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with the muscles of the buccal cavity (Black and Hyatt, 1969). The
device was carefully calibrated with a mercury manometer before
any testing session. Multiple regression analysis did not disclose
any signicant difference between pre- and post-RMT calibration
curves and no signicant differences were found between the
regression lines and the identity line, as shown in Fig. 1. Moreover,
two-way (trial time) analysis of variance (ANOVA) for repeated
measures showed a signicant difference between pre- and postRMT values (P = 0.002), but no differences among trials (P = 0.668)
and no interactions (P = 0.597). Thus, it can be reasonably concluded
that during the pre-RMT testing sessions a learning effect was either
not present, or at least minimal. Furthermore, during the training period, participants did not perform any PImax measurements,
which would exclude a learning effect due to pre-RMT maneuvers
in the post-RMT testing session. Concerning pre-training absolute
values, provided that the instrumentation was correctly calibrated
and the maneuvers supervised by experts, we agree that our PImax
values were lower than reported by others. However, they t into
the normal range dened by Evans and Whitelaw (2009), as shown
in Fig. 2. Also Hautmann et al. (2000) questioned what is the lower
limit of the normal range of PImax . They proposed a prediction equation for PImax , which takes into account age and body mass index
(BMI), both independent predictors of inspiratory muscle strength
(Hautmann et al., 2000). The formula for healthy male subjects is
the following:
PImax = (0.158 BMI) (0.051 age) + 8.22
the lower limit of the normal range being 60% of the value determined from the equation.
In our study, average age and BMI were 24 4 years and
23 3, respectively. Thus, resolving the equation described above,
our values are higher than the lower physiological limit (see
Fig. 2).
2. Effectiveness of respiratory muscle training
Radtke and Benden question whether the training volume was
sufcient to induce gains in respiratory muscle strength. Moreover,
they reported different functional respiratory muscle adaptations
for endurance RMT and inspiratory muscle training, with the latter training modality, but not the former, inducing increases in
PImax .
Our study involved nine healthy, moderately active, collegiate
students. They reported to the laboratory for each training session, which was always performed under expert supervision. The
training protocol lasted 8 weeks (5 training sessions per week,
1020 min each including warm-up) and was performed by means
of a specic device (SpiroTiger Medical, Idiag AG, Fehraltorf,
Switzerland), which allowed a personalized respiratory training
through deep inspirations and expirations without hypocapnia.
During the rst week, participants familiarized with instrumen-
116
Reply to Letter to the Editor / Respiratory Physiology & Neurobiology 173 (2010) 115117
tory workload was: volume of the bag 3.29 0.04 L (+9%; P < 0.05),
respiratory rate of 36.0 0.1 b min1 (+15%; P < 0.05), for a total
amount of time of 824 12 s (+109%; P < 0.05), per training session. According to the instrumentation working modality, to allow
a breathing pattern under isocapnic hyperpnea, tidal volume (VT )
during training was 30% higher than the respiratory bag volume.
Thus, at the beginning of RMT, VT was 76% of the vital capacity (VC),
while at the end of training VT was 79% of VC, making questionable
whether the training in our work was aimed to endurance and not
to strength performance, as supposed by Radtke and Benden. In
other studies, subjects trained with VT set at 5060% of VC, and
respiratory rate adjusted accordingly to maintain a certain amount
of ventilation per training session (Spengler et al., 1999; Verges
et al., 2009). It is likely that the differences in VT between those
studies and ours could explain different training session durations.
Moreover, underestimation of the training bag volume with respect
to VC, or other spirometric parameters, could have accounted for
longer training session in other studies.
Fig. 1. Calibration curves of the digital pressure monitor with the mercury
manometer, before () and after () 8 weeks of RMT. Multiple regression analysis, did not show signicant differences between the two calibration curves
(P > 0.05). Thus, a single regression line was drawn and plotted against the identity line (dashed line). No signicant differences were found (P > 0.05) between
the calibration line and the identity line. The mercury manometer unit (mm Hg)
was converted in cm H2 O according to the International System of Units
(1 mm Hg = 1.359506 cm H2 O).
3. Spirometric parameters
Pulmonary function tests, usually performed and reported also
in other studies, were carried out to assess the effectiveness of the
RMT protocol. After RMT, while total lung capacity (TLC) did not
change, VC increased signicantly by 7% and RV decreased signicantly by 20%. Moreover, forced expired volume in the 1st s
(FEV1 ) and forced inspiratory ow rate at 50% from the beginning
of the inspiration (FIF50% ) increased signicantly by 9 and 47%,
respectively. Lastly, after RMT, a signicant decrease in total airway resistances (RAW ) by 17% took place. Together with the large
increase in PImax previously discussed, these results clearly suggest that the training protocol did have an effect on pulmonary and
respiratory function.
Although previous reports did not show changes in pulmonary
function after RMT (Lindholm et al., 2007; Verges et al., 2008, 2009;
Fig. 2. Relationship between reference and lower limit of normal (LLN) in male maximal inspiratory pressure (MIP) versus age (from Evans and Whitelaw, 2009). Average
PImax values from Esposito et al. study (2010), before () and after () RMT are drawn over the graph.
Reply to Letter to the Editor / Respiratory Physiology & Neurobiology 173 (2010) 115117
Keramidas et al., 2010), other authors found signicant improvements after training (Sonetti et al., 2001; Wells et al., 2005; Enright
et al., 2006; Wylegala et al., 2007).
4. Conclusions
In conclusion, we can reasonably reject the hypothesis that the
results of Esposito et al. (2010) were biased by a learning effect
and/or measurement errors. However, we agree with Radtke and
Benden that more precise guidelines are needed to non-invasively
assess the effects of RMT on pulmonary and respiratory function.
Indeed, differences in training devices (isocapnic hyperpnoea or
resistive) and modalities, in training intensity and duration, in initial workload assessment and workload adjustments throughout
the training period could signicantly affect RMT outcome.
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Fabio Esposito
Eloisa Limonta
Giampiero Alberti
Arsenio Veicsteinas
Department of Sport, Nutrition and Health Sciences,
University of Milan, Via G. Colombo 71, I-20133
Milan, Italy
Guido Ferretti a,b
Department of Biomedical Sciences and
Biotechnologies, University of Brescia, V.le Europa 11,
I-25123 Brescia, Italy
b Department of Basic Neuroscience, University of
Geneva, 1 rue Michel Servet, CH-1211 Geneva 4,
Switzerland
a
Corresponding