5):696-702. PMid:5772056.
,
55. Bruschi C, Cerveri I, Zoia MC, Fanfulla F, Fiorentini M, Casali L,
etal. Reference values of maximal respiratory mouth pressures: a population-based
study. Am Rev Respir Dis. 1992;146(3):790-3.http://dx.doi.org/10.1164/
ajrccm/146.3.790. PMid:1519865
http://dx.doi.org/10.1164/ ajrccm/146.3....
,
1111. McConnell AK, Copestake AJ. Maximum static respiratory pressures in
healthy elderly men and women: issues of reproducibility and interpretation.
Respiration. 1999;66(3):251-8.http://dx.doi.org/10.1159/000029386.
PMid:10364742
http://dx.doi.org/10.1159/000029386...
,
3535. McElvaney G, Blackie S, Morrison NJ, Wilcox PG, Fairbarn MS, Pardy
RL. Maximal static respiratory pressures in the normal elderly. Am Rev Respir Dis.
1989;139(1):277-81.http://dx.doi.org/10.1164/ajrccm/139.1.277.
PMid:2912349
http://dx.doi.org/10.1164/ajrccm/139.1.2...
, although most studies reported a decrease in
MRPs with advancing age in both genders, especially for MIP77. Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth
pressures (PIMAX) in healthy subjects-what is the lower limit of normal? Respir Med.
2000;94(7):689-93.http://dx.doi.org/10.1053/rmed.2000.0802.
PMid:10926341
http://dx.doi.org/10.1053/rmed.2000.0802...
,
88. Costa D, Gonçalves HA, Lima LP, Ike D, Cancelliero KM, Montebelo MI.
New reference values for maximal respiratory pressures in the Brazilian population. J
Bras Pneumol. 2010;36(3):306-12.http://dx.doi.org/10.1590/S1806-37132010000300007.
PMid:20625667
http://dx.doi.org/10.1590/S1806-37132010...
,
1010. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325.
11. McConnell AK, Copestake AJ. Maximum static respiratory pressures in
healthy elderly men and women: issues of reproducibility and interpretation.
Respiration. 1999;66(3):251-8.http://dx.doi.org/10.1159/000029386.
PMid:10364742
http://dx.doi.org/10.1159/000029386...
12. Neder JA, Andreoni S, Lerario MC, Nery LE. Reference values for lung
function tests. II. Maximal respiratory pressures and voluntary ventilation. Braz J
Med Biol Res. 1999;32(6):719-27. PMid:10412550.
-
1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. The cutoff point for the decline in MIP
differed between studies, ranging from 3010 10. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325. to
657 7. Hautmann H, Hefele S, Schotten K, Huber RM. Maximal inspiratory mouth
pressures (PIMAX) in healthy subjects-what is the lower limit of normal? Respir Med.
2000;94(7):689-93.http://dx.doi.org/10.1053/rmed.2000.0802.
PMid:10926341
http://dx.doi.org/10.1053/rmed.2000.0802...
years. This difference may prevent the
appearance of a negative correlation with age as a result of the age group studied, as
in the study of Camelo et al.3636. Camelo JS, Filho JT, Manco JC. Pressões respiratórias máximas em
adultos normais. J Pneumol. 1985;11(4):181-4. , which analyzed
the 20-49 year age group. The low number of subjects above 55 years of age also explains
the absence of a negative correlation between MRPs and age in certain studies44. Black LF, Hyatt RE. Maximal respiratory pressures: normal values and
relationship to age and sex. Am Rev Respir Dis. 1969;99(5):696-702. PMid:5772056.
,
3535. McElvaney G, Blackie S, Morrison NJ, Wilcox PG, Fairbarn MS, Pardy
RL. Maximal static respiratory pressures in the normal elderly. Am Rev Respir Dis.
1989;139(1):277-81.http://dx.doi.org/10.1164/ajrccm/139.1.277.
PMid:2912349
http://dx.doi.org/10.1164/ajrccm/139.1.2...
. One possible explanation for MIP decreasing
with advancing age is the aging process, which causes increased RV and decreased
inspiratory capacity3737. Pride NB. Ageing and changes in lung mechanics. Eur Respir J.
2005;26(4):563-5.http://dx.doi.org/10.1183/09031936.05 .00079805.
PMid:16204583
http://dx.doi.org/10.1183/09031936.05 .0...
.
MEP showed a quadratic relationship with age. This finding is consistent with previous
studies1010. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325.
,
3838. Ringqvist T. The ventilatory capacity in healthy subjects. An
analysis of causal factors with special reference to the respiratory forces. Scand J
Clin Lab Invest Suppl. 1966;88:5-179. PMid:4283858. . Possible explanations for the decrease in MEP
are the loss of elastic recoil of the chest cavity, the presence of calcification in
joints, and increased thoracic kyphosis, given that all these factors contribute to low
rib cage compliance and decreased MEP, which is performed based on TLC3737. Pride NB. Ageing and changes in lung mechanics. Eur Respir J.
2005;26(4):563-5.http://dx.doi.org/10.1183/09031936.05 .00079805.
PMid:16204583
http://dx.doi.org/10.1183/09031936.05 .0...
. Atrophy, decreased metabolic efficiency, and a
decline in nerve conduction velocity may also explain the decrease in MRPs with
advancing age1010. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325.
,
3030. Enright PL, Kronmal RA, Manolio TA, Schenker MB, Hyatt RE.
Respiratory muscle strength in the elderly. Correlates and reference values.
Cardiovascular Health Study Research Group. Am J Respir Crit Care Med. 1994;149(2 Pt
1):430-8.http://dx.doi.org/10.1164/ajrccm.149.2.8306041.
PMid:8306041
http://dx.doi.org/10.1164/ajrccm.149.2.8...
.
Weight was a positive predictor for MIP, a finding in agreement with previous
studies99. Gopalakrishna A, Vaishali K, Prem V, Aaron P. Normative values for
maximal respiratory pressures in an Indian Mangalore population: A cross-sectional
pilot study. Lung India. 2011;28(4):247-52.http://dx.doi.org/10.4103/09702113.85684.
PMid:22084536
http://dx.doi.org/10.4103/09702113.85684...
,
3030. Enright PL, Kronmal RA, Manolio TA, Schenker MB, Hyatt RE.
Respiratory muscle strength in the elderly. Correlates and reference values.
Cardiovascular Health Study Research Group. Am J Respir Crit Care Med. 1994;149(2 Pt
1):430-8.http://dx.doi.org/10.1164/ajrccm.149.2.8306041.
PMid:8306041
http://dx.doi.org/10.1164/ajrccm.149.2.8...
,
3232. Harik-Khan RI, Wise RA, Fozard JL; The Baltimore Longitudinal Study
of Aging. Determinants of maximal inspiratory pressure. Am J Respir Crit Care Med.
1998;158(5 Pt 1):1459-64.http://dx.doi.org/10.1164/ ajrccm.158.5.9712006.
PMid:9817693
http://dx.doi.org/10.1164/ ajrccm.158.5....
,
3939. Enright PL, Adams AB, Boyle PJ, Sherrill DL. Spirometry and maximal
respiratory pressure references from healthy Minnesota 65- to 85-year-old women and
men. Chest. 1995;108(3):663-9.http://dx.doi.org/10.1378/ chest.108.3.663.
PMid:7656613
http://dx.doi.org/10.1378/ chest.108.3.6...
, in particular Simões et al.'s study1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. There is no consensus regarding the variation of
MRPs due to weight gain1010. Vincken W, Ghezzo H, Cosio MG. Maximal static respiratory pressures
in adults: normal values and their relationship to determinants of respiratory
function. Bull Eur Physiopathol Respir. 1987;23(5):435-9. PMid:3450325.
,
1313. Simões RP, Deus AP, Auad MA, Dionísio J, Mazzonetto M, Borghi-Silva
A. Maximal respiratory pressure in healthy 20 to 89 year-old sedentary individuals of
central São Paulo State. Rev Bras Fisioter. 2010;14(1):60-7.http://dx.doi.
org/10.1590/S1413-35552010000100010. PMid:20414563
http://dx.doi.
org/10....
. Both pulmonary function and respiratory
muscle strength improved with a small increase in body weight, called the "muscularity
effect," as there is a theory that relates the weight and length of different isometric
muscle groups4040. Schoenberg JB, Beck GJ, Bouhuys A. Growth and decay of pulmonary
function in healthy blacks and whites. Respir Physiol.
1978;33(3):367-93.http://dx.doi.org/10.1016/00345687(78)90063-4.
PMid:705072
http://dx.doi.org/10.1016/00345687(78)90...
. In this study, both weight and
muscle percentage correlated positively with one another and each in isolation with MIP.
It can be hypothesized that the influence of weight on MIP is related to the higher
percentage of lean mass of the respiratory muscles.
Waist circumference was a positive predictor of MEP. This study was the first in which
this variable was considered in the model for MEP. The volunteers in this study were not
obese and had normal mean waist circumference values. It is possible that the positive
correlation with MEP was due to the larger abdominal muscle. It could be hypothesized
that there is a cutoff point for decline in MEP similar to the behavior of the MIP when
it is correlated with waist circumference (MIP declines from 95-105 cm in waist
circumference, according to Carpenter et al.2929. Carpenter MA, Tockman MS, Hutchinson RG, Davis CE, Heiss G.
Demographic and anthropometric correlates of maximum inspiratory pressure: The
Atherosclerosis Risk in Communities Study. Am J Respir Crit Care Med.
1999;159(2):415-22.http://dx.doi.org/10.1164/ ajrccm.159.2.9708076.
PMid:9927352
http://dx.doi.org/10.1164/ ajrccm.159.2....
).
Future studies using a sample with increased circumference values might investigate this
hypothesis more thoroughly to establish the type of predictive model that exists between
waist circumference and MEP and thereby explain the influence of visceral fat on
abdominal muscle strength.
A limitation of this study was the small sample sizes in the different age subgroups, in particular, the over 70-year-old group. Sample size directly affects the predictive accuracy of the equation4141. Portney LG, Watkins MP. Foundations of Clinical Research: applications to practice. 2nd ed. New Jersey: Prentice-Hall Health; 2000.. However, representativeness of the sample was achieved in terms of the number of individuals of each gender and in age group being in keeping with IBGE data for the population of Belo Horizonte, MG, Brazil.
In conclusion, this Brazilian study, conducted with a sample of the population of Minas Gerais (Belo Horizonte, MG, Brazil), provides equations, means, and standard deviations by age group, as well as formulas for calculating the lower and upper limits of normality. The study is innovative in that it strictly follows the methodology proposed by
Brazilian and international standards, notably the use of a digital manometer to ensure the validity of measurements.
Acknowledgements
The authors would like to thank the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Brazil (Process 309494/20133), the Fundação de Amparo à Pesquisa do Estado de Minas Gerais (FAPEMIG), Brazil (PPM-00374-12) and the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil (PROCAD NF 779/2010) for financial support.
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Publication Dates
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Publication in this collection
12 Sept 2014 -
Date of issue
Sept-Oct 2014
History
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Received
12 Sept 2013 -
Reviewed
12 Mar 2014 -
Accepted
19 May 2014