Asynchronous Breathing Movements in Pati·ents with Chronic Obstructive Pulmonary Disease* Kumar Ashutosh, M.D.;t Robert Gilbert, M.D.;t ]. H. Auchincloss, Jr., M.D.;t and David Peppi
An electromagnetic ventilation monitor w• med to record the separate anterior-posterior movements of the chest and abdomen during the breathing cycle In 30 patients with chronic obstructive pulmonary dl8ea8e (COPD) and In 10 normal subjects. In all normal subjects and 17 COPD patients, the chest and abdomen movemenis were synchronous and In phme with the ftow of air • measured with a spirometer. In 13 COPD patlenfB chest movement was synchronous with the ftow of
A form of discoordination of the respiratory mus-
cles (Hoover's sign) was described as far back as 1920. 1 The sign consisted of a drawing in of the costal margins during inspiration and indicated advanced airway obstruction. Abnormal movements of the chest and abdomen during breathing have been described in patients with respiratory failure, 2•8 and expansion of the chest during expiration has been considered to be a contraindication for "weaning" from assisted ventilation. 4 Campbell5 and Agostoni8 have observed contractions of the abdominal muscles during inspiration at large lung volumes in some normal subjects. Similarly Bergofsky7 has described an "asynchronous" breathing pattern in normal subjects suggestive of a downward descent of the diaphragm during expiration. We have noted a previously undescribed type of asynchronous breathing movements in a number of patients with chronic obstructive pulmonary disease ( COPD). The present study was undertaken to define and evaluate this asynchrony and to correlate its presence with the clinical state and prognosis. °From the Deparbnent of Medicine, State. University of New York Upstate Medical Center, Syracuse, New York. tFellow in Pulmonary Disease. tProfessor of Medicine. This study was supported by Training Grant No. HL-05954 from the National Heart and Lung Institute, Research Grant No. 12995 from the National Heart and Lung Institute, Grant No. PN-10569 from the Heart Association of Upstate New Distress" from York, a grant "Development of R~iratory the New York Heart Assembly, and a grant from the Parker B. Francis Foundation. Manuscript received June 5; revision accepted Oct:ober 11.
Reprint requests: ~. Ashutosh, Upstate Medical Center, Syracuse, New YOf'k 13210
CHEST, 67: 5, MAY, 1975
air, but the abdomen moved inward suddenly near or at end Inspiration and then outward during a variable part of expiration. Compared to COPD patienU with a normal breathing pattern, those with asyuchronons breathing movements had poorer ventilatory mechanics and 10 of the 13 were dependent on Blllisted ventilation. Nine of the 13 patients with tlS)'llchronons breathing have died In a 10 month period, a slpificantly higher mortality than in those with normal breathing.
PATIENTS
Thirty patients ( 24 men, 6 women) with COPD were studied, 16 during their regularly scheduled outpatient visits and 14 during hospitalization for management of complications of their disease. Ten hospitalized subject:s 50 years of age or older without pulmonary disease constituted a control group. METHODS
The separate motions of the chest (rib cage) and abdomen were studied with an elect:romagnetic ventilation monitor (magnetometer) described in detail previously.8,9 Changes in the anterior-posterior dimensions of the chest and abdomen were measured by magnetic coils. The receiver coil for rib cage motion was placed in the midline a variable distance cephalad to the xiphoid at a point which gave maximum deflect:ion for quiet breathing; the receiver coil for abdomen motion was placed in the midline 5 cm cephalad to the umbilicus. Corresponding exciter coils were placed at the same level on the back. Alternating current sent to the exciter coils produced a magnetic &eld which induced a voltage in the receiver coils inversely proportional to the distance between the receiver and exciter coils. Movement of air in and out of the lungs was recorded by a spirometer &tted with a torque potentiometer. The chest, abdomen, and spirometer signals were recorded simultaneously on a strip chart recorder. The polarity of the signals was adjusted to give an upward deflection of the spirometer signal during inspiration, and upward deflect:ions of the chest and abdomen signals during outward (expansion) movements of the chest and abdomen. All patients were studied supine with no or slight elevation of the head of the bed. Forced vital capacity ( FVC) and one-second forced expiratory volume ( FEV1 ) were obtained by standard spirometric techniques on the same day as the study of the breathing movements. H a patient was unable to perform spirometry on the day of the study, the most recent spirometric values
ASYNCHRONOUS BREATHING MOVEMENTS IN COPD 553
Table l-..4ge, Pulmonary Function, and Suniillfll Data for 30 COPD Patienu
Normal breathing pattern
Asynchronous breathing pattern
55.8 (13.1)
62.1 (8.6)
NS
FEV1,ml
700 (343)
392 (177)
.003
FVC,ml
1524 (697)
793 (339)
An electromagnetic ventilation monitor w• med to record the separate anterior-posterior movements of the chest and abdomen during the breathing cycle In 30 patients with chronic obstructive pulmonary dl8ea8e (COPD) and In 10 normal subjects. In all normal subjects and 17 COPD patients, the chest and abdomen movemenis were synchronous and In phme with the ftow of air • measured with a spirometer. In 13 COPD patlenfB chest movement was synchronous with the ftow of
A form of discoordination of the respiratory mus-
cles (Hoover's sign) was described as far back as 1920. 1 The sign consisted of a drawing in of the costal margins during inspiration and indicated advanced airway obstruction. Abnormal movements of the chest and abdomen during breathing have been described in patients with respiratory failure, 2•8 and expansion of the chest during expiration has been considered to be a contraindication for "weaning" from assisted ventilation. 4 Campbell5 and Agostoni8 have observed contractions of the abdominal muscles during inspiration at large lung volumes in some normal subjects. Similarly Bergofsky7 has described an "asynchronous" breathing pattern in normal subjects suggestive of a downward descent of the diaphragm during expiration. We have noted a previously undescribed type of asynchronous breathing movements in a number of patients with chronic obstructive pulmonary disease ( COPD). The present study was undertaken to define and evaluate this asynchrony and to correlate its presence with the clinical state and prognosis. °From the Deparbnent of Medicine, State. University of New York Upstate Medical Center, Syracuse, New York. tFellow in Pulmonary Disease. tProfessor of Medicine. This study was supported by Training Grant No. HL-05954 from the National Heart and Lung Institute, Research Grant No. 12995 from the National Heart and Lung Institute, Grant No. PN-10569 from the Heart Association of Upstate New Distress" from York, a grant "Development of R~iratory the New York Heart Assembly, and a grant from the Parker B. Francis Foundation. Manuscript received June 5; revision accepted Oct:ober 11.
Reprint requests: ~. Ashutosh, Upstate Medical Center, Syracuse, New YOf'k 13210
CHEST, 67: 5, MAY, 1975
air, but the abdomen moved inward suddenly near or at end Inspiration and then outward during a variable part of expiration. Compared to COPD patienU with a normal breathing pattern, those with asyuchronons breathing movements had poorer ventilatory mechanics and 10 of the 13 were dependent on Blllisted ventilation. Nine of the 13 patients with tlS)'llchronons breathing have died In a 10 month period, a slpificantly higher mortality than in those with normal breathing.
PATIENTS
Thirty patients ( 24 men, 6 women) with COPD were studied, 16 during their regularly scheduled outpatient visits and 14 during hospitalization for management of complications of their disease. Ten hospitalized subject:s 50 years of age or older without pulmonary disease constituted a control group. METHODS
The separate motions of the chest (rib cage) and abdomen were studied with an elect:romagnetic ventilation monitor (magnetometer) described in detail previously.8,9 Changes in the anterior-posterior dimensions of the chest and abdomen were measured by magnetic coils. The receiver coil for rib cage motion was placed in the midline a variable distance cephalad to the xiphoid at a point which gave maximum deflect:ion for quiet breathing; the receiver coil for abdomen motion was placed in the midline 5 cm cephalad to the umbilicus. Corresponding exciter coils were placed at the same level on the back. Alternating current sent to the exciter coils produced a magnetic &eld which induced a voltage in the receiver coils inversely proportional to the distance between the receiver and exciter coils. Movement of air in and out of the lungs was recorded by a spirometer &tted with a torque potentiometer. The chest, abdomen, and spirometer signals were recorded simultaneously on a strip chart recorder. The polarity of the signals was adjusted to give an upward deflection of the spirometer signal during inspiration, and upward deflect:ions of the chest and abdomen signals during outward (expansion) movements of the chest and abdomen. All patients were studied supine with no or slight elevation of the head of the bed. Forced vital capacity ( FVC) and one-second forced expiratory volume ( FEV1 ) were obtained by standard spirometric techniques on the same day as the study of the breathing movements. H a patient was unable to perform spirometry on the day of the study, the most recent spirometric values
ASYNCHRONOUS BREATHING MOVEMENTS IN COPD 553
Table l-..4ge, Pulmonary Function, and Suniillfll Data for 30 COPD Patienu
Normal breathing pattern
Asynchronous breathing pattern
55.8 (13.1)
62.1 (8.6)
NS
FEV1,ml
700 (343)
392 (177)
.003
FVC,ml
1524 (697)
793 (339)
