What Does Retraction Breathing Look Like?

Retraction breathing shows up as visible pulling or sinking of skin and soft tissue around the ribs, collarbones, or throat each time a person inhales. Instead of the smooth, almost invisible rise and fall you see during normal breathing, the skin between the ribs, above the collarbones, or below the breastbone gets sucked inward with every breath, sometimes dramatically. It is a sign that someone is working much harder than usual to pull air into the lungs, and it can look different depending on where on the body the retractions appear and how severe the underlying breathing difficulty is.

What You Actually See

During normal breathing, the chest expands outward and the belly gently rises. The movement is subtle and symmetrical. With retraction breathing, the body’s struggle to move air becomes visible on the surface. The key visual is skin being drawn inward during inspiration rather than expanding outward. Picture someone taking a breath, and instead of the chest puffing up normally, you see grooves or hollows form between the ribs, or a dip appear just above the collarbones, or a tug under the chin. The harder the person works to breathe, the deeper and more widespread those indentations become.

In mild cases, you might only notice slight dipping between the lower ribs if you look carefully. In moderate cases, the pulling is obvious enough that you can see it from across a room. In severe cases, the chest and abdomen can start moving in opposite directions, a pattern sometimes called “seesaw” breathing, where the chest rises while the belly sucks inward, or vice versa. One case report described an elderly man with massive lung consolidation whose breathing showed exactly this pattern: as his chest wall expanded, his abdomen was “paradoxically sucked inward,” with severe retractions visible below the chin.¹ That seesaw motion is an advanced form of what starts as simple retraction breathing.

Where Retractions Appear and What Each Location Suggests

Not all retractions look the same, and their location on the body tells clinicians something about how hard the person is working and where the airway problem sits. You can see retractions in several distinct areas:

• Intercostal: The skin between the ribs pulls inward. This is the most commonly noticed type, especially in thin or young patients where the spaces between ribs are easy to see.
• Subcostal: The area just below the bottom edge of the rib cage sinks in. You can spot this by looking at the upper abdomen where it meets the lower ribs.
• Suprasternal: A dip appears in the notch at the top of the breastbone, between the collarbones. This one is often visible even in larger people because the notch is a natural hollow that deepens noticeably with effort.
• Supraclavicular: Hollows form above the collarbones, where the muscles of the neck attach. This tends to appear when someone is recruiting neck and shoulder muscles to help breathe.
• Substernal: The lower tip of the breastbone gets pulled inward. In infants, the flexible cartilage of the chest makes this especially pronounced.
• Submental: The soft tissue under the chin pulls downward with each breath. This is a sign of severe upper-airway obstruction and is sometimes called “tracheal tug.”

Generally, the more locations involved, the more serious the situation. Mild intercostal retractions alone suggest moderate effort, but once you see suprasternal, supraclavicular, and submental retractions appearing together, the person is using every available muscle group to move air. Clinical scoring systems used in emergency departments actually grade retractions on a scale from none to severe as part of assessing respiratory distress. One validated pediatric scoring tool, the Clinical Respiratory Score, rates retractions alongside other signs and has found that children scoring in the severe range were far more likely to need intensive care than those with mild scores.² Similarly, the Pulmonary Score used for childhood asthma rates retractions on a 0-to-3 scale alongside respiratory rate and wheezing to track whether a child is improving or getting worse.³

Why It Happens

Retractions are a visible consequence of the physics of breathing. Normally, your diaphragm contracts and drops downward, expanding the chest cavity and creating a slight negative pressure that draws air into the lungs. The chest wall is stiff enough in a healthy adult that it does not deform much during this process. But when the airway is partially blocked, or the lungs are stiff and hard to inflate, the diaphragm has to generate much more negative pressure to pull air in. That extra suction has to go somewhere, and it pulls on the softest, most compliant parts of the chest wall. The skin and tissue between the ribs, above the collarbones, and below the sternum get sucked inward because they cannot resist the pressure difference.

Think of it like trying to drink a thick milkshake through a narrow straw. You have to suck much harder, and the straw collapses inward. The chest wall is the straw. The narrower or more obstructed the airway, or the stiffer the lungs, the more the soft tissues of the chest get pulled in. Researchers have actually built devices to measure this inward pull at the intercostal spaces and found that it correlates closely with the negative pressures inside the chest, confirming that visible retractions are a reliable external indicator of how hard the respiratory muscles are working.⁴

Why Babies and Young Children Are Especially Vulnerable

If you have ever watched a baby breathe during a bad cold, you may have noticed retractions that would be unusual in an adult with the same illness. There are real anatomical reasons for this. A newborn’s chest wall is far more flexible than an adult’s. The ribs are largely cartilage rather than bone, and the muscles between them are relatively weak. Research on neonatal respiratory mechanics confirms that this high chest wall compliance makes infants prone to visible chest wall distortion during breathing, which reduces their breathing efficiency and forces the respiratory muscles to work harder just to keep the chest from collapsing inward.⁵ On top of that, infants have a higher proportion of fast-twitch muscle fibers in their diaphragm, which fatigue more quickly than the slow-twitch fibers adults rely on. So not only do babies show retractions more easily, they also tire out faster once the extra work of breathing starts.

Young children also have narrower airways than adults, which means even a small amount of swelling from a viral infection can significantly reduce airflow. A few millimeters of inflammation that an adult would barely notice can cut a toddler’s airway cross-section dramatically, triggering visible retractions. This is why diseases like croup and bronchiolitis, which are common viral respiratory infections in early childhood, frequently produce prominent retraction breathing. Croup in particular tends to peak in the second year of life, with around 15% of children experiencing at least one episode, and the resulting airway narrowing primarily occurs during inspiration in the upper airway.⁶

Common Causes in Children and Adults

In children, the usual suspects behind retraction breathing are viral respiratory infections. Croup causes swelling around the voice box and upper trachea, producing a distinctive barking cough along with retractions that are often worst at night. Bronchiolitis, most commonly caused by respiratory syncytial virus (RSV), inflames the small airways in the lungs and tends to hit infants under a year old hardest. Asthma flare-ups are another frequent cause, particularly in school-aged children, where airway constriction and mucus production make it difficult to move air. Severe pneumonia, foreign body aspiration, and allergic reactions can also produce retractions in children.

Adults can show retractions too, though it takes more severe obstruction or lung disease to make them visible because the adult chest wall is stiffer. Severe asthma attacks, acute exacerbations of chronic lung disease, pneumonia, anaphylaxis, and upper-airway obstruction from conditions like epiglottitis or tumors can all produce visible retractions in adults. In adult patients, retractions tend to signal a more critical situation than in children precisely because it takes a bigger pressure swing to deform the more rigid adult chest wall.

Seesaw Breathing and Paradoxical Movement

When retraction breathing progresses, it can evolve into what clinicians call paradoxical breathing. In normal breathing, the chest and abdomen rise together during inhalation and fall together during exhalation. In paradoxical breathing, they move in opposite directions. The abdomen pushes out while the chest sinks in, or the chest rises while the abdomen gets pulled inward. This seesaw pattern indicates that the respiratory muscles are overwhelmed or that something has disrupted the normal coordination between the diaphragm and the chest wall.

Paradoxical movement is not always caused by lung disease. Nerve damage can produce a similar picture. A case report documented a patient with a one-sided spinal cord injury at the C7 level who showed paradoxical chest wall movement on the injured side, mimicking the appearance of broken ribs. The cause was paralysis of the intercostal muscles on that side, so the diaphragm’s downward pull during inhalation sucked the unsupported rib cage inward rather than expanding it.⁷ In that situation, the visual appearance closely resembles retraction breathing from airway obstruction, but the underlying problem is completely different. This is a reminder that what retraction breathing looks like and what is causing it are separate questions, and the visual alone does not give you a diagnosis.

When to Get Help

Mild intercostal retractions in a child with a runny nose and cough can sometimes be managed at home with close monitoring, especially if the child is still eating, drinking, and reasonably comfortable. But several features should prompt you to seek emergency care immediately:

• Multiple retraction sites: Retractions appearing above the collarbones, below the sternum, and between the ribs simultaneously suggest significant distress.
• Color changes: Bluish or grayish tinting around the lips, fingertips, or tongue indicates low oxygen levels. A meta-analysis of studies in young children with acute respiratory infections found that cyanosis was highly specific for low oxygen, meaning that when you see it, the child is very likely hypoxic.⁸
• Head bobbing: In infants, the head nodding forward with each breath is a sign of severe respiratory effort. The same meta-analysis identified head nodding as another highly specific sign of dangerously low oxygen levels.
• Inability to eat or drink: When breathing takes so much effort that a child refuses to feed, or an adult cannot finish a sentence without pausing for air, the situation is urgent.
• Rapid breathing rate: Respiratory rates above 60 breaths per minute in infants or above 40 in older children are concerning, particularly when combined with retractions.
• Altered consciousness: Drowsiness, confusion, or difficulty waking in someone showing retractions is a medical emergency.

In adults, visible retractions almost always warrant medical evaluation because, as noted above, it takes substantial respiratory compromise to produce visible chest wall deformation through a stiffer adult rib cage.

What Happens in the Emergency Department

When a patient arrives with retraction breathing, the clinical team assesses severity quickly. Pulse oximetry tells them oxygen levels. Clinicians use scoring tools like the Clinical Respiratory Score mentioned earlier, which combines retraction severity with other signs to categorize patients as mild, moderate, or severe. In that scoring system, children in the severe range had a 90% rate of needing critical care admission, compared to 23% for those with mild-to-moderate scores.²

Imaging may follow. In infants with bronchiolitis, bedside lung ultrasound has emerged as a radiation-free way to assess severity. A study of 200 infants found that ultrasound patterns correlated with the need for respiratory support, with more severe interstitial patterns on ultrasound predicting higher rates of needing breathing assistance.⁹ Treatment depends on the cause. Croup often responds to a single dose of oral steroid and sometimes nebulized epinephrine. Bronchiolitis is primarily managed with supportive care. Asthma gets bronchodilators and steroids. Severe cases of any cause may require supplemental oxygen or breathing support.

How Breathing Support Reduces Retractions

One of the more practical things to understand about retraction breathing is that effective treatment makes the retractions visibly improve. This is why clinicians watch retractions so closely as a real-time measure of whether a therapy is working. High-flow nasal cannula therapy, which delivers heated, humidified air or oxygen at higher-than-normal flow rates, has become a common tool for this. In children with bronchiolitis, high-flow nasal cannula significantly reduced the effort of breathing as measured by esophageal pressure monitoring, with all patients in one study showing measurable improvement.¹⁰ In adults recovering from acute respiratory failure, the same technology roughly halved the work of breathing when set at 60 liters per minute, with pressure swings inside the esophagus dropping by about half compared to baseline.¹¹

The visible payoff is straightforward: as the extra airflow support reduces the negative pressure the patient has to generate, the soft tissues of the chest stop being sucked inward. Retractions become shallower and may disappear entirely. Parents watching their child in the emergency department will often see this happen in real time as high-flow therapy starts working, and it is one of the most reassuring things to witness.

Spotting Retractions on Video

An interesting development in respiratory monitoring is the use of video-based systems to detect breathing patterns automatically. Researchers have developed computer-vision tools that can track the chest and abdominal movements of newborns using a standard camera, extracting the respiratory signal from motion analysis. One such system achieved a segmentation accuracy above 94% for identifying the thoracoabdominal region and estimated respiratory rate with a mean error of just about 2 breaths per minute compared to clinical assessment.¹² While these systems are currently focused on breathing rate rather than specifically detecting retractions, the underlying technology of tracking chest wall motion could eventually help identify abnormal inward movement patterns associated with retraction breathing. For now, the practical takeaway for parents is simpler: if you need to show a doctor what your child’s breathing looks like, taking a short video on your phone of the child’s bare chest during a breathing episode can be extremely useful. Clinicians increasingly encourage this, because retractions may come and go, and having visual evidence to share during a telehealth visit or emergency department triage can speed up assessment.

Retraction Breathing in Premature Infants

Premature babies deserve special mention because they sit at the extreme end of the vulnerability spectrum. Their chest walls are even more compliant than those of full-term newborns, their airways are narrower, and their respiratory muscles fatigue more quickly. The combination of a highly flexible chest wall and fewer fatigue-resistant muscle fibers in the diaphragm means that premature infants can develop visible retractions from conditions that would cause minimal distress in a term infant.⁵ Respiratory distress syndrome, caused by a lack of surfactant in underdeveloped lungs, is one of the most common causes of retraction breathing in premature infants and often appears within the first hours after birth. In neonatal intensive care units, nurses assess retractions as part of standardized scoring systems multiple times per hour, and the appearance or worsening of retractions is one of the earliest signs that a premature infant’s breathing support needs to be adjusted.

For parents of premature babies who have been discharged home, knowing what retractions look like is a genuine safety skill. These infants may develop viral respiratory infections that would be mild in an older child but can escalate quickly in a baby with an already-vulnerable respiratory system. Being able to undress the baby, watch the chest and belly during breathing, and recognize inward pulling at the ribs or sternum can be the difference between a timely call to the pediatrician and a delayed presentation to the emergency department.