Type or different retraction in breathing difficulties
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types of retractions in respiratory distress breathing difficulty clinical signs
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https://www.webmd.com/lung/lung-chest-retraction
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types of retractions suprasternal subcostal substernal supraclavicular intercostal clinical significance severity
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http://www.tomwademd.net/retractions%E2%80%94a-serious-sign-…
Here is a thorough breakdown of the types of retractions seen in breathing difficulties:
What Are Retractions?
Retractions are the inward movement of the skin, soft tissue, or even the sternum during inspiration. They occur when a person works harder than normal to breathe. When airways are blocked or lungs are stiff, the diaphragm and accessory muscles generate more negative intrathoracic pressure - and the soft tissues get "sucked inward" as a result.
They are most visible in infants and young children because their chest walls are softer and more compliant, but they can occur at any age.
Causes of Retractions
The underlying cause is always one of three categories:
- Upper airway obstruction - croup, epiglottitis, foreign body, anaphylaxis
- Lower airway obstruction - asthma, bronchiolitis, COPD exacerbation
- Parenchymal lung disease - pneumonia, pulmonary edema, acute respiratory distress syndrome (ARDS)
Types of Retractions by Location
Retractions are named by where they appear on the body. Their location also reflects severity - the higher up on the chest and neck they appear, the more severe the respiratory distress.
| Type | Location | Severity |
|---|---|---|
| Subcostal | Just below the rib cage (upper abdomen) | Mild-moderate |
| Substernal | Below the breastbone (lower end of sternum) | Mild-moderate |
| Intercostal | Between the ribs | Mild-moderate |
| Suprasternal | Skin at the middle of the neck, just above the top of the breastbone | Severe |
| Supraclavicular | Above the collarbone (clavicle), in the neck | Severe |
| Sternal | The breastbone itself moves inward toward the spine | Severe |
Detailed Description of Each Type
1. Subcostal Retractions
- Inward pulling of the abdomen just below the rib cage
- Sometimes called "belly breathing" in reverse
- One of the first and most common signs of respiratory distress
2. Substernal Retractions
- Inward movement at the lower end of the breastbone
- Visible as a dip or hollow below the sternum
- Indicates moderate respiratory effort
3. Intercostal Retractions
- Skin and muscle between the ribs pulls inward during each breath
- You may be able to see the outline of individual ribs
- Caused by narrowed or blocked airways forcing the intercostal muscles to pull inward against the negative pressure
4. Suprasternal Retractions (Tracheal Tug)
- Skin at the center of the neck, above the sternum sucks inward
- Also called a tracheal tug
- A sign of significant respiratory distress - indicates the patient is working very hard to breathe
5. Supraclavicular Retractions
- Visible hollowing above the collarbone on either side of the neck
- Indicates severe respiratory distress
- Reflects the use of neck accessory muscles
6. Sternal Retractions
- The breastbone itself moves backward toward the spine with each breath
- Seen mainly in infants (pliable chest wall)
- Indicates severe distress
Severity Progression
As distress worsens, retractions "move upward":
Subcostal → Substernal → Intercostal → Suprasternal / Supraclavicular / Sternal
Mild-moderate distress: Subcostal, Substernal, Intercostal
Severe distress: Suprasternal, Supraclavicular, Sternal
Other signs that accompany severe retractions:
- Nasal flaring
- Head bobbing (use of neck muscles - common in infants, a sign of impending respiratory failure)
- Grunting
- Cyanosis
Clinical Importance
- Retractions at rest are always abnormal and require urgent evaluation
- Retractions during heavy exertion (e.g., after sprinting) can be physiologic
- In adults with COPD, pursed-lip breathing and use of accessory muscles may accompany retractions
- Any patient with suprasternal or supraclavicular retractions should be treated as a respiratory emergency
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