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Ventilatory function in breath-hold divers: Effect of glossopharyngeal insufflation

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This study was conducted to determine whether ventilatory parameters would change in breath-hold divers (BHDs) after they performed the glossopharyngeal technique for lung insufflation. Fifteen elite BHDs, 16 non-expert BHDs and 15 control subjects participated in this cross-sectional study. Volumes and expiratory flow rates were measured twice, before and after the glossopharyngeal technique performed at rest. Before the technique, greater forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV(1)) and lower FEV(1)/FVC were noted in the elite and non-expert BHDs compared with controls. No difference was noted regarding the other pulmonary parameters. After the technique, increases were noted in FVC, FEV(1) and maximal voluntary ventilation in the elite BHDs (P < 0.001, respectively). The FEF(25-75%)/FVC ratios were lower in the BHDs both before and after the technique, indicating possible dysanapsis. The ventilatory parameters observed after the glossopharyngeal technique indicated (1) higher lung volumes in expert BHDs and (2) a correlation with BHD performance (maximal dynamic BH performance). This correlation became more significant after the technique, indicating a positive effect of glossopharyngeal insufflation on performance.
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ORIGINAL ARTICLE
Ventilatory function in breath-hold divers: effect
of glossopharyngeal insufflation
Frederic Lemaı
ˆtre Eric Clua Bernard Andre
´ani
Ingrid Castres Didier Chollet
Accepted: 26 October 2009
ÓSpringer-Verlag 2009
Abstract This study was conducted to determine whether
ventilatory parameters would change in breath-hold divers
(BHDs) after they performed the glossopharyngeal tech-
nique for lung insufflation. Fifteen elite BHDs, 16 non-
expert BHDs and 15 control subjects participated in this
cross-sectional study. Volumes and expiratory flow rates
were measured twice, before and after the glossopharyn-
geal technique performed at rest. Before the technique,
greater forced vital capacity (FVC) and forced expiratory
volume in 1 s (FEV
1
) and lower FEV
1
/FVC were noted in
the elite and non-expert BHDs compared with controls. No
difference was noted regarding the other pulmonary
parameters. After the technique, increases were noted in
FVC, FEV
1
and maximal voluntary ventilation in the elite
BHDs (P\0.001, respectively). The FEF
25–75%
/FVC
ratios were lower in the BHDs both before and after the
technique, indicating possible dysanapsis. The ventilatory
parameters observed after the glossopharyngeal technique
indicated (1) higher lung volumes in expert BHDs and (2) a
correlation with BHD performance (maximal dynamic BH
performance). This correlation became more significant
after the technique, indicating a positive effect of glosso-
pharyngeal insufflation on performance.
Keywords Dysanapsis Expert breath-hold divers
Lung function
Introduction
Glossopharyngeal breathing (GPB) relies on the glosso-
pharyngeal muscles instead of the respiratory muscles to
move air into the lungs (glossopharyngeal insufflation, GI)
and out of them (glossopharyngeal exsufflation) (Collier
et al. 1956; Lindholm and Nyren 2005, Nygren-Bonnier
et al. 2009). The volume of each GI or gulp has been
reported to be up to 200 ml (Astrand et al. 1963). GI was
first described by Dail et al. (1955) as a technique for
patients with poliomyelitis. These patients were able to
augment their tidal breathing by repeatedly insufflating a
few gulps of air, typically starting at around their func-
tional residual capacity, while still relying on passive
expirations. More recently, GI was used successfully for
patients with cervical spinal cord injury (Nygren-Bonnier
et al. 2009). After practicing GI for 8 weeks, the patients
were able to improve pulmonary function and chest
expansion (Nygren-Bonnier et al. 2009). GI has also been
used in healthy breath-hold divers (BHDs) to increase air
volume in the lungs above normal total lung capacity
(TLC); by doing so, the intrapulmonary oxygen stores are
increased, thereby preventing the lungs from dangerous
compression at depth (Lindholm and Nyren 2005; Muth
et al. 2005; Tetzlaff et al. 2008). Loring et al. (2007)
reported that GI was able to increase TLC in elite BHDs by
Communicated by Susan Ward.
F. Lemaı
ˆtre (&)I. Castres D. Chollet
Centre d’Etudes des Transformations des Activite
´s Physiques
et Sportives, Equipe d’Accueil UPRES N°3832,
Faculte
´des Sciences du Sport et de l’Education Physique
de Rouen, Universite
´de Rouen, Boulevard Siegfried,
Mont-Saint-Aignan, Rouen 76130, France
e-mail: frederic.lemaitre@univ-rouen.fr
F. Lemaı
ˆtre E. Clua B. Andre
´ani
Association pour la Promotion de la Recherche
sur l’Apne
´e et les Activite
´s Subaquatiques (APRAAS),
LeBausset, France
E. Clua
CPS-BP D5, CRISP, 98848 Noume
´a Cedex,
Nouvelle-Cale
´donie, France
123
Eur J Appl Physiol
DOI 10.1007/s00421-009-1277-1
up to 47%. It has been suggested that breath-holding (BH)
performances are related to lung volumes (Andersson and
Schagatay 1998; Overgaard et al. 2006). Indeed, the vol-
ume added by GI may be used by BHDs to increase both
diving depth and duration (Lindholm and Nyren 2005)or
maximal BH at rest or during underwater swimming
(Overgaard et al. 2006). Many competitive BHDs have
large lung volumes (Lindholm and Nyren 2005), but it is
not known whether this is solely the result of the selection
of individuals with a genetic advantage or whether GPB
plays a role. We hypothetized (1) that elite BHDs represent
a particular group of BHDs with high capacity to achieve
the GI and (2) that this capacity is correlated to their BH
performance.
The aims of this cross-sectional study were (1) to detect
whether GI would result in ventilatory changes in BHDs
and/or controls, and (2) to specify the breath-hold training
parameters associated with any observed changes.
Materials and methods
The cohort
Forty-six healthy men responded to an invitation to partici-
pate in this study. They were separated into three groups of
15 elite BHDs, 16 novice BHDs and 15 non-BHDs. The elite
BHDs were professional competitors and this study was
conducted during a training session 2 days before a world
BH championship. To be selected for the national team
participating in this championship, the elite BHDs had to
have been among the top performers in static and dynamic
BH in their respective countries. The BHDs were considered
to be novices when they had been practicing BH for at least
6 months with static BH performances of less than 2 min
and dynamic performances of less than 75 m. All subjects
were non-smokers and they did not consume caffeinated
beverages or heavy meals on the day of the experiment.
Table 1presents the baseline morphological characteristics
and sports activities per week as assessed by questionnaire.
The body mass index (BMI =weight/height
2
) was calcu-
lated. The percentage of fat mass was assessed by the skin-
fold method according to Durnin and Womersley (1974)
using a calibrated skinfold calliper. Cumulative BH expo-
sure documented years of BH practice (YBHP), maximal
static breath-holding (MSBH) performance and maximal
dynamic breath-holding (MDBH) performance. The exper-
imental procedures were conducted in accordance with the
Declaration of Helsinki and were approved by the local
ethics committee. Methods were explained in detail and
informed written consent was obtained from all subjects.
Glossopharyngeal insufflation
All subjects received instruction on the GI technique from
the same physician. They watched an instructional video,
reviewed written information and practiced GI with the
physician. Each subject first inhaled from the spirometer
filling up their lungs to TLC. Then, after additional filling
by GI off the spirometer, the exhaled volume and flow
profiles were measured to allow the volume of GI filling to
be obtained. All subjects performed GI via the mouth and
wore a nose-clip to avoid air leakage (Bach et al. 1987;
Dail et al. 1955). All briefly warmed up with stretching
exercises for the chest, then performed ten repetitions of GI
in a sitting position until they felt ‘‘full enough’’ (Loring
et al. 2007). The subjects were instructed to fill their lungs
to maximal level with only these ten GI. It allows us to see
what supplementary volume provided to the same number
of gulps is possible to have and to reduce the great vari-
ability in number of gulps and volume per gulp that has
been reported in a previous study (Tetzlaff et al. 2008). The
Table 1 Characteristics of
subjects and training parameters
expressed as years of breath-
holding practice (YBHP),
maximal static breath-holding
(MSBH) and maximal dynamic
breath-holding (MDBH)
The body mass index
(BMI =weight/height
2
) was
calculated
** P\0.01, ***P\0.001
between elite and controls
??
P\0.01,
???
P\0.001
between elite or controls and
novices
Elite (n=15) PNovice (n=16) PControls (n=15)
Age (years) 33.7 ±6.1 ns 33.4 ±9.7 ns 30.2 ±4.2
Height (cm) 179.8 ±9.3 ns 176.8 ±6.7 ns 170.8 ±9.0**
Body mass (kg) 72.9 ±9.8 ns 73.4 ±11.6 ns 66.3 ±12.5
Fat mass (%) 15.7 ±3.3
??
22.2 ±5.1
??
15.5 ±4.1
BMI (kg m
-2
) 22.4 ±1.4 ns 23.4 ±2.8 ns 22.5 ±2.4
Sports activities
(h week
-1
)
14.4 ±6.0
???
5.9 ±2.8 ns 3.4 ±3.9***
Breath-hold training
(h week
-1
)
8.7 ±3.7
???
2.8 ±1.6 –
YBHP (years) 12.3 ±6.3
??
4.9 ±8.3 –
MSBH (s) 449 ±55
???
281 ±61 –
MDBH (m) 175 ±28
???
94 ±18 –
Eur J Appl Physiol
123
air was then passively expelled and the subjects resumed
normal respiration.
Pulmonary function tests
Several parameters were measured: forced vital capacity
(FVC), forced expiratory volume in 1 s (FEV
1
), FEV
1
/
FVC, peak expiratory flow, maximal expiratory flow rates
at 75, 50 and 25% of FVC (MEF
75%
, MEF
50%
, MEF
25%
),
and forced mid-expiratory flow rate (FEF
25–75%
). For each
parameter, the best value was chosen from at least three
consecutive maneuvers differing by not more than 5%
(Quanjer et al. 1993). The FEF
25–75%
/FVC ratio was also
calculated as an indicator of disproportionately small air-
ways for a given lung size (Green et al. 1974; Martin et al.
1987; Parker et al. 2003). The forced expiratory time (FET)
defined and recorded by the spirometer software was used
(PFT suite version 8.1, Cosmed, Rome, Italy). The begin-
ning point in time for the FET measurement was deter-
mined by the back extrapolation method according to the
ATS/ERS 2005 standards (Pellegrino et al. 2005). The end-
point in time for FET measurement was the beginning of
the end-expiratory plateau. An end-expiratory plateau with
zero flow for 1 s was required for the acceptable maneu-
vers, but this zero-flow time was not included in the
measured FET. The spirometer system and time measure-
ment were computer based. The predicted maximal vol-
untary ventilation (MVV) was calculated according the
following equation: MVV (l min
-1
)=FEV
1
940.
Ventilatory function variations (D) were calculated as the
index of change (magnitude and direction) induced by GI
[for example, DFVC =(FVC
GI
-FVC)/FVC) 9100)]. D
values were negative or positive, depending on the param-
eter kinetics (increase or decrease). This method minimized
the differences between before and after GI values of the
ventilatory parameters. All of the parameters were mea-
sured using a Microquark spirometer (Cosmed, Rome,
Italy) in the same conditions, with air temperature and
hygrometry monitored by the same technician. The pul-
monary function tests (before and after GI) were performed
in a sitting position, with the subject breathing through the
mouthpiece with a nose-clip. The spirometer volume was
calibrated twice daily with a 3-l calibrated syringe. The
results were corrected to BTPS conditions and compared
with predicted values (Quanjer et al. 1993).
Statistics
The results are presented as means and standard deviations
(±SD) and as percentages of predicted values according to
Quanjer et al. (1993). Morphological characteristics, lung
parameters (percentages of predicted, and before and after
GI) and lung function changes (D: mean) were compared
by a Wilcoxon signed rank test. Multiple linear regression
analysis, performed in a stepwise backward fashion, was
used to assess relevant correlations of age and BH exposure
with the lung function parameters. Pearson correlations
were also performed. Ancova analysis was performed to
test differences on regression slopes. A Pvalue \0.05 was
considered significant. Analyses were performed with
Statview software (Abacus Concepts, Inc., Berkeley, CA,
USA; 1992).
Results
Because height was different between the groups, all
lung parameters were expressed as % of predicted values
for comparison. Table 2shows the results of lung
function testing for the three groups before GI and
Table 3after GI. Table 4shows the lung function
changes (Dmean) between before and after GI for the
three groups.
Before GI, the elite BHDs had the highest FVC values
of all groups (P\0.01). They also had lower FEV
1
/FVC
than novice BHDs but higher FEV
1
/FVC and lower
FEF
25–75%
/FVC than controls. The novice BHDs had
higher FVC and FEV
1
and lower FEV
1
/FVC than
controls.
After GI, the elite BHDs had higher values of FVC,
FEV
1
and FET than the novice BHDs and the control
group. They also had lower FEV
1
/FVC and FEF
25–75%
/
FVC than these two groups. The novice BHDs had higher
FVC and FET and lower FEV
1
/FVC than the controls. All
subjects had increased their FET with GI.
Table 2 Lung function parameters of elite and novice breath-hold
divers and controls before glossopharyngeal insufflation
Elite PNovice PControls
FVC (%) 123 ±15
?
114 ±10
?
105 ±11***
FEV
1
(%) 111 ±13 ns 111 ±9
?
102 ±8*
FEV
1
/FVC (%) 94 ±8
?
100 ±5
???
84 ±7***
PEF (%) 99 ±12 ns 106 ±14 ns 96 ±13
MEF
75%
(%) 92 ±16 ns 100 ±15 ns 95 ±17
MEF
50%
(%) 83 ±19 ns 93 ±16 ns 93 ±17
MEF
25%
(%) 83 ±24 ns 93 ±18 ns 88 ±26
FEF
25–75%
(%) 86 ±18 ns 95 ±14 ns 91 ±18
FEF
25–75%
/FVC (%) 71 ±17 ns 84 ±14 ns 88 ±22*
FET (s) 4.44 ±1.12 ns 4.81 ±0.90
?
3.88 ±0.76
FVC forced vital capacity, FEV
1
forced expiratory volume in 1 s, PEF peak
expiratory flow, MEF
75,50,25%
maximal expiratory flow at 75, 50 and 25% of
vital capacity, FEF
25–75%
forced mid-expiratory flow rate; FET forced expi-
ratory time, ns non-significant
** P\0.01, ***P\0.001 between elite and controls
??
P\0.01,
???
P\0.001 between elite or controls and novices
Eur J Appl Physiol
123
The Dchanges in all lung function parameters are sig-
nificant in controls (Table 4), except for FEF
25–75%
/FVC,
which changed least in this group (P\0.001). The D
changes in FVC and FET were greater in the elite and non-
expert BHDs. The latter also showed greater Dchanges in
FEV
1
and MVV. The volume per gulp was higher in elite
BHDs than in novice and controls (136 ±87 vs. 28 ±62
vs. 20 ±10 ml, P\0.001 respectively).
In the BHDs (elite plus novice BHDs), YBHP was cor-
related with MSBH performance (r=0.77, P\0.0001)
and MDBH performance (r=0.76, P\0.0001). Stepwise
regression analyses of FVC and FEF
25–75%
/FVC before GI
and the independent parameters (age, height, YBHP,
MSBH, MDBH, hours of BH training and hours of sports
activities) showed that the main factor contributing to the
changes in FVC and FEF
25–75%
/FVC was the MDBH per-
formance (r=0.49 and r=-0.38, respectively;
P\0.01). After GI, FVC and FEF
25–75%
/FVC were also
correlated with MDBH (r=0.71 and r=-0.62, respec-
tively; P\0.001) (Figs. 1,2). The FEF
25–75%
/FVC ratio
before and after GI was positively correlated with
FEF
25–75%
(P\0.001) and FEV
1
/FVC (P\0.001). FEV
1
/
FVC showed a negative correlation with FET and FET after
GI (FET
GI
)(r=0.31, P\0.05 and r=0.58, P\0.0001,
respectively). When the BHD data from the two groups was
pooled versus the control data, the FVC values were also
correlated with age but only in controls (Fig. 3).
Discussion
The principal findings of this study were the classically
higher lung volumes (FVC and FEV
1
) in elite divers
compared with the values in the less trained BHDs and
controls. Dysanapsis and FET were increased after GI in
the elite BHDs. These changes were associated with their
best dynamic performance.
Pulmonary volumes
The greater lung volumes before GI were close to those
found by previous authors in BHDs with similar BH
experience (about ?24%) (Lindholm and Nyren 2005;
Overgaard et al. 2006; Seccombe et al. 2006; Tetzlaff et al.
2008) and in swimmers (Armour et al. 1993; Nygren-
Bonnier et al. 2007a). Our novice BHDs had lower volumes
Table 3 Lung function parameters of elite and novice breath-hold
divers and controls after glossopharyngeal insufflation
Elite PNovice PControls
FVC (%) 149 ±27
???
122 ±13 ns 109 ±11***
FEV
1
(%) 126 ±18
?
115 ±13
?
105 ±8***
FEV
1
/FVC (%) 89 ±9
???
98 ±6
??
106 ±1***
PEF (%) 93 ±21 ns 105 ±15 ns 97 ±13
MEF
75%
(%) 91 ±21 ns 98 ±15 ns 95 ±17
MEF
50%
(%) 92 ±18 ns 96 ±16 ns 95 ±17
MEF
25%
(%) 93 ±17 ns 93 ±18 ns 91 ±26
FEF
25–75%
(%) 95 ±18 ns 97 ±12 ns 93 ±18
FEF
25–75%
/
FVC (%)
64 ±13
??
83 ±12 ns 86 ±21***
FET (s) 5.91 ±1.21
?
5.01 ±0.80
??
4.17 ±0.67***
FVC forced vital capacity, FEV
1
forced expiratory volume in 1 s, PEF
peak expiratory flow, MEF
75,50,25%
maximal expiratory flow at 75, 50 and
25% of vital capacity, FEF
25–75%
forced mid-expiratory flow rate, FET
forced expiratory time, ns non-significant
** P\0.01, ***P\0.001 between elite and controls
??
P\0.01,
???
P\0.001 between elite or controls and novice
Table 4 Lung function parameter changes [D%=(after GI -
before GI)/before GI) 9100] of elite and novice breath-hold divers
and controls
D% Elite Novice Controls
FVC 20 ±12*** 7 ±6** 4 ±1***
FEV
1
14 ±15** 3 ±83±0.5***
FEV
1
/FVC -5±11 -1±727±12***
PEF -6±17 -1±61±0.2***
MEF
75%
1±27 -2±11 1 ±0.1***
MEF
50%
15 ±28 4 ±15 2 ±1***
MEF
25%
20 ±36 2 ±15 3 ±1***
FEF
25–75%
14 ±29 3 ±92±0.6***
FEF
25–75%
/FVC -7±21 1 ±21 -2±1***
FET 43 ±49** 7 ±12* 8 ±11*
FVC forced vital capacity, FEV
1
forced expiratory volume in 1 s,
PEF peak expiratory flow, MEF
75,50,25%
maximal expiratory flow at
75, 50 and 25% of vital capacity, FEF
25–75%
forced mid-expiratory
flow rate, FET forced expiratory time, ns non-significant
** P\0.01, ***P\0.001, between before and after glossopharyn-
geal insufflation (GI)
80
100
120
140
160
180
200
220
60 80 100 120 140 160 180 200 220 240
Best dynamic performance (m)
After Gi
Before GI
FVC% = 99.80 + 0.14 * Best dyn; r=0.5 p<0.01
FVCGI% = 85.91 + 0.37 * Best dyn; r=0.71 p<0.001
FVC (%)
Fig. 1 Change in forced vital capacity (FVC) with the best dynamic
performance (best dyn) before or after glossopharyngeal insufflation
(GI) in breath-hold divers
Eur J Appl Physiol
123
than elite BHDs but higher than those of the controls (?9%)
or the predicted values (?14%). Moreover, the greater lung
volumes of the BHDs were correlated with MDBH, indi-
cating a possible BH training effect on pulmonary volumes.
Indeed, the above-normal lung volumes of our BHDs could
be partly an adaptation to breath-hold diving. It has been
suggested that these large lung volumes are the result of an
increased number of alveoli or alveolar size due to training
(Armour et al. 1993; Calder et al. 1987; Donnelly et al.
1995). However, the differences could be attributed to a
selection of subjects with initially large lung volumes.
After GI, all groups had increased their FVC, but this
was less so in controls (?4%) than in novices (?7%)
and elite BHDs (?22%). Our results are close to the
results of previous studies with BHDs (Table 5). It is
interesting to note that when experienced subjects per-
formed this technique, the increases were greater than
with inexperienced subjects (Table 5). For example, the
Dchanges were lower in healthy women and in the
controls of our study (Nygren-Bonnier et al. 2007b). We
chose to fix the number of gulps in each group, which
could explain why the untrained subjects had lower
added volumes with this technique even though they felt
‘full enough’’ like the BHDs. Although the increases
and gains were lower in controls and healthy women
(0.2 and 0.88 l, respectively, Table 5), these maneuvers
always improved their ventilatory parameters. Indeed, GI
training or GI maneuvers seem to enhance performance
in trained BHDs but even more so in untrained subjects
with ‘‘normal’’ lung volumes. The BHDs were probably
able to increase VC in only ten GI because they
increased their tidal volume during each GI. This ability
to increase VC more than controls could also be partly
explained by sensation (Loring et al. 2007; Whittaker
and Irvin 2007) rather than the mechanics of the lung,
chest wall, or respiratory muscles, and by long years of
GI practice ([5 years). The correlation between FVC
after GI (FVC
GI
) and their best dynamic performance, as
well as the different slopes of the correlation between
FVC and age for the control and BHD values before and
after GI (-0.19 and -0.03, respectively; P\0.01),
accounted for this (Fig. 1). It has been found that the
high lung volumes in BHDs after GI could be explained
partly by the capacity to withstand greater transpulmo-
nary pressures and volumes than those to which lungs
would normally be exposed (Loring et al. 2007). More-
over, the GI maneuver has been associated with transient
lung distension. Approximately one-third of the addi-
tional air is accommodated by air compression (Sec-
combe et al. 2006), thus the remainder is due to volume
distension of the lungs. The pressure will reduce the
amount of blood in the chest, which will give more
space for air. Some studies suggested that respiratory
muscle training and the subsequent increase in respira-
tory muscle force can increase lung volumes (Cordain
et al. 1990; Doherty and Dimitriou 1997; Zinman and
Gaultier 1986), whereas others found no change in lung
volumes (Clanton et al. 1987; Wells et al. 2005). Indeed,
maximal expiratory and inspiratory pressure did not
change after any form of training (Nygren-Bonnier et al.
2007b; Tetzlaff et al. 2008). This was expected, as the
GI maneuvers were aimed at stretching the chest wall
alone (Eichinger et al. 2008; Nygren-Bonnier et al.
2007a,b). GI increases thoracic circumference. BHDs
able to insufflate large volumes thus expand the chest
significantly, giving them a barrel chest appearance. It is
possible that they have increased joint mobility and
stretch their respiratory muscles so they can increase the
chest volume to whatever is anatomically possible
(Eichinger et al. 2008; Whittaker and Irvin 2007).
30
40
50
60
70
80
90
100
110
120
60 80 100 120 140 160 180 200 220 240
Best dynamic performance (m)
After GI
Before GI
FEF25-75/FVC% = 94.40 - 0.13 * Best dyn; r=0.38 p<0.05
FEF25-75GI/FVC% = 101.59 - 0.21 * Best dyn; r=0.62 p<0.001
FEF25-75/FVC (%)
Fig. 2 Change in the FEF
25–75%
/FVC ratio with the best dynamic
performance (best dyn) before or after glossopharyngeal insufflation
(GI) in breath-hold divers. Forced mid-expiratory flow rate
(FEF
25–75%
), forced vital capacity (FVC)
2
3
4
5
6
7
8
9
10
11
15 20 25 30 35 40 45 50 55
Age (years)
After GI (CTL)
Before GI (CTL)
After GI (BHDs)
Before GI (BHDs)
FVCGI = 7.73 - 0.03 * A
g
e; ns (BHDs)
FVC = 6.53 - 0.02 * Age; ns (BHDs)
FVCGI = 10.61 - 0.18 * Age; r=0.73 p<0.01 (CTL)
FVC = 10.41 - 0.18 * Age; r=0.73 p<0.001 (CTL)
FVC (L)
BHDs
CTL
Fig. 3 Change in the forced vital capacity (FVC) with age, before or
after glossopharyngeal insufflation (GI) in breath-hold divers (BHDs)
and controls (CTL)
Eur J Appl Physiol
123
Expiratory flow rates
It is generally assumed that divers have large lung vol-
umes with proportionately greater increases in vital
capacity than in FEV
1
, which lowers the FEV
1
/FVC ratio
(Lemaitre et al. 2002,2006). In our study, the FVC of the
elite BHDs was higher than that of the novice BHDs and
controls, but with proportionately greater increases in
FVC than in FEV
1
, which decreased the FEV
1
/FVC ratio.
Thus, FEV
1
/FVC was diminished in the elite BHDs
compared with novice BHDs and controls both before and
after GI. Only one other study reported diminished FEV
1
/
FVC in BHDs (Tetzlaff et al. 2008). However, our mean
value and that of Tetzlaff et al. were still within the
normal range even after GI. In patients with respiratory
disease, a low FEV
1
/FVC, even when FEV
1
is within the
normal range, predicts morbidity and mortality (Mannino
et al. 2003). For healthy subjects, low FEV
1
/FVC with
FEV
1
within the normal range is probably due to ‘‘dys-
anaptic’’ or unequal growth of the airways and lung
parenchyma (Green et al. 1974). These differences may
have an embryologic basis reflecting disproportionate but
physiologically normal growth of the airways and paren-
chyma within the lung. The FEF
25–75%
/FVC ratio has
been used as a non-invasive measure of dysanapsis
(Parker et al. 2003) and is associated with airways sen-
sitivity and reactivity to metacholine (Parker et al. 2003).
Individuals with a low FEF
25–75%
/FVC ratio will have
small airways size relative to lung size and may be more
likely to develop expiratory flow limitation than subjects
with a higher ratio. In our study, FEF
25–75%
/FVC was low
because the subjects had normal FEF
25–75%
but increased
FVC before and after GI. The FEF
25–75%
/FVC ratio was
‘normal’’ compared with the predicted values and the
other groups, but decreased more after GI, reflecting
‘artificial’’ dysanapsis. Thus, the higher lung volumes and
normal expiratory flow rates in our elite BHDs indicated
small airways size relative to their lung size. This ‘‘arti-
ficial’’ dysanapsis was correlated with the best dynamic
performance of the BHDs, indicating a possible training
effect. FET has gained new interest in the joint recom-
mendations of the American Thoracic Society and the
European Respiratory Society for the assessment of spi-
rometry. Mean FET is about 11 s in a non-selected adult
population and about 10 s in healthy non-smokers (Kainu
et al. 2008). The FETs were shorter for our subjects than
those of Kainu et al. (2008), which could be partially
explained by the younger age of our subjects. The pro-
longed FET observed after GI in our divers, especially the
elite BHDs (?43%), and in the controls was concurrent
with changes in the pulmonary mechanics, such as
‘dysanapsis’’. The negative correlation of FET with
FEV
1
/FVC may indicate that physiological airflow limi-
tation tends to prolong FET.
Conclusion
This study evaluated the acute ventilatory effects of GI in
BHDs and revealed increased FVC and FEV
1
before and
also after GI. These ventilatory changes could be explained
by the combination of several factors, particularly the
capacity to withstand greater transpulmonary pressures and
volumes than those to which lungs are normally exposed.
These changes could be important to ensure the best static
and dynamic performance. Artificial dysanapsis could be
created by GI in elite BHDs. Long term-effect remains to
be examined.
Table 5 Vital capacity (VC)
changes [% =(after GI -
before GI)/before GI) 9100]
and their respective added
volumes after glossopharyngeal
insufflation (GI) in breath-hold
divers (BHDs), swimmers and
healthy women
a
Swimmers
b
Healthy women
Studies nAge Added VC with GI (l) %
Simpson et al. (2003) 1 30 1.73 18.6
Lindholm and Nyren (2005) 5 33 1.9 24
Muth et al. (2005)1 /2 21
Seccombe et al. (2006) 7 33 1.92 30
Overgaard et al. (2006) 7 30 1.59 16.4
Potkin et al. (2007) 5 37.2 1.3 21
Loring et al. (2007) 4 29.7 2.37 36
Nygren-Bonnier et al. (2007a)16
a
21.1 1.64 22.8
Nygren-Bonnier et al. (2007b)25
b
47 0.88 28
Tetzlaff et al. (2008) 8 30 1.75 25
Eichinger et al. (2008) 1 42 2.6 34
Lemaı
ˆtre (2009) 15 (elite BHDs) 33.7 1.36 20
16 (novice BHDs) 33.4 0.28 7
15 (controls) 30.2 0.20 4
Mean ±SD 33.1 ±6.3 1.5 ±0.7 22 ±9
Eur J Appl Physiol
123
Acknowledgments Special thanks are given to the BHDs for their
cooperation. We also thank Cathy Carmeni for help in preparing the
manuscript.
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Resumen Antecedentes Las enfermedades neuromusculares y las lesiones medulares comprometen los músculos respiratorios y función pulmonar ocasionando complicaciones respiratorias. La insuficiencia respiratoria aguda y el compromiso respiratorio crónico ocasionan alto riesgo de morbilidad y mortalidad. Se ha descrito el uso de la respiración glosofaríngea para mejorar variables de función pulmonar y muscular respiratoria que promueven la tos más efectiva y aumento del tiempo libre de ventilación mecánica. Objetivo Describir y presentar la evidencia actual de la efectividad de la respiración glosofaríngea en mejorar la función pulmonar y muscular respiratoria en pacientes adultos y pediátricos con enfermedades neuromusculares o lesión medular con o sin ventilación mecánica. Diseño Revisión exploratoria con la metodología PRISMA-ScR. Se realizó una búsqueda en las bases de datos PEDro, Web of Science, Scopus, PubMed, ScienceDirect, Springer, Medline, Cochrane, SciELO, Lilacs, Google Académico, se usaron palabras claves y términos MeSH en idiomas español, inglés y portugués, entre los años 2000-2020. Los resultados se presentan de forma descriptiva. Resultados Se identificaron 491 estudios y fueron incluidos 12. El 58,3% fueron realizados en países europeos. El 41,6% de los estudios fueron valorados y ninguno cumplió totalmente los criterios de calidad. La efectividad de la respiración glosofaríngea en la función pulmonar y muscular respiratoria estuvo relacionada con mejoría de capacidad vital en 66,6% y pico flujo de tos en 33,3% de los estudios. Se reportó mejoría en expansión torácica en 66,6% de los estudios y complicaciones como síncope, mareo en 33,3%. Conclusión La efectividad de respiración glosofaríngea en pacientes con enfermedades neuromusculares y lesión medular está relacionada con aumento de capacidad vital y pico flujo de tos. Se recomienda la realización de estudios con más rigurosidad científica para soportar la validez de estos resultados.
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The purpose of this study was to determine differences between vital capacity and length of a dive in dynamics (DYN) with and without glossopharyngeal insufflation in breath-hold divers. The sample consisted of 15 elite breath-hold divers (12 male subjects and 3 female subjects) who were in regular training process and members of national team in Croatia. The sample of variables consisted two measures for estimating valuation of vital capacity (VC and VCP) and two measures for determining length of a dive in meters (URON and URONP). All variables have standard their basic statistic parameters and were tested to determine statistically significant differences between the vital capacity and length of a dive with and without glossopharyngeal insufflation as technique of air packaging. One-sided t- test for dependent samples was used and with results (significance level of p = 0.00) it can be concluded that there is a statistically significant difference between vital capacity and length of a dive with and without glossopharyngeal insufflation. Technique of packing air (glossopharyngeal insufflation) is producing better results for competitors, but with this advantage athletes must be aware of disadvantages of using this technique which can cause injuries to respiratory system and its organs. Key words: divers, dynamics, breathing technique, dive length, respiratory system
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Simpson G, Ferns J, Murat S. Pulmonary effects of 'lung packing' by buccal pumping in an elite breath-hold diver. SPUMS J 2003; 33: 122-126) Buccal pumping is a technique used by breath-hold divers to increase lung capacity above normal total lung capacity (TLC) and thus increase depth capability. Concern has been expressed that hyperinflating the lungs using the pharyngeal muscles could itself produce pulmonary barotrauma, but transpulmonary pressures after buccal pumping have not previously been measured. We studied a breath-hold diver (SM) using whole-body plethysmography and oesophageal balloon manometry. Spirometry demonstrated that vital capacity could be increased from 7.48 to 9.22 l by buccal pumping. TLC increased from 9.28 to 11.02 l, calculated by assuming a constant residual volume of 1.8 l. At normal TLC, mean maximal pulmonary relaxation pressure measured at the mouth was 8.9 cm H 2 O. This rose to 86 cm H 2 O following buccal pumping to 'super' TLC. Mean transpulmonary pressure (mouth pressure minus oesophageal balloon pressure) at normal TLC was 31.6 cm H 2 O and at super TLC was very similar at 29.3 cm H 2 O. There did not seem to be a dramatic alteration in pulmonary compliance at higher lung volumes, although this was technically difficult to measure. These data suggest that buccal pumping itself does not carry a risk of pulmonary barotrauma. We postulate that the lack of rise in transpulmonary pressure relates to increased elastic recoil of the chest wall at volumes greater than normal TLC giving a positive intrapleural pressure and preventing pulmonary over-distension. Splinting of the chest wall has been shown experimentally to reduce the risk of pulmonary barotrauma in anaesthetised animals and fresh human cadavers, probably by a similar mechanism.
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