MAXIMAL RESPIRATORY PRESSURES: NORMAL VALUES AND

RELATIONSHIP TO AGE AND SEX1

LEO F. BLACK AND ROBERT E. HYATT

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.

INTRODUCTION long with an internal diameter (i.d.) of 3 em (figure

Rahn and associates (1) described in detail
the relationship between lung volume and
maximal static respiratory pressures. Cook and
associates (2) and Ringqvist (3) recently re-
viewed the literature concerning the deter-
mination of the maximal pressures, described
new methods for measurement, and further
studied the relationship to lung inflation.
Ringqvist (3) has published the only large
series of maximal pressure determinations in
adult males and females of different ages.
Measurement of the maximal respiratory pres-
sures may be a useful method of quantifying
the respiratory muscle weakness that occurs in
neuromuscular disease.
In this study a simplified method for de-
termining the pressures is described. Normal
values for the maximal pressures in a large
group of men and women, the effect of age on
the maximal pressures, and the reproducibility
of the measurement by the method were de-
termined. Preliminary data are presented to
illustrate the potential application of this
measurement.
MATERIALS AND METHODS
The pressures, in centimeters of water, were
measured by two diaphragm gauges2 mounted on a
metal bar connected to a metal cylinder 152 em
1 From the sections of Medicine and Physiology,
Mayo Clinic and Mayo Foundation, Rochester,
Minnesota.
2 Marshalltown Manufacturing Inc., Marshall-
1). The gauges were connected to a pressure tap in
the distal end of the cylinder by rigid plastic tub-
ing; one gauge recorded negative pressure and the
other recorded positive pressure. The distal end of
the cylinder was closed except for a small opening
(internal diameter: 2 mm; length: 15 mm) that
prevented the facial muscles from producing sig-
nificant pressures. The proximal end of the cylin-
der was fitted with a circular rubber mouthpiece
(internal diameter: 3.2 em; outer diameter: 4.4
em). The gauges were calibrated with a pressure
transducer; their registered pressures were within
plus-minus 5 per cent of transducer pressure up to
300 em H20 expiratory pressure and minus 160
em H20 inspiratory pressure.
One hundred twenty normal adults were tested
(60 males and 60 females). There were 10 males
and 10 females in each decade from 20 to 70 years
and in a group of subjects older than 70 years in
which the oldest male was 80 and the oldest fe-
male, 86. No attempt was made to separate smok-
ers and nonsmokers. Most of the subjects were
patients who came to this clinic for a general ex-
amination. They had no respiratory symptoms, no
abnormal chest findings on physical examination,
no abnormality on thoracic roentgenograms, and
no evidence of neuromuscular dysfunction. The
remainder of the subjects were healthy physicians
and laboratory technicians.
The measurements were made while each subject
was seated and wore a noseclip. The subject held
the metal cylinder in his hand and pressed the
mouthpiece tightly against his lips during the
pressure measurement to prevent perioral leak.
Maximal expiratory pressure (PE max) was meas-
ured near total lung capacity (TLC) after a maxi-
mal inspiration. Maximal inspiratory pressure (PI
max) was measured near residual volume (RV)
3 Statham PM 131 pressure transducer, Statham

town, Iowa. Laboratories, Inc., Hato Rey, Puerto Rico.

696 AMERICAN REVIEW OF RESPIRATORY DISEASE, VOLUME 99, 1969
 MAXIMAL RESPIRATORY PRESSURES 697

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
capacity. The maximal pressures were markedly
decreased in both patients.
DISCUSSION
The effect of lung volume on maximal static
pressures has been previously described (1-3).
Cook and associates (2) and Ringqvist (3)
found that the highest maximal expiratory
pressures were obtained at lung volumes
greater than 70 per cent of TLC and the
highest maximal inspiratory pressures were ob-
tained at volumes less than 40 per cent to 50
per cent of TLC. By initiating the measure-
ment of PE max from TLC and that of Pr
max from RV, the highest maximal pressures
for the respiratory system should be recorded
by the present method. Hyatt found that this
method provided results similar to those of
another method for measuring respiratory mus-
cle strength. He recorded intraesophageal
pressures from a balloon placed in the lower
third of the esophagus during cough at differ-
ent lung volumes in 9 normal subjects and
compared the pressures with those obtained by
the present method at the same lung volumes.
The mean value for the cough pressures, un-
corrected for lung retractive force, was 203 em
H,O; the mean value for PE max by the present
method was 204 em H.O.
Measurements of the maximal pressures
should be more reproducible at the lung vol-
umes chosen in the present study than meas-
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

Fw. 3. Effect of age on maximal respiratory pressures in 60 normal females.

urements at other lung volumes because it has
been shown that the change in maximal pres-
sure for a given change in lung volume is
small at these selected volumes compared with
those elsewhere in the TLC (2, 3). The average
coefficient of variation for duplicate measure-
ments of 9 per cent, which is similar to results
obtained in repeated testing of other muscle
groups (3, 4), is in agreement with this. It is
important to note that the short-term learning
effect was not great, because such learning, if
significant, could influence the results obtained
in repeated testing in patients with muscular
weakness.
The values for PE max and PI max in fe-
males were 65 per cent to 70 per cent of those
obtained in males; this is in agreement with
previous reports (2, 3). The actual values for
the maximal pressures in different age groups
are similar to those reported by Cook and as-
sociates (2) and are 10 em to 20 em H.O less
than those reported by Ringqvist (3). This
difference may be related to Ringqvist's use of
an extensive series of measurements in each
subject whereas in this study only two tech-
nically satisfactory measurements were used.
Linear regression of PI max on age was
noted in both males and females, but the re-
gression was not significant in subjects younger
than 55 in either group or in males older
than 55. Ringqvist (3) demonstrated a linear
regression of PI max with age but did not di-
vide the subjects into subgroups. He found a
parabolic regression of PE max with age in
males and a similar but not significant tendency
in females. Although the residual variance in
our data does not decrease with a parabolic
regression, it does appear likely that a curvilin-
ear regression exists for PE max. The regres-
sions for the males in our study may be af-
fected to some extent by the fact that the
maximal pressure range of the gauges used
was plus 300 em to minus 160 em H.O.
Gauges for recording higher pressures are
available, but the present ones are adequate
for use in clinical studies.
700 BLACK AND HYATT

Neuromuscular diseases involving the res- TABLE 3

piratory muscles are common, and it would be RESULTS OF PULMONARY FUNCTION TESTS IN Two
helpful to have a method of quantifying this PATIENTS WITH NEUROMUSCULAR DISEASE
muscle weakness. Miller and associates (5) de- Test Patient t Patient 2*
scribed 3 patients with progressive muscular
Vital capacity, liters 4.5 (4.4) 2.8 (3.2)
TABLE 1 Residual volume, liters 3.4 ( <3.0) 2.4 (<2.7)
Total lung capacity, liters 7.9 (7.4) 5.2 (5.9)
REGRESSION EQUATIONS RELATING MAXIMAL Maximal breathing capac- 85 (113) (90)
61
RESPIRATORY PRESSURES AND AGE ity, liters/min
P (signifi-
Maximal midexpiratory 3.3 (~2.0) 2.2 (>1.3)
cance of flow rate, liters/sec
Age Range r:gession Nitrogen washout index, 1.4 (~2.5) 0.9 (~2.5)
Sex (yr) Equation co cient)j
%N
Arterial oxygen
Male All ages PI max <0.01 saturation, %t
= 143- 0.55A Resting (air) 98 (95-98) 97 (95-98)
PE max <0.01 Resting (Os) 100 (100) 100 (100)
= 268- 1.03A Exercise (air) for 5 min 99 (95-98) 99 (95-98)
2Q-54 PI max NS Maximal inspiratory pres- 30 (<80) 30 (<70)
= 129- 0.13A sure, em H20
PE max NS Maximal expiratory pres- 90 (>150) 65 (>120)
= 229 +0.08A sure, em HsO
55-80 PI max NS
= 120- 0.25A * The numbers in parentheses represent pre-
PE max <0.01 dicted normal values.
= 353- 2.33A t By oximeter.
Female All ages PI max <0.01
= 104- 0.51A atrophy and amyotrophic lateral sclerosis with
PE max <0.01 the primary complaint of exertional dyspnea.
= 170 -IJ.53A Pulmonary function tests revealed decreased
20-54 PI max NS
= 100- 0.39A vital capacity (VC), maximal breathing ca-
PE max NS pacity (MBC), and TLC with normal RV.
= 158- 0.18A Gillam and associates (6) studied 10 patients
55-86 PI max <0.01 with myotonic dystrophy; they measured the
= 122- 0.79A
PE max <0.01 maximal expiratory pressure with a sphygmo-
= 210- 1.14A manometer mercury column and found that
the maximal expiratory pressure frequently
* Regression equations apply only to adults was decreased when VC, indirect MBC, and
more than 20 years of age. A = age in years; PI mixed venous Pco. were normal. Maximal in-
max = maximal inspiratory pressure in centi-
meters HsO; PE max = maximal expiratory pres- spiratory pressures and the lung volume at
sure in centimeters H20. which the maximal expiratory pressures were
t NS = not significant (P > 0.05). measured were not described.

TABLE 2
NORMAL VALUES FOR MAXIMAL RESPIRATORY PRESSURES

Pressure*
(cmHO)

Age
(yr)

Pressure Sex 2Q-54 55-59 60-64 65-69 7G-74

PI max Male 124 44 103 32 103 32 I 103 32 103 32

Female 87 32 77 26 73 26 70 26 65 26
PE max Male 233 84 218 74 209 74 197 74 185 74
Female 152 54 145 40 140 40 135 40 128 40
*Numbers represent mean 2 SD or regression line 2sy-x.
 MAXIMAL RESPIRATORY PRESSURES
In contrast to lung volume measurements
and dynamic tests such as the MBC, which may
be altered by many intrapulmonary diseases,
determination of the maximal pressures is a
specific method for estimating respiratory mus-
cle strength. In addition to its use in patients
with neuromuscular disease alone, it provides a
method for evaluating the possible contribu-
tion of muscle weakness in the production of
symptoms in patients who have more than one
disease affecting the respiratory system. For
example, chronic obstructive lung disease com-
monly occurs in the age group affected by
many neuromuscular diseases and causes a de-
crease in VC and MBC. When these two dis-
eases occur in the same patient, however, the
determination of maximal pressures will pro-
vide a measure of the respiratory muscle
weakness. Byrd and Hyatt (7) have shown that
respiratory muscle strength is normal or in-
creased in obstructive lung disease when the
lung volume at which the pressures are meas-
ured is taken into consideration. This test
may also be of value in following response to
treatment in such conditions as myasthenia
gravis and polymyositis.
Cook and associates (2) have pointed out the
difficulty of preventing air leaks at the mouth
when pressures of more than 150 em H20 are
produced and conventional mouthpieces are
used. The facial muscles are important in
preventing air leaks, and weakness of these
muscles in disease states could increase this
problem. The special mouthpiece used in this
study is similar to that of Cook and co-
workers (2) and prevented air leaks at high
pressures in normal subjects. In a small group of
patients with neuromuscular disease tested to
date, an adequate mouthpiece-face seal has
been obtained. In addition to Patient 2, another
patient with myasthenia gravis with bulbar in-
volvement has been studied. An adequate
mouthpiece-face seal was obtained and the PE
max differed little from the intraesophageal
pressure measured during cough at comparable
lung volumes.
Acknowledgment
The writers express their appreciation to Dr.
Lila R. Elveback for advice regarding the statisti-
cal analysis and to Miss Elizabeth Enderson for
technical assistance.
(Received for publication November 21, 1968)
701
RESUMEN_________________________
PRESIONES RESPIRATORIAS MAXI MAS: VA LORES
N ORMALES Y SUS RELACIONES
CoN LA EnAD Y EL SExo
Se describe un metoda practico para determinar
las presiones respiratorias maximas. La prueba es
facil de efectuar, los resultados son reproducibles,
y no bubo complicaciones en los 120 sujetos
estudiados. Se determinaron los valores normales
de las presiones inspiratorias y espiratorias maxi-
mas en varones y hembras de 20 a 74 afios de
edad. No se observ6 disminuci6n en las presiones
con Ia edad, en sujetos menores de 55 afios. En
aquellos mayores de 55 afios, se encontr6 dismi-
nuci6n importante en la presion espiratoria en los
varones yen las hembras. La posible aplicaci6n de
este metoda qued6 demustrada por los resultados
en 2 pacientes afectos de enfermedad neuromuscu-
lar.
RESUME__________________________
PRESSIONS RESPIRATOIRES MAXI MALES; V ALEURS
NORMALES, ET RELATION
DE CELLES-CI AVEC L'AGE ET LE SEXE
On decrit une methode pratique permettant de
determiner les pressions respiratoires maximales.
Cette epreuve s'est revelee facile a pratiquer. Des
resultats reproductibles ant ete obtenus. Aucune
complication n'a ete observee chez les 120 person-
nes etudiees. La dispersion normale des valeurs
obtenues pour les pressions, lors de !'inspiration
maximale et de !'expiration maximale, ont ete
determinees chez des sujets masculins et feminin
ages de 20 a 74 ans. On n'a pas note de diminution
significative des pressions maximales inspiratoire
ou expiratoire en relation avec l'age chez des
sujets n'ayant pas atteint 55 ans. Chez des
personnes ayant depasse 55 ans, on a trouve une
diminution significative de la pression expiratoire
maximale, tant chez les sujets masculins que chez
les sujets feminins, ainsi qu'une diminution
significative de la pression inspiratoire maximale
chez les sujets de sexe feminin. Les applications
possibles de cette methode sont illustrees par les
resultats obtenus chez deux malades atteints d'une
affection neuromusculaire.
REFERENCES
(1) Rahn, H., Otis, A. B., Chadwick, L. E., and
Fenn, W. 0.: The pressure-volume diagram
of the thorax and lung, Amer. J. Physiol.,
1946, 146, 161.
(2) Cook, C. D., Mead, J., and Orzalesi, M. M.:
Static volume-pressure characteristics of the
respiratory system during maximal efforts,
J. Appl. Physiol.. 1964, 19, 1016.
(3) Ringqvist, T.: The ventilatory capacity in
702 BLACK AND HYATT
healthy subjects: An analysis of causal fac-
tors with special reference to the respiratory
forces, Scand. J. Clin. Lab. Invest., 1966,
18 (Supplement 88, p. 1).
(4) Tornvall, G.: Assessment of physical capabili-
ties: With special reference to the evalua-
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strength and maximal working capacity:
An experimental study on civilian and mili-
tary subject groups, Acta Physiol. Scand.,
1963,58 (Supplement 201, p. 1).
(5) Miller, R. D., Mulder, D. W., Fowler, W. S.,
and Olsen, A. M.: Exertional dyspnea: A
primary complaint in unusual cases of pro-
gressive muscular atrophy and amyotrophic
lateral sclerosis, Ann. Intern. Med., 1957,
46, 119.
(6) Gillam, P. M. S., Heaf, P. J. D., Kaufman, L.,
and Lucas, B. G. B.: Respiration in dys-
trophia myotonica, Thorax, 1964, 19, 112.
(7) Byrd, R. B., and Hyatt, R. E.: Maximal res-
piratory pressures in chronic obstructive
lung disease, Amer. Rev. Resp. Dis., 1968,
98,848.