chest excursion vs chest expansion

• Introduction
• Palp/Percus
• Auscultation

Palpation/Percussion

Thoracic expansion:.

• Is used to evaluate the symmetry and extent of thoracic movement during inspiration.
• Is usually symmetrical and is at least 2.5 centimeters between full expiration and full inspiration.
• Can be symmetrically diminished in ankylosing spondylitis .
• Can be unilaterally diminished in chronic fibrotic lung disease , extensive lobar pneumonia, large pleural effusions, bronchial obstruction and other disease states.

Percussion:

Percussion is the act of tapping on a surface, thereby setting the underlying structures in motion, creating a sound and palpable vibration. Percussion is used to determine whether underlying structures are fluid-filled, gas-filled, or solid. Percussion:

• Penetrates 5 - 6 centimeters into the chest cavity.
• May be impeded by a very thick chest wall.
• Produces a low-pitched, resonant note of high amplitude over normal gas-filled lungs.
• Produces a dull, short note whenever fluid or solid tissue replaces air filled lung (for example lobar pneumonia or mass) or when there is fluid in the pleural space (for example serous fluid, blood or pus).
• Produces a hyperresonant note over hyperinflated lungs (e.g. COPD ).
• Produces a tympanitic note over no lung tissue (e.g. pneumothorax ).

Diaphragmatic excursion:

• Can be evaluated via percussion.
• Is 4-6 centimeters between full inspiration and full expiration.
• May be abnormal with hyperinflation , atelectasis , the presence of a pleural effusion , diaphragmatic paralysis, or at times with intra-abdominal pathology.

The Lung Exam

• Inspection and Observation
• Auscultation

Sample Lung Sounds

The 4 major components of the lung exam (inspection, palpation, percussion and auscultation) are also used to examine the heart and abdomen. Learning the appropriate techniques at this juncture will therefore enhance your ability to perform these other examinations as well. Vital signs, an important source of information, are discussed elsewhere.

Inspection/Observation:

A great deal of information can be gathered from simply watching a patient breathe. Pay particular attention to:

• General comfort and breathing pattern of the patient. Do they appear distressed, diaphoretic, labored? Are the breaths regular and deep?
• Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids). Their use signifies some element of respiratory difficulty.

• Breathing through pursed lips, often seen in cases of emphysema.
• Ability to speak. At times, respiratory rates can be so high and/or work of breathing so great that patients are unable to speak in complete sentences. If this occurs, note how many words they can speak (i.e. the fewer words per breath, the worse the problem!).
• Any audible noises associated with breathing as occasionally, wheezing or the gurgling caused by secretions in large airways are audible to the "naked" ear.
• The direction of abdominal wall movement during inspiration. Normally, the descent of the diaphragm pushes intra-abdominal contents down and the wall outward. In cases of severe diaphragmatic flattening (e.g. emphysema) or paralysis, the abdominal wall may move inward during inspiration, referred to as paradoxical breathing. If you suspect this to be the case, place your hand on the patient's abdomen as they breathe, which should accentuate its movement.

Review of Lung Anatomy:

Understanding the pulmonary exam is greatly enhanced by recognizing the relationships between surface structures, the skeleton, and the main lobes of the lung. Realize that this can be difficult as some surface landmarks (eg nipples of the breast) do not always maintain their precise relationship to underlying structures. Nevertheless, surface markers will give you a rough guide to what lies beneath the skin. The pictures below demonstrate these relationships. The multi-colored areas of the lung model identify precise anatomic segments of the various lobes, which cannot be appreciated on examination. Main lobes are outlined in black. The following abbreviations are used: RUL = Right Upper Lobe; LUL = Left Upper Lobe; RML = Right Middle Lobe; RLL = Right Lower Lobe; LLL = Left Lower Lobe.

Palpation plays a relatively minor role in the examination of the normal chest as the structure of interest (the lung) is covered by the ribs and therefore not palpable. Specific situations where it may be helpful include:

Pathologic conditions will alter fremitus. In particular:

• Lung consolidation: Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue, most commonly in the setting of pneumonia. If a large enough segment of parenchyma is involved, it can alter the transmission of air and sound. In the presence of consolidation, fremitus becomes more pronounced.
• Pleural fluid: Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards. Fremitus over an effusion will be decreased.

In general, fremitus is a pretty subtle finding and should not be thought of as the primary means of identifying either consolidation or pleural fluid. It can, however, lend supporting evidence if other findings (see below) suggest the presence of either of these processes.

• Investigating painful areas: If the patient complains of pain at a particular site it is obviously important to carefully palpate around that area. In addition, special situations (e.g. trauma) mandate careful palpation to look for evidence of rib fracture, subcutaneous air (feels like your pushing on Rice Krispies or bubble paper), etc.

Percussion:

This technique makes use of the fact that striking a surface which covers an air-filled structure (e.g. normal lung) will produce a resonant note while repeating the same maneuver over a fluid or tissue filled cavity generates a relatively dull sound. If the normal, air-filled tissue has been displaced by fluid (e.g. pleural effusion) or infiltrated with white cells and bacteria (e.g. pneumonia), percussion will generate a deadened tone. Alternatively, processes that lead to chronic (e.g. emphysema) or acute (e.g. pneumothorax) air trapping in the lung or pleural space, respectively, will produce hyper-resonant (i.e. more drum-like) notes on percussion. Initially, you will find that this skill is a bit awkward to perform. Allow your hand to swing freely at the wrist, hammering your finger onto the target at the bottom of the down stroke. A stiff wrist forces you to push your finger into the target which will not elicit the correct sound. In addition, it takes a while to develop an ear for what is resonant and what is not. A few things to remember:

• If you're percussing with your right hand, stand a bit to the left side of the patient's back.
• Ask the patient to cross their hands in front of their chest, grasping the opposite shoulder with each hand. This will help to pull the scapulae laterally, away from the percussion field.
• Work down the "alley" that exists between the scapula and vertebral column, which should help you avoid percussing over bone.
• Try to focus on striking the distal inter-phalangeal joint (i.e. the last joint) of your left middle finger with the tip of the right middle finger. The impact should be crisp so you may want to cut your nails to keep blood-letting to a minimum!
• The last 2 phalanges of your left middle finger should rest firmly on the patient's back. Try to keep the remainder of your fingers from touching the patient, or rest only the tips on them if this is otherwise too awkward, in order to minimize any dampening of the perucssion notes.

• The goal is to recognize that at some point as you move down towards the base of the lungs, the quality of the sound changes. This normally occurs when you leave the thorax. It is not particularly important to identify the exact location of the diaphragm, though if you are able to note a difference in level between maximum inspiration and expiration, all the better. Ultimately, you will develop a sense of where the normal lung should end by simply looking at the chest. The exact vertebral level at which this occurs is not really relevant.
• "Speed percussion" may help to accentuate the difference between dull and resonant areas. During this technique, the examiner moves their left (i.e. the non-percussing) hand at a constant rate down the patient's back, tapping on it continuously as it progresses towards the bottom of the thorax. This tends to make the point of inflection (i.e. change from resonant to dull) more pronounced.

Practice percussion! Try finding your own stomach bubble, which should be around the left costal margin. Note that due to the location of the heart, tapping over your left chest will produce a different sound then when performed over your right. Percuss your walls (if they're sheet rock) and try to locate the studs. Tap on tupperware filled with various amounts of water. This not only helps you develop a sense of the different tones that may be produced but also allows you to practice the technique.

Auscultation:

Prior to listening over any one area of the chest, remind yourself which lobe of the lung is heard best in that region: lower lobes occupy the bottom 3/4 of the posterior fields; right middle lobe heard in right axilla; lingula in left axilla; upper lobes in the anterior chest and at the top 1/4 of the posterior fields. This can be quite helpful in trying to pin down the location of pathologic processes that may be restricted by anatomic boundaries (e.g. pneumonia). Many disease processes (e.g. pulmonary edema, bronchoconstriction) are diffuse, producing abnormal findings in multiple fields.

• Put on your stethoscope so that the ear pieces are directed away from you. Adjust the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly on the diaphragm, which should produce a noise. If not, twist the head and try again. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin.

• The lingula and right middle lobes can be examined while you are still standing behind the patient.
• Then, move around to the front and listen to the anterior fields in the same fashion. This is generally done while the patient is still sitting upright. Asking female patients to lie down will allow their breasts to fall away laterally, which may make this part of the examination easier.

Thoughts On "Gown Management" & Appropriately/Respectfully Touching Your Patients:

There are several sources of tension relating to the physical exam in general, which are really brought to the fore during the chest examine. These include:

• Area to be examined must be reasonably exposed - yet patient kept as covered as possible
• The need to Palpate sensitive areas in order to perform accurate exam - requires touching people w/whom you've little acquaintance - awkward, particularly if opposite gender
• As newcomers to medicine, you're particularly aware that this aspect of the exam is "unnatural" & hence very sensitive.. which is a good thing!

Keys to performing a sensitive yet thorough exam:

• Explain what you're doing (" why) before doing it → acknowledge "elephant in the room"!
• Expose the minimum amount of skin necessary - this requires "artful" use of gown & drapes (males & females)
• Ask pt to remove bra prior (you can't hear the heart well thru fabric)
• Expose the chest only to the extent needed. For lung exam, you can listen to the anterior fields by exposing only the top part of the breasts (see picture below).
• Enlist patient's assistance, asking them to raise their breast to a position that enhances your ability to listen to the heart
• Don't rush, act in a callous fashion, or cause pain
• It reflects Poor technique
• You'll miss things
• You'll lose points on scored exams (OSCE, CPX, USMLE)!

A few additional things worth noting.

• Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present.
• Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases.
• If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their side. Get help if the patient is unable to move on their own. In cases where even this cannot be accomplished, a minimal examination can be performed by listening laterally/posteriorly as the patient remains supine.

What can you expect to hear? A few basic sounds to listen for:

• A healthy individual breathing through their mouth at normal tidal volumes produces a soft inspiratory sound as air rushes into the lungs, with little noise produced on expiration. These are referred to as vessicular breath sounds.
• Wheezes are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by bronchoconstriction, secretions, and/or associated mucosal edema. As this most commonly occurs in association with diffuse processes that affect all lobes of the lung (e.g. asthma and emphysema) it is frequently audible in all fields. In cases of significant bronchoconstriction, the expiratory phase of respiration (relative to inspiration) becomes noticeably prolonged. Clinicians refer to this as a decrease in the I to E ratio. The greater the obstruction, the longer expiration is relative to inspiration. Occasionally, focal wheezing can occur when airway narrowing if restricted to a single anatomic area, as might occur with an obstructing tumor or bronchoconstriction induced by pneumonia. Wheezing heard only on inspiration is referred to as stridor and is associated with mechanical obstruction at the level of the trachea/upper airway. This may be best appreciated by placing your stethescope directly on top of the trachea.
• Rales (a.k.a. crackles) are scratchy sounds that occur in association with processes that cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to that produced by rubbing strands of hair together close to your ear. Pulmonary edema is probably the most common cause, at least in the older adult population, and results in symmetric findings. This tends to occur first in the most dependent portions of the lower lobes and extend from the bases towards the apices as disease progresses. Pneumonia, on the other hand, can result in discrete areas of alveolar filling, and therefore produce crackles restricted to a specific region of the lung. Very distinct, diffuse, dry-sounding crackles, similar to the noise produced when separating pieces of velcro, are caused by pulmonary fibrosis, a relatively uncommon condition.
• Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea... known as tubular or bronchial breath sounds) to the periphery. In this setting, the consolidated lung acts as a terrific conducting medium, transferring central sounds directly to the edges. It's very similar to the noise produced when breathing through a snorkel. Furthermore, if you direct the patient to say the letter 'eee' it is detected during auscultation over the involved lobe as a nasal-sounding 'aaa'. These 'eee' to 'aaa' changes are referred to as egophony. The first time you detect it, you'll think that the patient is actually saying 'aaa'... have them repeat it several times to assure yourself that they are really following your directions!
• Secretions that form/collect in larger airways, as might occur with bronchitis or other mucous creating process, can produce a gurgling-type noise, similar to the sound produced when you suck the last bits of a milk shake through a straw. These noises are referred to as ronchi.
• Auscultation over a pleural effusion will produce a very muffled sound. If, however, you listen carefully to the region on top of the effusion, you may hear sounds suggestive of consolidation, originating from lung which is compressed by the fluid pushing up from below. Asymmetric effusions are probably easier to detect as they will produce different findings on examination of either side of the chest.
• Auscultation of patients with severe, stable emphysema will produce very little sound. These patients suffer from significant lung destruction and air trapping, resulting in their breathing at small tidal volumes that generate almost no noise. Wheezing occurs when there is a superimposed acute inflammatory process (see above).

Most of the above techniques are complimentary. Dullness detected on percussion, for example, may represent either lung consolidation or a pleural effusion. Auscultation over the same region should help to distinguish between these possibilities, as consolidation generates bronchial breath sounds while an effusion is associated with a relative absence of sound. Similarly, fremitus will be increased over consolidation and decreased over an effusion. As such, it may be necessary to repeat certain aspects of the exam, using one finding to confirm the significance of another. Few findings are pathognomonic. They have their greatest meaning when used together to paint the most informative picture.

(courtesy of Dr. Michael Wilkes, MD-- UC Davis and UCLA Schools of Medicine)

• Bronchial Breath Sounds
• Vesicular Breath Sounds
• Normal Voice E

Oftentimes, a patient will complain of a symptom that is induced by activity or movement. Shortness of breath on exertion, one such example, can be a marker of significant cardiac or pulmonary dysfunction. The initial examination may be relatively unrevealing. In such cases, consider observed ambulation (with the use of a pulse oxymeter, a device that continuously measures heart rate and oxygen saturation, if available) as a dynamic extension of the cardiac and pulmonary examinations. Quantifying a patient's exercise tolerance in terms of distance and/or time walked can provide information critical to the assessment of activity induced symptoms. It may also help unmask illness that would be inapparent unless the patient was asked to perform a task that challenged their impaired reserves. Pay particular attention to the rate at which the patient walks, duration of activity, distance covered, development of dyspnea, changes in heart rate and oxygen saturation, ability to talk during exercise and anything else that the patient identifies as limiting their activity. The objective data derived from this low tech test can aid you in determining disease and symptom severity, helping to create a list of possible diagnoses and assisting you in the rational use of additional tests to further delineate the nature of the problem. This can be particularly helpful in providing objective information when symptoms seem out of proportion to findings. Or when patients report few complaints yet seem to have a cosiderable amount of disease. It will also generate a measurement that you can refer back to during subsequent evaluations in order to determine if there has been any real change in functional status.

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• Examination
• Respiratory Exam

Chest Expansion

How to assess.

• While the patient is in maximal expiration, place your palms over the patient's posterolateral ribs with your thumbs touching in the midline. Ask the patient to take a deep breath in and measure the distance that the thumbs move apart.

Causes of Decreased Chest Expansion

• Airway obstruction - asthma, COPD
• Pulmonary fibrosis
• Musculoskeletal - arthritides, rib fracture
• Pneumothorax
• Atelectasis
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Pulmonary Exam: Percussion & Inspection

The pulmonary exam is one of the most important and often practiced exam by clinicians. While auscultation is most commonly practiced, both percussion and inspection are equally valuable techniques that can diagnose a number of lung abnormalities such as pleural effusions, emphysema, pneumonia and many others.

Introduction to the Pulmonary Exam

Though taught extensively in early medical training the pulmonary exam is often neglected apart from auscultation.

Percussion During the Pulmonary Exam

The "5-7-9 rule".

• The upper border of liver dullness is defined by:
• 5th intercostal space in the midclavicular line
• 7th intercostal space in the midaxillary line
• 9th intercostal space in the scapular line
• Note: 9th intercostal space is located approximately at the inferior border of the scapula
• Hyperresonance that continues below these boundaries can be suggestive of hyperinflation (e.g. emphysema)

Cardiac dullness

Be able to outline the area of "absolute" cardiac dullness— a fist sized area just to the left of the sternum. If it is not there it suggests emphysema.

Traube's space

• Superiorly: Left 6th rib
• Inferiorly: Left costal margin
• Laterally: Anterior axillary line
• Left pleural effusion (however NOT in left lower lobe pneumonia without effusion as it is the effusion that falls into the costophrenic recess that is above the gastric bubble)
• Splenomegally (less reliable compared to Castell’s Sign)
• Very full colon
• Recently eaten (i.e. stomach is full)

Click here to read an article on the Ludwig Traube.

Tidal Percussion

• Percuss down the back until the normal hyperresonance of the lungs becomes dull over the diaphragm. Then simply have the patient breath in and out deeply while continuing to percuss. The sound should wax and wane.
• Pleural effusion
• Hyperinflation such as emphysema from a maximally contracted diaphragm

Major and Minor Fissures of the Lung

• The major fissure can be located by drawing a line from the T2 spinous process to where the 6th rib meets the sternum. The minor fissure can be approximated by drawing a horizontal line from the 4th rib attachment of the sternum to the major fissure.
• Easier method: Simply ask the patient to put their hands over their head. The scapula will rotate externally and its medial border will outline the major fissure (see figure below).

Historical Perspective of the Pulmonary Exam

Percussion was first described by  Dr. Josef Leopold Auenbrugger , an Austrian physician who first observed his father tapping on wine barrels in the cellar of his hotel to determine how much wine was left. The son applied this technique to patients when he became a physician. He is credited with bringing the technique of percussion to the field of medicine. Much of his work occurred around 1760 where he described that by percussing the thorax he could accurately predict the contents of what was inside, as confirmed with post-mortum studies he conducted.

Inspection During the Pulmonary Exam

Signs of copd.

• Inspiratory descent of trachea.
• Use of accessory muscles.
• Pursed lips on exhalation (provides a small amount of PEEP).
• Normal in infancy and increased with aging.
• Prominent angle of Louis (or sternal angle).
• Flaring of the lower costal margins.
• Dahl Sign: Above the knee, patches of hyperpigmentation or bruising caused by constant 'tenting' position of hands or elbows.
• The "subcostal angle" is the angle between the xiphoid process and the right or let costal margin. Normally, during inhalation the chest expands laterally, increasing this angle. When the diaphragms are flattened (as in COPD), inhalation paradoxically causes the angle to decrease.
• Harrison's sulcus: a horizontal grove where the diaphragm attaches to the ribs; associated with chronic asthma, COPD, & Rickets.

REMEMBER : "The side that moves less, is the side of disease!"

Look for signs of volume loss (or gain) on the side that moves less (hollow supraclavicular fossae, intercostal spaces prominent, shoulder droopy, scapula outline more prominent).

Consult the Expert

Dr. Peadar Noone

Dr. Peadar Noone  trained in Galway, Dublin, Boston, the UK and Chapel Hill, where he is now Associate Professor of Medicine and Medical Director of the Lung Transplant Program at the University of North Carolina, Chapel Hill.

Clinical Pearl

Insert (in a normal individual) three fingers vertically in the space under the cricoid cartilage, and above the sternal notch. As the person breathes in, the space may reduce to two fingers at most (i.e. the fingers get "squeezed" as the sternum rises with inspiration). In a patient with severe hyperinflation, the crico-sternal distance is much shorter (because the sternum is elevated), maybe 1-2 fingers at most. With inspiration one's fingers get "squeezed" out as the already "high" sternum rises up to the level of the cricoid, thus, in many cases, obliterating the crico-sternal distance altogether. Some clinicians label this sign "tracheal shortening" but strictly speaking, the actual tracheal length does not get shorter. Classically this is seen with severe emphysema / hyperinflation, or severe air trapping. Often accompanied by reduced hepatic and cardiac dullness on percussion, a widened / flared costal angle, and Hoover's sign.

Other Findings in the Chest

• Pectus Excavatum (Funnel Chest) : depression of sternum; in severe cases may compress heart and great vessels.
• Pectus Carinatum (Pigeon chest) : anterior displacement of sternum, usually benign.
• Flail Chest:  secondary to multiple rib fractures, depression of diaphragm causes injured area to cave inward producing a "paradoxical thoracic movement" in breathing.

Key Learning Points

• Percussion of the lung exam
• Inspection of the lung exam

Related to Pulmonary Exam: Percussion & Inspection

• Precordial Movements
• Cardiac Second Sounds
• Neck Veins & Wave Forms
• BP & Pulsus Paradoxus

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Chest Expansion

Assessment of chest expansion with deep inspiration helps identify the side of abnormality.

Method of Exam

Normally, a 2-5" of chest expansion can be observed. Any lung or pleural disease can give rise to a decrease in overall chest expansion. It is typically low in patients with COPD. These patients have a very high FRC and have limited capability to expand the chest from this position.

• Symmetry of Chest Expansion: Have patient seated erect or stand with arms on the side. Stand behind patient. Grab the lower hemithorax on either side of axilla and gently bring your thumbs to the midline. Have patient slowly take a deep breath and expire. Watch the symmetry of movement of the hemithorax. Simultaneously, feel the chest expansion. Place your hands over upper chest and apex and repeat the process. Next, stand in front and lay your hands over both apices of the lung and anterior chest and assess chest expansion.

Normal Chest expansion is symmetrical. Both sides take off at the same time and to the same extent.

Abnormal Asymmetrical chest expansion is abnormal. The abnormal side expands less and lags behind the normal side. Any form of unilateral lung or pleural disease can cause asymmetry of chest expansion.

• Apply different amounts of pressure and note the effect
• Have patient sit crouched up and note its effect on the symmetry of chest expansion. Chest expansion is asymmetrical in both of these instances. That is why it is important to have patient erect and use equal amount of pressure with hands in assessing chest expansion.

Example: Let us say that the patient has decreased chest expansion on right side. Now that we know the abnormal side is right, with the mediastinum shifted to left, then it would mean a pushing lesion from right. The pushing lesions are pneumothorax, pleural effusion and large mass. The next step will help us narrow down those possibilities.

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Development of new measurement system of thoracic excursion with biofeedback: reliability and validity

Yukiko nishigaki.

1 Department of Rehabilitation, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan

Hiroko Mizuguchi

Eriko takeda, tomokazu koike, takeshi ando.

2 Graduated School of Medicine, Osaka University, 1-7 Yamadaoka, Suita, Osaka 565-0781, Japan

3 Faculty of Science and Engineering, Waseda University, 3-4-1 Ohkubo, Shinjyuku-ku, Tokyo 169-8555, Japan

Kazuya Kawamura

Takuro shimbo.

4 Department of Clinical Research and Informatics, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan

Hidetoshi Ishikawa

Masashi fujimoto, ikuko saotome, kazuko omoda, shohei yamashita, tomoko yamada, toshihito omi, yuya matsushita, manami takeda, sawako sekiguchi, saki tanaka, masakatsu fujie, haruhi inokuchi.

5 Department of Rehabilitation Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan

Junko Fujitani

Respiratory rehabilitation reduces breathlessness from patient with respiratory dysfunction. Chest expansion score, which represents the circumference magnitude of the thoracic cage, is used for a target when treating patients with respiratory disease. However, it is often difficult for patients to understand the changes in the respiratory status and be motivated for therapy continuously. We developed a new measurement system with biofeedback named BREATH which shows chest expansion scores in real time. The purpose of this study was to determine the reliability and validity of the novel system in advance of clinical application.

Three evaluators measured chest expansion in 33 healthy individuals using tape measure, which is used for the measurement traditionally, and BREATH. The wire for BREATH system was threaded over the thoracic continuously and the data was recorded automatically; whereas the tape was winded and measured each maximal expiration and inspiration timing by evaluator. All participants were performed both measurement simultaneously for three times during deep breath. In this study, we studied chest expansion score without using biofeedback data of BREATH to check the validity of the result. To confirm intra- and inter-evaluator reliability, we computed intra-class correlations (ICCs). We used Pearson’s correlation coefficient to evaluate the validity of measurement result by BREATH with reference to the tape measure results.

The average (standard deviation) chest expansion scores for all, men and women by the tape measure were 5.53 (1.88), 6.40 (1.69) and 5.22 (1.39) cm, respectively, and those by BREATH were 3.89 (2.04), 4.36 (1.83) and 2.89 (1.66) cm, respectively. ICC within and among the three evaluators for BREATH and the tape measure were 0.90-0.94 and 0.85-0.94 and 0.85 and 0.82, respectively. The correlation coefficient between the two methods was 0.76-0.87.

The novel measurement system, BREATH, has high intra- and inter-evaluator reliabilities and validity; therefore it can lead us more effective respiratory exercise. Using its biofeedback data, this system may help patients with respiratory disease to do exercises more efficiently and clinicians to assess the respiratory exercise more accurately.

Respiratory rehabilitation reduces breathlessness from patients with respiratory dysfunction; i.e. chronic obstructive pulmonary disease (COPD) and postoperative respiratory dysfunction. In COPD patients, flat diaphragm and overexpanded lungs reduce the expansion efficiency of lower chest. Breathing muscle stretching exercise improves chest expansion ability and pulmonary function [ 1 ].

We measure chest expansion to assess the effect of treatment for patient with respiratory disease. There are some devices to measure chest expansion; i.e. spirometry or respiratory inductive plethysmograph, which can measure both chest and abdominal expansion [ 2 ]. In Japanese guidelines for pulmonary rehabilitation, the chest expansion scores, representing the thoracic cage movement while breathing, are described as a standardized evaluation for the exercise of respiratory ailments [ 3 ]. The score represents the circumference magnitude of the thoracic cage from maximum inhalation to maximum exhalation, which is measured by tape traditionally [ 3 - 5 ]. It is known that the chest expansion score of patient with COPD at the level of 10 th rib height significantly improved after chest mobilization [ 6 ].

Biofeedback is known to be useful for re-education of the dysfunctional muscles. Past study shows that it is effective to perform respiratory rehabilitation with biofeedback to strengthen the muscles which control breathing [ 7 - 9 ]. Other studies suggest that respiratory rehabilitation with biofeedback helped ventilator weaning for patients with various disease [ 10 - 13 ].

Tape measurement of the chest expansion is generally performed during exercise in research or clinic, but it shows only temporary numerical value, which is difficult for subject or patient to interpret. Recently, new techniques for measuring the motion of the thoracic cage with biofeedback data have been developed [ 14 , 15 ]; however, it is often difficult for subjects or patients to understand changes in the respiratory status and be motivated for therapy continuously by the data. Thus, to show clear-cut biofeedback data will become feasible for them if the differences in thoracic expansion is measured and visualized in real time with uncomplicated technique.

We developed a new measurement system with biofeedback, which displays chest expansion scores simply in real time [ 16 ]. The purpose of the present study was to determine the reliability and validity of the novel system in advance of clinical application.

Chest expansion measurement device (BREATH)

Prior to the research, we had developed a novel system to measure the thoracic circumference, named BREATH [ 17 ]. Figure  1 shows a schema of our novel system and a measurement scenario. To measure the magnitude of chest circumference, we use a wire-type linear encoder to wrap around the thoracic cage (Figure  2 ). The wire changes its length automatically to fit with the thoracic cage. The encoder detects the displacement length of wire over time, and the counter board transverses wire length to numerical data. The data is sent to a connected personal computer (PC), whose monitor displays chest circumferences and a trend of chest expansion scores over about 10 past breaths, which is the expanded length from minimum circumference (Figure  3 ).

Schema of our novel system and a measurement scenario. To measure the magnitude of chest circumference, we use a wire-type linear encoder to wrap around the thoracic cage. The wire changes its length automatically to fit with the thoracic cage. The encoder detects the displacement length of wire over time, and the counter board transverses wire length to numerical data. The data is sent to a connected personal computer.

Scenary of measurement. Participant was asked to wear T-shirt and sit comfortably. The wire was threaded over the thoracic continuously, whereas the tape was winded and measured each maximal expiration and inspiration timing. We placed the wire and the tape over the 10 th rib edge to the sternum and wrapped them around the trunk horizontally.

Display of the PC. The personal computer monitor displays ( a ) trend graphs of chest expansion score over about 10 past breaths, and the circumference ( b ) in real time (cm), ( c ) at the maximal (cm), and ( d ) at the minimal (cm).

Ethical considerations

The Institutional Review Board of our center had approved the study protocol. Each participant gave written informed consent prior to the study.

Healthy individuals from 20 to 60 years old with no history of lung or locomotor diseases were recruited for the study.

Measurement procedure

We measured the thoracic circumference by tape and BREATH. Participant was asked to wear a T-shirt and to seat comfortably. We chose tape measure as a comparison because it has been widely used in a clinical situation and can conduct simultaneously with BREARH measurement to check the validity. The wire was threaded over the thoracic continuously, whereas the tape was winded and measured each maximal expiration and inspiration timing. We placed the wire and the tape over the 10 th rib edge to the sternum and wrapped them around the trunk horizontally. The height was chosen in regards of the past study result which showed the measurement result from the height had higher clinical value [ 6 ].

We randomized the order of two measurement methods; 16 participants underwent BREATH first, and the other 17 did the tape measure first. Before starting the measurement, all participants were instructed to “breathe as deeply as possible” and practiced to breath for several times. To check the validity of result from BREATH, they were blinded to the results of the test. The interval between each evaluation was at least 5 minutes to minimize participant’s fatigue among the study.

Three evaluators repeated measurements three times using both tape measurement and BREATH to all participants. Evaluator A had 6 years of experience as a physical therapist, and evaluators B and C had 2 and 10 years of experience, as occupational therapists, respectively. Each evaluator calculated and recorded chest expansion scores by tape measure data and by BREATH data. The evaluators were blinded to one another’s results.

Statistical analysis

We used two-sample t test to compare variables of men with those of women. To confirm the intra-evaluator reliability of the measurement result by each evaluator using tape measure and BREATH, the intra-class correlation coefficient (ICC) was computed. Similarly, the inter-evaluator reliability among the measurement results by all three evaluators was evaluated using ICC, computed from the average data of each evaluator. ICCs of >0.9, 0.8-0.9, 0.7-0.8, 0.6-0.7 and <0.6 were considered excellent, good, acceptable, marginal and unreliable, respectively [ 18 ].

The validity of measurement result by BREATH was evaluated using Pearson’s correlation coefficient with reference to the tape measure results. To visualize the validity, we also constructed a Bland-Altman plot in which the y axis showed the difference between both measurements and the x axis showed the average of both measurements [ 19 ]. For all test, a p value < 0.05 was considered significant. All data were analyzed using IBM SPSS Statistics ver.19.

Thirty-three healthy participants (13 men and 20 women, age 29.2 years old, body height 166.6 cm, body weight 59.6 kg, body mass index (BMI) 21.4 kg/m 2 in average) enrolled this study (Table  1 ). Body height, body weight, and BMI were significantly higher for men than for women.

Characteristics of the participants

Average ± standard deviation. BMI , body mass index. *, Test of significance between men and women: two sample t-test.

Chest expansion scores

All participant completed trials and all evaluator finished measurement without any deficit. The average (standard deviation: SD) chest expansion scores for all, men and women by the tape measure were 5.53 (1.88), 6.40 (1.69) and 5.22 (1.39) cm, respectively, and those by BREATH were 3.89 (2.04), 4.36 (1.83) and 2.89 (1.66) cm, respectively (Table  2 ). Chest expansion score was significantly higher for men than for women in both measurements.

Average chest expansion scores from three evaluators

Average ± standard deviation. *, Test of significance between men and women: two sample t-test.

Intra- evaluator reliability

All evaluators showed similar results for either method (Table  3 ). The ICCs for the three evaluators ranged from 0.90 to 0.94 for BREATH and from 0.85 to 0.94 for the tape measure (Table  4 ). There were no apparent correlations between years of experience and the reliabilities for either method.

Average chest expansion scores by each evaluator

Average ± standard deviation.

Intra-evaluator reliability of BREATH and tape measure

Inter-class correlation (95% confidence interval).

Inter- evaluator reliability

The result from evaluator B, whose clinical experience was shorter than other two, did not differ from results from others. The ICCs among the three evaluators were 0.85 (95% confidence interval: 0.70-0.90) for BREATH and 0.82 (95% confidence interval: 0.73-0.92) for the tape measure, indicating that both measurement techniques were reliable.

Validity of BREATH compared with the tape measure

Pearson’s correlation coefficients for the measurement methods were 0.76-0.87 for the three evaluators, which confirmed high validity of BREATH compared with the rape measure (p < 0.001, Figure ​ Figure4). 4 ). Figure ​ Figure5 5 shows that the average (SD) difference between both measurement was -1.65 (1.21) cm and that the difference of the chest expansion scores was not significant (correlation coefficient 0.139, p = 0.169). There was no bias to make gradient in the plot.

Scatterplots of chest expansion scores by BREATH and tape measure. Each dot shows data of each participant by each evaluator. Pearson’s correlation coefficients for the measurement methods were 0.76-0.87 for the three evaluators, which confirmed high validity of BREATH compared with the tape measure (p < 0.001).

Bland-altman plot for rape measurement and BREATH. Each dot shows data of each participant by each evaluator. The total the average (SD) of differences between both measurement was -1.65 (1.21) cm. The averages and the difference of the chest expansion scores were not significant (correlation coefficient 0.139, p = 0.169). There was no bias to make gradient.

We developed the novel BREATH system that displays chest expansion scores in real time [ 17 ], and, thus, renders feasible training by visual biofeedback. Moreover, tasks such as calibration, measurement start and stop, and printing results can be easily performed with only three mouse clicks, which allow us to use it in a clinical setting. We got high reproducibility and reliability of BREATH and high validity compared with the conventional tape measure method. Though, there are some other devices to measure respiratory function [ 2 ], they have no visible biofeedback information. With its high validity as a measurement system and with its biofeedback data, BREATH would also help to increase efficacy of respiratory rehabilitation.

Intra- evaluator reliability for BREATH and tape measure was high, with ICC values of ≥0.8. The reproducibility and reliability of automated measurements taken by BREATH were higher than those obtained manually by the tape measure. We presume the high reliability of BREATH is due to the location invariance of the wire compared to the tape. As the tape was removed between each measurement, the position might be changed; whereas wire for BREATH was remained during all measurement. Therefore, we believe that BREARH can measure chest expansion score accurately regardless of the evaluator’s work experience.

We suggest that the chest circumference measured by BREATH describes more precise data than tape measurement. Although the values obtained by BREATH and the tape measure closely correlated, those by BREATH were lower with an average of -1.65 cm. We hypothesize the wire used in BREATH system fits more tightly to participant’s body than the tape used in the conventional method; therefore, it served smaller numerical values. The difference should be taken into account when we compare the results from both methods.

We think we should use chest expansion score from men and women data separately. In both measurements, men showed higher score than women. We presume that men have lager rib cage and larger magnitude than women.

We confirmed that our measurement system was feasible and, thus, chest expansion training would be more effective by using the system with biofeedback. We need further study using biofeedback system because we did not give biofeedback data for the participants in this study. The present results suggest a promising future for chest measurement system with biofeedback in respiratory rehabilitation. It would be important to compare BREATH and other measurement for respiratory function. Other limitation of the present study is that we included only healthy adults as participants and excluded elderly persons and patients with thoracic cage abnormalities. We should confirm the accuracy of measurement for such individuals before we use BREATH for routine clinical applications.

The novel biofeedback technology, BREATH, is reliable and valid and can lead us more effective respiratory exercise. This system may help patients with respiratory disease to do exercises more efficiently and clinicians to assess the respiratory exercise more accurately.

Competing interests

All authors declare that they have no competing interests.

Authors’ contributions

YN participated in the design of the study, recruited the participants, managed acquisition of data, and drafted the manuscript. HM, ET and TK assisted in the design of the study, recruited the participants, managed acquisition of data. TA, KK and MF participated in the development of device. TS participated in data analysis and drafted the manuscript. HI, MF, IS, RO, KO, SY, TO, YM, MK, SK, ST and MF participated in managed acquisition of data. JF and HI participated in the design of the study, and drafted the manuscript. All authors read and approved the final manuscript.

Acknowledgements

We sincerely thank all participants who took part in this study. And we thank the technical assistance of Faculty of Science and Engineering, Waseda University.

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