Expiratory flow maneuvers in patients with neuromuscular diseases

Objectives: To compare cough peak flows (CPF), peak expiratory flows (PEF), and potentially confounding flows obtained by lip and tongue propulsion (dart flows, DF) for normal subjects and for patients with neuromuscular disease/restrictive pulmonary syndrome and to correlate them with vital capacity and maximum insufflation capacity. Design: A cross-sectional analytic study of 12 5 stable patients and 5 2 normal subjects in which CPF, PEF, and DF were measured by peak flow meter and vital capacity and maximum insufflation capacity by spirometer. Results: In normal subjects and in patients, the DF significantly exceeded PEF and CPF (P <= 0.001). For normal subjects, PEF and CPF were not significantly different. For patients with neuromuscular disease/restrictive pulmonary syndrome, the CPF significantly exceeded PEF (P < 0.05). No normal subjects but 14 patients had DF lower than CPF. Thirteen of these 14 had the ability to air stack (maximum insufflation capacity greater than vital capacity), indicating greater compromise of mouth and lip than of glottic muscles. For 14 of 88 patients, maximum insufflation capacity values did not exceed vital capacity, mostly because of inability to close the glottis (inability to air stack). Nonetheless, for 11 of these 14 patients, the DF were within a standard deviation of the whole patient group; thus, bulbar-innervated muscle dysfunction was not uniform. CPF and PEF correlated with vital capacity (r = 0.85 and 0.86, respectively), and with maximum insufflation capacity (r = 0.76 and 0.72, respectively). Conclusions: Measurements of CPF, PEF, and DF are useful for assessing bulbar-innervated, inspiratory, and expiratory muscle function. Care must be taken to not confuse them.