Retraction breathing is a distinct visual sign of respiratory distress where the chest wall visibly pulls inward during inhalation. This inward movement, also known as chest indrawing, occurs when a person is working harder than normal to take a breath. Observing this pattern indicates a significant struggle for air and is an important warning sign that requires close attention.
Identifying the Key Locations of Retractions
The appearance of retraction breathing is defined by the locations on the torso and neck where soft tissues are drawn inward with each breath. The location of the pull offers clues about the degree of increased effort being exerted.
The intercostal area, the space between the ribs, is one of the most common spots. A pull in the area just below the rib cage is referred to as subcostal retraction, where the soft tissues of the upper abdomen sink in. Similarly, a substernal retraction appears as an inward movement just beneath the breastbone (sternum) in the center of the chest.
Higher up, retractions around the neck and collarbone indicate a more severe level of difficulty. Supraclavicular retractions are observed as a hollowing of the skin just above the collarbones (clavicles). The suprasternal area, the notch directly above the breastbone at the base of the neck, may also show an inward pull. In the most severe cases, the entire sternum itself may be drawn inward, which is known as a sternal retraction.
Distinguishing Levels of Severity
The location and depth of retractions serve as a practical guide for assessing the severity of the respiratory struggle. Generally, the lower the location and the less obvious the pull, the milder the distress.
Mild retractions are often confined to the subcostal or substernal areas, where the inward movement is slight and may only be noticed with careful observation. The person may also show minimal signs of increased effort, such as a slightly elevated breathing rate.
Moderate respiratory distress is characterized by the involvement of multiple lower sites, including intercostal and subcostal areas, with a more pronounced depth of indrawing. The breathing rate is noticeably faster, and the effort is clearly visible.
When retractions progress to involve the neck area, appearing as supraclavicular or suprasternal pulls, the situation is considered severe. Severe retractions are deep, obvious, and signal a maximum effort to draw air into the lungs. These deep pulls are frequently accompanied by other signs, such as nasal flaring or a high-pitched sound on exhalation called grunting.
The Mechanism Behind the Appearance
The appearance of retraction breathing is a direct consequence of the body attempting to overcome an obstruction or stiffness within the respiratory system. Normal breathing relies on the contraction of the diaphragm muscle, which moves downward and creates negative pressure inside the chest cavity, drawing air into the lungs.
When a blockage or reduced lung capacity is present, the diaphragm and other chest muscles must generate a much stronger negative pressure to move air past the resistance. This strong suction overcomes the structural integrity of the chest wall, particularly in areas where soft tissue covers bone, such as between the ribs. Consequently, the skin and muscle in these flexible areas are pulled inward with great force on every attempted inhalation.
Immediate Action and When to Seek Emergency Care
Retraction breathing is never a normal finding and always warrants immediate medical evaluation. If retractions are mild and only involve the lower chest, contact a healthcare provider or pediatrician immediately for guidance.
Emergency intervention is necessary if retractions are deep, involve the neck and collarbone areas, or are accompanied by a change in the person’s color. Signs like blue or gray lips, tongue, or fingertips (cyanosis) indicate critically low oxygen levels and require calling emergency services immediately. Other emergency signs include lethargy, unresponsiveness, or an inability to speak or cry due to the intense effort of breathing. While waiting for help, keep the person calm and allow them to sit upright, as this position often makes breathing easier.