Airflow limitation: clinical examination helped diagnosis, but did not help rule it out.

Clinical bottom line (level 2a)

  1. In patients with suspected airflow limitation, presence of barrel chest, decreased cardiac dullness, match test and rhonchi made airflow limitation more likely, and presence of wheezing made it much more likely.
  2. A history of smoking 70 or more pack-years made airflow limitation more likely.
  3. Presence of other symptoms or history of symptoms made airflow limitation slightly more likely.
  4. The absence of any of the physical or history symptoms did not help rule out airflow limitation.
Holleman and Simel: Journal of the American Medical Association 1995; 273 (4): 313-319
Expires May 2003

The study

Systematic review of all of
  • Patients: suspected airflow limitation
  • Intervention: clinical examination
  • Outcome: diagnosis
Articles found in English using MEDLINE, ? (search terms: medical history taking; physical examination; lung disease, obstructive )

Selection criteria: as above
Appraisal criteria: two independent reviewers selected the papers used- no details were given on criteria
Articles excluded if: ?

unclear how many studies were included in the analysis

The evidence

 
diagnostic test airflow limitation no airflow limitation LR+
(95% CI)		 LR-
(95% CI)
wheezing 36
(- to -) 		0.85
(- to - )
barrel chest 10
(- to - ) 		0.90
(- to - )
decreased cardiac dullness 10
(- to - ) 		0.88
(- to - )
match test 7.1
(- to - ) 		0.43
(- to - )
rhonchi 5.9
(- to - ) 		0.95
(- to - )
hyperresonance 4.8
(- to - ) 		0.73
(- to - )
forced expiratory time more than 9 seconds 4.8
(- to - ) 		-
(- to - )
forced expiratory time 6-9 seconds 2.7
(- to - ) 		-
(- to - )
forced expiratory time less than 6 seconds 0.45
(- to - ) 		-
(- to - )
subxiphoid cardiac apical impulse 4.6
(- to - ) 		0.94
(- to - )
pulsus paradoxus (more than 15 mmHg) 3.7
(- to - ) 		0.62
(- to - )
decreased breath sounds 3.7
(- to - ) 		0.70
(- to - )
accessory muscle use -
(- to - ) 		0.70
(- to - )
excavated supraclavicular fossae -
(- to - ) 		0.69
(- to - )
smoked 70 or more (vs less than 70) pack-years 8.0
(- to - ) 		0.63
(- to - )
smoked ever vs never 1.8
(- to - ) 		0.16
(- to - )
history of sputum production of a quarter cup or more 4.0
(- to - ) 		0.84
(- to - )
history of symptoms of chronic bronchitis 3.0
(- to - ) 		0.78
(- to - )
history of wheezing 3.8
(- to - ) 		0.66
(- to - )
history of exertional dyspnoea, grade 4 vs 3 or less 3.0
(- to - ) 		0.98
(- to - )
history of exertional dyspnoea, any vs none 2.2
(- to - ) 		0.83
(- to - )
history of coughing 1.8
(- to - ) 		0.69
(- to - )
history of any dyspnoea 1.2
(- to - ) 		0.55
(- to - )
total

  • Intraobserver agreement for physical examination:
    • subxiphoid apical impulse, ? 0 to 0.3
    • hyperresonance, ? 0 to 0.42
    • wheezing, ? 0.43 to 0.93
    • measuring forced expiratory time, ? 0.7
    • interpreting match test, ? 0.39
  • Intraobserver agreement for history items:
    • smoking history, ? 0.95
    • presence or absence of wheezing, ? 0.61
    • chronic bronchitis, ? 0.55
    • dyspnoea, ? 0.44 to 0.48
    • coughing, ? 0.46

Comments

  1. The lack of well described inclusion / exclusion criteria makes this analysis less useful.
  2. No confidence intervals were reported in the study and there was insufficient data available to calculate them.

Citation

  1. Holleman DR, and Simel DL: Does the clinical examination predict airflow limitation?. Journal of the American Medical Association 1995; 273 (4): 313-319
Contributor: Clare Wotton and Musab Hayatli, May 2000
Reviewer: William Stringer

Clinical Question.
Patient suspected airflow limitation
Intervention or Exposure clinical examination
Outcome diagnosis