Pediatric Pulrnonology 3:255-258 (1987)

Normal Values of Maximal lnspiratory and Expiratory

Pressures With a Portable Apparatus in Children,
Adolescents, and Young Adults
Arnir Szeinberg, MD,* Jacque E. Marcotte, M D , ~Hector Roizin, M D , ~Catherine Mindorff, R N , ~
Sandra England, phD,l Elvan Tabachnik, M D , ~and Henry Levison, MD'
Summary. Maximal inspiratory and expiratory mouth pressures (Plmax and PEmax) were
measured over a wide age range using a cylindrical mouthpiece and a multiple trial procedure.
Two hundred forty-three students and 30 adults were studied. In addition, a comparison of a
cylindrical and a scuba-type mouthpiece was made in 16 subjects. Fifty percent of the subjects
required five or more trials to achieve their maximal mouth pressures. Higher PEmax values
were obtained using a cylindrical mouthpiece than with a scuba-type mouthpiece in 15 of the
16 subjects tested. Plmax was not affected by mouthpiece type. Males had higher Plmax and
PEmax values than females except in the 8-10 years age group. Maximal mouth pressures
correlated with age in boys only. Technical considerations, such as the number of trials and
the type of mouthpiece used, are important determinants of maximal mouth pressure values.
Pediatr Pulmonol 1987;3:255-258.

Key words: Mouthpiece, cylindrical vs scuba-type; sex and age effects.

INTRODUCTION
Maximal respiratory mouth pressures are important
measurements in the evaluation and follow-up examina-
tion of children with neurornuscular and chronic respira-
tory disease. Normal values for maximal inspiratory
and expiratory pressures (PImax and PEmax) in adults
and children have previously been reported.3-" How-
ever, interstudy discrepancies are striking particularly in
relation to PEmax. These discrepancies appear to be due
to differences in measurement techniques. Ringqvid has
demonstrated that, to obtain reproducible maximal res-
piratory mouth pressures, at least five to ten measure-
ments are necessary. Furthermore, Cook et a15 have
demonstrated the importance of using a cylindrical
mouthpiece so that perioral leakage at high expiratory
pressures is eliminated. In the present study, under field
conditions, we measured PImax and PEmax in normal
subjects over a wide age range using a multiple trial
procedure and a cylindrical mouthpiece. In addition, we
compared the efficacy of a scuba-type mouthpiece to that
of a cylindrical mouthpiece in the measurement of PImax
and PEmax. The results so obtained reconcile discrep-
ancies in previous studies and can be used as a normal
data base for comparison of studies in patients over a
wide age range.
MATERIALS AND METHODS
The study population consisted of 142 elementary and Hospital for Sick Children, 555 University Avenue, Toronto, Ontario,
high school students aged 8-19 years (80 males and 62 M5G I X8 Canada.
01987 Alan R. Liss, Inc.
females), 101 ballet school students aged 10-2 1 years (34
males and 67 females), and 30 volunteers from the hos-
pital staff aged 2 1-40 years (14 males and six females).
Two students were excluded from the study because of
technical difficulties in performing the tests and another
16 because of the presence of respiratory or cardiac
diseases.
Maximal static respiratory pressures were measured
using an apparatus previously described by Black and
Hyatt4 (Fig. 1). Anaeroid negative (0 to -160 cmH20)
and positive (0 to 300 cmH20) pressure manometers
were connected via a three-way valve to a metal tube, 17
From the Respiratory Physiology Department, Research Institute of
the Hospital for Sick Children, Toronto, Ontario, Canada;' Depart-
ment of Pediatrics, The Chaim Sheba Medical Center, Tel Hashomer,
Israel.'
Received August 22, 1985; (revision) accepted for publication Feb-
ruary 26, 1987.
Presented in part at the Annual Meeting of The American Thoracic
Society, Anaheim, California, May, 1985.
Amir Szeinberg is a Fellow of the Canadian Cystic Fibrosis Founda-
tion. His current address is the Chaim Sheba Medical Center, Tel
Hashomer, Israel.
Address correspondence and reprint requests to Dr. H. Levison, The
256 Szeinberg et a1
Fig. 1. Pressure gauge with plastic cylindrical mouthpiece
used for the measurements of static maximal inspiratory and
expiratory mouth pressures.
cm long and 3 cm in diameter, with a rigid, cylindrical
mouthpiece. The latter had 3 cm ID and 3.4 cm OD. A
small air leak, an orifice of 1 mm diameter, was drilled
at the base of the tube to eliminate oral pressure artifacts.
The pressure gauges were calibrated by the manufacturer
and checked in our laboratory with a mercury manome-
ter. The registered values were found to be accurate
within 5% ' .
The pressures were measured with the subject seated,
wearing a nose clip, and pressing the lips tightly against
the mouthpiece so that they were encircled by the inner
perimeter of the mouthpiece while being kept slightly
parted. PImax was measured from residual volume, at
the end of maximal expiration, and PEmax from total
lung capacity, at the end of a maximal inspiration. Max-
imal pressures were read visually and had to be main-
tained for at least 1 sec. This procedure was repeated
five to ten times; subjects were encouraged to persevere
until at least two reproducible maximal values were
achieved. Spirometric measurements were performed us-
ing a turbine portable spirometer (P.K. Morgan, Rain-
han, Kent, England). '*
In an additional 16 healthy, young adults (eight females
and eight males) with normal lung functions, we com-
pared maximal mouth pressures obtained using a scuba-
type mouthpiece vs a cylindrical mouthpiece. The sub-
jects were studied in a random cross-over sequence, with
an interval of 10 min between changes in mouthpiece
type.
Values are expressed as mean SD. The statistical
analysis includes two-tailed paired and nonpaired t test,
least square regression analysis, and stepwise multi-
regression analysis. A P value less than 0.05 was consid-
ered statistically significant.
RESULTS
The subjects mastered the maximal mouth pressure
technique without any apparent difficulties. Only two of
the subjects examined were unable to perform the proce-
dure adequately. No side effects were observed. Of the
270 subjects studied, 50% required five trials or more to
achieve their maximal expiratory pressures, and 12.5 %
required seven or more trials. Subjects were divided
arbitrarily into five age groups: 8-10.9, 11-13.9, 14-
16.9, 17-20.9, and 2 1 4 0 years. Data on age, height,
spirometric measurements, and maximal mouth pres-
sures are presented in Table 1. Since there were no
significant differences in spirometric or maximal mouth
pressure values between the regular and ballet school
students, data from these two groups were pooled.
Maximal inspiratory and expiratory pressures of males
were significantly higher than those of females in the
corresponding age groups (P < 0.01), except for the 8-
10.9 year age group. In both males and females, PImax
correlated significantly with PEmax, r = 0.609 and r =
0.662, respectively (P c 0.001).
The influence of age, height, and forced vital capacity
(FVC) on the variability of maximal respiratory pres-
sures was evaluated using a stepwise multiregression
analysis technique. In the 114 male students, the variabil-
ity in both PImax and PEmax could be explained in
relation to age (? = 0.237 and 0.301, respectively; P C
0.01); the addition of height and FVC did not contribute
to regression analysis. In the 129 female students, none
of the parameters analyzed could explain the variability
in maximal respiratory mouth pressures.
The intraindividual reproducibility of the technique
was assessed by measuring PImax and PEmax on five
occasions during a period of 7 months in four subjects.
The mean coefficient of variation was 3.6 k 3.3% and
4.5 f 2.9% for PImax and PEmax, respectively.
Cylindrical VS Scuba-Type Mouthpiece
Significantly higher PEmax values were obtained with
the cylindrical mouthpiece than with the scuba-type
mouthpiece; 161 st 59 cmHz0 vs 129 k 49 cmH20 (P
< 0.01, paired t test). With the scuba type mouthpiece,
subjects experienced perioral leaks at high expiratory
pressures. No consistent difference in PImax values was
observed with the two mouthpieces.
DISCUSSION
In the present study, maximal mouth pressures in chil-
dren, adolescents, and young adults were generally higher
than has been previously reported.*-" Our results sup-
 Normal Maximal Respiratory Pressures 257

TABLE 1-Spirometric and Maximal Respiratory Mouth Pressure Values for All Subjects

Age Height FVC FEV I PImax PEmax

(Yrs) (cm) (liters) (liters) (cm HzQ (cm H2O) n
Males
8-10.9 136 f7 1.98 f 0.36 1.65 f 0.30 116 f 26 142 f 25 16
11-13.9 151 f 10 2.78 f 0.58 2.36 f 0.48 130 f 16 176 f 24 47
14-16.9 172 f8 4.34 f 0.69 3.51 f 0.66 126 f 22 166 f 44 29
17-20.9 179 f6 5.04 f 0.69 4.09 f 0.60 143 f 12 204 f 37 22
2 1-40 180 f7 -a -a 126 f 12 242 f 41 14
Females
8-10.9 139 f7 2.10 f 0.29 1.77 f 0.23 104 f 20 129 k 29 16
11-13.9 154 f7 2.71 f 0.43 2.29 f 0.39 112 f 20 138 f 31 55
14-16.9 162 f6 3.42 f 0.54 2.83 k 0.46 109 f 21 135 f 29 38
17-20.9 164 f7 3.59 f 0.64 2.93 f 0.48 107 25 138 f 33 20
2 1-40 163 f 8 -a -a 91 *
20 143 f 36 16
aIn this age group, FVC and FEVl were not measured.

TABLE 2-Comparison of Maximal Expiratory Pressure Values (PEmax) Obtained in Adults by Different investigators in
Relation to the Mouthpiece Useda
Cy Iindrical mouthpiece Scuba-type mouthpiece
Present
Black and Hyatt4 Cook et a15 Ringqvid study Leech et aI8 Smyth et al" Wilson et a19
Males 233 f 42 237 k 45 248 38 242 f 41 161 f 42 112 f 36 148 f 34
Females 152 f 27 146 f 36 163 29 143 f 36 92 k 31 95 f 36 93 f 7
aValues are mean & SD (cmH.20).

port Ringqvist's6 suggestion that multiple trials are nec- In many of the previous studies in which low PEmax
essary to obtain maximal mouth pressures. Indeed, values were reported,*-" a scuba-type mouthpiece was
maximal pressures were obtained only after five or more employed. The results for PEmax in the adult group are
efforts in half of the subjects tested. Wagner et all' shown in Table 2 together with those of previous studies.
studied 20 maximal efforts in children and reported that, The superiority of the cylindrical mouthpiece is evident.
when the first five of the inspiratory or expiratory efforts The effect of age on maximal mouth pressures is more
were compared with all 20 efforts, the PImax and PEmax evident in males than in females. We were able to dem-
were significantly lower. It is not surprising, therefore, onstrate a definite correlation between age and maximum
that the values reported in the present study are in accor- mouth pressures in boys and adolescent males. Interest-
dance with those of Ringqvist6 and Black and H ~ a t t . ingly,
~ in the adult male group, the PImax tended to be
Although Black and Hyatt do not specifically state the lower than in the 17-21 year age group, whereas the
number of efforts that each subject was allowed, deter- PEmax values in adults were substantially higher. We
minations were repeated until at least two technically have no logical explanation for this finding. Age depen-
satisfactory measurements were recorded. Substantially dency of maximum mouth pressures in boys and adoles-
lower maximum mouth pressures have been reported cent males has also been described by Wagner et all and '
in studies in which only two or three efforts were al- Gaultier and Zinman.' The latter authors also reported
lowed. *-lo age dependence of maximal mouth pressures in prepu-
In addition to the multiple trial procedure, the choice bertal females. We were unable to substantiate this find-
of mouthpiece appears to be of major importance in ing, presumably because our study group did not include
obtaining maximum expiratory pressures. Cook et a15 girls in the 7-8 year age group. It is evident from our
have pointed out that a cylindrical mouthpiece that can study and from others that girls attain adult values at an
be pressed firmly over the mouth is necessary to prevent earlier age than boys. After puberty, males attain signifi-
perioral leaks at high expiratory pressures. In the 16 cantly higher pressures than do females. Since maximal
subjects in whom a comparison between a cylindrical and expiratory pressures are determined by chest wall and
a scuba-type mouthpiece was made, 15 of the 16 achieved abdominal muscle strength as well as by lung and chest
higher PEmax values with a cylindrical mouthpiece. PI- wall elastic recoil, the higher PEmax values in adult
max values were not influenced by choice of mouthpiece. males most likely is due to a greater muscle mas^."^'^
258 Szeinberg et al
In the four subjects in whom the intraindividual repro-
ducibility of our technique was tested on different days,
the coefficient of variation was less than 5 % suggesting
that once the procedure is well understood by the subject
there is no further learning effect, which makes this
technique useful for long-term follow-up studies. It has
been suggested in the past that the differences in reported
values for maximum mouth pressures could in part be
due to chest wall configuration; however, Zinman et all4
have convincingly shown that abdominothoracic config-
uration is not an important determinant of maximum
static pressures. Smyth et all0 suggested that the multiple
trial technique may be too exhausting for measurement
in some patients; however, in our laboratory, we have
successfully applied this technique in hyperinflated, mal-
nourished patients with cystic fibrosis,15 in elderly pa-
tients with advanced chronic obstructive lung disease, l6
and in wheelchair-bound patients with muscular dys-
trophy. *’
In conclusion, measurements of maximal mouth pres-
sures are best obtained with a multiple trial procedure
using a cylindrical mouthpiece. The methodology de-
scribed allows for the routine measurement of maximum
mouth pressures in ambulatory and hospitalized patients
as well as in field studies.
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