Physiotherapy 101 (2015) 239241

Short communication

Body position influences the maximum inspiratory and

expiratory mouth pressures of young healthy subjects
Rui Costa , Ndia Almeida, Fernando Ribeiro
School of Health Sciences, University of Aveiro, Aveiro, Portugal

Abstract
Objective The purpose of this study was to determine the effects of body position on respiratory muscle strength of young healthy subjects.
Participants Sixty-three (50 female, mean age 19.7 1.5 years) healthy subjects participated in the study.
Design Participants were measured in the sitting position, semi-upright sitting position, and in the supine position. The order of the three
conditions was randomly determined.
Outcome Measures Maximal inspiratory and expiratory mouth pressures (PImax, PEmax) and lung function.
Results A significant effect of body position was observed on PEmax values, controlling for gender. PImax in the sitting position
(92.8 20.05 cm H2 O) was significantly higher than in the supine (84.1 15.1 cm H2 O; mean difference: 8.70, 95% CI [5.95, 12.45],
p < 0.001) and semi-upright sitting positions (84.4 17.5 cm H2 O; mean difference: 8.43, 95% CI [5.78, 11.07], p < 0.001). PEmax was also
significantly higher in the sitting position (125.4 34.2 cm H2 O) than in the supine (115.8 29.0 cm H2 O; mean difference: 9.59, 95% CI
[4.86, 14.32], p < 0.001) and semi-upright sitting positions (120.2 33.9 cm H2 O; mean difference: 5.21, 95% CI [0.87, 9.54], p = 0.013).
Conclusions Body position influences respiratory muscle strength of young healthy subjects. PImax and PEmax are higher in the sitting
position than in the supine or semi-upright sitting positions.
2014 Published by Elsevier Ltd on behalf of The Chartered Society of Physiotherapy.

Keywords: Expiration; Inspiration; Respiratory muscles; Posture

Introduction patients with chronic obstructive pulmonary disease (COPD)

The muscle lengthtension relationship implies that the
ability of a muscle fibre to generate active tension is depend-
ent of its length [1]. Thus, changes in body position may
alter the length of respiratory muscles, namely diaphragm,
influencing its ability to generate tension. Nevertheless, the
studies conducted a couple of decades ago did not provide
definitive results. Some showed that in healthy subjects body
position has no influence on respiratory muscle strength [2],
while others observed a decrease in the supine position [3]. In
Correspondence: School of Health Sciences, University of Aveiro, Build-
ing 30, Agras do Crasto, Campus Universitrio de Santiago, 3810-193
Aveiro, Portugal. Tel.: +351 234401558x27118;
fax: +351 234401597x27160.
E-mail addresses: rcosta@ua.pt, rdcosta63@gmail.com (R. Costa).
http://dx.doi.org/10.1016/j.physio.2014.08.002
0031-9406/ 2014 Published by Elsevier Ltd on behalf of The Chartered Society of Physiotherapy.
[4], the supine position also promoted inferior values, while
in patients with cystic fibrosis no changes where observed
[5].
The position of the body is a concern in respiratory
physiotherapy. Patients are treated in several positions,
including supine, semi-Fowler position, side lying, and
sitting. Nonetheless, these positions could influence the per-
formance of the respiratory muscles. This is particularly
relevant as the optimization of the respiratory muscle strength
in clinical conditions were they are prone to be weak is a cru-
cial task for physiotherapists. Due to the importance of the
body position in the optimization of muscle strengthening
and the contrasting results, even in healthy subjects, reported
in the literature, we decided to revisit this issue by conducting
a study assessing the effects of body position on respiratory
muscle strength of young healthy subjects.
240 R. Costa et al. / Physiotherapy 101 (2015) 239241
Methods
Participants
A convenience sample of university students was recruited
via email sent to all students stating that we were seeking
volunteers to participate in the study. Eligible participants
were those aged 18 or over, men and women, students at
our School of Health Sciences. Exclusion criteria: athletes;
smokers; overweight or obese; and known, actual or previous,
cardiopulmonary, neuromuscular, or orthopaedic (involving
the thorax) disorders. Participants provided written informed
consent, and all procedures were conducted according to the
Declaration of Helsinki. The institutional ethics committee of
FADEUP (Faculty of Sport of University of Porto) approved
the study.
Procedures
Lung function was assessed using a spirometer (MicroGP,
CareFusion, Basingstoke, UK), according to the proposed
standard methods [6,7]. Participants performed three accept-
able manoeuvres with a one-minute rest between each one.
The variables measured were forced expiratory volume in one
second (FEV1 ), forced vital capacity (FVC), peak expiratory
flow (PEF), and the fraction of FVC expired in one second
(FEV1 FVC%).
Respiratory muscle strength was measured with a mouth
pressure meter (MicroRPM, CareFusion, Basingstoke, UK).
This measurement in sitting demonstrated an intraclass cor-
relation coefficient of 0.86 for maximal inspiratory pressure
(PImax) and 0.88 for maximal expiratory pressure (PEmax);
the standard error of measurement was 10 and 9 cm H2 O,
respectively for PImax and PEmax [8]. Measurements were
performed as previously described [9] in the following con-
ditions in random order: sitting position, semi-upright sitting
position (45 ), and supine position. Shortly, PImax was mea-
sured after full expiration; participants were asked to exhale
slowly to residual volume and then to inhale with as much
force as possible and to sustain the pressure for at least two
seconds. PEmax was performed after full inspiration; partic-
ipants were asked to slowly inhale to total lung capacity and
then to exhale with as much force as possible and to sustain the
pressure for at least two seconds. A rest period of one minute
was allowed between each trial, and 10 minutes were allowed
between each condition. The best of three measurement trials
was taken in each condition.
Sample size calculation and data analysis
The power calculation was computed a priori based on an
expected effect size of 0.2; assuming a power of 90% and
using a repeated measures analysis of variance (ANOVA) at
the 5% significance level revealed a need for 55 participants.
A target of 63 participants was identified to accommodate a
maximal dropout rate of 15%.
Data were analyzed using SPSS v 17.0. The normality of
data distribution was tested with the ShapiroWilk test. The
data were normally distributed. Repeated-measures analysis
of variance, using gender as a covariate, was used to test for
the main effect of body position on PImax and PEmax. Post
hoc comparisons were made using Bonferroni tests. Effect
size was reported using partial eta-squared (2p ). p < 0.05 was
considered indicative of statistical significance.
Results
Sixty-three subjects (50 female; age: 19.7 1.5
years; weight: 59.1 1.8 kg; height: 1.67 0.85 metres)
participated in this study. Participants exhibited a
FEV1 = 3.54 0.08 l, FVC = 3.86 0.10 l, PEF = 441.6
11.1 l/minute, and FEV1FVC% = 92.11 0.65. A sig-
nificant main effect of body position was observed on
PImax (F2.122 = 12.925, p < 0.001; 2p = 0.175) and PEmax
(F2.122 = 5.637, p = 0.005; 2p = 0.085), controlling for gen-
der (F2.122 = 1.518, p = 0.223 and F2.122 = 0.673, p = 0.512,
respectively). PImax values were significantly higher
in sitting position in comparison to semi-upright sitting
position (mean difference: 8.43, 95% CI [5.78, 11.07],
p < 0.001) and supine position (mean difference: 8.70, 95%
CI [5.95, 12.45], p < 0.001) (Table 1). PEmax values were
also significantly higher in sitting position in comparison to
semi-upright sitting position (mean difference: 5.21, 95% CI
[0.87, 9.54], p = 0.013) and supine position (mean difference:
9.59, 95% CI [4.86, 14.32], p < 0.001). No difference was
observed between semi-upright sitting and supine in PImax
and PEmax values (Table 1).
Table 1
Respiratory muscle strength values (mean SD) at the different conditions.
Body position
Sitting Semi-upright Supine
PImax (cm H2 O) 92.8 20.05* 84.4 17.5 84.1 15.1
PEmax (cm H2 O) 125.4 34.2* 120.2 33.9 115.8 29.0
PEmax, maximal expiratory pressure; PImax, maximal inspiratory pressure.
* Significantly different from semi-upright sitting and supine positions,
p < 0.05.
Discussion
Our results are similar to others who showed a decrease
in the respiratory muscle strength in the supine position in
healthy [3] and COPD subjects [4]. Nonetheless, a recent
study measured in ten healthy subjects the PImax in the
standing, sitting, right-sided and left-sided lying, supine, and
head-down-tilt positions and found no differences, except in
the head-down-tilt position where PImax was lower than in
the other positions [10].
 R. Costa et al. / Physiotherapy 101 (2015) 239241
The decreased PImax observed in supine position could
be related to the fact that in supine position the diaphragm is
overloaded by abdominal content displacement during max-
imal inspiratory effort, which could compensate for the more
favourable position of the diaphragm in the lengthtension
curve [10]. Furthermore, the length of all other inspiratory
muscles may become less optimal in supine position. In fact,
a recent study [10] showed that the supine position elicited
a decrease in peak inspiratory activity of the parasternal
and sternocleidomastoid muscles during maximal inspiratory
effort compared to the standing position.
Our results should be interpreted with caution, since we
used a non-random sample composed by young healthy sub-
jects. Nevertheless, if the results of this study are validated
in future studies enrolling patients with pulmonary disorders
and when the underlying cause for impairment is the weak-
ness of inspiratory muscle, the sitting position seems to be
the most suitable to help the generation of active tension by
inspiratory muscle, thus increasing the pressure differences
necessary to ventilation. In the same way, when maximal
expiratory muscle strength is need, for instance in cough
manoeuvres, the sitting position should be preferred over
supine or semi-upright sitting position.
Conclusions
Body position influences respiratory muscle strength of
young healthy subjects. PImax and PEmax are higher in
the sitting position than in the supine or semi-upright sit-
ting positions. When the goal is to facilitate the development
of maximal force by inspiratory or expiratory muscles, for
instance in cough manoeuvres, the sitting position seems
to be more suitable than the supine or semi-upright sitting
positions.
Available online at www.sciencedirect.com
ScienceDirect
241
Ethical approval: The study was approved by the Ethics
Committee of the Faculty of Sport of the University of Porto
(CEFADE 23).
Conict of interest: None declared.
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