Protocol for Measurement of Sniff Nasal Inspiratory Pressure (SNIP)

TABLE OF CONTENTS
1
GLOSSARY OF TERMS.... 2
2
DOCUMENT CONTROL RECORD..... 2
3
INTRODUCTION..... 2
4
PURPOSE OF TEST... 3
4.1
Indications... 3
4.2
Contraindications.. 3
4.3
Test Complications... 3
5
REQUIRED PERSONNEL..... 4
6
EQUIPMENT..... 4
6.1
Description... 4
6.2
Set-Up.... 5
6.3
Calibration.... 7
7
TEST PROCEDURE.... 7
7.1
Patient Preparation.... 7
Withholding Medications..... 7
Height and Weight measurement...... 7
7.2
Testing Procedure..... 8
Test Explanation.. 8
Criteria for Test Termination.. 8
Indications for Test Termination........ 8
7.3
Patient Instruction.. 8
7.4
Performing the test SNIP.. 9
7.5
Procedure Notes...... 10
8
ACCEPTABILITY AND REPEATABILITY CRITERIA.... 11
9
TROUBLESHOOTING..... 11
10 QUALITY ASSURANCE...... 11
10.1 Biological Control Subjects...... 11
10.2 System Quality Assurance Messages.... 11
11 CLEANING AND MAINTAINANCE.... 12
12 INFECTION CONTROL AND SAFETY..... 12
13 ISSUING REPORTS..... 13
13.1 Interpretation of Test Results... 13
13.2 Limitations of the Test.... 13
14 REFERENCE VALUES.... 13
15 BIBLIOGRAPHY.... 15
16 DETAILS OF ALTERATIONS TO THE PROTOCOL..... 16
17 SIGNED AUTHORITY... 16

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GLOSSARY OF TERMS

SNIP

Sniff Nasal Inspiratory Pressure

MIP

Maximal Inspiratory Pressure

MEP

Maximal Expiratory Pressure

cmH2O

Centimeter of Water (pressure unit)

FRC

Functional Residual Capacity

Litre

Second

ms

Millisecond

LLN

Lower Limit of Normal

DOCUMENT CONTROL RECORD

This protocol was written August 2015, annual reviews and needed modifications should
be conducted.

INTRODUCTION

Measuring respiratory muscle strength is an important procedure as it gives an insight into

the progression of neuromuscular disease or other muscular disorders. This is
considerably notable in children with neuromuscular disease, as they can have reduced
respiratory muscle strength while lung volumes remain within normal ranges. 2
Maximal inspiratory pressure measured at the mouth against an occlusion (MIP) is
classically used to assess inspiratory muscle strength, however, this manoeuvre is highly
effort dependant and can be difficult for a child to perform. 4 An easier alternative method
for measuring maximal inspiratory pressure involves the patient performing short sniffs at
maximal intensity (SNIP). This method is much less volatile and gives a more reliable
result for maximal inspiratory pressure.
During a maximal sniff, when a pressure differential of approximately -20cmH2O is
reached in the throat, the nasal valve collapses. The pressure measured just beyond this
point of collapse closely reflects oesophageal pressure and, therefore, inspiratory muscle
strength.3
Many children find the SNIP manoeuvre to be more natural and easier to perform than a
MIP manoeuvre.2,4,8 A SNIP manoeuvre consists of measuring the maximal nasal pressure
in an occluded nostril, during a fast sharp sniff performed through the contralateral nostril.
This maximal sniff should be performed from FRC. 8 SNIP is a simple, non-invasive
procedure, that appears to be useful for the clinical assessment of inspiratory muscles
strength.

PURPOSE OF TEST
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4.1

Indications

SNIP is an additional respiratory muscle strength test that is usually measured in

conjunction with MIP/MEP. In cases where the patient is unable to perform MIPS/MEPS
testing, SNIP testing alone may be used for evaluation. 3
The following are common indications for SNIP testing: 2,3

Assessing and quantifying the degree of respiratory muscle weakness that may
occur in neuromuscular diseases and in other incidences of muscular weakness

Diagnosis or management of patients with suspected diaphragmatic or respiratory

muscle injury

Routine evaluation of respiratory muscle function

Evaluation of respiratory muscle therapy effectiveness

4.2

Contraindications

SNIP testing alone has minimal identified contraindications. SNIP is not referenced in any
of the current literature on respiratory testing contraindications. Although, it should be
noted that if other testing, such as spirometry or MIP/MEP are being performed in
conjunction with SNIP then contraindications for these tests need to be considered for the
patient.
The absolute contraindications for SNIP testing are related to the reliability of the results
obtained and include:4

4.3

Recent nasal surgery or any nasal discomfort which would contribute to a

submaximal effort

Any nasal congestion; if nasal congestion is present on the day of SNIP testing, the
test should be rescheduled to a later date.

Anatomic abnormalities, such as nasal septal deviation or a septal defect; this could
potentially hinder the measurement of nasal pressure in some patients.
Test Complications

Excessive SNIPS may exacerbate an already existent discomfort, if the patient complains
of headaches, nausea or any form of discomfort during the testing procedure then stop
testing immediately and allow a period of rest. If the patient does not feel better upon
resting then stop testing procedure entirely.

REQUIRED PERSONNEL 9
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SNIP testing requires a clinical measurement professional who has the capability to
perform pulmonary function testing on patients. Clinical professionals are expected to have
knowledge of pulmonary function tests and the pathophysiological changes associated
with disease processes.

EQUIPMENT

6.1

Description

Vmax hot wire flow sensor

Nasal Canual tube

Nasal insert of appropriate size attached to the canula. Size is chosen according to
the size of the patients nostrils.
Fig 1: Vmax hot wire flow sensor

Fig 2: Small, Medium and Large Nasal Inserts

6.2

Set Up
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Check that the Vmax system is switched on, operational and calibrated as per the Vmax
Operators Manual. 1
1. Connect the nasal canual tube to the hot wire flow sensor in place of the
directional pressure sensor line (right side of mouthpiece)
2. New Patient: Click New Study and enter patient details into the demographic.
These details need to include: ID number, name, date of birth, gender, height
and weight. Then exit back out into the main menu.
Returning Patient: Click New Study and enter details into one of the fields,
press F6 to search database and select correct patient.
Fig 3: Setting up

3. Press F3 to save and exit, ensure patient name is in the bar at the top of the
screen.
4. Click Pulmonary Function then select Max Pressure from the pop up menu.
When in the testing screen, click on Test from the bar in the left upper corner of
the screen, then select SNIP. This should bring up the SNIP testing screen and
trials can be started.
Fig 4: Starting the Muscle Pressures test

Fig 5: Selecting SNIP

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Fig 6: Nasal Insert attached to pressure line

6.3

Calibration
Flow Sensor Calibration
Page 6 of 16

Flow sensor calibration is not important specifically in relation to SNIP testing.

Although, it should be noted if other respiratory tests are being performed in
conjunction with SNIP, such as spirometry and MIPS/MEPS, then calibration should
be performed prior to testing using a 3L syringe according to the Vmax calibration
program.1
Pressure Transducer Calibration
Calibration verification is an unavailable feature of the Vmax system. Calibration is
performed during annual preventative maintenance by a Carefusion professional.
The accuracy and range of the Vmax pressure transducer is as follows:

Accuracy: 1% full scale

Range: 300 cmH2O

TEST PROCEDURE

7.1

Patient Preparation

If it is requested, spirometry and other lung function tests should be performed prior to the
SNIP test.2 Patient demographic information needs to be entered into the Vmax system
prior to beginning the test. This includes, patients URN, first and last name, date of birth,
gender, height, weight and current medications.
Withholding medications
Unless stated otherwise by the referring practitioner, SNIP testing generally does not
require withholding of any medications. The scientist should record the type and dosage of
any (inhaled or oral) medication that may alter lung function and when the drugs were last
administered. 9
Height and weight measurement2,9
Height and weight is to be measured without shoes and any outer clothing. Ensure patient
has no heavy objects on them. Standing height is measured using a stadiometer; ensure
patient is standing with their feet together and heels against the stadiometer base. The
patient should be looking straight ahead, with their head in a horizontal plane. When taking
the height measurement, instruct the patient to inhale deeply to ensure an accurate height
is taken.
When patients are unable to stand or accurate height measurements cannot be acquired
due to deformity, then we can get an estimate of height using ulna length. 6 The ulna length
is measured using Vernier callipers and is substituted into a prediction equation. This
equation is easily used through an excel spreadsheet which can be accessed through the
Respiratory and Sleep network drive.
Weight is measured standing on scales available to the laboratory; if patient is unable to
stand, weight can be measured using a wheel chair scale.
7.2

Testing Procedure

Test Explanation
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The testing protocol should be briefly and simply explained to the patient prior to beginning
testing. This will provide a better understanding of what we are trying to achieve and will
guide the patient
Criteria for Test Termination5
At least 10 SNIP manoeuvres should be performed; until at least 3 maximal results are
achieved. If the last SNIP value is higher than the preceding values then further SNIPs
should be done until a plateau or decline is reached.
Note: in the Vmax system only 8 trials are displayed, after 8 attempts the system will
overwrite previous results which have been disabled by the testing scientist.
Indications for Test Termination7

Chest pain suggestive of Ischemia

Severe headache, nausea or discomfort

Nasal bleeding or pain

Sudden pallor, loss of coordination or mental confusion

Dizziness or faintness

Signs of respiratory failure

Adequate number of trials achieved

7.3

Patient Instruction

The patient should be carefully instructed on the details of the procedure, including
difficulties that may be experienced, prior to commencing the test.
Instructions to the patient should include:

To sit comfortably

In a situation where the patient is struggling to keep the nasal insert inside the
nostril; instruct them to help hold it in with their hand.

Breathe normally through the nose, keeping their mouth closed. Their mouth must
be kept closed during the sniff.

A minimum of 10 sniffs will be performed, alternating between each nostril. 5 If better

results are achieved with a specific nostril, conduct more trials in this side.

Rest pauses in between each sniff will be at least 30 seconds. 2

Repeat the instructions if necessary, demonstrating and coaching the patient to perform at
a maximal effort.

7.4

Performing the test SNIP

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After following the set up procedure in section 6.2 of this manual, pressing F1 should bring
up the screen as below and testing can begin.
Fig 7: SNIP testing screen

Connect patient to pressure line by instructing them to gently insert the nasal insert into
their nostril, ensuring a secure fit with no leaks. If necessary, try other nasal insert sizes
until an optimal size is chosen. The patient should also support the insert with their hand
during testing.
Instruct patient to breathe normally (tidally) with mouth closed.
At the end of a normal exhalation during resting breathing, press F1 and instruct patient to
perform a strong, sharp sniff. Ensure to encourage the patient to get maximal effort.
After the sniff is completed, the results screen should show. This will give values for SNIP
max, SNIP peak time, SNIP Ecode, SNIP time and SNIP date. A graph will also be
displayed, each corresponding to a trial.
Fig 8: SNIP results screen

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After a 30 second rest period, the patient should be instructed to move the insert into the
opposite nostril. Press F1 to start the trial for this SNIP, and F1 again when the patient is at
FRC and ready to perform the sniff manoeuvre.
If you wish to review individual trials press F6 and select trial to see an enlarged graph.
Repeat until 8 trials are performed, press F2 and disable all submaximal and unacceptable
trials by clicking on the corresponding number down the bottom of the screen.
Fig 9: Deselecting trials

An unacceptable trial has a SNIP peak time of greater than 0.5s or 500ms. If a SNIP trial is
unacceptable it will present with a SNIP Ecode which is not 000. This can be seen in trial 7
of Fig 9 above.
Keep testing in alternating nostrils until 10 trials have been completed, if the 3 highest
acceptable SNIP values are within 5% of the mean then repeatability has been met.
Although, if the last trial provides the highest value than continue testing until a plateau or
decline in the value occurs.
When finished testing, exit to the main menu and exit out of Vmax to transfer data into the
sentrysuite database.
Ensure to replace pressure line into the hot wire flow sensor.
7.5

Procedure Notes

In the Vmax system only 8 trials are displayed, after 8 attempts the system will
overwrite previous results which have been disabled by the testing scientist.

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ACCEPTABILITY AND REPEATABILITY CRITERIA

Continue measuring SNIP trials at 30 second intervals 2, from alternating nostrils, for at
least 10 trials. If the final trial performed has a higher value then continue testing until a
plateau or decline is seen. Acceptable and Repeatable trials show: 3,4

The maximum value of the three best trials vary by less than 5%

If the final effort is the highest value, an additional trial should be obtained

Each trial is only acceptable if the sniff duration is less than 0.5 Seconds (500ms)

Do not continue beyond 20 attempts. If repeatable results are not obtained, the highest of
the technically acceptable results is to be reported with a comment that repeatability was
not achieved.

TROUBLESHOOTING

Ensure that the circuit does not have any leaks, and that the nasal insert is sealing at the
nostrils.
If nasal congestion is present the SNIP value may be reduced. Reschedule the test for a
later date.
If sniff attempts are longer than 500ms, then they are marked as not acceptable. To
overcome this coach the patient to give sharper and faster maximal sniffs.
If any technical issues arise within the software, consult the Vmax operators manual for
solutions to fix these problems or contact Biomedical Engineering support.

10

QUALITY ASSURANCE

10.1

Biological Control Subjects10

A log should be maintained with recorded SNIP values from at least 3 healthy subjects,
these measurements should be repeated quarterly and whenever questions arise
regarding accuracy of test results. When sufficient data is available on a given subject,
these results can provide a basis to evaluate the instrument, operator or measurement
failures. Any results which are greater than 2 standard deviations from the mean for each
subject should result in a complete system check to fix potential problems.
10.2

System Quality Assurance Messages

When performing SNIP testing in the Vmax system, a SNIP Ecode will be provided for
each trial, this code represents a fault in the SNIP manoeuvre which will affect the
acceptability on the trial. The Ecode of 000 represents an acceptable trial, whereas an
Ecode of 001 represents a slow time to peak.
For a final check of repeatability and acceptability, select window from the menu bar then
click on QC status. Vmax will analyse results to determine if they are within repeatable
limits.
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Fig 10: Using the QC status to determine test quality

11

CLEANING AND MAINTAINENCE

Aside from the components of the patient-breathing circuits (hot wire sensor, etc), the
instruments should not require frequent cleaning and disinfection. When surface cleaning
is needed, use a spray disinfectant to wipe down the surfaces of the instruments. The hotwire flow sensors must be cleaned weekly and disinfected. 1 The cleaning process used in
this lab is a Revital-ox soak, followed by rinsing and drying in an Atherton drying cabinet.
When performing a pulmonary function test, a single- use mouthpiece containing a
bacterial filter is used, you do not need to sterilize the sensor after each patient. 1
Routine maintenance is performed annually by a professional; if any maintenance or faulty
part replacement is required to be conducted by a scientist then the procedures for the
specific task can be located in the Vmax Operators Manual. 1

12

INFECTION CONTROL AND SAFETY 9

The goal of infection control is to prevent the transmission of infection to patients and staff
during pulmonary function testing. The number of documented cases of infection
transmission is very small, but the potential is real. Prevention of infection transmission to
staff exposed to contaminated equipment surfaces can be accomplished through proper
hand washing and use of barrier devices, such as suitable gloves. To avoid crosscontamination between patients, reusable mouthpieces, breathing tubes, valves and
manifolds should be disinfected or sterilized regularly. Mouthpieces, nose clips and any
other equipment that comes into direct contact with mucosal surfaces should be
disinfected, sterilized or, if disposable, discarded after each use.

13

ISSUING REPORTS

To finalise a muscle strength report, ensure SNIP testing has been completed on the Vmax
system and the Vmax system has been exited since, transferring the data to sentrysuite.
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In sentrysuite, search for the patient and double click todays SNIP test. Click Application
then select a Respiratory Mechanics test. Insert any needed comments in the
Interpretation/Comments section. From here select the report named
LCCH_MUSCLEPRESS_V0.02 and click on the quick view button. This should display a
report with the SNIP values and graphs, along with MIP/MEP if they were done in
conjunction with SNIP. Print a copy of this report and save as a preliminary report.
Printed reports are initially labelled as Interim Report Do not scan. Issue as per policy.
An example of this report is seen in Fig 11, overleaf.
13.1

Interpretation of Test Results

Paediatric reports are to be interpreted within 5 days of test completion by the SHO or
paediatric respiratory fellows, and then filed in the medical record. If not reported within 5
days, a senior scientist interprets the report and this is sent to ieMR and/or the requesting
physician.
Although there is no set severity grading regarding SNIP results, normality can be
assessed using z-scores and LLN values. Results are said to be normal/abnormal and are
commonly used serially to monitor patient disease progression.
13.2

Limitations of the Test

In patients with nasal obstruction, chronic obstructive pulmonary disease and severe
neuromuscular disease, SNIP may underestimate muscle strength. 11

14

REFERENCE VALUES

This Laboratory uses the reference values of Stefanuti 2 for children and Uldry3 for adults.
Patients tested outside these ranges require a cautionary note added to their report that
states that the reference data has been extrapolated and may be inaccurate.

SNIP

Males 6-18 Years

Females 6-18
Years

Males 20-80 Years Females 2080Years

104 26 cmH2O

93 23 cmH2O

(-0.42Age + 126.8)
39 cmH2O

(-0.22Age + 94.9)
28 cmH2O

Fig 11: SNIP Report Format

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15

BIBLIOGRAPHY

1. Vmax series Operators Manual, Carefusion, Literature Number 777360 Rev M.

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2. Stefanutti, D., Fitting, J.W., 1999, Sniff Nasal Inspiratory Pressure, Reference Values in
Caucasian Children, AM J Respir Crit Care Med, 159:107-111
3. Uldry, C., Fitting, J.W., 1995, Maximal value of sniff nasal inspiratory pressure in
healthy subjects, Thorax, 50:371-375
4. Heritier, F., Rahm, F., Pasche, P., Fitting, J.W., 1994, Sniff Nasal Inspiratory Pressure, A
Noninvasive Assessment of Inspiratory Muscle Strength, Am J Respir Care Med
150:1678-83
5. Lofaso, F., Nicot, F., Lejaille, M., 2006, Sniff nasal inspiratory pressure: what is the
optimal number of sniffs?, European Respiratory Journal, 27:980-982
6. Gauld, L.M., Kappers, J., Carlin, J.B., Robertson, C.F., 2004, Height prediction from
Ulna Length, Developmental Medicine and Child Neurology, 46:475-480
7. Cooper, B.G., 2011, An update on contraindications for lung function testing, Thorax,
66(8):714-23
8. Fauroux, B., 2003, Respiratory muscle testing in children, Paediatric Respiratory
Reviews, 4:243-249
9. Miller, M.R., Crapo, R., Hankinson, J., Brusasco, V., Burgos, F., Casaburi, R., et al.
2005, General considerations for lung function testing, The European respiratory journal,
26(1):153-61
10. Gardner, R.M., Clausen, J.L., Crapo, R.O., Epler, G.R., Hankinson, J.L., et al. 1986,
Quality Assurance in Pulmonary Function Laboratories, The American Review of
Respiratory Disease, 134:625-627
11. Prigent, H., Lejaille, M., Falaize, L., et al. 2004, Assessing inspiratory muscle strength
by sniff nasal inspiratory pressure, Neurocrit care, 1(4):475-478

16

DETAILS OF ALTERATIONS TO THE PROTOCOL

Section

Summary

Reason

Signed/Date
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17

SIGNED AUTHORITY

This protocol has been approved by the Senior Respiratory Scientist.

Signed:

Date:

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