MIP/MEP/SNIP
Physiology
Resp muscles composed of striated fibers and contract rhythmically and intermittently
Contractile activity either voluntarily controlled or automatically driven by resp. centers
Respiratory muscles = active during inspiration and inactive during quiet breathing (exhalation is a
passive event-should not be actively using any muscles during this phase of breathing).
Most important respiratory muscle = diaphragm
o Scalenes
o Intercostal
o Abdominal wall
o Sternocleidomastoid
o Pectoralis major
o Latissimus dorsi hyperventilation and severe exertion
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Forced maneuvers require:
o patient to give max effort
o normal muscle function
muscle strength is critical in supporting adequate ventilation
Muscle function is assessed by using MIP and MEP
Measured under static conditions
MIP – maximal inspiratory pressure
the lowest pressure developed during a forceful sustained inspiration against an occluded airway
Measured after maximal expiration – near RV
Recorded as a negative number (cmH2O or mmHg)
Primarily measures inspiratory muscle strength
o Healthy women MIP = - 50 cmH2O
o Healthy men MIP = - 75 cmH2O
o Intubated patients= > -25 cmH2O
Decreased MIP
o Neuromuscular patients
o Diseases involving:
Diaphragm
Intercostals
Compromised by injury or disease of the chest wall
Accessory muscles
Compromised by injury or disease of the chest wall
o Pts with hyperinflation – emphysema pts
Diaphragm is flattened by increased volume of trapped gas in lungs
o Chest wall or spinal deformities – kyphoscoliosis
Sometimes used to assess patient response to strength training of respiratory muscles
Often used in the assessment of respiratory muscle function in patients who need ventilatory support
Falsely high = patient pulls in forcefully with a closed glottis
MEP – maximal expiratory pressure
the highest pressure that can be developed during a forceful sustained expiratory effort against an
occluded airway
Measured after maximal inspiration – near TLC
Recorded as a positive number (cmH2O or mmHg)
Measures pressure generated during maximal expiration
o Healthy women MEP = + 80 cmH2O
o Healthy men MEP = + 100cmH2O
Depends on function of
o Abdominal muscles
o Accessory muscles of respiration
o Elastic recoil of lungs and thorax
Decreased MEP
o Neuromuscular disorders
Generalized muscle weakness
o High cervical spine fracture
Damage to nerves controlling abdominal and accessory muscles of expiration
MIP is usually normal in these pts
o Increased RV – emphysema patients
o Inability to cough effectively - May complicate chronic bronchitis and CF that result in excessive
mucus secretion
Falsely high = pumping cheeks against a closed glottis
Accurate measurement of MIP and MEP depends largely on patient effort
Low values may result if patient doesn’t inhale or exhale completely before airway occlusion
Some patients show increased MIP or MEP with repeated effort training effect
Some show decreased pressures with repeated effort muscle fatigue
Indications for Respiratory Muscle Strength Testing
ALS To wean pts from mechanical ventilation
Paralyzed diaphragm o > - 25cmH2O = successful extubation
Fibromyalgia Unexplained dyspnea
Dermatomyositis MS
Muscular dystrophy Spinal injury – paraplegia, quadriplegia
Chronic fatigue syndrome Myasthenia Gravis
Guillain-Barre Post-polio syndrome
Phrenic nerve damage Polymyalgia rheumatica
Peripheral neuropathy Polymyositis
Obstructive lung disease causing Stroke
hyperinflation Cerebral palsy
Unexplained reductions in VC
Technique
Patient connected to either
o A valve
o Shutter apparatus
o PF testing system
With a mouthpiece (flanged) + nose clips
mouthpiece should be a tight fit that the patient can exert maximal pressure
Airway is occluded by blocking a port in the valve or closing a shutter
o A small fixed leak is present between the occlusion and the patient’s mouth
This leak eliminated pressures generated by the cheek muscles during the MEP
maneuver by allowing small amounts of gas to escape the oral cavity
Leak prevents glottic closure during MIP maneuver
The leak does not significantly change lung volume or the pressure measurement
Pressure measured by
o Manometer or aneroid-type gauge
Pressure directly observed and recorded by the RT
Commonly used at the hospital where measuring VC and respiratory pressure are used
to assess ventilatory adequacy
Record the plateau pressure that the patient can maintain for 1-2 seconds
o Pressure transducer
Used in PF testing systems
Pressure device should be able to record pressures from -200 to +200 cmH2O
Calibration
o Done every day
o Verified using oil or water manometer
Quality control apply 2 pressures (50 and 200 cmH2O) to verify range and linearity
MIP
Pt instructed to expire maximally airway is occluded pt inspires maximally + maintains the inspiration for
1-2 seconds
The first portion of each maneuver is disregarded because it may include transient pressure changes
that initially occur
Most negative value from at least 3 efforts that vary less than 20% is recorded
MEP
Pt inhales maximally airway is occluded patient expired maximally for 1-2 seconds
Longer efforts should be avoided can reduce cardiac output due to high thoracic pressures
Usually larger than MIP in healthy patients
Most positive value from at least 3 efforts that vary less than 20% from each other is recorded
Initial pressure transients are disregarded
*Both MIP and MEP require patient effort and cooperation
low values may be due to lack of understanding or insufficient effort
Criteria for Acceptability
1. Pressure tracing (if available) should show 1-2 seconds of sustained
effort
Should be a pressure plateau after initial transients
2. Pressure plateau should be observed 1-2 seconds if manometer used
3. At least three MIP and three MEP maneuvers should be performed
4. The largest value from three acceptable efforts that vary less than 20%
is recorded
*The best efforts should be repeatable within 20% or 10cmH2O whichever is
greater
SNIP – Sniff Nasal Inspiratory Pressure
Alternative or complementary test to MIP
Occlude a nostril during maximal sniff maneuver performed through contralateral nostril from FRC or
RV
o In the opposite nare (one that is not being occluded) nasal plug with a central catheter is
connected to pressure transducer
Measurement limitations:
o Nasal obstruction
o Collapse during maneuver
SNIP < 40cmH2O has been shown to predict mortality in patients with ALS
