Sniff and Muller manoeuvres to measure diaphragmatic muscle strength

Prigent, Hélène; Orlikowski, David; Fermanian, Christophe; Lejaille, Michèle; Falaize, Line; Louis, Alain; Fauroux, Brigitte; Lofaso, Frédéric

doi:10.1016/j.rmed.2008.07.004

« Previous Next »Respiratory Medicine
Volume 102, Issue 12 , Pages 1737-1743, December 2008

Sniff and Muller manoeuvres to measure diaphragmatic muscle strength

Hélène Prigent
- Service de Physiologie – Explorations Fonctionnelles, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Centre d'Investigation Clinique – Innovations Technologiques, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Université de Versailles Saint Quentin en Yvelines, France
David Orlikowski
- Service de Réanimation Médicale, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Centre d'Investigation Clinique – Innovations Technologiques, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Université de Versailles Saint Quentin en Yvelines, France
Christophe Fermanian
- Centre d'Investigation Clinique – Innovations Technologiques, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Université de Versailles Saint Quentin en Yvelines, France
Michèle Lejaille
- Service de Physiologie – Explorations Fonctionnelles, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Centre d'Investigation Clinique – Innovations Technologiques, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Université de Versailles Saint Quentin en Yvelines, France
Line Falaize
- Service de Physiologie – Explorations Fonctionnelles, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Université de Versailles Saint Quentin en Yvelines, France
Alain Louis
- Service de Physiologie – Explorations Fonctionnelles, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Université de Versailles Saint Quentin en Yvelines, France
Brigitte Fauroux
- Pediatric Pulmonary Department, Hôpital Armand Trousseau, AP-HP, Paris, France
- Inserm UMR-S 893, Équipe 12, Université Pierre et Marie Curie-Paris 6, 75012 Paris, France
Frédéric Lofaso
- Service de Physiologie – Explorations Fonctionnelles, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Centre d'Investigation Clinique – Innovations Technologiques, Hôpital Raymond Poincaré, AP-HP, 92380 Garches, France
- Université de Versailles Saint Quentin en Yvelines, France
- Inserm UMR 841, 94000 Créteil, France
- Corresponding author. Service de Physiologie – Explorations Fonctionnelles, Hôpital Raymond Poincaré, 92380 Garches, France. Tel.: +33 1 47 10 79 41; fax: +33 1 47 10 79 43.

Received 2 May 2008; accepted 3 July 2008. published online 19 August 2008.

Summary

We hypothesized that peak values of oesophageal (Poes) and transdiaphragmatic pressure (Pdi) swings during a maximal sniff manoeuvre and a maximal static inspiratory manoeuvre (Muller manoeuvre) are comparable or give complementary information for assessing diaphragmatic and global inspiratory muscle strength.

We studied 98 patients with suspected diaphragmatic dysfunction. Poes and Pdi swings were measured during maximal sniff manoeuvres (sniff), maximal Muller manoeuvres (max), and cervical magnetic phrenic nerve stimulation (cervical Tw).

Eighty eight patients were able to perform both volitional manoeuvres. Among them, mean Poes sniff was significantly higher than mean Poes max (48.7±28.7cm H₂O vs. 42.9±27.4cm H₂O, p<0.05) and mean Pdi sniff was higher than mean Pdi max (49.2±35.1cm H₂O vs. 42.9±33.3cm H₂O, respectively, p=0.05). Cervical Pdi Tw correlated better with Pdi sniff (p<0.0001, r=0.62) than with Pdi max (p<0.0001, r=0.44). Poes and Pdi swings were greatest during the sniff manoeuvre in 42 patients (48%) and during the Muller manoeuvre in 29 patients (33%). Among the 17 remaining patients, nine had the greatest Poes swing during a maximal sniff manoeuvre and the greatest Pdi swing during a maximal static inspiratory manoeuvre; the opposite occurred in the other eight patients.

The combination of Muller manoeuvre and sniff manoeuvre increased the diagnosis of normal diaphragmatic strength from 18 patients (20%) to 21 patients (24%), and the additional analysis of cervical Pdi Tw further increased the diagnosis of normal diaphragmatic strength to 27 patients (31%).

In conclusion, though sniff manoeuvre gave significantly higher values than Muller manoeuvre, both volitional manoeuvres and cervical Pdi Tw are complementary and should be used in combination to evaluate diaphragmatic muscle strength.

Keywords: Diaphragm, Maximal inspiratory pressure, Maximal sniff manoeuvre, Isometric manoeuvre, Neuromuscular disease