Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 14 nº 4 - Oct/Dec - 2017

Original Article Imprimir 

Páginas 77 a 84

Assessment of maximal respiratory pressures and pulmonary function in visually impaired adolescents

Evaluación de las presiones respiratorias máximas y función pulmonar en adolescentes con deficiencia visual

Avaliação das pressões respiratórias máximas e função pulmonar em adolescentes com deficiência visual

Autores: Regina Kátia Cerqueira Ribeiro1; Maria de Fátima Bazhuni Pombo March2; Clemax Couto Sant'Anna3

1. Professional Master's Degree in Maternal and Child Health from the Fluminense Federal University (UFF). Niterói, RJ, Brazil. Professor and Coordinator of Orientation and Mobility of the Benjamin Constant Institute (IBC). Rio de Janeiro, RJ, Brazil
2. PhD in Medicine from the Federal University of Rio de Janeiro (UFRJ). Rio de Janeiro, RJ, Brazil. Associate Professor at Fluminense Federal University (UFF). Niterói, RJ, Brazil. Associate Professor at the Federal University of Rio de Janeiro (UFRJ). Rio de Janeiro, RJ, Brazil
3. Doctorate in Medicine. Member of the Brazilian Tuberculosis Research Network (REDE-TB). Associate Professor at the Federal University of Rio de Janeiro (UFRJ). Rio de Janeiro, RJ, Brazil

Regina Kátia Cerqueira Ribeiro
Rua Visconde Silva 140 aptº 504, Humaita
Rio de Janeiro, RJ, Brasil. CEP:22271-044

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Keywords: Visually impaired persons, respiratory muscles, adolescent.
Palabra Clave: Personas con deficiencia visual, músculos respiratorios, adolescente.
Descritores: Pessoas com deficiência visual, músculos respiratórios, adolescente.

OBJECTIVE: Describe the respiratory muscle strength (RMS) and pulmonary function in visually impaired adolescents between 12 and 19 years old.
METHODS: This was an observational, cross-sectional and descriptive study. Were conducted spirometry tests and evaluations of maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP) with the aid of a digital manometer. The body mass index (BMI) was calculated by the equation Quetelet. The comparison of variables between boys and girls were made by Mann-Whitney test for numerical data and the χ2 test for categorical, with p significance criterion < 0.05.
RESULTS: A total of 77 students, with a median age of 16 years, where 39 (50.65%) were male. The median MIP = 94 cmH2O and the median MEP =95 cmH2O ; CVF 2,82 liters, VEF1 2,77 liters e VEF1/ CVF 0,997 liters. Boys had significantly higher values compared to girls in the variables: weight, height, MIP and MEP.
CONCLUSION: Students with visual impairments showed lower FMR and spirometric values than the predicted values, but not characterizing respiratory disorders.

OBJETIVO: Describir la fuerza muscular respiratoria (FMR) y la función pulmonar de adolescentes deficientes visuales (ciegos y con baja visión) con edades entre 12 y 19 años.
MÉTODOS: Se trata de un estudio observacional, transversal y descriptivo. Fue realizada espirometría y medidas de presiones inspiratorias máximas (PImáx) y presiones expirativas máximas (PEmáx) con la ayuda de manovacuometría digital. El índice de masa corporal (IMC) fue calculado por la ecuación de Quetelet. La comparación de las variables entre niños y niñas fue hecha por el test de Mann-Whitney para datos numéricos y por el test de c2 para os categóricos, con criterio de significancia de p <0,05.
RESULTADOS: Fueron evaluados 77 alumnos, con promedio de edad de 16 años, siendo 39 (50,65%) del sexo masculino. La mediana de PImáx fue 94 cmH2O y de PEmáx 95 cmH2O; CVF 2,82 litros, VEF1 2,77 litros y VEF1/CVF 0,997 litros. Los niños tuvieron valores significativamente mayores en relación a las niñas en las variables: peso, altura, PImáx y PEmáx.
CONCLUSIÓN: Los alumnos con deficiencia visual presentaron FMR y valores espirométricos menores que los valores predichos, no obstante, no caracterizando disturbios respiratorios.

OBJETIVO: Descrever a força muscular respiratória (FMR) e a função pulmonar de adolescentes deficientes visuais (cegos e com baixa visão) com idades entre 12 e 19 anos.
MÉTODOS: Trata-se de um estudo observacional, transversal e descritivo. Foi realizada espirometria e medidas de pressões inspiratórias máximas (PImáx) e pressões expiratórias máximas (PEmáx) com a ajuda de manovacuometria digital. O índice de massa corporal (IMC) foi calculado pela equação de Quetelet. A comparação das variáveis entre meninos e meninas foi feita pelo teste de Mann-Whitney para dados numéricos e pelo teste de χ2 para os categóricos, com critério de significância de p <0,05.
RESULTADOS: Foram avaliados 77 alunos, com mediana de idade de 16 anos, sendo 39 (50,65%) do sexo masculino. A mediana de PImáx foi 94 cmH2O e de PEmáx 95 cmH2O; CVF 2,82 litros, VEF1 2,77 litros e VEF1/CVF 0,997 litros. Os meninos tiveram valores significativamente maiores em relação às meninas nas variáveis: peso, altura, PImáx e PEmáx.
CONCLUSÃO: Os alunos com deficiência visual apresentaram FMR e valores espirométricos menores do que os valores preditos, porém não caracterizando distúrbios respiratórios.


For Faye and Barraga1, the visually impaired are individuals with blindness or with low vision. Blind learners have total absence of vision, and may have light perception, but use the Braille System in the teaching and learning process. Students with low vision are able to indicate light projection to the extent that reducing their visual acuity limits their performance. The degrees of vision include: visual acuity, binocularity and visual field2.

Visual impairment for not having up-to-date information regarding the position of body segments in relation to themselves and the environment may suffer musculoskeletal changes such as: hyperkyphosis, structured scoliosis, knee ligament laxity, improper head posture, shoulder asymmetry, alteration scapular and spinal disorders. The congenital visual deficits are still afflicted with body asymmetries related to head protrusion and knee symmetry, indicating a compensatory postural form of absence of vision3.

Some muscles of the respiratory system are inserted into the lumbar and cervical vertebrae and into the ribs. Inadequate postures can interfere with the ventilatory process, tending to muscles and ligaments, and may also cause changes in the spinal joints and, consequently, breathing. Blind people present five times more changes in postural control and scoliosis when compared with individuals who see4.

Respiratory muscle strength (FMR) was defined by Shaffer, Wolfson and Bhutani5 as the maximum pressure generated by the contraction of respiratory muscles and measured at the mouth level. FMR is estimated by maximum inspiratory pressures (MIP) and maximum expiratory (PEmax), respectively. In order to measure MIP and MEP, the pressure evaluation method has been used, by means of an instrument called a manovacuometer, introduced in 1969 by Black and Hyatt6.This apparatus can be of the analog or digital type, in order to measure positive pressures (manometer) and negative pressures (vacuum gauge), in which the values are given in a scale of cmH2O.

The evaluation of pulmonary function is widely used in research and diagnostic centers. It involves measures of arterial oxygenation, lung volumes, gas transport and ventilation. This evaluation is generally performed by spirometry, which provides subsidies for the characterization of respiratory disorders.

The literature indicates that age is a negative predictor for pulmonary function, so we aim to know the pulmonary function and FMR of adolescents with visual impairment, in order to contribute with preventive measures so that this decrease is no more significant than the one that occurs with increasing age. It should be noted that no studies were found that correlate FMR measurement and pulmonary function in people with visual impairment.


This is a cross-sectional, descriptive, observational study that was developed at the Benjamin Constant Institute (IBC) in Rio de Janeiro, which serves a varied clientele with several visual diseases that cause blindness and low vision. Data collection was carried out from October to December 2014. The project was approved by the Ethics Committee of the Fluminense Federal University/HU, under the number CAAE 33733714.5.0000.5243.

We included blind and low vision students who attended only physical education classes in the IBC and also students who, besides physical education, participated in sports projects offered by the IBC in the school shift. A clinical form developed by the team was completed using the standardized questionnaire (ATS-DLD-78-C)7, to verify the underlying disease to group them according to anatomical diagnosis and ophthalmologic classification. Students who had some clinical restriction to perform the exams, such as: fever, dizziness, dyspnoea, cough, headache and cold at the time of evaluation were excluded. Still on this form, there was the questioning to the student to check for respiratory diseases such as bronchitis, rhinitis and sinusitis.

Measurements of MIP and MEP were done with MVD 300® digital manovacuometer (GlobalMed, RS, Brazil). The FMR measurement was collected with the students seated using a nasal clip to prevent air leak through the nose. For the evaluation of the MIP, a maximum inspiratory effort was requested from the residual volume, and for MEP was directed to perform a maximum expiratory effort from the total lung capacity.

The students did at least three repetitions, technically satisfactory, that is, no air leak, with a duration of at least 1 second, with a rest interval of one minute between each evaluation and was used the result of greater value. For the calculation of predicted values of PRM, the equation proposed by Neder8 was used for healthy and non-visually impaired individuals according to age and gender.

Pulmonary function tests were performed through spirometry, with the seated and nasal clips evaluated. The equation used to compare the measured and predicted was Pereira9, was adopted as criteria of normality values above 80% for steps (FVC, FEV1) and above 70% for ratio (FEV1 / FVC ratio) of the predicted value . The micro-spirometer Micro Medical Limited, Micro Plus Model MS03® was used. The procedures were performed according to the criteria of the American Thoracic Society10. The body mass index (BMI) was calculated by the equation of Quetelet: BMI = body mass (KG) / height (m2) Seidell (2000) quoted by Petroski11.

The results were presented in tables and expressed by the median and interquartile range (Q1 and Q3), minimum and maximum for numerical data, and frequency (n) and percentage (%) for categorical data. The inferential analysis consisted of the following methods: the comparison of clinical variables, manovacuometer and spirometry between boys and girls was evaluated by the Mann-Whitney test for numerical data and the X2 test for categorical data. Non-parametric methods were applied, since the variables did not present a normal distribution (Gaussian), due to rejection of the normality hypothesis of the Shapiro-Wilks test in the total sample and / or in the subgroups. The significance level of 5% was adopted and the statistical analysis was processed by the statistical SAS ® System software, version 6.11 (SAS Institute).


We evaluated 86 students aged 12 to 19 enrolled in 2014 in elementary school. Of these, nine were excluded because they had, in addition to visual impairment, another associated deficiency and did not understand the examination. The final sample consisted of 77 students, 39 males and 38 females. Of the participants, 34 students were blind and 43 with low vision.

Table 1 presents the categorical variables of educational level, nutritional status, sports practice and ophthalmological classification, according to the sex of the 77 visually impaired students. There was no significant difference in the degree of schooling between the sexes, since all were basically in the same series. There was a significant difference in nutritional status, where boys tended to be overweight. There was no statistically significant difference in the variables of sports practice and ophthalmologic classification.

Table 2 describes the FMR and spirometry measures of the students. Students with visual impairment had lower values of MIP (78.5% of predicted) and MEP (81.6% of predicted) and lung function. The boys had significantly higher values in relation to the following variables: weight, height, MIP cmH2O, MEP cmH2O, observed in table 3. The students with low vision had all the respiratory variables greater when compared to the blind students (Table 4).


In our series, we found values below the normality of MIP and MEP without respiratory disturbances identified by spirometry. Our results demonstrated that MIP and MEP values were lower in females than males. Perhaps, due to the fact that girls tended to refer more respiratory diseases than boys.

We did not find studies in the literature investigating the FMR of people with visual impairment. According to the bibliographic review of Freitas et al.12 published in 2011, no articles with normal values for PRM were found in Brazilian children and adolescents. In 2013 Mendes et al.13 published an article with predictive equations of MIP and MEP for Brazilian adolescents, but in their MEP equation, the authors used only sex, not taking into account age, differently from Neder et al.8. Thus, we found it more appropriate to use the latter authors to calculate the PRM predicted values of our sample.

In our study, students with higher BMI showed also higher, although not significantly higher, FMR. It is believed that there is a direct relationship between BMI and FMR. When correlating the FMR with the anthropometric variables of eutrophic and obese women, the authors concluded that they present a higher FMR when compared to the eutrophic ones, either due to the adaptation to obesity, the difference in muscle fibers or, also, the overload imposed on the diaphragm muscle for its functioning14.

Male students presented significantly higher BMI values than females. It is noteworthy that, like other authors, we only used BMI for obesity classification. Domingos-Benício et al.15 however warn that BMI is not a specific indicator for fat, since the obese individual should be subjected to more adequate evaluations, such as percentage and distribution of body fat.

The students with some respiratory disease, although they presented all the variables inferior to the others, showed significant difference only in MIP. Perhaps because of their inadequate postures and due to stress, there has been a decrease in the length of respiratory muscles, which have become ineffective with low contractile capacity and, consequently, decreased MIP. Based on studies carried out by Souchard16, we hypothesized the muscular fragility of our sample. This author showed that the main causes of shortening of the inspiratory musculature are: neuropsychic aggressions (stress), increase in the volume of visceral mass, inadequate posture and respiratory diseases. Although in our study we did not perform any kind of postural evaluation, nor did we apply a stress checking protocol.

There was no significant difference between the subgroups of students who participate only in IBC physical education classes and students participating in physical education classes and Sports Projects offered twice a week. However, in all evaluated variables, students who practice sports activities presented higher values. Studies show that the majority of adolescents do not practice moderate to intense physical activity for at least one hour per day, since the activities offered to them are of low intensity, frequency and duration. Thus, they do not reach the adaptations and beneficial health effects offered by physical exercise17. The students we evaluated also did not practice physical activities in sufficient quantity and intensity to promote a significant difference in their physical conditioning. It should be remembered that for people with visual impairment, as for any individual, the practice of physical activity presents benefits not only for the body, but also for the mind, promoting social integration, preventing psychological / social isolation and contributing to the improvement of self-image and self-confidence, which increases the chances of social inclusion. Physical group activities are very important for people with visual impairment, since this exchange of experiences form emotional connections with positive social interactions among them18. It is important that family members and teachers encourage the participation of extracurricular physical activities as they contribute to the improvement of social skills. Santos et al.19 observed that participation in physical education classes by students who see also reduces social isolation.

In the analysis of respiratory variables, students with low vision presented all respiratory variables in percentage higher than blind students. These results suggest that such a difference may occur through the greater postural compensation of the blind person, who, when moving, needs more attention to find the references and clues memorized. Thus, such people may be more tense and insecure about body movements in various environments. In an article about postural changes in the visually impaired, it was observed that individuals with blindness, due to having greater postural alterations when compared to individuals with low vision, adopt compensatory posture, causing increase of thoracic kyphosis, pelvic anterior, shoulder girdle protrusion and pelvic anterior for alignment of the center of gravity20.

Usually, with increasing age, there is a significant reduction in FMR. As the posture influences the respiratory muscles, it is important to have a greater attention to the postures of people with visual impairment, thus avoiding that this deficit increase more than would happen physiologically, providing an improvement in their quality of life.

We consider that it is important that the visually impaired child be stimulated early to motor activities directed by professionals to prevent these respiratory and postural lags. Periodic evaluations of your FMR would contribute to monitor respiratory system conditions. These evaluations could help in the orientation of preventive measures with specific works for this musculature in the classes of physical education or in specialized and individual care with professionals of the health area.


Benjamin Constant Institute´s Direction, the physiotherapists Patrícia Helena Medeiros Cézar de Oliveira Rodrigues, Gabriela Fernandes and Carla Peixoto Vinha de Souza, who assisted in the data collection.


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