**Observation of respiratory symptoms and chest wall mobility**

General screening of respiratory problems can be assessed from the signs or symptoms of respiratory depression such as tachypnea, use of accessory muscles, abnormal breathing pattern, cyanosis, nasal flaring etc. which refer to hard work in breathing (Irwin & Tecklin, 1995).

Normal shape of the chest can be observed by the diameter of anterior and lateral views, where the ratio of diameter between anterior and lateral measurement should be more than 1.0. However, in the case of COPD, this ratio may be less than 1.0 and the shape is called barrel chest (Jardins & Tietsort, 1997). In COPD, the barrel chest is shown simply from intrapulmonary air trapping or emphysema, which depresses the diaphragm downward and intercostal outward in a shortened position. The shortening of muscle length before inspiration causes insufficient contractile force. Shortness of breath and decreased chest expansion can be observed clinically. Finally, aggressive dyspnea and low ventilation induce physical deconditioning via low exercise performance (Celli, 2000).

Dyspnea intensity is quantified most easily by using the modified Brog (0-10) category ratio scale (Borg, 1982). This tool evaluates also within other protocols such as the Medical Research Council (MRC) scale, New York Heart Association (NYHA) scale, London Chest Activity of Daily Living scale and Pulmonary Functional Status and Dyspnea Questionnaire (Meek, 2004). Many reports and studies used a Brog scale for identification the dyspnea symptoms and interprets the effectiveness of program.

#### **Palpation on chest expansion**

Evaluation of chest expansion is very comfortable for the clinician. Various protocols such as the three levels of upper, middle, and lower lobes (Cherniack, 1983) can be performed manually. Circumferential change from full expiration to maximal inspiration at supine position can be applied with a tape at the axilla (upper lung) and xiphoid (lower lung) levels, as suggested by previous reports (Carlson, 1973), and this protocol has shown good reliability (Lapier et al., 2000). For example, 3 ¼ inches ± ¼ inch could be increased at the axillary level of 20-to 30-year old women (Carlson, 1973). Another level that can be measured to present chest expansion by tape is the 4th intercostal rib space (Fisher et al., 1990). Furthermore, the chest caliper is a new tool that can be used to evaluate chest expansion. Previous evidence has shown that application of the chest caliper enables measurement of thoracic diameters at rest and during activity, but it could not refer to the normal data for chest expansion (Davis & Troup, 1966).

Original palpable examination is of chest expansion in the respiratory system, and less expansion may reflect intrapulmonary lesion such as secretion obstruction or atelectasis. Sometimes, incomplete recoiling from expiration results in many issues such as mass, emphysema, or air trapping. Although, no scientific data have shown normal length of complete recoiling in chest expiration, clinical experience can adjust muscle tightness or shortening around the chest wall. Palpation of the chest wall for flexibility can be evaluated in sitting, side lying, supine, or prone position. Conventional chest movement can be performed with manual evaluation.

#### **Upper costal chest expansion** (Figure 6)

404 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

General screening of respiratory problems can be assessed from the signs or symptoms of respiratory depression such as tachypnea, use of accessory muscles, abnormal breathing pattern,

Normal shape of the chest can be observed by the diameter of anterior and lateral views, where the ratio of diameter between anterior and lateral measurement should be more than 1.0. However, in the case of COPD, this ratio may be less than 1.0 and the shape is called barrel chest (Jardins & Tietsort, 1997). In COPD, the barrel chest is shown simply from intrapulmonary air trapping or emphysema, which depresses the diaphragm downward and intercostal outward in a shortened position. The shortening of muscle length before inspiration causes insufficient contractile force. Shortness of breath and decreased chest expansion can be observed clinically. Finally, aggressive dyspnea and low ventilation

Dyspnea intensity is quantified most easily by using the modified Brog (0-10) category ratio scale (Borg, 1982). This tool evaluates also within other protocols such as the Medical Research Council (MRC) scale, New York Heart Association (NYHA) scale, London Chest Activity of Daily Living scale and Pulmonary Functional Status and Dyspnea Questionnaire (Meek, 2004). Many reports and studies used a Brog scale for identification the dyspnea

Evaluation of chest expansion is very comfortable for the clinician. Various protocols such as the three levels of upper, middle, and lower lobes (Cherniack, 1983) can be performed manually. Circumferential change from full expiration to maximal inspiration at supine position can be applied with a tape at the axilla (upper lung) and xiphoid (lower lung) levels, as suggested by previous reports (Carlson, 1973), and this protocol has shown good reliability (Lapier et al., 2000). For example, 3 ¼ inches ± ¼ inch could be increased at the axillary level of 20-to 30-year old women (Carlson, 1973). Another level that can be measured to present chest expansion by tape is the 4th intercostal rib space (Fisher et al., 1990). Furthermore, the chest caliper is a new tool that can be used to evaluate chest expansion. Previous evidence has shown that application of the chest caliper enables measurement of thoracic diameters at rest and during activity, but it could not refer to the

Original palpable examination is of chest expansion in the respiratory system, and less expansion may reflect intrapulmonary lesion such as secretion obstruction or atelectasis. Sometimes, incomplete recoiling from expiration results in many issues such as mass, emphysema, or air trapping. Although, no scientific data have shown normal length of complete recoiling in chest expiration, clinical experience can adjust muscle tightness or shortening around the chest wall. Palpation of the chest wall for flexibility can be evaluated in sitting, side lying, supine, or prone position. Conventional chest movement can be

cyanosis, nasal flaring etc. which refer to hard work in breathing (Irwin & Tecklin, 1995).

induce physical deconditioning via low exercise performance (Celli, 2000).

symptoms and interprets the effectiveness of program.

normal data for chest expansion (Davis & Troup, 1966).

performed with manual evaluation.

**Palpation on chest expansion** 

**4. Physical examination and outcomes** 

**Observation of respiratory symptoms and chest wall mobility** 


Chest Mobilization Techniques for Improving

**Thoracic Flexibility Evaluation** (Figure 8)

be evaluated by many procedures in different positions.

result is concerned with the lateral intercostal part.

(Figure 8)

Direction: 1. Hemi-cross counterpressure. 2. Hemi-caudal stretching force. 3. Bilater-caudal stretching force.

with hand elevation (Figure 8)

C. Position: Sitting position without support (Figure 9) Sternum movement and upper chest expansion

Lateral bending test or anterioposterial flexion test

increasing the aeroted areas or resolving the lung collapse on the chest film.

line).

chest.

Trunk rotation test

stretching.

Trunk flexion and extension test.

Ventilation and Gas Exchange in Chronic Lung Disease 407

inspiration. Although results were studied in 9 healthy subjects, the mean of upper and lower expansion ranged from 1.0 to 7.0 cm, and 1.5 to 7.98 cm, respectively. For the chest

The thoracic or chest wall flexibility is not determined or evaluated exactly for standard value or comparison between healthy and chronically ill subjects. Thus, many practitioners make decisions individually from clinical experience. Thoracic or chest wall flexibility can

In supine or side lying positions, the examiner can evaluate in various directions, but the

A. Position: Supine with head supported with or without a pillow at the mid-thorax

Handling: Two hands on the lateral lower chest (6th to 8th rib at the mid -axillary

B. Position: Side lying position with or without a pillow in the mid-thorax, combined

Handling: Two hands on the lateral lower chest (6th to 8th rib at the mid axillary line).

Direction: Hemi-caudal stretching force with two hands, and opposite and cephalic

**Chest X-ray film**: Evaluation of lung volume from a chest X-ray (CXR) film is measured possibly from previous evidence of using manual illustration for free hand tracing (May et al., 2009) or calculating total lung capacity from the thoracic roentgen image (Dieterich et al., 1990). In fact, improvement of air entry or volume can be observed from clinically increasing the dark field on the film. In COPD, silhouette sign and secretion retention are identified commonly, including atelectasis from a secretion block (Reid & Chung, 2004), which is the main problem in decreasing lung volume or resorptive atelectasis (Harden, 2009). Thus, the effectiveness of chest mobilization to improve lung ventilation can be reassessed by

**Dynamic lung ventilation**: In the case of lung volume evaluation, functional residual capacity (FRC), tidal volume (Vt) and forced vital capacity (FVC) from the pulmonary function test are challenging outcomes (Dexter, 2010). FRC decreases when there is an

One hand holding the subject's hand and the other on the lateral lower

caliper, there was no report or data for the range of normal chest expansion.

Fig. 6. Three levels of manual evaluation for upper (above the 4th rib anteriorly) (a), middle (between the 4th and 6th ribs anteriorly) (b), lower lung expansion (below the scapulae and above the 12th thoracic vertebrae, posteriorly) (c), and sternum flexibility (d).

#### **Tape and Caliper Evaluation (**Fisher et al., 1990; Carlson, 1973)(Figure 7)

Both of these methods can be applied in a sitting position, which is better than lying supine. From the author's experience, the three levels: upper, middle and lower, can be measured at the axillary, nipple line, and xiphoid process. The latest report on measuring the thoracic excursion or expansion was carried out by Bockenhauer and coworker (2007) (Bockenhauer et al., 2007). It suggests anatomic landmarks on the chest wall as follows;

Upper thoracic expansion is seen as the third intercostal space at the midclavicular line and the fifth thoracic spineous process.

Lower thoracic expansion is seen at the tip of the xiphoid process and the 10th thoracic spineous process.

Fig. 7. Application of cloth tape for measuring the upper (right above), lower (right below) thoracic expansion and hand position, and use of the caliper to measure chest expansion (left).

The cloth tape method has been modified by placing the circumference on the specific landmarks transversly and measuring the different changes between full expiration and full inspiration. Although results were studied in 9 healthy subjects, the mean of upper and lower expansion ranged from 1.0 to 7.0 cm, and 1.5 to 7.98 cm, respectively. For the chest caliper, there was no report or data for the range of normal chest expansion.

#### **Thoracic Flexibility Evaluation** (Figure 8)

406 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

(a) (b) (c) (d)

above the 12th thoracic vertebrae, posteriorly) (c), and sternum flexibility (d).

**Tape and Caliper Evaluation (**Fisher et al., 1990; Carlson, 1973)(Figure 7)

et al., 2007). It suggests anatomic landmarks on the chest wall as follows;

the fifth thoracic spineous process.

spineous process.

(left).

Fig. 6. Three levels of manual evaluation for upper (above the 4th rib anteriorly) (a), middle (between the 4th and 6th ribs anteriorly) (b), lower lung expansion (below the scapulae and

Both of these methods can be applied in a sitting position, which is better than lying supine. From the author's experience, the three levels: upper, middle and lower, can be measured at the axillary, nipple line, and xiphoid process. The latest report on measuring the thoracic excursion or expansion was carried out by Bockenhauer and coworker (2007) (Bockenhauer

Upper thoracic expansion is seen as the third intercostal space at the midclavicular line and

Lower thoracic expansion is seen at the tip of the xiphoid process and the 10th thoracic

Fig. 7. Application of cloth tape for measuring the upper (right above), lower (right below) thoracic expansion and hand position, and use of the caliper to measure chest expansion

The cloth tape method has been modified by placing the circumference on the specific landmarks transversly and measuring the different changes between full expiration and full The thoracic or chest wall flexibility is not determined or evaluated exactly for standard value or comparison between healthy and chronically ill subjects. Thus, many practitioners make decisions individually from clinical experience. Thoracic or chest wall flexibility can be evaluated by many procedures in different positions.

In supine or side lying positions, the examiner can evaluate in various directions, but the result is concerned with the lateral intercostal part.


**Chest X-ray film**: Evaluation of lung volume from a chest X-ray (CXR) film is measured possibly from previous evidence of using manual illustration for free hand tracing (May et al., 2009) or calculating total lung capacity from the thoracic roentgen image (Dieterich et al., 1990). In fact, improvement of air entry or volume can be observed from clinically increasing the dark field on the film. In COPD, silhouette sign and secretion retention are identified commonly, including atelectasis from a secretion block (Reid & Chung, 2004), which is the main problem in decreasing lung volume or resorptive atelectasis (Harden, 2009). Thus, the effectiveness of chest mobilization to improve lung ventilation can be reassessed by increasing the aeroted areas or resolving the lung collapse on the chest film.

**Dynamic lung ventilation**: In the case of lung volume evaluation, functional residual capacity (FRC), tidal volume (Vt) and forced vital capacity (FVC) from the pulmonary function test are challenging outcomes (Dexter, 2010). FRC decreases when there is an

Chest Mobilization Techniques for Improving

improvement clinically.

during extension (below).

Ventilation and Gas Exchange in Chronic Lung Disease 409

imbalance between the lungs and chest wall. Both atelectasis and kyphoscoliosis from abnormal posture affect the elastic recoil of the chest. A barrel chest affects the muscle length of the chest wall or diaphragm by either increasing or decreasing it , and a reduction in force results, which reduces vital capacity (VC) (Henderson & Clotworthy, 2009). In the case of patient who used a ventilator, improvement in lung volume or ventilation can be evaluated from tidal volume (Vt), expiratory tidal volume (ETV), or minute ventilation (VE). In the early exacerbation stage, evaluation of lung volume is difficult because of dynamic hyperinflation, but if the patient is on a ventilator with SMIV or CPAP modes, minute ventilation (VE) and FRC is very easy to measure (Vines, 2010). Finally, the weaning time from a ventilator is the final outcome that presents the

Fig. 10. Passive stretching of the pectoralis major (above and middle) and active stretching of the pectoralis muscles with inspiration with exhalation during flexion and breathing in

Fig. 8. Rib torsion (right above) and trunk extension (left above) and lateral stretching technique (below). (Leelarungrayub et al., 2009)

Fig. 9. Functional trunk test as flexion (right above), extension (middle above), rotation(left above), lateral flexion(right below), combined extension, and rotation tests (left below).

Fig. 8. Rib torsion (right above) and trunk extension (left above) and lateral stretching

Fig. 9. Functional trunk test as flexion (right above), extension (middle above), rotation(left above), lateral flexion(right below), combined extension, and rotation tests (left below).

technique (below). (Leelarungrayub et al., 2009)

imbalance between the lungs and chest wall. Both atelectasis and kyphoscoliosis from abnormal posture affect the elastic recoil of the chest. A barrel chest affects the muscle length of the chest wall or diaphragm by either increasing or decreasing it , and a reduction in force results, which reduces vital capacity (VC) (Henderson & Clotworthy, 2009). In the case of patient who used a ventilator, improvement in lung volume or ventilation can be evaluated from tidal volume (Vt), expiratory tidal volume (ETV), or minute ventilation (VE). In the early exacerbation stage, evaluation of lung volume is difficult because of dynamic hyperinflation, but if the patient is on a ventilator with SMIV or CPAP modes, minute ventilation (VE) and FRC is very easy to measure (Vines, 2010). Finally, the weaning time from a ventilator is the final outcome that presents the improvement clinically.

Fig. 10. Passive stretching of the pectoralis major (above and middle) and active stretching of the pectoralis muscles with inspiration with exhalation during flexion and breathing in during extension (below).

Chest Mobilization Techniques for Improving

lower lobe of both lungs.

joints.

(left below)

**5.2 Postero-lateral chest wall mobilization** 

**5.3 Lateral chest wall mobilization (Figure 12)** 

Ventilation and Gas Exchange in Chronic Lung Disease 411

This technique has many procedures such as trunk torsion, rotation, and lateral bending (Frownfelter, 1987). It not only affects the ribs and tissue, but also moves the costovertebral and facet joints. This pattern is very useful in ordet to improve the ventilation around in the

This technique can be applied in cases of unconsciousness and good consciousness. This part can be mobilized either by therapist likes lateral flexion on the bed, or rib torsion. Other procedures can be performed by passive stretching in sitting position. The last choice that is very strong and give the best result in order to stretching by side lying on the pillow and passive stretching. This pattern helps to improve the chest wall flexibility around the lower thoracic and improves the ventilation in both lower lungs. Sometime, lateral chesl wall stretching effects to the thoracic joints either sterocostal or costovertebral

Fig. 12. Chest Mobilization Techniques for improving lateral thoracic mobility; Passive lateral flexion (above), passive rib torsion (right below) (Wetzel et al., 1995), and trunk flexion (middle below), including passive lateral flexion in side lying position on the pillows

From the overall outcomes, chest expansion, dyspnea, chest radiography, and dynamic lung ventilation are most important in representing the effectiveness of a technique. Other parameters can be evaluated such as breathing pattern, respiratory rate, oxygen saturation, etc., and respiratory muscle strength if protocol training is included.
