Retractions are visible indentations of the soft tissue of the chest wall that occur when increased effort is needed for inspiration. Common locations include:

• Suprasternal: Above sternum and clavicles

• Intercostal: Between the ribs

• Subcostal: Below the lower rib margin

• Substernal: Just below the xiphoid process

Retractions may be mild or severe, producing barely visible to deep indentations. They often indicate respiratory distress in infants and children and are typically accompanied by accessory muscle use.

Physiologic Note

• Infants primarily use abdominal muscles for breathing.

• Retractions occur when accessory muscles assist respiration, usually during increased respiratory effort.

Emergency interventions

• Assess for other signs of distress: cyanosis, tachypnea, tachycardia, low oxygen saturation.

• Prepare for suctioning, artificial airway insertion, and oxygen administration.

• Observe depth, location, and quality of retractions, as well as rate and depth of respirations.

• Monitor for nasal flaring or grunting, which indicate significant respiratory effort.

• Record sputum characteristics (color, consistency, odor) if present.

• Auscultate lungs for abnormal breath sounds.

Observing Retractions:

• Subcostal/substernal: suggest lower respiratory tract disorder

• Suprasternal: suggest upper respiratory tract disorder

• Mild intercostal only: may be normal

• Intercostal + subcostal/substernal: moderate distress

• Deep suprasternal: severe distress

History and Physical Examination

Ask parents/caregivers:

• Birth history: premature, low birth weight, complicated delivery

• Recent illness: upper respiratory infection signs (runny nose, cough, fever)

• Past respiratory issues: frequency, RSV history, aspiration events

• Allergies/asthma history

• Exposure: daycare, school-aged siblings, contact with sick individuals

Physical examination should include:

• Observation of retractions location and severity

• Respiratory rate, effort, accessory muscle use

• Cyanosis, grunting, nasal flaring

• Lung auscultation for adventitious sounds

Medical causes

Special Considerations

• Continuous vital signs monitoring

• Keep suction and appropriately sized airway ready

• Oxygen administration:

  • <15 lb (6.8 kg): oxygen hood

  • ≥15 lb: cool mist tent

• Chest physiotherapy and postural drainage to mobilize secretions

• Use bronchodilators or steroids as indicated

• Prepare for chest X-rays, cultures, pulmonary function tests, ABG analysis

• Instruct parents on procedure explanations, calming, and comfort measures

Patient counseling

• Educate caregivers on proper medication use at home

• Maintain a humidified environment

• Ensure adequate hydration

Pediatric pointers

Crying may accentuate retractions, so interpret observations carefully.

Geriatric pointers

Retractions are harder to assess in older adults due to obesity, chest wall stiffness, or deformities.

References

1. Buttaro TM, Tybulski J, Bailey PP, Sandberg-Cook J. Primary Care: A Collaborative Practice. St. Louis, MO: Mosby Elsevier; 2008.

2. Colyar MR. Well-Child Assessment for Primary Care Providers. Philadelphia, PA: F.A. Davis; 2003.

3. McCance KL, Huether SE, Brashers VL, Rote NS. Pathophysiology: The Biologic Basis for Disease in Adults and Children. Maryland Heights, MO: Mosby Elsevier; 2010.

4. Sommers MS, Brunner LS. Pocket Diseases. Philadelphia, PA: F.A. Davis; 2012.