Respiratory Retractions: Definition, Types, and More

What Are Respiratory Retractions?

Respiratory retractions, also called chest retractions or chest wall retractions, occur when soft tissue is pulled inward during inhalation. The pulling may appear between the ribs, underneath the rib cage, around the breastbone, above the collarbones, or at the base of the neck.

During normal inhalation, the diaphragm moves downward and the rib cage expands. This creates negative pressure inside the chest, allowing air to flow into the lungs. When an airway is narrowed or blocked, the body must generate stronger negative pressure to pull air through the restricted passage. That extra suction can draw the flexible tissues of the chest wall inward.

Think of trying to drink a thick milkshake through a narrow straw. The harder you pull, the more the straw threatens to collapse. The chest wall does not literally become a straw, of course, but the pressure principle is similar.

Are retractions the same as shortness of breath?

No. Shortness of breath is the sensation that breathing is difficult or insufficient. Retractions are a visible physical sign. A person may feel short of breath without having obvious retractions, while infants cannot describe breathlessness and may show retractions as one of the clearest warning signs.

Are respiratory retractions always serious?

Retractions that occur briefly after intense physical activity may improve once breathing and heart rate return to normal. Retractions that appear while a person is resting, feeding, sleeping, talking, or performing an easy activity are much more concerning.

The location and depth of the pulling can offer clues, but caregivers should not attempt to determine severity based on location alone. Mild-looking retractions can worsen, and children may become tired after working hard to breathe.

What Do Chest Retractions Look Like?

Retractions usually appear during inhalation. Instead of the chest expanding smoothly, one or more areas seem to sink inward. The ribs may become unusually visible, or the skin may form temporary grooves around them.

Depending on the cause and the person’s age, retractions may occur with:

• Fast, shallow, or irregular breathing
• Nasal flaring
• Wheezing or whistling from the chest
• Stridor, a harsh sound often heard during inhalation
• Grunting during exhalation
• Head bobbing in infants
• Difficulty speaking, crying, drinking, or feeding
• A pale, gray, or bluish color around the lips or face
• Cool, clammy, or sweaty skin
• Unusual irritability, confusion, drowsiness, or exhaustion

A child may also lean forward, lift the chin, or extend the neck in an instinctive effort to open the airway. These unusual breathing positions deserve immediate attention, not a debate over whether the child is simply “sitting funny.”

Types of Respiratory Retractions

Healthcare professionals name retractions according to where the tissue pulls inward. A person may have one type or several types at the same time.

Intercostal retractions

Intercostal retractions occur between the ribs. The spaces separating the ribs sink inward during inhalation, making the rib outlines more visible. This is one of the most commonly recognized forms of chest retraction.

Intercostal retractions may occur with asthma attacks, bronchiolitis, pneumonia, respiratory syncytial virus infection, croup, chronic obstructive pulmonary disease exacerbations, allergic reactions, or airway obstruction.

Subcostal retractions

Subcostal retractions appear directly underneath the lower edge of the rib cage. The upper abdomen may seem to pull inward as the person inhales. These retractions are frequently seen in infants and young children with lower-airway disease.

Subcostal retractions should not be confused with normal abdominal breathing in babies. A healthy infant’s belly often rises and falls during breathing. With a true retraction, the tissue under the ribs is sharply drawn inward rather than expanding smoothly.

Substernal retractions

Substernal retractions occur underneath the sternum, or breastbone, near the center of the lower chest. This area may form a visible hollow with each breath.

They can appear when the lungs are difficult to expand or when airflow is restricted. In newborns, substernal pulling may accompany respiratory distress syndrome, transient breathing problems after birth, pneumonia, or other neonatal lung conditions.

Suprasternal retractions

Suprasternal retractions occur in the notch just above the breastbone at the base of the neck. This movement is sometimes called tracheal tugging because the tissue around the windpipe appears to pull downward during inhalation.

This type may be particularly noticeable when an upper airway is narrowed, as can happen with croup, severe throat swelling, laryngomalacia, or an inhaled foreign object.

Supraclavicular retractions

Supraclavicular retractions appear above the collarbones. The normally soft areas in this region become deeply indented with each breath.

Because the neck and upper-chest muscles are being recruited to assist breathing, supraclavicular retractions can indicate substantial respiratory effort. They may occur along with visible movement of the neck muscles.

Multiple-site retractions

When pulling is visible between the ribs, under the rib cage, and around the neck at the same time, the person is using several accessory muscle groups to breathe. Multiple-site or deep retractions are especially concerning and require urgent assessment.

What Causes Respiratory Retractions?

Anything that makes it difficult to move air through the airways or expand the lungs can potentially cause retractions. The underlying problem may begin in the nose and throat, the larger airways, the small airways, the lung tissue, or occasionally outside the respiratory system.

Viral respiratory infections

Bronchiolitis is a common cause in infants and toddlers. It occurs when a virus inflames the small airways and increases mucus production. Respiratory syncytial virus, commonly called RSV, is a major cause, although several other viruses can produce similar symptoms.

A child may begin with congestion, coughing, or reduced appetite and develop wheezing, fast breathing, nasal flaring, or retractions as the illness progresses. Very young babies may not develop a fever, so the absence of fever does not guarantee that the illness is mild.

Asthma

During an asthma attack, airway muscles tighten while inflammation and mucus narrow the breathing passages. Wheezing is common, but a severe asthma attack may produce little wheezing because airflow has become extremely limited.

Retractions during an asthma flare suggest that the person is working harder than normal to breathe. Emergency help is necessary when prescribed rescue medication does not improve breathing, the person cannot speak normally, or symptoms are rapidly worsening.

Croup and upper-airway swelling

Croup commonly causes a barking cough, hoarse voice, and stridor in young children. Swelling around the upper airway makes inhalation difficult. Mild croup may be managed according to a clinician’s instructions, but stridor at rest, significant retractions, drooling, exhaustion, or color changes require urgent evaluation.

Pneumonia

Pneumonia causes infection and inflammation within the lungs. Air sacs may fill with fluid or inflammatory material, making oxygen transfer and lung expansion more difficult. Symptoms may include fever, cough, rapid breathing, chest discomfort, fatigue, poor feeding, and chest wall retractions.

Foreign-body aspiration

A piece of food, small toy part, coin, bead, or other object can enter the airway. Sudden coughing, choking, noisy breathing, asymmetric chest movement, or abrupt retractions may indicate an airway emergency.

Do not blindly sweep a finger inside the mouth, as this can push an object deeper. Follow age-appropriate choking first-aid guidance and call 911 when a person cannot breathe, cough effectively, cry, or speak.

Severe allergic reaction

Anaphylaxis can cause rapid swelling of the throat and airways. Possible signs include hives, facial or tongue swelling, vomiting, wheezing, hoarseness, breathing difficulty, dizziness, and retractions.

Use prescribed epinephrine immediately when anaphylaxis is suspected and call 911. Antihistamines do not replace epinephrine for a severe reaction.

Conditions affecting newborns

Premature babies may develop respiratory distress syndrome because their lungs do not produce enough surfactant, the substance that helps keep tiny air sacs open. Other newborn causes include transient tachypnea, infection, meconium aspiration, pneumothorax, congenital heart disease, and structural airway conditions.

Retractions in a newborn are always worth prompt medical attention, especially when combined with grunting, poor feeding, breathing pauses, rapid breathing, or a blue or gray color.

Other possible causes

• Chronic obstructive pulmonary disease exacerbations in adults
• Airway tumors or thick mucus plugs
• Vocal cord dysfunction or paralysis
• Laryngomalacia or tracheomalacia
• Pneumothorax, or air around a partially collapsed lung
• Severe metabolic conditions that alter breathing
• Neuromuscular disorders that weaken respiratory muscles
• Serious lung inflammation or respiratory failure

When Are Respiratory Retractions an Emergency?

New retractions at rest should be evaluated immediately. Call 911 when retractions occur with any of the following:

• Blue, gray, or very pale lips, face, tongue, or nail beds
• Severe breathing difficulty or gasping
• Inability to speak, cry, or drink because of breathlessness
• Pauses in breathing
• Sudden symptoms after choking or possible object inhalation
• Swelling of the lips, tongue, face, or throat
• Confusion, fainting, limpness, or difficulty waking
• Severe stridor, grunting, or rapidly worsening wheezing
• Failure of prescribed asthma rescue medicine to relieve symptoms
• Exhaustion after prolonged labored breathing

Do not delay emergency care while repeatedly checking oxygen with a consumer pulse oximeter. A normal-looking reading does not erase visible respiratory distress, and inaccurate readings can occur because of movement, cold fingers, poor circulation, device limitations, or incorrect placement.

What Should You Do While Waiting for Help?

1. Keep the person upright. Sitting upright may make breathing easier than lying flat.
2. Keep the environment calm. Crying and panic can increase oxygen demand, although nobody expects perfect serenity during a breathing emergency.
3. Loosen restrictive clothing. Remove tight garments around the neck or chest.
4. Use prescribed emergency medication. Follow the person’s asthma action plan or administer prescribed epinephrine for suspected anaphylaxis.
5. Do not force food or fluids. A person working hard to breathe may choke or aspirate.
6. Do not use another person’s medication. The correct treatment depends on the cause.
7. Watch breathing and responsiveness. Tell emergency personnel if the person becomes less alert or stops breathing.

If the person becomes unresponsive and is not breathing normally, begin CPR if you are trained and follow instructions from the emergency dispatcher.

How Are Chest Retractions Diagnosed?

Healthcare professionals first assess whether the airway is open and whether the person is receiving enough oxygen. They evaluate breathing rate, oxygen saturation, heart rate, alertness, skin color, breath sounds, chest movement, and the depth and location of retractions.

The medical team may ask when the symptoms began, whether they appeared suddenly, and whether the person has asthma, allergies, lung disease, fever, coughing, choking, recent infection, or exposure to smoke or chemicals.

Depending on the situation, tests may include:

• Pulse oximetry to estimate blood oxygen saturation
• Blood tests to evaluate infection, oxygen, or carbon dioxide
• Chest X-rays or other imaging
• Viral testing
• Airway examination or laryngoscopy
• Lung function testing after the person is stable
• Heart testing when a cardiac cause is possible

Testing should never delay immediate breathing support when respiratory distress is severe.

How Are Respiratory Retractions Treated?

Treatment focuses on improving airflow and oxygen delivery while correcting the underlying cause. Retractions themselves are not treated with a single universal medicine.

Possible emergency treatments

• Supplemental oxygen
• Inhaled bronchodilators for appropriate asthma or airway conditions
• Corticosteroids to reduce certain types of airway inflammation
• Nebulized medication for severe croup
• Epinephrine for anaphylaxis
• Fluids for dehydration when drinking is unsafe or inadequate
• Antibiotics for specific bacterial infections
• Removal of an inhaled foreign object
• Positive airway pressure, intubation, or mechanical ventilation
• Surfactant and respiratory support for some premature newborns

As airflow and oxygenation improve, retractions should become less pronounced. Persistent or worsening retractions suggest that the breathing problem remains unresolved.

Can Respiratory Retractions Be Prevented?

Not every episode is preventable, but several practical measures can reduce risk:

• Follow a written asthma action plan and keep prescribed rescue medication available.
• Avoid cigarette smoke, vaping aerosols, and known airway irritants.
• Keep small foods and objects away from infants and toddlers.
• Learn age-appropriate choking first aid and CPR.
• Practice regular handwashing and avoid close contact with people who are ill.
• Keep recommended vaccinations and respiratory immunizations current.
• Discuss RSV prevention options with a qualified prenatal or pediatric healthcare professional.
• Seek early care when a high-risk infant develops feeding problems or breathing symptoms.
• Carry prescribed epinephrine when there is a known risk of anaphylaxis.

Frequently Asked Questions

Can adults have respiratory retractions?

Yes. Retractions are more visible in young children because their chest walls are flexible, but adults can develop them during severe asthma, COPD exacerbations, airway obstruction, anaphylaxis, pneumonia, or respiratory failure.

Can anxiety cause chest retractions?

Anxiety can cause rapid breathing, chest tightness, tingling, and a sensation of breathlessness. Pronounced retractions are more suggestive of significant physical work of breathing and should not automatically be attributed to anxiety.

Are retractions and belly breathing the same?

No. Babies normally rely heavily on the diaphragm, so their bellies often move outward during inhalation. Subcostal retractions involve distinct inward pulling beneath the rib cage. Seesaw breathing, in which the chest and abdomen move in opposite directions, is particularly concerning.

Can retractions occur without wheezing?

Yes. Croup may cause stridor rather than wheezing, pneumonia may produce crackling sounds, and a severe asthma attack may become unusually quiet because very little air is moving. The absence of wheezing does not rule out serious respiratory distress.

Should I record a video of the breathing pattern?

A brief video may help a clinician understand an intermittent symptom, but recording should never delay emergency care. Call for help first. The camera is an assistant, not the attending physician.

Caregiver Experiences and Practical Lessons

Respiratory retractions can be difficult to recognize the first time, particularly when they develop gradually. A child may begin the day with what looks like an ordinary cold: a runny nose, mild cough, and slightly reduced appetite. Several hours later, a caregiver may notice that the child is unusually quiet and breathing faster. Only after lifting the child’s shirt does the inward pulling beneath the ribs become obvious.

A common practical lesson is to watch the chest and abdomen, not merely listen for coughing. Cough volume does not reliably measure breathing difficulty. One child may cough dramatically while moving air reasonably well; another may cough only occasionally while using every available muscle to breathe.

Consider a realistic bronchiolitis scenario. An eight-month-old develops congestion and initially continues drinking bottles. The following evening, feeding becomes difficult because the baby repeatedly stops sucking to breathe. The nostrils widen, the skin beneath the ribs pulls inward, and the baby becomes sleepier. The important change is not simply that the cough sounds worse. It is that breathing is interfering with feeding and alertness. Those combined signs warrant urgent medical assessment.

Asthma offers another instructive example. A school-age child begins wheezing after playing outside. A prescribed rescue inhaler usually improves symptoms, but this time the child remains hunched forward, speaks only a few words at a time, and shows deep intercostal retractions. Repeatedly administering medicine beyond the prescribed action plan while hoping for a turnaround can waste critical time. When rescue treatment fails and retractions continue, emergency care is the next step.

Parents also describe uncertainty about whether they are seeing normal infant belly breathing. A useful observation is to watch the lower rib margin in good lighting while the baby is calm. Normal diaphragmatic breathing produces smooth abdominal expansion. Retractions create a distinct inward groove under or between the ribs. However, caregivers do not need to become amateur respiratory therapists. When the pattern is new, persistent, or paired with poor feeding, noisy breathing, or color changes, professional evaluation is appropriate.

Another lesson involves the apparent improvement that can occur when a struggling child becomes quiet. Quietness is not always recovery. After prolonged respiratory effort, a child may become exhausted and produce less noise because the breathing muscles are tiring. A reduction in crying or wheezing accompanied by drowsiness, weaker breathing, or worsening color is an emergency.

Clothing can also hide important signs. Thick pajamas, blankets, and winter layers make it difficult to see chest movement. When breathing trouble is suspected, briefly exposing the chest in a warm environment can help a caregiver observe the ribs, breastbone, collarbones, and neck. Count breaths for a full minute if it can be done without delaying care, and note whether the person can talk, cry, feed, or stay alert normally.

Finally, many caregivers learn that documenting the sequence of symptoms helps clinicians. Useful details include when the retractions began, whether the onset was sudden, whether choking was possible, which medications were given, how much the child has consumed, the number of wet diapers, and whether symptoms worsen during sleep or feeding. A short video may also be useful when symptoms come and go.

The central practical lesson is simple: trust visible breathing effort. Retractions are the body’s version of raising a red flag, waving it enthusiastically, and adding a small siren for emphasis. Prompt recognition and timely medical care can prevent respiratory distress from progressing to fatigue or respiratory failure.

Conclusion

Respiratory retractions occur when the tissue around the ribs, breastbone, collarbones, or neck pulls inward during inhalation. Intercostal, subcostal, substernal, suprasternal, and supraclavicular retractions describe different locations, but each can signal increased work of breathing.

Common causes include bronchiolitis, RSV, asthma, croup, pneumonia, severe allergies, foreign-body aspiration, newborn lung disorders, and other conditions that narrow the airway or make the lungs harder to expand. Retractions at rest should receive prompt medical attention. Call 911 when they occur with blue or gray coloring, severe breathlessness, choking, swelling, breathing pauses, confusion, extreme drowsiness, or inability to speak, cry, drink, or respond normally.

Recognizing the sign is valuable, but identifying the exact cause belongs to a healthcare professional. When someone appears to be fighting for every breath, the safest response is action rather than observation.