Hoovers Sign (Pulmonary)
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
- ↑ 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.
- ↑ 2.0 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.
- ↑ Gilmartin JJ, Gibson GJ. Abnormalities of chest wall motion in patients with chronic airflow obstruction. Thorax. 1984 Apr 1;39(4):264-71.
- ↑ 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.
- ↑ 5.0 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.
- ↑ 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.
- ↑ 7.0 7.1 7.2 Campbell EJ. Physical signs of diffuse airways obstruction and lung distension. Thorax. 1969 Jan 1;24(1):1-3.
