Hoovers Sign (Pulmonary)

Original Editor - Jonathan Wong Top Contributors - Jonathan Wong, Kim Jackson, Vidya Acharya and Carina Therese Magtibay

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].

Frequency[edit | edit source]

Hoover's sign is a frequent finding in COPD. One study found Hoover's sign in up to 77% of patients with airway obstruction[5]. Another study found 45% of patients with COPD exhibited Hoover's sign, with it being undetectable in mild patients, present in 36% of moderate patients, 43% of severe and 76% of very severe patients with COPD[6].

The sign can also be present in patients with congestive heart failure, asthma, severe pneumonia (especially in children), bronchiolitis, as well as seen unilaterally in diaphragmatic paralysis, pleural effusion and pneumothorax[7].

Risk Factors[edit | edit source]

Previous studies found that the presence of Hoover’s sign is associated with[6][8][9]:

Clinical Application[edit | edit source]

Observation[edit | edit source]

Normally, the costal margin exhibits little motion during quiet breathing, but if it does, it moves outwards and upwards[10]. However, in patients with COPD, there is a greater tendency for it to move paradoxically i.e. inwards. 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[11]. Hoover's sign may occur at end inspiration or throughout[12]. It occurs both at rest and during exercise[11]. 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[11]. Of the various chest wall motion abnormalities described in patients with COPD, Hoover's sign is the most common and the most easily recognizable clinically[3]. Some, but not all patients with COPD show Hoover's sign, though the reason for this remains unclear[13].

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[10]. The therapist should feel an inward draw throughout inspiration[10]. 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[10].

[14]

Diagnostic accuracy[edit | edit source]

Hoover's sign demonstrates high inter-rater reliability, with one study yielding an observer agreement of 0.74[15].

Reported sensitivity of 58% and specificity of 86% for detecting obstructive airway disease which may make it useful for diagnosing COPD[15].

Clinical Implications[edit | edit source]

Hoover's sign is associated with:

  • higher exacerbation frequency[16]
  • higher dyspnea symptoms at rest, during normal activities, and after exercise, independent of patient's FEV1 and the body mass index[13]
  • an increased frequency of hospitalizations and emergency department visits, independent of patient's FEV1 and the body mass index[16][13]

Hence, Hoover's sign allows for identification of a group of patients with COPD who have more severe dyspnea symptoms and require more healthcare resources[13].

One study found a correlation between Hoover's sign and an increased Maximal Expiratory Pressure/Maximal Inspiratory Pressure ratio in patients with COPD with stage 3 and 4 GOLD criteria disease - providing a simple alternative to assess for diaphragm dysfunction in this population[17].

Diaphragm Palsy[18][edit | edit source]

One study looked at the use of Hoover's sign as a tool for identifying diaphragm palsy (DP). Hoover's sign had high specificity (84.6%), but low sensitivity (65.6%) for the diagnosis of DP. Hoover's sign can diagnose the side of DP in patients with unilateral diaphragmatic paralysis by observing outward movement of the lower intercostal muscles on the affected side, while there is indrawing of lower intercostal muscles on the unaffected side. Patients with bilateral diaphragmatic palsy exhibit paradoxical respiration. Furthermore, in patients with diaphragm paresis, a respiratory pattern may be normal during calm breathing, while exertion (crying, pain, activity, and other associated respiratory problems) may unmask paradoxical thoracic movement. Hoover's sign is thus a valuable clinical sign for identifying DP.

References[edit | edit source]

  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. ↑ 3.0 3.1 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. ↑ Gilmartin JJ, Gibson GJ. Mechanisms of paradoxical rib cage motion in patients with chronic obstructive pulmonary disease. American Review of Respiratory Disease. 1986 Oct;134(4):683-7.
  6. ↑ 6.0 6.1 Garcia-Pachon E, Padilla-Navas I. Frequency of Hoover's sign in stable patients with chronic obstructive pulmonary disease. International journal of clinical practice (Esher). 2006;60(5):514–7.
  7. ↑ Johnston CR 3rd, Krishnaswamy N, Krishnaswamy G. The Hoover's Sign of Pulmonary Disease: Molecular Basis and Clinical Relevance. Clin Mol Allergy. 2008 Sep 5;6:8. doi: 10.1186/1476-7961-6-8. PMID: 18775073; PMCID: PMC2546439.
  8. ↑ Bruyneel M, Jacob V, Sanida C, Ameye L, Sergysels R, Ninane V. Hoover's sign is a predictor of airflow obstruction severity and is not related to hyperinflation in chronic obstructive pulmonary disease. European journal of internal medicine. 2011 Dec 1;22(6):e115-8.
  9. ↑ Binazzi B, Bianchi R, Romagnoli I, Lanini B, Stendardi L, Gigliotti F, Scano G. Chest wall kinematics and Hoover's sign. Respiratory physiology & neurobiology. 2008 Feb 29;160(3):325-33.
  10. ↑ 10.0 10.1 10.2 10.3 Campbell EJ. Physical signs of diffuse airways obstruction and lung distension. Thorax. 1969 Jan 1;24(1):1-3.
  11. ↑ 11.0 11.1 11.2 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.
  12. ↑ 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.
  13. ↑ 13.0 13.1 13.2 13.3 Garcia-Pachon E, Padilla-Navas I. Clinical implications of Hoover's sign in chronic obstructive pulmonary disease. European Journal of Internal Medicine. 2004 Feb 1;15(1):50-3.
  14. ↑ Medicine Textbooks Simplified. Hoover's Sign of COPD. Available from: http://www.youtube.com/watch?v=_36qvr_K-y8
  15. ↑ 15.0 15.1 Garcia-Pachon E. Paradoxical Movement of the Lateral Rib Margin (Hoover Sign) for Detecting Obstructive Airway Disease. Chest. 2002;122(2):651–5.
  16. ↑ 16.0 16.1 Aliverti A, Quaranta M, Chakrabarti B, Albuquerque AL, Calverley PM. Paradoxical movement of the lower ribcage at rest and during exercise in COPD patients. European respiratory journal. 2009 Jan 1;33(1):49-60.
  17. ↑ Maloney TG, Anderson ZS, Vincent AB, Magiera AL, Slocum PC. Association of Hoover's Sign with Maximal Expiratory-to-Inspiratory Pressure Ratio in Patients with COPD. Chronic Obstr Pulm Dis. 2023 Jan 25;10(1):1-6. doi: 10.15326/jcopdf.2022.0341. PMID: 36394525; PMCID: PMC9995237.
  18. ↑ Parmar D, Panchal J, Parmar N, Garg P, Mishra A, Surti J, Patel K. Early diagnosis of diaphragm palsy after pediatric cardiac surgery and outcome after diaphragm plication - A single-center experience. Ann Pediatr Cardiol. 2021 Apr-Jun;14(2):178-186. doi: 10.4103/apc.APC_171_19. Epub 2021 Feb 16. PMID: 34103857; PMCID: PMC8174623.
Retrieved from "https://www.physio-pedia.com/index.php?title=Hoovers_Sign_(Pulmonary)&oldid=341730"