Chest Expansion and Lung Function for Healthy Subjects and Individuals

With Pulmonary Disease

Marion Derasse, Stéphanie Lefebvre, Giuseppe Liistro, and Gregory Reychler

BACKGROUND: The purposes of this study were to verify the correlation between chest expan-
sion and lung function within a larger sample of subjects composed of both healthy subjects and
subjects affected by pulmonary disease, and to verify the influence of age, body mass index, and
gender on chest expansion. METHODS: Adults were recruited prospectively when they visited
the lung function lab. Chest expansion was measured with a measuring tape at 2 different levels
of the rib cage by 1 blinded examiner. Spirometry was performed for each subject. RESULTS:
Data from 251 subjects between 18 and 88 y old were collected and analyzed. Among the analyzed
subjects, mean upper and lower chest expansion were 4.82 6 1.84 cm and 3.99 6 2.15 cm, respec-
tively. A significant but poor correlation was found between both chest expansion and all lung
function parameters (total lung capacity, FVC, and FEV1) (P 5 .01). Negative significant correla-
tions were found between chest expansion and age as well as body mass index. The difference in
upper chest expansion between obese and nonobese subjects was not statistically significant, but
the difference in lower chest expansion was significant for these 2 groups. Finally, upper and lower
chest expansion were not different between males and females. CONCLUSIONS: Based on these
results, one cannot validate the use of chest expansion measurement to define lung function. In
centers that have easy access to more precise and complete methods to measure lung function,
the measurement of chest expansion for diagnostic purposes seems to be archaic. Additionally,
age and body mass index are 2 parameters that can influence chest expansion. Key words: thorax;
chest expansion; lung function; respiratory mechanics; chest wall mobility; assessment. [Respir Care
2021;66(4):661–668. © 2021 Daedalus Enterprises]

Introduction measured using a measuring tape, it is a simple, inexpen-

sive, and noninvasive tool for assessing chest mobility.8
Over the last 50 years, many authors have sought to find Its measurement has become standardized at 2 different
a way to measure chest wall mobility and use it as a clini- levels to obtain upper and lower thoracic circumference,4
cal sign for diagnostic purposes1,2 or in therapeutic and both intra- and inter-rater reliability have been largely
responses.3-7 Chest expansion, defined as the difference in demonstrated in healthy populations9-13 and in individuals
thoracic girth after maximum inspiration and maximum with respiratory disease.14 Its use is applied throughout
expiration, is one indicator of chest wall mobility. As it is the world, mainly as a clinical sign in the field of pulmo-
nology15 and rheumatology,1 and as a measure of response
to treatment in rehabilitation.5,16,17 The aforementioned
Dr Derasse is affiliated with the Service de Pneumologie, Cliniques definition of chest expansion implies that there is a direct
Universitaires Saint-Luc, Université Catholique de Louvain, Brussels,
Belgium. Ms Lefebvre, Dr Liistro, and Dr Reychler are affiliated with
the Service de Pneumologie, Cliniques Universitaires Saint-Luc,
Woluwe-Saint-Lambert, Belgium. Drs Liistro and Reychler are affiliated The authors have disclosed no conflicts of interest.
with the Institut de Recherche Expérimentale et Clinique, Pôle de
Pneumologie, ORL & Dermatologie, Université Catholique de Louvain, Correspondence: Marion Derasse MD, Service de Pneumologie, Cliniques
Woluwe-Saint-Lambert, Belgium. Universitaires Saint-Luc, Université Catholique de Louvain, Av Hippocrate
10, 1200, Brussels, Belgium. E-mail: [email protected].
Supplementary material related to this paper is available at http://www.
rcjournal.com. DOI: 10.4187/respcare.08350

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relationship between chest expansion and respiratory vol-

umes. Such a correlation was indeed found in subjects QUICK LOOK
with ankylosing spondylitis,18,19 pneumothorax, pleural
Current knowledge
effusion,20 asbestos-related pleural fibrosis,21 and chest
wall distortion,22,23 However, discrepancies in this rela- Chest expansion is a simple, inexpensive, and noninva-
tionship have been found in subjects with COPD.13,14,24 sive tool for assessing chest mobility. Its intra-rater and
Moreover, factors such as age, body mass index, pain, and inter-rater reliability has been largely demonstrated in
physical condition also have an impact on both chest healthy populations and in individuals with respiratory
expansion and lung function.25-31 By contrast, it is not evi- disease. A correlation between chest expansion and
dent whether gender influences chest expansion, although lung function was found in subjects with ankylosing
it is related to the lung function.8,32-34 The correlation spondylitis, pneumothorax, pleural effusion, asbestos-
between chest expansion and lung function has mainly related pleural fibrosis, and chest wall distortion.
been studied in specific conditions such as restrictive dis-
What this paper contributes to our knowledge
ease, and then only using small samples sizes.
The primary objective of this study was to verify the Based on our results, the use of chest expansion mea-
correlation between chest expansion and lung function surement to define lung function can not be validated.
within a larger sample of subjects composed of both In clinical practice, the measurement of chest expan-
healthy subjects and subjects affected by pulmonary dis- sion can be used as a parameter that imperfectly pro-
eases. The goal was to identify whether chest expansion vides an idea of lung volume in centers or countries
measurements could be applicable in clinical practice. with limited access to tools to assess lung function.
The secondary objective was to verify the influence of Additionally, age and body mass index are 2 parame-
age, body mass index, and gender on chest expansion, ters that can influence chest expansion.
which would help to optimize interpretation of this test in
clinical practice. If this validity is verified, chest expan-
sion measurement could be used in centers or countries xiphoid process and the spinous process of the tenth tho-
where precise measures of lung function are not available. racic vertebrae were used as markers.
Instructions were given to the subjects and the procedure
was demonstrated to ensure adequate understanding. The
Methods 2 measurements of chest diameter were taken at the end of
deep inspiratory and expiratory maneuvers. Upper and
Subjects were recruited prospectively from the pulmo- lower chest expansion were obtained by subtracting the
nology unit of the Cliniques Universitaires Saint-Luc in inspiratory diameter from the expiratory diameter, accord-
January 2017. The inclusion criteria were age > 18 y, ing to the designated anatomical markers. Subjects were
spirometry assessment in the aforementioned unit, and sitting with their arms at their sides, with the trunk and
freedom from any acute organic pathology that could chest uncovered. The examiner performed 1 measurement
compromise lung function (eg, acute respiratory disease of upper chest expansion and then 1 measurement of the
such as an exacerbation of COPD35 or sepsis). Exclusion lower chest expansion consecutively, holding the meas-
criteria included a lack of understanding of the instruc- uring tape at both ends with thumb and index finger around
tions (eg, cognitive impairment or language barrier) the subject’s body. The measuring tape was snug but not
based on a medical interview or the absence of the asses- tight.
sor for the day of the lung function test. Patients who Spirometry and plethysmography were performed by a
were unable to perform measurements or who were con- qualified and blinded technician as recommended by the
fined to bed were also excluded. The experiment was American Thoracic Society.36 Subjects were seated when
approved by the Institutional Medical Ethics Committee they received the instructions. Data recorded were total
of the Cliniques Universitaires Saint-Luc (2010/25fev/270). lung capacity, FEV1, FVC, and FEV1/FVC. Three trials
Before each experiment, written informed consent was were completed by all subjects, and the best result was
obtained from the subjects based on the Good Clinical selected for analysis. An obstructive defect was defined as
Practice guidelines from the Declaration of Helsinki. FEV1/FVC < 0.7, and a nonobstructive respiratory defect
Chest expansion was measured using a measuring tape at included all subjects with FEV1/FVC $ 0.7. A restrictive
2 different levels of the rib cage by 1 blinded examiner. defect was defined as total lung capacity < 0.8 of the
The anatomical markers used to define upper chest expan- predicted value, and a nonrestrictive respiratory defect
sion were the third intercostal space at the level of the cla- included all subjects with a total lung capacity $ 0.8 of the
vicular line and the spinous processus of the fifth thoracic predicted value. A mixed pattern was characterized by the
vertebrae.9 To define lower chest expansion, the tip of the association of both patterns.37 Body weight and height were

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Table 1. Subject Anthropometric and Lung Function Data

Assessed for eligibility
451
Age, y 54.3 6 15.9
Excluded Sex
197 Male 156
Unavailable: 195 Female 95
Language barrier: 2 Body mass index, kg/m2 27.3 6 5.6
Body mass index > 30 kg/m2 160 (62.3)
Eligible
Smoker status
254
Ex-smoker 100 (39.8)
Current smoker 48 (19.1)
Declined to participate: 3
Nonsmoker 103 (41)
FEV1, % of predicted 86.7 6 24.4
Subjects Total lung capacity, % of predicted 100.2 6 17.6
enrolled FEV1/FVC measured 71.1 6 12.8
251 FVC, % of predicted 94.7 6 24.9
Fig. 1. Flow chart. Upper chest expansion, cm 4.8 6 1.8
Coefficient of variation 0.38
Minimum, cm 4.6
determined using a calibrated balance and a stadiometer, Maximum, cm 5.0
respectively, and body mass index was calculated. Obesity Lower chest expansion, cm 4.0 6 2.2
was defined as a body mass index $ 30 kg/m2. Coefficient of variation 0.54
Statistical analyses were performed with SPSS 25.0 Minimum, cm 3.7
(IBM, Armonk, New York). Data are presented as means Maximum, cm 4.3
and standard deviations. Pearson coefficients were calcu-
Data are presented as n (%) or mean 6 SD. N ¼ 251 subjects.
lated to assess correlations between chest expansion meas-
urements (lower and upper chest expansion, separately) and
lung function parameters. The significance level was set at
and all lung function parameters (FEV1, FVC, and total
P < .05 for all tests. The correlation coefficient was charac-
lung capacity) ranged from 0.27 to 0.38 (Table 2).
terized as follows: > 0.80 was very good, 0.61–0.80 was
Significant negative correlations were found between
good, 0.41–0.60 was moderate, 0.21–0.40 was poor, and
chest expansion and age as well as body mass index
< 0.21 was very poor.38 The t test was used to compare the
(Table 2, Fig. 3). The difference of the upper chest expan-
means.
sion between obese and nonobese subjects was not statis-
tically significant, but the difference was significant for
Results
the lower chest expansion between these 2 groups (Table
3). Finally, upper and lower chest expansion were not dif-
A total of 451 patients were eligible. Among them, 195
ferent between males and females (Table 3).
were not included because their appointments were not dur-
ing the therapist’s schedule. Two patients were excluded
for language incomprehension. Among the 254 remaining Discussion
patients, 3 declined to participate. Data from 251 subjects
between 18 and 88 y old were collected and analyzed (Fig. To our knowledge, this is the first study assessing chest
1). The baseline characteristics of anthropometry and spi- expansion based on a large cohort composed of unspecific
rometry of the whole sample are presented in Table 1. subjects and assessing its relationship with the lung func-
There was a predominance of males (62%) in the sample. tion. The most important finding of the study was the sig-
The spirometric data showed that 12% of the subjects had a nificant but poor correlations between both upper and
restrictive respiratory defect and 38% had an obstructive re- lower chest expansion and the analyzed lung function pa-
spiratory defect. These patients had, on average, a mild rameters (ie, total lung capacity, FVC, and FEV1) (P ¼
degree of air-flow obstruction. .01). Indeed, because chest expansion is only weakly corre-
Among the analyzed subjects, mean upper and lower lated with lung function, this calls into question the utility
chest expansion measurements were 4.8 6 1.8 cm and of chest expansion measurement in clinical examination.
4.0 6 2.2 cm, respectively. A significant correlation was Previous studies have reported average chest expansion val-
found between both chest expansion and all lung function ues ranging from 5.5 cm to 7.5 cm among healthy subjects,
parameters (total lung capacity, FVC, and FEV1) (P ¼ .01) and from 2.2 cm to 6.3 cm among subjects with respiratory
(Fig. 2). All of these correlations were poor; the coefficient diseases (such as ankylosing spondylitis, COPD) (see the
of correlation between chest expansion (upper or lower) supplementary materials at http://www.rcjournal.com). Our

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12 12
A B
10 10
Upper CE (cm)

Lower CE (cm)
8 8

6 6

4 4

2 2
2
R = 0.13 R2 = 0.13
0 0
0 25 50 75 100 125 150 0 25 50 75 100 125 150
TLC (% of predicted) TLC (% of predicted)

12 12
C D
10 10
Upper CE (cm)

Lower CE (cm)
8 8

6 6

4 4

2 2

R2 = 0.14 R2 = 0.11
0 0
0 30 60 90 120 150 180 0 30 60 90 120 150 180
FVC (% of predicted) FVC (% of predicted)

12 12
E F
10 10
Upper CE (cm)

Lower CE (cm)

8 8

6 6

4 4

2 2
2
R = 0.11 R2 = 0.07
0 0
0 20 40 60 80 100 120 140 160 0 30 40 60 80 100 120 140 160
FEV1 (% of predicted) FEV1 (% of predicted)
Fig. 2. Correlation between chest expansion (upper and lower) and TLC (A and B), FVC (C and D), and FEV1 (E and F). CE ¼ chest expansion;
TLC ¼ total lung capacity, FVC = forced vital capacity.

results indicate average values of 4.8 cm and 4.0 cm for In our study, mean upper chest expansion was curiously
upper and lower chest expansion, respectively. These val- shorter than mean lower chest expansion. While lower
ues are slightly below the values found in previous studies chest expansion was systematically higher than upper chest
for healthy subjects but are within the range of values found expansion in previous studies,9,12,13,26,39 only Malaguti et
in previous studies for subjects with respiratory diseases. al14 reported upper chest expansion to be slightly higher
However, considering that our study is based on a larger than lower chest expansion in a COPD population. Three
sample of subjects and includes both healthy subjects and hypotheses could explain this observation. First, the aver-
those affected by pulmonary disease, one could argue that age body mass index in this study was higher than in the
the values of this study are aligned with previous findings. other studies. In previous studies, the mean body mass

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index did not exceed 24.1 kg/m2 compared to 27.3 kg/m2 expansion and body mass index in this study. More specifi-
in our study, and 62.3% of our sample had a body mass cally, lower chest expansion measurements were signifi-
index > 30 kg/m2.9,10,12,13,26,39 A negative correlation has cantly smaller among obese subjects compared to nonobese
been demonstrated between chest expansion and body mass subjects. This observation is also supported by the fact that,
index.8,27,40,41 This is explained by the fact that adipose tis- in obese subjects, ventilation was preferentially distributed
sue accumulation and decreased muscle strength related to to the upper zones of the lung,27,42-45 leaving the lower, de-
obesity cause a restricted expansion of the thoracic cavity, pendent zones relatively underventilated, consistent with
thus limiting diaphragmatic displacement and decreasing relative air trapping in the bases.27 Second, as expected, a
FVC.27 This is confirmed by the significantly negative cor- wide heterogeneity in respiratory status was found in our
relation found between both upper and lower chest
Table 3. Comparison of Chest Expansion Between Different Groups
Table 2. Correlation Coefficients (r) Between Lung Function
Upper Chest Expansion Lower Chest Expansion
Parameters and Chest Expansion
Obesity
Upper Chest Lower Chest Obese 4.2 6 1.7 2.9 6 1.5
Expansion Expansion
Not obese 5.1 6 1.8 4.4 6 2.2
Total lung capacity 0.35 0.37 P .72 < .001
FVC 0.37 0.34 Sex
FEV1 0.33 0.27 Male 4.4 6 1.7 3.4 6 1.9
Age 0.37 0.28 Female 5.5 6 1.9 5.0 6 2.1
Body mass index 0.43 0.31 P .37 .16

12 12
A B
10 10
Upper CE (cm)

Lower CE (cm)

8 8

6 6

4 4

2 2

0 0
0 15 30 45 60 75 90 0 15 30 45 60 75 90
Age (y) Age (y)

12 12
C D
10
10

8
Upper CE (cm)

Lower CE (cm)

8
6
6
4
4
2

2 0

0 −2
0 10 20 30 40 50 60 0 10 20 30 40 50 60
BMI (kg/m2) BMI (kg/m2)
Fig. 3. Correlation between chest expansion (upper and lower) and age (A and B) and BMI (C and D). CE ¼ chest expansion; BMI ¼ body mass
index.

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cohort; this can be explained by our recruitment process, than lower chest expansion. Adachi et al26 also found a cor-
which was not based on the subjects’ clinical condition. relation between age and upper chest expansion, but not for
Indeed, our sample was composed of both healthy and lower chest expansion or chest expansion measured at the
unhealthy subjects, including those with obstructive and tenth rib. These findings can be explained by the fact that
restrictive lung diseases. We know that up to 70% of the tenth rib does not have a sternal articulation and the an-
patients with severe airway obstruction present the terior portion of the tenth rib is covered by abdominal
Hoover’s sign,46 which refers to inspiratory retraction of muscles.26 Therefore, the movement of the inferior part of
the lower intercostal spaces resulting from alterations of the thorax would not be as markedly affected by age-related
the dynamics of diaphragmatic contraction due to hyper- changes in chest wall compliance.
inflation and a flattened diaphragm. This implies that the The findings of this study are particularly relevant in
lower chest circumference of patients with obstructive light of current medical practice in European countries,
ventilatory defect is reduced. As 38% of our sample had where patient age averages 43.7 y. Indeed, in previous stud-
an obstructive respiratory defect, it could decrease the ies associating chest expansion with lung function, the aver-
average value of lower chest expansion. This hypothesis age subject’s age was never > 28 y, whereas it was 54.3 y
is supported by the observation of Malaguti et al,14 who in our study.10,12,13,39 Most previous studies only evaluated
also noted that lower chest expansion values were infe- healthy subjects, whereas 50% of our subjects presented
rior to upper chest expansion values within a population with a pulmonary defect.
of COPD. Third, the subjects were in a sitting position in No significant difference in either upper or lower chest
our study, while the standing position was used in most expansion was found between male and female subjects.
other studies.8,9,11-13,26,39 Body position has a consider- Despite the difference in the size of the lungs between gen-
able impact on lung volume, which will affect the move- der, males and females maintain the same respiratory
ment of the ribcage and the abdomen, as well as the movement and thoraco-abdominal configuration.32,33
degree of diaphragm displacement.27,47 Thereby an
increase in upper chest movement was observed in a sit- Limitations
ting position in compensation of a decreased lower chest
movement.48 Debouche et al12 collected information about the physical
Among a mixed population composed of both healthy condition of subjects, considering arbitrarily that these sub-
and unhealthy subjects, all parameters of lung function jects were physically active because they were exercising
(total lung capacity, FVC, and FEV1) were poorly corre- for > 2 h/week. These authors12 found no influence of phys-
lated with chest expansion measurements with the same in- ical status on upper or lower chest expansion (P ¼ .97 and
tensity for lower and upper chest expansion (r ¼ 0.3–0.4) P ¼ .46, respectively).12 However, a broad literature review
(Table 2), which was reported previously.13 On the con- proved the major role of physical capacity on variations in
trary, a stronger correlation between lower chest expansion chest expansion measurements, namely that physically
and lung function than between upper chest expansion and well-conditioned individuals have higher inspiratory muscle
lung function was found within a healthy and young sample strength and lung volumes compared to individuals in poor
(see the supplementary materials at http://www.rcjournal. physical condition.6,50 Also, an increase in chest expansion
com).12,39 The hypothesis is that young age and good health has been observed after muscle training.7,51,52 We did not
favor the correlation between lower chest circumference analyze physical condition in this study. As explained
and lung function because a greater thoracic displacement above, the subject position can influence chest expansion
and compliance is found among these patients compared to measurements.27,46 For ease of handling and secondary to
older individuals, those with respiratory disease, or those improvements in chest movement compared to abdominal
with obesity.2,26,45,46 movement, we chose the sitting position.13,32 Different
A significant and inverse correlation between chest results might have been obtained if a standing or supine
expansion and age was found, especially considering upper position had been used. No data were collected on the state
chest expansion, as observed by several authors.8,11,25,26,49 of pain felt by the subject at the time of the chest expansion
Indeed, the literature describes a decline in lung function measurements. However, it has been observed that a state of
tests (FEV1 and FVC) associated to an increase in chest ri- pain can influence chest expansion values.28,30 We did not
gidity with age.11,49 Ruivo et al25 reported that chest expan- not consider psychometric properties such as reliability or
sion increases from the age of 11 y to 34 y, after which it responsiveness, which were discussed in previous studies.9
begins to drop slowly to around 2.5 among individuals > 74
y old. This decrease in chest wall compliance is related to Conclusions
the calcification of the costal cartilage and the costovertebral
articulations and results in a natural decrease of chest expan- Based on our results, we can not validate the use of chest
sion. Upper chest expansion is more correlated with age expansion measurement to define lung function. In

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developed centers, which have easy access to more precise 17. Permadi AW, Putra IMWA. Comparison of respiratory training meth-
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surement of chest expansion for diagnostic purposes seems monary disease. J Phys Educ Sport 2018;18(4):2230-2234.
18. Fisher LR, Cawley MI, Holgate ST. Relation between chest expan-
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