Sniff test: does what we measure at the nose reflect what happens in the chest wall?

Nasal pressure measured during sniff (SNIP) is a technically simple voluntary test. Since the contraction of the diaphragm expands the abdomen, the volume variation during sniff manoeuvre should therefore be predominantly abdominal in order to be considered a specific index of diaphragm strength. We aimed to verify if and how SNIP varied according to thoraco-abdominal volume variations. We measured abdominal volume variations, using opto-electronic plethysmography, during quiet breathing (ABQB) and sniff manoeuvres (ABSN) in supine position on 30 patients (age: 42; FVC:47.5%; FEV1:30%) on the waiting list for lung transplant. SNIP was measured simultaneously with ABSN. 68 sniff were analysed and classified into 4 groups according to ABSN: 16 with thoracic paradox, 24 predominantly abdominal, 16 predominantly thoracic and 12 with abdominal paradox. By definition ABSN was different (p<0.001) among the 4 groups, whereas ABQB (~75%; p=0.373) and SNIP (~53 cmH2O, p= 0.792) were similar (figure 1). SNIP did not change with the different thoraco-abdominal strategies. The diaphragm was not weak and leaded inspiration, therefore ABSN varied because the patients misperformed the manoeuvre. In order to not misunderstand the clinical significance of a sniff test, care should be paid also in thoraco-abdominal movement because SNIP, per se, cannot differentiate between thoracic or diaphragmatic manoeuvre with the risk to lose its specificity.