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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 3  |  Page : 918-922

Respiratory muscle strength in patients with allergic rhinitis


1 Department of Chest Diseases and Tuberculosis, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt
2 Department of ENT, Faculty of Medicine, Menoufiya University, Menoufiya, Egypt

Date of Submission03-Apr-2016
Date of Acceptance06-Jun-2016
Date of Web Publication15-Nov-2017

Correspondence Address:
Walaa M Abd El-Aziz
El-Mahalla, 31951, Gharbia
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.218253

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  Abstract 

Objective
The aim of this study was to investigate respiratory muscle strength in patients with allergic rhinitis.
Background
Nasal obstruction and mouth breathing have an impact on respiratory muscle behavior, leading to changes in their power.
Patients and methods
This study included 27 adult patients aged 20–45 years with already diagnosed allergic rhinitis. In addition, 10 healthy age-matched and sex-matched controls were included in this study. Both groups were evaluated for pulmonary functions, including forced vital capacity, slow vital capacity, and respiratory muscle strength as assessed on the basis of maximal inspiratory and expiratory pressures (MIP and MEP).
Results
Patients with allergic rhinitis showed a significant decrease in MIP and MEP when compared with the control group (P < 0.05). Patients with allergic rhinitis showed a nonsignificant decrease in other respiratory functions. Patients with allergic rhinitis showed a significant decline in MIP and MEP with age (P < 0.05) and in the female population more than in the male population. The decrease in MIP and MEP was affected by the degree of severity of allergic rhinitis (P < 0.05).
Conclusion
Patients with allergic rhinitis have decreased respiratory muscle strength as expressed by decreased MIP and MEP. This decrease in MIP and MEP in patients with allergic rhinitis increases after the age of 40, was affected by the degree of severity of allergic rhinitis, and was more pronounced in female patients than in male patients.

Keywords: allergic rhinitis, maximal expiratory pressure, maximal inspiratory pressure, respiratory muscles


How to cite this article:
Azab N, El-Mahallawy II, Agha MA, Abd El-Shafy IA, Abd El-Aziz WM. Respiratory muscle strength in patients with allergic rhinitis. Menoufia Med J 2017;30:918-22

How to cite this URL:
Azab N, El-Mahallawy II, Agha MA, Abd El-Shafy IA, Abd El-Aziz WM. Respiratory muscle strength in patients with allergic rhinitis. Menoufia Med J [serial online] 2017 [cited 2019 Nov 21];30:918-22. Available from: http://www.mmj.eg.net/text.asp?2017/30/3/918/218253


  Introduction Top


Evaluation of respiratory muscle strength is very important as respiratory muscle fatigue has been postulated as a cause of ventilatory failure. Dyspnea in patients without pulmonary cause can be due to respiratory muscle weakness [1]. Many factors can affect respiratory muscles and in turn lead to acute or chronic respiratory failure [2]. Respiratory muscle strength can be assessed by different means such as history and examination, volitional tests in the form of lung function test, mouth pressure, and nasal pressure (which have the advantage of being simple, easy, and inexpensive but have the disadvantage of being dependent on patient understanding and cooperation), and nonvolitional tests such as electrical stimulation and magnetic stimulation (which have the advantage of not being dependent on patient understanding and cooperation but the disadvantage of being expensive and invasive) [3].

Allergic rhinitis has nasal symptoms as well as non-nasal symptoms. It also has psychological and cognitive symptoms such as fatigue, depression, anxiety, poor concentration, sleep disturbances, and limited daily activities and exercise capacity. Frequent respiratory infections [4] and other respiratory sequelae are reported. However, whether allergic rhinitis can affect respiratory muscle strength remains to be elucidated. The importance of detection of such changes or decreased respiratory muscle strength in patients with allergic rhinitis is that the decrease in respiratory muscle strength in patients with allergic rhinitis may lead to a decrease in the quality of life and productivity for these individuals, urging a life-long control of the problem [5].

The aim of this study was to study respiratory muscle strength in patients with allergic rhinitis.


  Patients and Methods Top


This study included 27 adult patients aged 20–45 years with already diagnosed allergic rhinitis from the ENT outpatient clinic in Menoufia University Hospitals during the period October 2014 to January 2015. In addition, 10 healthy age-matched and sex-matched controls were included in the study.

Criteria for diagnosis of allergic rhinitis [6]:

  • Sneezing
  • Nasal congestion
  • Watery nasal discharge
  • Itchy watery eyes
  • Postnasal drip
  • Pale blue, edematous turbinate.


Individuals with respiratory disorders (acute and chronic), neuroskeletal disorders, myopathies, malignancy, cachexia, diabetes mellitus, renal or hepatic impairment, and cardiac diseases were excluded from this study. Diagnosis of allergic rhinitis was confirmed by an ENT specialist using appropriate procedures to assess the presence or absence of allergic rhinitis and evaluate severity on the basis of the symptom scores and control the problem. The measures for diagnosis were:

  • History and clinical examination
  • Laboratory investigations (Total IgE)
  • Radiological investigation (Radiography for nasal sinuses).


After giving informed consent, each patient underwent full medical history taking, physical examination {including calculation of BMI [weight (kg)/height (m)2]}, routine laboratory investigations (complete blood count, total and differential), liver and kidney function tests, random blood sugar, chest radiograph (posteroanterior view), and ECG. Pulmonary function tests were performed for all patients in the pulmonary function test unit in Menoufia University Hospital using Quark PFT3(Pavona di Albano, RM, Italy) and included forced vital capacity and slow vital capacity. Respiratory muscle strength was assessed by measuring the maximal inspiratory and expiratory pressures (MIP/MEP).

Statistical analysis

Data were collected, tabulated, and statistically analyzed using an IBM compatible personal computer using SPSS statistical package, version 20 (SPSS Inc., Chicago, Illinois, USA). P values of 0.05 or less were considered statistically significant. P values of 0.001 or less were considered statistically highly significant. Pearson's correlation coefficients were used to compute correlations between variables.


  Results Top


This study included 27 adult patients with already diagnosed allergic rhinitis. Twenty patients were female and seven were male. Their mean age was 28.97 ± 6.9 years (29.96 ± 9.9 in female and 27.98 ± 8.6 in male patients). The mean BMI of all patients was 28.2 ± 4.49 (29.1 ± 5.6 in female and 27.3 ± 3.5 in male patients). Twenty-two of the studied patients had a family history of allergic rhinitis. There were three patients with mild allergic rhinitis (two female and one male patient), 14 patients with moderate allergic rhinitis (10 female and four male patients), and 10 patients with severe allergic rhinitis (eight female and two male patients) [Table 1].
Table 1: Demographic criteria of the studied patients

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There was a significant decrease in MIP and MEP in the allergic rhinitis group (P < 0.05) when compared with the MIP of the control group [Table 2].
Table 2: Comparison of the MIP and MEP in allergic rhinitis group and the control group

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There was a nonsignificant decrease in pulmonary functions of the allergic rhinitis group (P > 0.05) when compared with the control group [Table 3].
Table 3: Comparison of pulmonary functions in the allergic rhinitis group and the control group

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When the actual MIP (MIP) and the actual MEP (MEP) were compared with the predicted MIP (MIPpred) and predicted MEP (MEPpred) values in patients with allergic rhinitis in each age group, there was a significant decrease in both parameters in patients aged 20–30 years and in those aged greater than 30–40 years (P < 0.05) and a highly significant decrease in both parameters in patients older than 40 years (P < 0.001) [Table 4].
Table 4: Comparison of the actual MIP (MIP) and the MIP predicted values (MIPpred) in each age group among allergic rhinitis patients

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When the actual MIP (MIP) and the actual MEP (MEP) were compared with the MIP predicted value (MIPpred) and the MEP predicted values (MEPpred) in subgroups with different severities of allergic rhinitis, there was a nonsignificant decrease in both parameters in patients with mild allergic rhinitis (P > 0.05), a significant decrease in both parameters in patients with moderate allergic rhinitis (P < 0.05), and a highly significant decrease in both parameters in patients with severe allergic rhinitis (P < 0.001) [Table 5].
Table 5: Comparison of the actual MEP (MEP) and the MEP predicted values (MEPpred) in each age group among allergic rhinitis patients

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When the actual MIP (MIP) and the actual MEP (MEP) were compared with the MIP predicted (MIPpred) and the MEP predicted (MEPpred) values in both sexes in patients with allergic rhinitis, a significant decrease in both parameters was seen in female patients more than in male patients (P < 0.05) [Table 6]).
Table 6: Comparison of the actual MIP with the MIP predicted values in subgroups with different severities of allergic rhinitis

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  Discussion Top


Ventilation plays a key role in the adequacy of the external gas exchange, the ultimate lung function. The appropriateness of the 'ventilatory pump' response to a given metabolic load, however, is intrinsically linked to the ability of the force-generator units (i.e., the respiratory muscles) to provide the required output. Dysfunction in this musculature or decreased respiratory muscle strength can lead to hyperventilation, reduction in exercise tolerance, and even respiratory insufficiency [7].

This study measured the respiratory muscle strength in patients with allergic rhinitis. There was a significant decrease in MIP and MEP in the allergic rhinitis group compared with the control group.

Renata et al. [8] found that maximal respiratory pressure was lower in mouth breathers than in nose breathers among children, and this accentuated with age. The mouth-breathing syndrome includes ineffective contraction of diaphragmatic and abdominal muscles. Furthermore, mouth breathing requires less muscle efforts, which together with inhibition of afferent nasal nerves results in poor use of respiratory muscles and progressive muscle weakening.

There was a nonsignificant decrease in both large and small airway functions of the allergic rhinitis group. Also, the slow vital capacity showed a nonsignificant decrease in IVC, EVC, ERV, IRV, VE, and Vt in the allergic rhinitis group and a nonsignificant increase in Vt/Ti, Ti/Ttot, and Rf in the same group.

Dalakas et al. [9] reported that respiratory functions in mouth-breathing children were lower than predicted spirometry values, characterizing a mostly mild to moderate obstructive-type ventilation disorder in mouth breathers. The bronchi may also be compromised; increased nasal resistance changes intrathoracic pressures and decreases the pulmonary volume and these changes are accentuated by increased age.

Dalakas [10] pointed out that lung volumes are insensitive measures of respiratory muscle weakness and, for this reason, MIP and MEP are often used to assess respiratory muscle strength.

Impaired nasal functions, pulmonary aspiration of nasal contents, and increased absorption of inflammatory mediators in the bloodstream may be responsible for lower airway dysfunction in the allergic rhinitis group [11].

MIP and MEP in the studied patients declined with age.

Neder et al. [12] and Vincken et al. [13] reported that respiratory muscle strength in healthy adults decreases with age and that MIP and MEP values presented significant negative correlation with age for both sexes. Also MIP and MEP values were significantly lower compared with the predicted values from the age of 40, unlike the present study, in which the decrease in MIP and MEP was found from the age of 20 years and increased highly significantly after the age of 40 years. This difference may be due to a lack of cooperation. MIP has high coefficients of intraindividual and interindividual variation.

There was a nonsignificant decrease in both MIP and MEP in patients with mild allergic rhinitis, a significant decrease in both MIP and MEP in patients with moderate allergic rhinitis, and a highly significant decrease in both MIP and MEP in patients with severe allergic rhinitis.

The above results concur with that of Pires et al. [14] as they reported that maximal respiratory pressures are lower in children with increased severity of nasal obstruction when there are other complications that increase nasal obstruction, such as nasal polyps or negligence of treatment of nasal obstruction.

Imbaud et al. [15]. The younger the mouth-breathing patient, the fewer orofacial and lung function changes they present, suggesting that, with growth, these changes can accentuate the lower respiratory problems.

The decrease in MIP and MEP was more significant in female patients.

Similar results were reported by William et al. [16], who found that male maximal respiratory pressures are higher than female maximal respiratory pressures in normal persons, and hence it is expected to be exaggerated in female patients with allergic rhinitis.

Reduction of respiratory muscle strength in patients with allergic rhinitis may be explained by different factors:

Maximal respiratory pressures were lower in allergic rhinitis patients than among controls. The mouth-breathing syndrome includes ineffective contraction of diaphragmatic and abdominal muscles. Furthermore, mouth breathing requires less muscle efforts, which together with inhibition of afferent nasal nerves results in poor use of respiratory muscles and progressive muscle weakening [7].

Respiratory functions in allergic rhinitis patients was lower than that of controls. The bronchi may also be compromised; increased nasal resistance changes intrathoracic pressure and decreases the pulmonary volume, and these changes accentuate with increasing age [8].

Inspiratory loading and inspiratory flow limitation lead to increased airway resistance and consequently increased effort while breathing, ending in fatigue and weakness of the skeletal muscles as a result of high-load repeated muscle contractions [3].

Increased airway resistance leads to inspiratory flow limitation and progressive increase in pulmonary resistance and increased resistive load, resulting in a higher pressure time product of the diaphragm. Tidal volume and minute ventilation can be decreased. There is an increase in the contribution of the lateral rib cage to tidal volume, an increase in the contraction of abdominal muscles during a substantial part of expiration, and abrupt relaxation of the abdominal muscles at the onset of inspiration [17].

The magnitude of increase in pulmonary resistance leads to dynamic compression of the airways. During inspiration, there is marked distortion of the rib cage, recruitment of the intercostal muscles, and increased contribution of the expiratory muscles. Thus, increased pulmonary resistance acts as an internal resistive load that probably contributes to hypoventilation and CO2 retention [18].

As a result of increased airway resistance reported in patients with allergic rhinitis, as one of the diagnostic pillars of the disease is nasal obstruction with or without polypi, increased work of breathing, and increased load and pressure of the respiratory muscles, their protein content and anaerobic enzyme activity is increased. The total amount of muscle fibers in a cross-sectional area is significantly increased [3].

Disturbed sleep and limited daily activities and decreased exercise capacity can reduce respiratory muscle strength and endurance as there is a linear relationship between peripheral and respiratory muscle strength and the regular level of physical activity and individual ventilatory capacity [4].


  Conclusion Top


Patients with allergic rhinitis have decreased respiratory muscle strength as expressed by decreased MIP and MEP. The decrease in MIP and MEP in patients with allergic rhinitis occurs early and is marked after the age of 40. The decrease in MIP and MEP in patients with allergic rhinitis is affected by the degree of severity of allergic rhinitis and is more pronounced in female patients than in male patients.

Recommendations

Further studies should focus on assessing respiratory muscle strength in patients with allergic rhinitis on larger numbers of patients and controls. Further studies should focus on assessing respiratory muscle strength in patients with allergic rhinitis using nonvolitional tests to confirm the finding of decreased respiratory muscle strength in patients with allergic rhinitis. Further studies should focus on assessing respiratory muscle strength in patients with other causes of upper-airway obstruction through volitional and nonvolitional tests [Table 7], [Table 8], [Table 9].
Table 7: Comparison of the actual MEP with the MEP predicted values in subgroups with different severities of allergic rhinitis

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Table 8: Comparison of the actual MIP and the MIP predicted values in both sexes among patients with allergic rhinitis

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Table 9: Comparison of the actual MEP and the MEP predicted values in both sexes among patients with allergic rhinitis

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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