Breathing Movements of the Chest and Abdominal Wall

in Healthy Subjects
Hideo Kaneko PT PhD and Jun Horie PT PhD

BACKGROUND: Physical assessment of breathing is an important component of physical therapy

evaluations. However, there are no standardized reference values of breathing movements available
for use in clinical practice. The purpose of this study was to determine the 3-dimensional distances
of observational points on the thorax and abdomen during breathing in healthy subjects and to
assess the effects of age, posture, and sex on breathing movements. METHODS: We studied the
3-dimensional breathing movement distances of the thorax and abdomen in 100 healthy subjects
(50 males, 50 females). Breathing movements were measured with a 3-dimensional motion system
during quiet and deep breathing with subjects in supine and sitting positions. Thirteen reflective
markers were placed on the upper (the clavicles, 3rd ribs, and sternal angle) and lower thorax (the
8th ribs, 10th ribs, and xiphoid process) and the abdomen (upper abdomen and lateral abdomen).
Range of movement in both breathing conditions was measured as the 3-dimensional distance at
half respiratory cycle. Respiratory rates were calculated based on the breathing movements ana-
lyzed. One-way analysis of variance, t tests, and multiple regression were used for statistical anal-
ysis. RESULTS: The average marker distances for the thorax and abdomen during quiet breathing
were less than one third of those during deep breathing. Upper thoracic movement was significantly
decreased with age. There was less abdominal movement in females than in males, except during
quiet breathing in the supine position. The distances between the thoracic markers were greater and
those of the abdomen were less during quiet and deep breathing in the sitting position, compared
with those in the supine position. CONCLUSIONS: We found that the observed breathing move-
ments were related to the effects of age, sex, and posture. These findings are in agreement with those
reported in previous studies. The results may be helpful in assessing breathing movement by
physical examination. Key words: breathing; breathing movement; chest wall; abdominal wall; 3-di-
mensional motion analysis; aging; posture; sex. [Respir Care 2012;57(9):1442–1451. © 2012 Daedalus
Enterprises]

Introduction rometry is useful for quantitative assessments of lung vol-

ume and flow, and can be objectively compared with other
In clinical practice, respiratory function is generally eval- spirometric results. Physical examinations, such as inspec-
uated using spirometry and physical examinations. Spi- tion and palpation of respiratory function, provide real-

Congress of the World Confederation for Physical Therapy, held June 23,
Dr Kaneko is affiliated with the Department of Physical Therapy, School 2011, in Amsterdam, The Netherlands.
of Rehabilitation Sciences at Fukuoka, International University of Health
and Welfare, Fukuoka, Japan. Dr Horie is affiliated with the Department The authors have disclosed no conflicts of interest.
of Physical Therapy, Faculty of Rehabilitation, Kobe International Uni-
Correspondence: Hideo Kaneko PT PhD, Department of Physical Ther-
versity, Hyogo, Japan.
apy, School of Rehabilitation Sciences at Fukuoka, International Univer-
This work was partly supported by grant 22500472 from the Japan So- sity of Health and Welfare, 137–1 Enokizu, Okawa-shi, Fukuoka 831-
ciety for the Promotion of Science. 8501, Japan. E-mail: [email protected].

Dr Kaneko presented a version of this paper at the 16th International DOI: 10.4187/respcare.01655

1442 RESPIRATORY CARE • SEPTEMBER 2012 VOL 57 NO 9

 BREATHING MOVEMENTS OF THE CHEST AND ABDOMINAL WALL IN HEALTHY SUBJECTS

time observations and do not require a special measuring

instrument; thus, they are important components of assess- QUICK LOOK
ments in clinical settings. However, physical examinations Current knowledge
are not quantitative and depend on the experience of the
The physical assessment of breathing is important dur-
assessor. Therefore, an objective assessment of breathing
ing physical therapy evaluations. The impact of pos-
movement is difficult because there are no previous re-
ports of reference values that can be used in observational ture, age, and sex on breathing movements complicates
assessments of breathing movement. these assessments.
The breathing movements and patterns reported by pre-
What this paper contributes to our knowledge
vious studies were measured by magnetometers,1,2 respi-
ratory inductive plethysmography,3,4 and optoelectronic A 3-dimensional analysis of thoracic and abdominal
plethysmography.5–9 These methods are used to estimate breathing movements in healthy subjects demonstrated
lung volumes from the chest and abdominal motions. The that patient age, sex, and posture impact both quiet and
respiratory movement measuring instrument,10 –14 which deep breathing movements. These findings may assist
consists of 6 laser distance sensors, has been developed to in future assessment in patients with pulmonary disease.
measure changes in breathing movements of the thorax
and abdomen. However, it is limited to measuring the
anteroposterior diameters of breathing movements. Al-
and Welfare, Fukuoka, Japan. Fifty healthy males and 50
though several previous studies have assessed the 3-di-
healthy females participated in this study. Subjects were
mensional motions of the thorax and abdomen during
recruited from the university, hospital, and general popu-
breathing using infrared cameras15,16 and an electromag-
lation (students, clerks, teachers, healthcare providers, res-
netic device,17 there is no reported literature on the 3-di-
idents). We excluded those with a history of respiratory,
mensional distances of the observational points on the tho-
circulatory, or neurological disorders; smoking; abnormal
rax and abdomen during breathing.
spirogram; respiratory symptoms; or body mass index of
Motion analysis using optical and electromagnetic de-
⬎ 30 kg/m2. The included subjects were divided into 5 age
vices allows accurate measurement of the kinematics of
groups from 20 to 74 years of age: 20 –29 years, 30 –
the chest and abdominal wall in different positions. An
39 years, 40 – 49 years, 50 –59 years, and 60 –74 years.
electromagnetic device requires the use of heavier sensors
Each group included 10 males and 10 females. The study
that are placed on the thorax and abdomen and can be
was approved by the local ethics committee, and all sub-
affected by other devices that produce magnetic fields. On
jects gave their informed consent.
the other hand, optical devices for measuring motion re-
quire only lightweight reflective markers that cause min-
imum interference by the measuring system with the sub- Spirometry
jects. Recently, a study9 using an optical device showed
that posture and sex strongly influenced breathing and Spirometry (HI-801, Chest MI, Tokyo, Japan) was per-
chest wall kinematics. Therefore, we think that optical formed according to American Thoracic Society stan-
devices are more suitable for measurements of the 3-di- dards.18
mensional distances of observational points on the thorax
and abdomen during breathing. Breathing Movement Measurement
We believe that establishing reference values and un-
derstanding the characteristics of the breathing movements Breathing movements were measured using a 3-dimen-
of the chest and abdominal wall are necessary for objec- sional motion system (Vicon MX, Oxford Metrics, Ox-
tive assessments during physical examinations. These could ford, United Kingdom) during quiet breathing and deep
become the foundation for a new assessment tool for use breathing in the supine and sitting positions. This system
in clinical practice. The purpose of this study was to de- consists of 8 infrared cameras that track the movement
termine the 3-dimensional distances of observational points trajectories of 14-mm passive markers attached to the tho-
on the thorax and abdomen during breathing in healthy rax, chest wall, and abdominal wall. The cameras sample
subjects and to assess the effects of age, posture, and sex at a rate of 50 Hz. Motion data were processed using the
on breathing movements. system’s software (Vicon Workstation 5.2.4, Oxford Met-
rics, Oxford, United Kingdom) to produce 3-dimensional
Methods coordinates of each marker. The 3-dimensional coordi-
nates were smoothed using a Woltring filter routine. The
This study was performed at the School of Rehabilita- 3-dimensional distances between the markers were calcu-
tion Sciences at Fukuoka, International University of Health lated using spreadsheet software (Excel, Microsoft, Red-

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 BREATHING MOVEMENTS OF THE CHEST AND ABDOMINAL WALL IN HEALTHY SUBJECTS

mond, Washington). We estimated the resolution to be iners were physical therapy students trained in the mea-
0.1 mm by measuring the signal to noise ratio while the surement procedure. The order of measurements in each
system was recording the position of a static marker. data collection session was randomized between the sub-
Thirteen passive markers were placed along the vertical jects. The subjects were examined in the supine position.
line through the medial one third of the clavicle (CL), the During the measurements the subjects were told to rest
3rd rib (R3), the 8th rib (R8), approximately 3 cm below comfortably and breathe as normally as possible. Between
the costal margin on the lateral abdomen (LAB), along the the measurements the subjects walked a few minutes and
midaxillary line on the 10th rib (R10) bilaterally, and along then returned to the supine position again. Next, the mark-
the vertical line through the umbilicus (the sternal angle ers were placed on the defined points. Bland-Altman plot-
[SA]), the xiphoid process [XP], the midpoint between the ting was performed for the measurement for repeatability.
xiphoid process and umbilicus [abdomen - ABD]). In or- The intra- and inter-rater reliabilities were analyzed using
der to allow natural breathing, we designed the system so the intraclass correlation coefficient (ICC). As a result,
that the markers could be worn on clothing (T-shirt); there were no systemic differences between the 2 mea-
15 ⫻ 1.2 mm magnets were attached to the markers and surements. The ICCs (1,1) were 0.66 – 0.94 with standard
the surface of interest of the thorax and abdomen with error of measurement (SEM) values of 0.31–1.14 mm. The
double-faced adhesive tape. ICCs (2,1) were 0.63– 0.95 with SEMs of 0.34 –1.19 mm.
The range of movement for each of the 2 breathing Most of the ICCs exceeded 0.70, an acceptable level of
conditions was measured as the 3-dimensional distances reliability, except for the right CL (ICC (2,1) 0.68), SA
between markers at half respiratory cycle. The distances (ICC (2,1) 0.69), and the left 10th rib marker (ICC (1,1)
were calculated based on the average values of 5 steady 0.66, ICC (2,1) 0.63).
breathing cycles during quiet breathing and maximal val-
ues of 3 deep breathing movements. Additionally, respi- Statistical Analysis
ratory rates during quiet breathing were also calculated
based on the number of data analyzed. The 3-dimensional Values are expressed as mean ⫾ SD for age, posture,
distances of each marker and the respiratory rates were and sex groups. Paired and unpaired t tests were used to
calculated using spreadsheet software. compare the breathing movements between the supine and
sitting position groups, and between the male and female
Protocol groups, respectively. One-way analysis of variance and the
Tukey multiple comparison test were used to compare the
After the anthropometric and spirometry measurements, breathing movements between the age groups. To further
the subjects were tested for breathing movement. Before assess the clinical importance of the breathing movement
the breathing movement measurements, the subjects were distances between the groups, an effect size coefficient
asked to wear similar T-shirts and to loosen their pants. (␩2, Cohen’s d) was calculated. Multiple regression anal-
Additionally, the female subjects were required to remove ysis was used to assess the associations between breathing
or loosen their bras. The subjects were instructed to remain movement distance in the supine and sitting positions and
as relaxed as possible on a comfortable reclining wheel- age and sex after adjusting for height and weight. Statis-
chair (RR70N, Kawamura Cycle, Kobe, Japan) in the su- tical analyses were performed using statistics software
pine and sitting position, at random, and not to talk or (SPSS 14.0, SPSS, Chicago, Illinois). Values of P ⬍ .05
move during the measurements. Postural change was per- were taken to be significant.
formed by the examiner leaning the backrest of the reclin-
ing wheelchair. During quiet breathing the subjects were Results
told to breathe as normally as possible, and the breathing
movements were recorded for 1 min. Then, during deep Subjects
breathing, the subjects were asked to breathe in and out
slowly up to the maximum and to repeat this pattern 3 The anthropometric and pulmonary functional data di-
times. The breathing movements were recorded during vided according to age and sex groups are summarized in
that time. Table 1. Mean height was significantly less among sub-
jects of the 60 –74-year age group than among subjects of
Measurement Repeatability the 20 –29-year and 40 – 49-year age groups. FVC was
significantly less in the 60 –74-year-old subjects, compared
Ten healthy volunteers (mean ⫾ SD age 22 ⫾ 1 y) were to subjects of the 20 –29-year, 30 –39-year, and 40 – 49-
included in these measurements. All subjects were mea- year age groups. FVC among subjects of the 50 –59-year
sured 3 times. Two of the measurements were performed age group showed a significant decrease, compared to sub-
by one examiner, and the third by another. The 2 exam- jects of the 20 –29-year age group. FEV1 was significantly

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 BREATHING MOVEMENTS OF THE CHEST AND ABDOMINAL WALL IN HEALTHY SUBJECTS

Table 1. Anthropometric Data for the Subjects (50 Males and 50 Females)

Height Weight BMI FVC FVC FEV1 FEV1/FVC

Group Age, y
(m) (kg) (kg/m2) (L) (% predicted) (L) (%)

Age, y
20–29 21.9 ⫾ 1.0 1.66 ⫾ 0.09* 58.6 ⫾ 9.5 21.2 ⫾ 2.4 4.43 ⫾ 1.05‡§ 118 ⫾ 14 4.20 ⫾ 0.95¶ 91 ⫾ 5
30–39 34.0 ⫾ 2.4 1.64 ⫾ 0.09 58.1 ⫾ 9.5 21.6 ⫾ 2.3 4.18 ⫾ 0.98‡ 120 ⫾ 16 3.53 ⫾ 0.78** 85 ⫾ 6
40–49 44.2 ⫾ 2.8 1.65 ⫾ 0.09* 59.8 ⫾ 13.2 21.8 ⫾ 3.2 3.96 ⫾ 0.88† 119 ⫾ 17 3.26 ⫾ 0.69** 83 ⫾ 6
50–59 54.6 ⫾ 2.9 1.62 ⫾ 0.07 59.8 ⫾ 9.3 22.7 ⫾ 3.0 3.53 ⫾ 0.75 110 ⫾ 28 2.96 ⫾ 0.66 84 ⫾ 5
60–74 69.4 ⫾ 4.3 1.57 ⫾ 0.08 56.6 ⫾ 6.7 22.9 ⫾ 1.8 2.92 ⫾ 0.69 106 ⫾ 13 2.64 ⫾ 0.65 81 ⫾ 7
Sex
Male 44.9 ⫾ 17.0 1.69 ⫾ 0.06㛳 65.8 ⫾ 7.7㛳 23.0 ⫾ 2.5㛳 4.48 ⫾ 0.84㛳 114 ⫾ 20 3.78 ⫾ 0.91㛳 83 ⫾ 7
Female 44.7 ⫾ 16.6 1.56 ⫾ 0.06 51.4 ⫾ 5.1 21.1 ⫾ 2.3 3.13 ⫾ 0.68 115 ⫾ 18 2.74 ⫾ 0.68 86 ⫾ 6

Values are expressed as mean ⫾ SD.

* Height was greater in the 20–29 y age group and 40–49 y age group than in the 60–74 y age group (P ⫽ .01 and .04).
† FVC was greater in the 40–49 y age group than in the 60–74 y age group (P ⫽ .003).
‡ FVC was greater in the 20–29 y age group and 30–39 y age group than in the 60–74 y age group (P ⬍ .001).
§ FVC was greater in the 20–29 y age group than in the 50–59 y age group (P ⫽ .02).
㛳 The male group was greater than the female group (P ⬍ .001).
¶ FEV1 was greater in the 20–29 y age group than in the 30–39 y age group (P ⫽ .008) and the other age groups (P ⬍ .001).
** FEV1 was greater in the 30–39 y age group and 40–49 y age group than in the 60–74 y age group (P ⬍ .001).
BMI ⫽ body mass index

higher for the subjects of age 20 –29 years than for sub- of the 20 –29-year age group were significantly greater
jects in the other age groups, and was significantly lower than those in subjects of the 50 –59-year and 60 –74-year
for the subjects of age 60 –74 years than for the subjects of age groups. Conversely, the XP distance in the sitting
age 30 –39 years and those age 40 – 49 years. Height, weight, position was significantly greater in subjects of the 60 –
body mass index, and FVC were significantly greater in 74-year age group than in subjects of the 20 –29-year age
the males than in the females. group. The effect sizes (␩2) for most of the markers except
upper thoracic markers were small (see Table 2).
Marker Distances Using multiple regression analysis, during quiet breath-
ing, there were significant negative relationships between
The distances of the markers on the chest and abdomen marker distance and age for R8 in the supine position and
in each age group are shown in Table 2. The average for CL in the sitting position. During deep breathing there
marker distances were greater for the abdomen than for the were significant negative relationships for CL, SA, and R3
thorax in the 2 positions under the 2 breathing conditions. in the supine position, but not in the sitting position. The
However, the differences in marker distances between the model results for these markers had a moderate R2 values,
thorax and abdomen were smaller in the sitting position ranging from 0.09 (SA during quiet breathing in the sitting
than in the supine position. In the supine position the position) to 0.19 (left CL during deep breathing in the
percentage of quiet breathing marker distances relative to supine position) (Table 3).
deep breathing marker distances ranged from 9.3% to 15.5%
for the thorax and from 24.1% to 27.8% for the abdomen,
Effect of Posture
whereas in the sitting position, the percentages ranged
from 10.9% to 18.1% for the thorax and from 20.6% to
23.1% for the abdomen. All marker distances except for the left R10 during quiet
breathing and left LAB during deep breathing showed sig-
Effect of Age nificant differences between the 2 postures, under both
breathing conditions. The distances of most markers for
When compared between age groups, there were no the thorax were significantly greater in the sitting position
significant differences in all marker distances during quiet than in the supine position, whereas all abdominal marker
breathing between the 2 positions. The distances of the distances were significantly shorter during quiet breathing
bilateral CL and right R3 were significantly greater during than during deep breathing. Conversely, the R10 distances
deep breathing in the supine position among subjects of were shorter during deep breathing in the sitting position
the 20 –29-year age group than among those of the other than in the supine position. Moreover, the effect sizes (d)
age groups. The SA and left R3 distances among subjects for more than half of the markers during quiet breathing

RESPIRATORY CARE • SEPTEMBER 2012 VOL 57 NO 9 1445

 1446
Table 2. Comparisons of Chest and Abdominal Movements With Age

Clavicle Third Rib Eighth Rib Tenth Rib Lateral Abdomen

Xiphoid
Group Sternal Angle Abdomen
Process
Right Left Right Left Right Left Right Left Right Left

Age (supine)
Quiet Breathing
20–29 y (n ⫽ 20) 1.77 ⫾ 0.86 1.83 ⫾ 1.21 2.42 ⫾ 1.42 3.16 ⫾ 1.52 2.96 ⫾ 1.64 2.21 ⫾ 0.88 4.40 ⫾ 1.62 4.04 ⫾ 1.48 3.16 ⫾ 1.38 2.91 ⫾ 1.20 8.07 ⫾ 2.08 6.14 ⫾ 1.99 6.08 ⫾ 1.91
30–39 y (n ⫽ 20) 2.26 ⫾ 1.46 2.16 ⫾ 1.43 2.99 ⫾ 1.59 3.62 ⫾ 1.74 3.35 ⫾ 1.57 3.25 ⫾ 1.44 4.92 ⫾ 1.71 4.53 ⫾ 1.64 4.09 ⫾ 1.42 3.93 ⫾ 1.53 10.02 ⫾ 2.85 7.92 ⫾ 2.75 7.35 ⫾ 2.38
40–49 y (n ⫽ 20) 1.76 ⫾ 1.15 1.72 ⫾ 1.23 2.37 ⫾ 1.38 2.86 ⫾ 1.33 2.87 ⫾ 1.57 2.97 ⫾ 1.43 4.42 ⫾ 1.40 4.21 ⫾ 1.58 3.97 ⫾ 1.33 3.70 ⫾ 1.37 10.32 ⫾ 3.00 7.44 ⫾ 2.38 7.34 ⫾ 2.25
50–59 y (n ⫽ 20) 1.70 ⫾ 1.32 1.56 ⫾ 1.23 2.36 ⫾ 1.61 3.02 ⫾ 2.13 2.81 ⫾ 2.01 2.90 ⫾ 1.52 3.90 ⫾ 1.79 3.67 ⫾ 1.89 3.51 ⫾ 1.53 3.71 ⫾ 1.85 10.31 ⫾ 5.18 7.45 ⫾ 3.35 7.53 ⫾ 4.09
BREATHING MOVEMENTS

60–74 y (n ⫽ 20) 2.08 ⫾ 1.81 1.94 ⫾ 1.54 2.72 ⫾ 2.04 3.46 ⫾ 2.39 3.12 ⫾ 2.17 2.77 ⫾ 1.77 3.94 ⫾ 1.78 3.59 ⫾ 2.02 4.03 ⫾ 1.48 3.61 ⫾ 1.58 10.85 ⫾ 3.30 8.12 ⫾ 2.74 7.34 ⫾ 2.82
Effect size 0.03 0.02 0.02 0.02 0.01 0.06 0.05 0.04 0.06 0.05 0.08 0.07 0.04
Deep Breathing
20–29 y 27.39 ⫾ 6.42 28.03 ⫾ 6.90 32.27 ⫾ 7.20 37.87 ⫾ 7.69 36.45 ⫾ 7.84 31.24 ⫾ 8.37 33.22 ⫾ 10.37 34.15 ⫾ 10.80 28.63 ⫾ 9.35 26.84 ⫾ 9.96 37.27 ⫾ 10.28 29.49 ⫾ 11.46 29.05 ⫾ 11.48
OF THE

30–39 y 20.12 ⫾ 6.76† 19.75 ⫾ 6.65‡ 26.59 ⫾ 8.64 29.92 ⫾ 9.29* 29.42 ⫾ 8.93 26.67 ⫾ 9.83 30.65 ⫾ 11.12 30.81 ⫾ 11.66 26.43 ⫾ 8.86 27.02 ⫾ 9.38 35.39 ⫾ 10.97 30.92 ⫾ 9.61 30.52 ⫾ 9.82
40–49 y 19.99 ⫾ 6.28† 19.98 ⫾ 7.40† 26.91 ⫾ 8.91 30.14 ⫾ 8.17* 30.02 ⫾ 9.02 27.83 ⫾ 10.01 29.80 ⫾ 11.19 29.14 ⫾ 10.96 27.17 ⫾ 10.89 26.65 ⫾ 9.99 37.31 ⫾ 11.05 32.44 ⫾ 11.70 32.00 ⫾ 10.09
50–59 y 19.09 ⫾ 5.36‡ 18.81 ⫾ 5.22‡ 25.04 ⫾ 7.60* 27.81 ⫾ 8.25† 27.44 ⫾ 8.28† 27.08 ⫾ 7.20 27.46 ⫾ 6.92 27.75 ⫾ 7.23 25.86 ⫾ 8.29 26.79 ⫾ 8.18 37.23 ⫾ 13.11 31.23 ⫾ 10.36 32.51 ⫾ 11.41
CHEST

60–74 y 19.29 ⫾ 5.58‡ 18.04 ⫾ 5.48‡ 25.16 ⫾ 6.53* 28.55 ⫾ 6.91† 26.68 ⫾ 6.33† 26.88 ⫾ 6.59 29.85 ⫾ 6.37 28.63 ⫾ 6.10 31.07 ⫾ 9.11 28.67 ⫾ 6.05 39.83 ⫾ 9.05 35.09 ⫾ 8.53 33.56 ⫾ 7.62
Effect size 0.22 0.25 0.11 0.17 0.16 0.04 0.04 0.06 0.04 0.01 0.02 0.03 0.03
AND

Age (sitting)
Quiet Breathing
20–29 y 2.93 ⫾ 1.63 3.13 ⫾ 1.86 3.34 ⫾ 1.87 4.14 ⫾ 2.06 3.93 ⫾ 1.87 3.01 ⫾ 1.36 5.14 ⫾ 1.74 4.54 ⫾ 1.38 4.12 ⫾ 1.73 3.39 ⫾ 1.28 7.22 ⫾ 3.30 5.57 ⫾ 2.60 5.27 ⫾ 2.57
30–39 y 2.85 ⫾ 1.37 2.93 ⫾ 1.46 2.93 ⫾ 1.33 3.64 ⫾ 1.45 3.45 ⫾ 1.55 3.96 ⫾ 1.97 5.55 ⫾ 1.86 5.11 ⫾ 1.67 4.51 ⫾ 1.98 4.43 ⫾ 2.53 7.69 ⫾ 3.50 6.16 ⫾ 2.94 6.30 ⫾ 3.23
40–49 y 2.75 ⫾ 1.83 2.67 ⫾ 1.97 3.00 ⫾ 1.97 3.60 ⫾ 2.21 3.44 ⫾ 2.01 3.56 ⫾ 1.98 4.73 ⫾ 2.03 4.66 ⫾ 1.86 4.09 ⫾ 2.46 3.87 ⫾ 2.65 6.59 ⫾ 2.34 5.40 ⫾ 2.42 5.73 ⫾ 2.64
50–59 y 2.40 ⫾ 1.49 2.26 ⫾ 1.32 2.87 ⫾ 1.74 3.25 ⫾ 1.75 3.44 ⫾ 1.79 4.21 ⫾ 1.94 4.95 ⫾ 2.02 4.61 ⫾ 2.07 3.74 ⫾ 2.33 3.21 ⫾ 2.10 5.25 ⫾ 2.97 4.26 ⫾ 2.57 4.37 ⫾ 2.41
60–74 y 2.22 ⫾ 1.41 2.23 ⫾ 1.26 2.86 ⫾ 1.44 3.69 ⫾ 1.96 3.29 ⫾ 1.44 3.78 ⫾ 1.84 4.98 ⫾ 2.00 4.41 ⫾ 1.69 5.15 ⫾ 3.29 3.83 ⫾ 1.93 7.30 ⫾ 3.11 6.28 ⫾ 2.86 6.02 ⫾ 2.37
Effect size 0.03 0.05 0.01 0.02 0.02 0.05 0.02 0.02 0.02 0.04 0.08 0.07 0.06
Deep Breathing
ABDOMINAL WALL

20–29 y 21.44 ⫾ 7.29 21.84 ⫾ 6.66 25.95 ⫾ 8.19 30.56 ⫾ 9.60 29.65 ⫾ 8.94 24.24 ⫾ 11.13 29.22 ⫾ 10.55 29.95 ⫾ 9.97 24.59 ⫾ 9.64 23.18 ⫾ 8.84 32.88 ⫾ 6.11 27.70 ⫾ 8.02 27.71 ⫾ 7.92
IN

30–39 y 28.10 ⫾ 10.24 28.23 ⫾ 10.08 30.76 ⫾ 10.24 34.16 ⫾ 11.27 33.62 ⫾ 10.43 30.23 ⫾ 10.02 33.93 ⫾ 10.86 33.71 ⫾ 11.02 25.28 ⫾ 8.77 25.90 ⫾ 10.14 35.37 ⫾ 13.60 30.62 ⫾ 11.53 30.90 ⫾ 11.88
40–49 y 25.41 ⫾ 9.14 24.47 ⫾ 9.15 28.00 ⫾ 10.59 31.89 ⫾ 10.76 30.85 ⫾ 11.04 28.28 ⫾ 11.80 29.46 ⫾ 14.57 29.31 ⫾ 13.50 25.84 ⫾ 12.87 24.53 ⫾ 14.03 30.61 ⫾ 14.14 28.35 ⫾ 14.22 28.84 ⫾ 14.00
50–59 y 27.90 ⫾ 9.21 27.08 ⫾ 8.79 30.74 ⫾ 10.36 33.63 ⫾ 11.20 32.98 ⫾ 10.24 32.49 ⫾ 12.83 32.26 ⫾ 10.46 32.45 ⫾ 10.63 25.86 ⫾ 13.06 25.67 ⫾ 13.56 32.06 ⫾ 15.38 28.58 ⫾ 14.31 29.45 ⫾ 14.47
60–74 y 28.97 ⫾ 9.95 28.37 ⫾ 9.74 33.29 ⫾ 10.68 34.83 ⫾ 10.13 34.37 ⫾ 10.76 35.61 ⫾ 11.08* 36.15 ⫾ 10.52 35.22 ⫾ 12.17 28.30 ⫾ 10.05 27.99 ⫾ 10.44 33.43 ⫾ 12.14 31.70 ⫾ 12.84 32.58 ⫾ 12.10
Effect size 0.09 0.08 0.06 0.02 0.03 0.11 0.05 0.04 0.01 0.02 0.02 0.02 0.02

Values are expressed as mean ⫾ SD.

* There was a significant difference, compared with the 20–29 y age group in marker distances (P ⫽ .02–.04).
† There was a significant difference, compared with the 20–29 y age group in marker distances (P ⫽ .001–.004).
‡ There was a significant difference, compared with the 20–29 y age group in marker distances (P ⬍ .001).
HEALTHY SUBJECTS

RESPIRATORY CARE • SEPTEMBER 2012 VOL 57 NO 9

 Table 3. Results of Age and Sex Regression Model With Height and Weight as Covariates in the Supine and Sitting Positions

Clavicle Third Rib Eighth Rib Tenth Rib Lateral Abdomen

Group Sternal Angle Xiphoid Process Abdomen
Right Left Right Left Right Left Right Left Right Left

Supine
Quiet Breathing
R2 0.11 0.10 0.07 0.12 0.08 0.13 0.14 0.13 0.03 0.03 0.16 0.12 0.09
Intercept 9.25 ⫾ 4.31* 9.10 ⫾ 4.25* 6.36 ⫾ 5.29 11.51 ⫾ 5.88 8.55 ⫾ 5.82 11.62 ⫾ 4.61* 9.96 ⫾ 5.29 12.34 ⫾ 5.51* 2.98 ⫾ 4.56 3.91 ⫾ 5.14 20.54 ⫾ 10.93 13.15 ⫾ 8.47 14.84 ⫾ 9.07
Age –0.01 ⫾ 0.01 –0.01 ⫾ 0.01 –0.00 ⫾ 0.01 –0.01 ⫾ 0.01 –0.01 ⫾ 0.01 –0.00 ⫾ 0.01 –0.02 ⫾ 0.01* –0.02 ⫾ 0.01* 0.01 ⫾ 0.01 0.01 ⫾ 0.01 0.03 ⫾ 0.02 0.02 ⫾ 0.02 0.01 ⫾ 0.02
Sex 0.38 ⫾ 0.45 0.28 ⫾ 0.45 0.64 ⫾ 0.56 0.83 ⫾ 0.62 0.71 ⫾ 0.61 0.37 ⫾ 0.48 0.88 ⫾ 0.55 0.62 ⫾ 0.58 0.32 ⫾ 0.51 0.11 ⫾ 0.54 –1.76 ⫾ 1.15 –1.10 ⫾ 0.89 –0.45 ⫾ 0.95
BREATHING MOVEMENTS

Height –5.34 ⫾ 2.53* –4.76 ⫾ 2.49 –3.21 ⫾ 3.11 –6.98 ⫾ 3.45* –4.72 ⫾ 3.42 –6.81 ⫾ 2.71* –4.16 ⫾ 3.11 –5.60 ⫾ 3.24 –0.05 ⫾ 2.85 –1.62 ⫾ 3.02 –10.21 ⫾ 6.42 –6.98 ⫾ 4.97 –8.19 ⫾ 5.33
Weight 0.03 ⫾ 0.02 0.01 ⫾ 0.02 0.02 ⫾ 0.03 0.05 ⫾ 0.03 0.04 ⫾ 0.03 0.04 ⫾ 0.02 0.03 ⫾ 0.03 0.03 ⫾ 0.03 0.00 ⫾ 0.02 0.03 ⫾ 0.03 0.92 ⫾ 0.05 0.09 ⫾ 0.04* 0.09 ⫾ 0.04*
Deep Breathing
R2 0.15 0.19 0.10 0.14 0.17 0.12 0.13 0.18 0.13 0.24 0.21 0.30 0.28
OF THE

Intercept 43.12 ⫾ 21.20* 41.47 ⫾ 22.08 54.72 ⫾ 26.13* 59.07 ⫾ 27.54* 51.48 ⫾ 26.99 28.85 ⫾ 27.11 31.00 ⫾ 29.85 30.72 ⫾ 29.79 29.27 ⫾ 29.62 9.52 ⫾ 25.83 51.40 ⫾ 32.69 49.02 ⫾ 29.53 53.50 ⫾ 29.13
Age –0.16 ⫾ 0.04‡ –0.19 ⫾ 0.05‡ –0.16 ⫾ 0.05† –0.20 ⫾ 0.06‡ –0.20 ⫾ 0.06‡ –0.08 ⫾ 0.06 –0.09 ⫾ 0.06 0.12 ⫾ 0.06 0.03 ⫾ 0.06 0.04 ⫾ 0.05 0.02 ⫾ 0.07 0.06 ⫾ 0.06 0.05 ⫾ 0.06
Sex –2.55 ⫾ 2.23 –3.25 ⫾ 2.32 –3.89 ⫾ 2.74 –3.66 ⫾ 2.89 –4.71 ⫾ 2.83 –3.38 ⫾ 2.85 –4.85 ⫾ 3.13 –5.96 ⫾ 3.13 –6.48 ⫾ 3.11* –6.11 ⫾ 2.71* –6.55 ⫾ 3.43 –7.78 ⫾ 3.10† –8.31 ⫾ 3.06†
CHEST

Height –5.96 ⫾ 12.45 –2.46 ⫾ 12.97 –10.25 ⫾ 15.34 –11.00 ⫾ 16.12 –3.89 ⫾ 15.85 –2.17 ⫾ 15.92 0.86 ⫾ 17.53 2.82 ⫾ 17.49 –0.02 ⫾ 17.39 9.38 ⫾ 15.16 –19.17 ⫾ 19.19 –22.19 ⫾ 17.34 –22.69 ⫾ 17.10

RESPIRATORY CARE • SEPTEMBER 2012 VOL 57 NO 9

Weight –0.06 ⫾ 0.10 –0.11 ⫾ 0.11 –0.03 ⫾ 0.13 0.01 ⫾ 0.13 –0.07 ⫾ 0.13 0.13 ⫾ 0.13 0.07 ⫾ 0.15 0.05 ⫾ 0.15 0.01 ⫾ 0.14 0.07 ⫾ 0.13 0.33 ⫾ 0.16* 0.35 ⫾ 0.14* 0.29 ⫾ 0.14*
Sitting
AND

Quiet Breathing
R2 0.10 0.09 0.04 0.03 0.02 0.15 0.08 0.06 0.11 0.07 0.16 0.19 0.16
Intercept 11.08 ⫾ 5.00* 12.15 ⫾ 5.22* 10.71 ⫾ 5.53 11.76 ⫾ 6.32 7.83 ⫾ 5.79 17.41 ⫾ 5.77† 20.06 ⫾ 6.23† 14.76 ⫾ 5.71* 18.55 ⫾ 7.74* 11.84 ⫾ 7.07 25.37 ⫾ 9.73* 21.21 ⫾ 8.30* 14.75 ⫾ 8.39
Age –0.03 ⫾ 0.01* –0.03 ⫾ 0.01† –0.02 ⫾ 0.01 –0.02 ⫾ 0.01 –0.02 ⫾ 0.01 –0.00 ⫾ 0.01 –0.02 ⫾ 0.01 –0.02 ⫾ 0.01 0.00 ⫾ 0.02 –0.01 ⫾ 0.02 –0.03 ⫾ 0.02 –0.01 ⫾ 0.02 –0.01 ⫾ 0.02
Sex 0.26 ⫾ 0.52 –0.08 ⫾ 0.55 0.03 ⫾ 0.58 –0.14 ⫾ 0.66 –0.02 ⫾ 0.61 0.09 ⫾ 0.61 0.59 ⫾ 0.65 0.16 ⫾ 0.60 –2.42 ⫾ 0.81† –1.82 ⫾ 0.74* –4.07 ⫾ 1.02‡ –3.77 ⫾ 0.87‡ –3.11 ⫾ 0.88‡
Height –6.13 ⫾ 2.94* –5.48 ⫾ 3.06 –5.10 ⫾ 3.25 –4.77 ⫾ 3.71 –2.65 ⫾ 3.40 –10.97 ⫾ 3.39† –10.09 ⫾ 3.66† –7.00 ⫾ 3.35* –7.40 ⫾ 4.55 –2.88 ⫾ 4.15 –4.97 ⫾ 5.71 –5.47 ⫾ 4.87 –2.48 ⫾ 4.92
Weight 0.04 ⫾ 0.02 0.01 ⫾ 0.03 0.02 ⫾ 0.03 0.01 ⫾ 0.03 0.01 ⫾ 0.03 0.07 ⫾ 0.03* 0.05 ⫾ 0.03 0.04 ⫾ 0.03 –0.02 ⫾ 0.04 –0.04 ⫾ 0.04 –0.12 ⫾ 0.05* –0.07 ⫾ 0.04 –0.06 ⫾ 0.04
Deep Breathing
R2 0.20 0.18 0.18 0.16 0.16 0.28 0.21 0.26 0.21 0.24 0.19 0.26 0.25
ABDOMINAL WALL

Intercept 80.22 ⫾ 28.74† 79.78 ⫾ 28.13† 87.94 ⫾ 31.28† 91.60 ⫾ 32.83† 81.32 ⫾ 31.95* 98.82 ⫾ 34.00† 89.41 ⫾ 34.99* 77.37 ⫾ 33.66* 29.50 ⫾ 32.74 26.45 ⫾ 33.99 56.60 ⫾ 38.32 36.07 ⫾ 35.84 43.00 ⫾ 35.86
IN

Age 0.06 ⫾ 0.06 0.33 ⫾ 0.06 0.06 ⫾ 0.06 0.00 ⫾ 0.07 0.02 ⫾ 0.07 0.13 ⫾ 0.07 0.04 ⫾ 0.07 0.02 ⫾ 0.07 0.05 ⫾ 0.07 0.06 ⫾ 0.07 –0.05 ⫾ 0.08 0.03 ⫾ 0.07 0.04 ⫾ 0.07
Sex –5.94 ⫾ 3.02 –6.54 ⫾ 2.95* –7.32 ⫾ 3.28* –6.86 ⫾ 3.45* –7.06 ⫾ 3.35* –8.19 ⫾ 3.57* –10.49 ⫾ 3.67† –9.89 ⫾ 3.53† –8.25 ⫾ 3.43* –8.51 ⫾ 3.59* –10.15 ⫾ 4.02* –9.81 ⫾ 3.76* –9.09 ⫾ 3.77*
Height –44.53 ⫾ 16.87* –41.55 ⫾ 16.51* –44.99 ⫾ 18.36* –45.66 ⫾ 19.28* –38.50 ⫾ 18.76* –55.94 ⫾ 19.97† –42.01 ⫾ 20.55* –38.06 ⫾ 19.76 –6.63 ⫾ 19.22 –7.23 ⫾ 19.96 –16.32 ⫾ 22.50 –10.63 ⫾ 21.04 –17.28 ⫾ 21.05
Weight 0.33 ⫾ 0.14* 0.27 ⫾ 0.14 0.28 ⫾ 0.15 0.33 ⫾ 0.16* 0.28 ⫾ 0.16 0.46 ⫾ 0.17† 0.25 ⫾ 0.17 0.35 ⫾ 0.16* 0.15 ⫾ 0.16 0.21 ⫾ 0.17 0.17 ⫾ 0.19 0.24 ⫾ 0.17 0.30 ⫾ 0.17

Results of the multiple regressions are presented as regression coefficient ⫾ standard error.
Sex: 0 ⫽ male, 1 ⫽ female.
* P ⫽ .01–.049.
† P ⫽ .002–.008.
‡ P ⬍ .001.
HEALTHY SUBJECTS

1447
 BREATHING MOVEMENTS OF THE CHEST AND ABDOMINAL WALL IN HEALTHY SUBJECTS

were moderate, and those of for most of the markers dur- deep breathing and lower thoracic movement during quiet
ing deep breathing were small (Table 4). breathing in the supine position decreased with age, except
during quiet breathing in the supine position; there was
Effect of Sex less abdominal movement in females than in males. These
observed data should be useful for the clinical assessment
During quiet breathing in the supine position the male of breathing movement during physical examinations, be-
group had significantly shorter distances for the thoracic cause the breathing movement that we generally observe is
markers (except for R10), and significantly greater dis- a 3-dimensional movement involving local regions of the
tances for the abdominal markers (except for the left LAB), chest and abdominal wall.
compared to the female group. In the sitting position the We measured the 3-dimensional distances of the tho-
R10 and abdominal marker distances were greater in the racic and abdominal markers to determine reference val-
male group than in the female group. During deep breath- ues of breathing movements that could be used for phys-
ing in the supine position the distances of all markers ical examinations, such as palpation and inspection.
except for the CL, SA, and R3 were significantly greater in Previous studies designed to measure specific points on
the male group than in the female group. In the sitting the chest and abdominal walls have mainly analyzed the
position there were significantly greater distances for all anteroposterior and mediolateral displacements. However,
markers in the male group than in the female group. The it has been reported that displacement of the ventral part of
effect sizes (d) for most of the markers except the upper the rib cage during quiet breathing primarily occurred in
thoracic markers during deep breathing in the supine po- the anteroposterior and craniocaudal directions.19 Leong
sition and during quiet breathing in the sitting position et al16 showed that the mean displacements of thoracic and
were from moderate to large (see Table 4). abdominal markers were greater in the craniocaudal direc-
By multiple regression analysis, during quiet breathing tion than in other directions during deep breathing. We
there were significant negative relationships between think that measuring only unidirectional displacements
marker distance and sex for R10, ABD, and LAB in the would be insufficient for assessments of breathing move-
sitting position, but there were no significant relationships ments for various breathing patterns.
for any of the markers in the supine position. During deep In this study, the intra- and inter-rater reliabilities of the
breathing there were significant negative relationships for marker distance measurements were acceptable. A previ-
R10 and LAB in the supine position and for all markers ous study20 that used the respiratory movement measuring
except for CL in the sitting position. The model results for instrument showed that the correlation for the left lower
markers with significant relationships between marker dis- thoracic sensor was poor, whereas the correlations for the
tance and sex had better than moderate R2 values, ranging thoracic and abdominal wall sensors were moderate to
from 0.09 (SA during quiet breathing in the supine posi- strong. We found that the ICCs of the left lower thoracic
tion) to 0.30 (right LAB in the supine position) (see Ta- markers were the lowest of all markers, which is consistent
ble 3). with the previous study’s findings; however, the values in
this study were apparently higher than those reported by
Respiratory Rate Olsén and Romberg.20 We assume that this difference was
caused by differences in the measuring methods. In our
Between the 2 positions during quiet breathing the mean method the 3-dimensional distances of the breathing move-
respiratory rates were significantly higher in the sitting ment markers were measured, which provided potentially
than in the supine position (15.4 ⫾ 3.6 breaths/min and more complete characterizations of the various breathing
14.6 ⫾ 3.7 breaths/min, respectively). However, no sig- movements.
nificant differences were found between the sex and age During deep breathing in the supine position the tho-
groups. racic movement distances decreased with age. The results
of this study are consistent with previous studies,4,21 which
Discussion used different measurement devices. Verschakelen and
Demedts,4 using respiratory inductive plethysmography,
To our knowledge, this is the first study to report 3-di- showed that males of ⬎ 50 years of age in particular had
mensional distances of observational points on the thorax shorter breathing movement distances for their rib cages.
and abdomen during quiet and deep breathing. These find- Moll and Wright21 showed, using calipers, that anteropos-
ings confirm and expand upon previous observations re- terior chest expansion reduced with age in normal sub-
garding breathing movements. In particular, the average jects. These results appear to be attributed to age-related
marker distances for the thorax and abdomen during quiet decreases in chest wall compliance22 and respiratory mus-
breathing were less than one third of those during deep cle strength.23–25 On the other hand, in the sitting position,
breathing. In addition, upper thoracic movement during while there was no significant relationship between breath-

1448 RESPIRATORY CARE • SEPTEMBER 2012 VOL 57 NO 9

 Table 4. Comparisons of Chest and Abdominal Movements With Posture and Sex

Clavicle Third Rib Eighth Rib Tenth Rib Lateral Abdomen

Xiphoid
Group Sternal Angle Abdomen
Process
Right Left Right Left Right Left Right Left Right Left

Posture
(n ⫽ 100)
Quiet Breathing
Supine 1.91 ⫾ 1.35 1.84 ⫾ 1.32 2.57 ⫾ 1.61 3.23 ⫾ 1.85 3.02 ⫾ 1.78 2.82 ⫾ 1.45 4.32 ⫾ 1.67 4.01 ⫾ 1.73 3.75 ⫾ 1.45 3.57 ⫾ 1.53 9.91 ⫾ 3.50 7.41 ⫾ 2.72 7.13 ⫾ 2.79
Sitting 2.63 ⫾ 1.55‡ 2.64 ⫾ 1.61‡ 3.00 ⫾ 1.66† 3.67 ⫾ 1.89* 3.51 ⫾ 1.72† 3.70 ⫾ 1.84‡ 5.07 ⫾ 1.91‡ 4.67 ⫾ 1.73‡ 4.32 ⫾ 2.41* 3.75 ⫾ 2.15 6.81 ⫾ 3.13‡ 5.53 ⫾ 2.73‡ 5.54 ⫾ 2.69‡
BREATHING MOVEMENTS

Effect size 0.50 0.55 0.26 0.24 0.28 0.53 0.42 0.38 0.29 0.10 0.94 0.69 0.58
Deep Breathing
Supine 21.18 ⫾ 6.75 20.92 ⫾ 7.24 27.20 ⫾ 8.12 30.86 ⫾ 8.72 30.00 ⫾ 8.70 27.94 ⫾ 8.51 30.19 ⫾ 9.43 30.09 ⫾ 9.69 27.83 ⫾ 9.34 27.20 ⫾ 8.69 37.41 ⫾ 10.84 31.84 ⫾ 10.36 31.53 ⫾ 10.10
Sitting
OF THE

26.36 ⫾ 9.44‡ 26.00 ⫾ 9.14‡ 29.75 ⫾ 10.18†㛳 33.02 ⫾ 10.51* 32.29 ⫾ 10.25* 30.17 ⫾ 11.82* 32.20 ⫾ 11.58* 32.13 ⫾ 11.51* 25.97 ⫾ 10.87* 25.46 ⫾ 11.46* 32.87 ⫾ 12.54‡ 29.39 ⫾ 12.25† 29.90 ⫾ 12.16
Effect size 0.63 0.62 0.28 0.22 0.34 0.22 0.19 0.19 0.18 0.17 0.39 0.22 0.15
Sex (supine)
Quiet Breathing
CHEST

RESPIRATORY CARE • SEPTEMBER 2012 VOL 57 NO 9

Male (n ⫽ 50) 1.57 ⫾ 1.22 1.49 ⫾ 1.19 2.21 ⫾ 1.52 2.74 ⫾ 1.71 2.63 ⫾ 1.65 2.49 ⫾ 1.18 3.82 ⫾ 1.42 3.53 ⫾ 1.51 3.61 ⫾ 1.33 3.65 ⫾ 1.39 10.81 ⫾ 3.55 80.16 ⫾ 2.80 7.48 ⫾ 2.81
Female (n ⫽ 50) 2.26 ⫾ 1.39† 2.19 ⫾ 1.37† 2.94 ⫾ 1.64* 3.71 ⫾ 1.87† 3.42 ⫾ 1.84* 3.15 ⫾ 1.62* 4.81 ⫾ 1.77† 4.49 ⫾ 1.82† 3.89 ⫾ 1.56 3.49 ⫾ 1.67 9.01 ⫾ 3.24† 6.67 ⫾ 2.44† 6.77 ⫾ 2.76
AND

Effect size 0.53 0.55 0.44 0.54 0.45 0.47 0.62 0.58 0.19 0.10 0.53 0.57 0.26
Deep Breathing
Male 21.62 ⫾ 6.57 21.60 ⫾ 7.16 28.26 ⫾ 8.16 32.02 ⫾ 9.10 31.61 ⫾ 8.80 30.44 ⫾ 9.08 33.18 ⫾ 10.01 33.62 ⫾ 10.45 31.14 ⫾ 7.83 31.32 ⫾ 7.63 41.88 ⫾ 9.96 36.82 ⫾ 9.02 36.34 ⫾ 8.37
Female 20.74 ⫾ 6.97 20.25 ⫾ 7.32 26.13 ⫾ 8.01 29.69 ⫾ 8.25 28.40 ⫾ 8.38 25.44 ⫾ 7.15† 27.21 ⫾ 7.81† 26.57 ⫾ 7.42‡ 24.52 ⫾ 9.62‡ 23.07 ⫾ 7.72‡ 32.93 ⫾ 9.87‡ 26.86 ⫾ 9.21‡ 26.72 ⫾ 9.42‡
Effect size 0.13 0.19 0.26 0.27 0.38 0.61 0.67 0.78 0.76 1.08 0.91 1.10 1.09
Sex (sitting)
Quiet Breathing
Male 2.43 ⫾ 1.58 2.44 ⫾ 1.60 2.86 ⫾ 1.73 3.50 ⫾ 2.03 3.44 ⫾ 1.87 3.48 ⫾ 1.85 5.07 ⫾ 1.92 4.58 ⫾ 1.67 4.95 ⫾ 2.52 4.22 ⫾ 2.06 7.65 ⫾ 3.31 6.55 ⫾ 2.53 6.52 ⫾ 2.62
Female 2.84 ⫾ 1.50 2.85 ⫾ 1.60 3.15 ⫾ 1.60 3.84 ⫾ 1.73 3.58 ⫾ 1.58 3.93 ⫾ 1.83 5.06 ⫾ 1.93 4.76 ⫾ 1.80 3.70 ⫾ 2.15† 3.28 ⫾ 2.16* 5.97 ⫾ 2.71† 4.51 ⫾ 2.54‡ 4.55 ⫾ 2.41‡
Effect size 0.27 0.26 0.17 0.18 0.08 0.25 0.01 0.12 0.54 0.45 0.56 0.81 0.79
ABDOMINAL WALL

Deep Breathing
IN

Male 28.88 ⫾ 9.76 28.58 ⫾ 9.50 32.56 ⫾ 11.03 35.93 ⫾ 11.07 35.42 ⫾ 10.93 34.05 ⫾ 12.38 36.63 ⫾ 11.89 37.22 ⫾ 11.77 30.80 ⫾ 10.86 30.75 ⫾ 10.90 38.17 ⫾ 11.56 35.36 ⫾ 11.33 35.54 ⫾ 11.42
Female 23.85 ⫾ 8.48† 23.42 ⫾ 8.05† 26.93 ⫾ 8.45† 30.10 ⫾ 9.14† 29.16 ⫾ 8.54† 26.30 ⫾ 9.92‡ 27.77 ⫾ 9.45‡ 27.04 ⫾ 8.74¶ 21.15 ⫾ 8.56‡ 20.16 ⫾ 9.44‡ 27.57 ⫾ 11.26‡ 23.42 ⫾ 10.08‡ 24.25 ⫾ 10.18‡
Effect size 0.55 0.59 0.58 0.58 0.64 0.69 0.83 0.99 0.99 1.04 0.93 1.12 1.05

Values are expressed as mean ⫾ SD.

* There was a significant difference, compared with the supine position or the male group, in marker distances (P ⫽ .01–.03).
† There was a significant difference, compared with the supine position or the male group, in marker distances (P ⫽ .001–.009).
‡ There was a significant difference, compared with the supine position or the male group, in marker distances (P ⬍ .001).
HEALTHY SUBJECTS

1449
 BREATHING MOVEMENTS OF THE CHEST AND ABDOMINAL WALL IN HEALTHY SUBJECTS

ing movement and age, movements in the XP distance we assumed that the marker distances of the lower thorax
significantly increased in the elderly group. These results were greater in the male subjects. In the sitting position,
are contrary to those for the supine position. Considering female subjects had significantly decreased upper thoracic
that no significant differences were observed in the chest movement, and there were significant negative relation-
wall movement marker distances, it is possible that limited ships between upper thoracic movement and sex. Although
chest movement in the elderly subjects was compensated the reason for this is not clear, it is possible that the tho-
by movements that were elicited in the sitting position, for racic movement for the male was overestimated by adding
which spinal flexion movement is easier during deep breath- spinal flexion movement, because the increase in average
ing, even though the subjects were instructed not to move thoracic marker distance was greater in male subjects than
during measurement. Therefore we believe that these re- in female subjects. Thus, we believe that there were no
sults were derived from limited chest movement accom- sex-related differences in upper thoracic movement.
panying aging. This study showed that posture had an influence on
In contrast, during quiet breathing there were no signif- breathing movements during quiet breathing. This finding
icant relationships between most of the marker distances is consistent with those of previous studies that have shown
and age, as observed in previous studies. However, R8 in that the contribution of the rib cage to tidal volume was
the supine position and CL in the sitting position were greater in the sitting position than in the supine posi-
significantly associated with age. Although we do not have tion.1,4,9,26 This effect has been explained by the decreased
a reasonable explanation for these results, we assume that compliance of the rib cage and increased compliance of
these could readily be influenced by limited chest move- the diaphragm and abdomen that results with the change in
ment, which might be dependent on posture. position from sitting to supine.22,29 During deep breathing
When compared by sex, we found that there were sig- the results we observed are in line with those of a previous
nificantly greater thoracic marker distances and signifi- study reported by Verschakelen and Demedts,4 indicating
cantly shorter abdominal marker distances in the female that the rib cage dominance in breathing patterns was greater
subjects than in the male subjects during quiet breathing in during deep breathing than during quiet breathing. How-
the supine position. Our findings were in line with those of ever, the changes in the R10 marker distances between the
previous studies,2,8,9,26,27 which have shown that females 2 positions were opposite to those observed during quiet
have a wider rib cage and lower abdominal contributions breathing. The cause of this difference is not known. Pos-
to tidal volume than males during quiet breathing. How- sible causes are more predominant rib cage breathing and
ever, in multiple models there were no significant rela- higher lung volumes. Loring and Mead28 showed that the
tionships between breathing movement during quiet breath- inspiratory action of the diaphragm on the rib cage was
ing in the supine position and sex. Verschakelen and greatest at low lung volumes. Accordingly, during deep
Demedts4 showed that there were no sex-related differ- breathing, which involves higher lung volumes and rela-
ences in thoracic and abdominal movements during quiet tively greater rib cage movement, expansion of the lower
breathing. These discrepancies might be related to the types rib cage seems to be more difficult in the sitting position
of measuring instruments that were used. Finally, from the than in the supine position.
present results it could be said that breathing movement As described above, most of our findings regarding the
during quiet breathing in the supine position is influenced effects of age, sex, and posture are in agreement with those
by body size rather than sex, because the breathing pattern of previous studies. We found that the 3-dimensional dis-
is predominantly diaphragmatic in the supine position.4 tances of the thoracic and abdominal markers can repre-
The present study also showed that during deep breath- sent the variable features of breathing movements. There-
ing the lower thoracic and abdominal marker distances fore we assume that the observed data should be useful for
were significantly shorter in the female subjects than in the observational assessments of breathing movement during
male subjects in the supine position. Furthermore, there physical examinations, and for which it will be necessary
were also significant relationships between lower thoracic to develop a new clinical assessment tool that specifies
and abdominal movement and sex. Ragnarsdóttir and Kris- positions, observation point, graded scaling, and other fac-
tinsdóttir11 reported that abdominal, but not lower tho- tors. However, the sample size in this study was relatively
racic, movements were significantly less during deep small and the individual variability in the breathing move-
breathing in females than in males. Verschakelen and ments was large. Given that the observed values in the
Demedts4 found that females exhibited slightly more rib present study were not considerably different from the
cage movement during deep breathing. In other words, range of previously presented values, they might be used
during deep breathing males would show predominantly as reference values in assessing breathing movements.
diaphragmatic breathing, compared to females. The dia- Moreover, in this study the tidal volume during quiet breath-
phragm has a mechanism of expansion that involves not ing was not measured, in order to avoid unnatural breath-
only the abdomen but also the lower thorax.28 Therefore ing. We therefore cannot discuss the effect of tidal volume

1450 RESPIRATORY CARE • SEPTEMBER 2012 VOL 57 NO 9

 BREATHING MOVEMENTS OF THE CHEST AND ABDOMINAL WALL IN HEALTHY SUBJECTS

on breathing movement. In previous studies there were no 10. Ragnarsdóttir M, Kristjansdóttir A, Ingvarsdóttir I, Hannesson P,
significant effects of age and posture on tidal volume, and Torfason B, Cahalin L. Short-term changes in pulmonary function
and respiratory movements after cardiac surgery via median sternot-
of sex on normalized tidal volume, and there were no
omy. Scand Cardiovasc J 2004;38(1):46-52.
significant differences in respiratory rates.9,25 Considering 11. Ragnarsdóttir M, Kristinsdóttir EK. Breathing movements and breath-
that respiratory rates were significantly higher in the sit- ing patterns among healthy men and women 20-69 years of age.
ting position than in the supine position, it is possible that Reference values. Respiration 2006;73(1):48-54.
the tidal volume was lower when sitting than when supine, 12. Ragnarsdóttir M, Geirsson AJ, Gudbjornsson B. Rib cage motion in
ankylosing spondylitis patients: a pilot study. Spine J 2008;8(3):505-
assuming that minute ventilation was the same between
509.
the 2 positions. However, we believe that there was little 13. Kristjansdóttir A, Ragnarsdóttir M, Hannesson P, Beck HJ, Torfason
effect on tidal volume because the differences in respira- B. Chest wall motion and pulmonary function are more diminished
tory rates were small. following cardiac surgery when the internal mammary artery retrac-
tor is used. Scand Cardiovasc J 2004;38(6):369-374.
14. Kristjansdóttir A, Ragnarsdóttir M, Hannesson P, Beck HJ, Torfason
Conclusions
B. Respiratory movements are altered three months and one year
following cardiac surgery. Scand Cardiovasc J 2004;38(2):98-103.
In this study, we measured the 3-dimensional distances 15. Ferrigno G, Carnevali P, Aliverti A, Molteni F, Beulcke G, Pedotti
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