Hoovers Sign (Pulmonary): Difference between revisions

(Created page with "== Background == Hoover's sign (pulmonary) is 1 of 2 signs named for Charles Franklin Hoover, the other being Hoover's sign (paresis)<ref>Hoover CF. THE DIAGNOSTIC SIGNIFICANCE OF INSPIRATORY MOVEMENTS OF THE COSTAL MARGINS. The American Journal of the Medical Sciences [https://www.proquest.com/openview/07a0fac1a18a285830219238f7c94d43/1?pq-origsite=gscholar&cbl=41361 (1827-1924). 1920 May 1;159(5):633.]</ref>. It refers to paradoxical inward movement of...")
 
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== Background ==
== Background ==
Hoover's sign (pulmonary) is 1 of 2 signs named for Charles Franklin Hoover, the other being [[Hoover Test|Hoover's sign (paresis)]]<ref>Hoover CF. THE DIAGNOSTIC SIGNIFICANCE OF INSPIRATORY MOVEMENTS OF THE COSTAL MARGINS. The American Journal of the Medical Sciences [https://www.proquest.com/openview/07a0fac1a18a285830219238f7c94d43/1?pq-origsite=gscholar&cbl=41361 (1827-1924). 1920 May 1;159(5):633.]</ref>. It refers to paradoxical inward movement of the lower lateral rib cage (costal margin) during inspiration, instead of outward as is normal<ref name=":0">McKenzie DK, Butler JE, Gandevia SC. Respiratory muscle function and activation in chronic obstructive pulmonary disease. Journal of applied physiology. [https://journals.physiology.org/doi/full/10.1152/japplphysiol.00163.2009 2009 Aug;107(2):621-9.]</ref>. [[COPD (Chronic Obstructive Pulmonary Disease)|COPD]], and more specifically [[emphysema]], often lead to hyperinflation of the lungs due to air trapping<ref name=":0" />. Lung hyperinflation causes flattening of the [[Diaphragm Anatomy and Differential Diagnosis|diaphragm]], which contracts downwards on inspiration, paradoxically pulling the inferior ribs inwards instead of out<ref>Gilmartin JJ, Gibson GJ. Abnormalities of chest wall motion in patients with chronic airflow obstruction. Thorax. [https://thorax.bmj.com/content/39/4/264.abstract 1984 Apr 1;39(4):264-71.]</ref><ref>Hoover CF. THE DIAGNOSTIC SIGNIFICANCE OF INSPIRATORY MOVEMENTS OF THE COSTAL MARGINS. The American Journal of the Medical Sciences [https://www.proquest.com/openview/07a0fac1a18a285830219238f7c94d43/1?pq-origsite=gscholar&cbl=41361 (1827-1924). 1920 May 1;159(5):633.]</ref>.  
Hoover's sign (pulmonary) is 1 of 2 signs named for Charles Franklin Hoover, the other being [[Hoover Test|Hoover's sign (paresis)]]<ref>Hoover CF. THE DIAGNOSTIC SIGNIFICANCE OF INSPIRATORY MOVEMENTS OF THE COSTAL MARGINS. The American Journal of the Medical Sciences [https://www.proquest.com/openview/07a0fac1a18a285830219238f7c94d43/1?pq-origsite=gscholar&cbl=41361 (1827-1924). 1920 May 1;159(5):633.]</ref>. It refers to paradoxical inward movement of the lower lateral rib cage (costal margin) during inspiration, instead of outward as is normal<ref name=":0">McKenzie DK, Butler JE, Gandevia SC. Respiratory muscle function and activation in chronic obstructive pulmonary disease. Journal of applied physiology. [https://journals.physiology.org/doi/full/10.1152/japplphysiol.00163.2009 2009 Aug;107(2):621-9.]</ref>. [[COPD (Chronic Obstructive Pulmonary Disease)|COPD]], and more specifically [[emphysema]], often lead to hyperinflation of the lungs due to air trapping<ref name=":0" />. Lung hyperinflation causes flattening of the [[Diaphragm Anatomy and Differential Diagnosis|diaphragm]], which contracts downwards on inspiration, paradoxically pulling the inferior ribs inwards instead of out<ref>Gilmartin JJ, Gibson GJ. Abnormalities of chest wall motion in patients with chronic airflow obstruction. Thorax. [https://thorax.bmj.com/content/39/4/264.abstract 1984 Apr 1;39(4):264-71.]</ref><ref>Hoover CF. THE DIAGNOSTIC SIGNIFICANCE OF INSPIRATORY MOVEMENTS OF THE COSTAL MARGINS. The American Journal of the Medical Sciences [https://www.proquest.com/openview/07a0fac1a18a285830219238f7c94d43/1?pq-origsite=gscholar&cbl=41361 (1827-1924). 1920 May 1;159(5):633.]</ref>.  
== Risk Factors ==
Previous studies found that the presence of Hoover’s sign is associated with:
* older age
* higher body mass index (BMI), and
* more severe airflow obstruction


== Clinical Relevance ==
== Clinical Relevance ==
Some healthy individuals may also exhibit a slight indrawing of the lower lateral ribcage on maximal inspiration, however, patients with COPD exhibit a gross exaggeration of this movement<ref name=":1">Sarkar M, Bhardwaz R, Madabhavi I, Modi M. Physical signs in patients with chronic obstructive pulmonary disease. Lung India. 2019 Jan-Feb;36(1):38-47. doi: 10.4103/lungindia.lungindia_145_18. PMID: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330798/#ref32 30604704; PMCID: PMC6330798.]</ref>. Hoover's sign may occur at end inspiration or throughout<ref>Maitre B, Similowski T, Derenne JP. Physical examination of the adult patient with respiratory diseases: inspection and palpation. European Respiratory Journal. [https://erj.ersjournals.com/content/8/9/1584.short 1995 Sep 1;8(9):1584-93.]</ref>. It occurs both at rest and during exercise<ref name=":1" />.


Hoover's sign is best appreciated by placing the first and second fingers on the costal margin near the anterior axillary line.[35] Occasionally, a biphasic Hoover's sign is seen when the costal margin moves out initially, then in, and then moves out again with the onset of expiration.[35] Paradoxical lateral rib cage movement is seen in both upper and lower rib cages, but it is greater at the lower rib cage level. COPD patients may also show inspiratory indrawing of the lower sternum known as anteroposterior ribcage paradox. It occurs typically in early inspiration and usually occurs along with lateral paradox.
=== Observation ===
Some healthy individuals may also exhibit a slight indrawing of the lower lateral ribcage on maximal inspiration, however, patients with COPD exhibit a gross exaggeration of this movement<ref name=":1">Sarkar M, Bhardwaz R, Madabhavi I, Modi M. Physical signs in patients with chronic obstructive pulmonary disease. Lung India. 2019 Jan-Feb;36(1):38-47. doi: 10.4103/lungindia.lungindia_145_18. PMID: [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330798/#ref32 30604704; PMCID: PMC6330798.]</ref>. Hoover's sign may occur at end inspiration or throughout<ref>Maitre B, Similowski T, Derenne JP. Physical examination of the adult patient with respiratory diseases: inspection and palpation. European Respiratory Journal. [https://erj.ersjournals.com/content/8/9/1584.short 1995 Sep 1;8(9):1584-93.]</ref>. It occurs both at rest and during exercise<ref name=":1" />. Paradoxical lateral rib cage movement is seen both at the upper and lower rib cages, but is more prominent at the lower rib cage level<ref name=":1" />. 
 
=== Technique ===
Hoover's sign is best noted by placing the first and second fingers on the costal margin near the anterior axillary line<ref name=":2">Campbell EJ. Physical signs of diffuse airways obstruction and lung distension. Thorax. 1969 Jan [https://thorax.bmj.com/content/24/1/1.short 1;24(1):1-3.]</ref>. The therapist should feel an inward draw throughout inspiration<ref name=":2" />. Occasionally, a biphasic Hoover's sign is witnessed when the costal margin moves out initially, then back in, and then moves out again with the beginning of expiration<ref name=":2" />.  


=== Diagnostic accuracy ===
The sign is reported to have a sensitivity of 58% and specificity of 86% for detecting obstructive airway disease3 which may make it a useful sign in the diagnosis of COPD. Previous studies have shown a frequency of Hoover’s sign of 36%, 43%, and 76% in Global initiative for chronic Obstructive Lung Disease (GOLD)4 moderate, severe, and very severe stages of COPD, respectively.


The sign is reported to have a sensitivity of 58% and specificity of 86% for detecting obstructive airway disease3 which may make it a useful sign in the diagnosis of COPD. Previous studies have shown a frequency of Hoover’s sign of 36%, 43%, and 76% in Global initiative for chronic Obstructive Lung Disease (GOLD)4 moderate, severe, and very severe stages of COPD, respectively.5
=== Clinical Implications ===
Hoover's sign is associated with:


In describing a phenotype of patients with Hoover’s sign, previous studies found that the presence of Hoover’s sign is associated with older age, higher body mass index (BMI), and more severe airflow obstruction. Studies have not shown that Hoover’s sign is associated with a higher degree of hyperinflation.6,7 The presence of Hoover’s sign in individuals with COPD may have important clinical implications because it is associated with higher exacerbation frequency,8 higher dyspnea symptoms with exercise,9 and an increased frequency of hospitalizations and emergency department visits.8
* higher exacerbation frequency
* higher dyspnea symptoms with exercise
* an increased frequency of hospitalizations and emergency department visits
<references />
[[Category:Respiratory System - Assessment and Examination]]
[[Category:Respiratory]]
[[Category:Respiratory Disease]]
[[Category:Cardiopulmonary]]
[[Category:Special Tests]]

Revision as of 16:26, 19 August 2023

Background[edit | edit source]

Hoover's sign (pulmonary) is 1 of 2 signs named for Charles Franklin Hoover, the other being Hoover's sign (paresis)[1]. It refers to paradoxical inward movement of the lower lateral rib cage (costal margin) during inspiration, instead of outward as is normal[2]. COPD, and more specifically emphysema, often lead to hyperinflation of the lungs due to air trapping[2]. Lung hyperinflation causes flattening of the diaphragm, which contracts downwards on inspiration, paradoxically pulling the inferior ribs inwards instead of out[3][4].

Risk Factors[edit | edit source]

Previous studies found that the presence of Hoover’s sign is associated with:

  • older age
  • higher body mass index (BMI), and
  • more severe airflow obstruction

Clinical Relevance[edit | edit source]

Observation[edit | edit source]

Some healthy individuals may also exhibit a slight indrawing of the lower lateral ribcage on maximal inspiration, however, patients with COPD exhibit a gross exaggeration of this movement[5]. Hoover's sign may occur at end inspiration or throughout[6]. It occurs both at rest and during exercise[5]. Paradoxical lateral rib cage movement is seen both at the upper and lower rib cages, but is more prominent at the lower rib cage level[5].

Technique[edit | edit source]

Hoover's sign is best noted by placing the first and second fingers on the costal margin near the anterior axillary line[7]. The therapist should feel an inward draw throughout inspiration[7]. Occasionally, a biphasic Hoover's sign is witnessed when the costal margin moves out initially, then back in, and then moves out again with the beginning of expiration[7].

Diagnostic accuracy[edit | edit source]

The sign is reported to have a sensitivity of 58% and specificity of 86% for detecting obstructive airway disease3 which may make it a useful sign in the diagnosis of COPD. Previous studies have shown a frequency of Hoover’s sign of 36%, 43%, and 76% in Global initiative for chronic Obstructive Lung Disease (GOLD)4 moderate, severe, and very severe stages of COPD, respectively.

Clinical Implications[edit | edit source]

Hoover's sign is associated with:

  • higher exacerbation frequency
  • higher dyspnea symptoms with exercise
  • an increased frequency of hospitalizations and emergency department visits
  1. ↑ Hoover CF. THE DIAGNOSTIC SIGNIFICANCE OF INSPIRATORY MOVEMENTS OF THE COSTAL MARGINS. The American Journal of the Medical Sciences (1827-1924). 1920 May 1;159(5):633.
  2. ↑ 2.0 2.1 McKenzie DK, Butler JE, Gandevia SC. Respiratory muscle function and activation in chronic obstructive pulmonary disease. Journal of applied physiology. 2009 Aug;107(2):621-9.
  3. ↑ Gilmartin JJ, Gibson GJ. Abnormalities of chest wall motion in patients with chronic airflow obstruction. Thorax. 1984 Apr 1;39(4):264-71.
  4. ↑ Hoover CF. THE DIAGNOSTIC SIGNIFICANCE OF INSPIRATORY MOVEMENTS OF THE COSTAL MARGINS. The American Journal of the Medical Sciences (1827-1924). 1920 May 1;159(5):633.
  5. ↑ 5.0 5.1 5.2 Sarkar M, Bhardwaz R, Madabhavi I, Modi M. Physical signs in patients with chronic obstructive pulmonary disease. Lung India. 2019 Jan-Feb;36(1):38-47. doi: 10.4103/lungindia.lungindia_145_18. PMID: 30604704; PMCID: PMC6330798.
  6. ↑ Maitre B, Similowski T, Derenne JP. Physical examination of the adult patient with respiratory diseases: inspection and palpation. European Respiratory Journal. 1995 Sep 1;8(9):1584-93.
  7. ↑ 7.0 7.1 7.2 Campbell EJ. Physical signs of diffuse airways obstruction and lung distension. Thorax. 1969 Jan 1;24(1):1-3.
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