Intercostal retractions

What are intercostal retractions?

Intercostal retractions are when the muscles and skin between your ribs pull inwards while you breathe in (inhale). “Intercostal” is the space between your ribs. Intercostal retractions can mean that inflammation or a blockage in your lungs is making it hard to breathe. They’re concerning if they happen when you’re at rest — but not necessarily when you’ve just run a marathon.

When you breathe in, your diaphragm (the muscle between your chest and your abdomen) pulls down, creating negative pressure (similar to suction) that pulls air into your lungs. The larger volume causes your chest and abdomen to expand outward. This happens every time we breathe, without us even thinking about it. But when your airways are narrowed or blocked, your diaphragm is still pulling, but you can’t get enough air into your lungs to fill the space.

Imagine sucking on a straw with the end covered — you’re pulling in, increasing the negative pressure inside the straw, but no air or fluid can get inside. So the sides start to collapse inward. This is what’s happening inside your chest if you have retractions — your muscles and skin start getting pulled inward from the suction-like pressure in your chest.

What do chest retractions look like?

Intercostal retractions look like dents between your ribs and can create a kind of outline around your ribs. They’re more common and noticeable in babies and young kids. Healthcare providers may have you look for them to help you know if your child is having trouble breathing. You might notice skin pulling in at other places, too, like the middle of your child’s chest.

Intercostal retractions at rest are a sign that someone is struggling to breathe. If you notice them in your child or someone else, seek emergency medical attention.

Other visible signs of respiratory distress you can look for include:

• Nostrils (opening of your nose) flaring out.
• Taking longer to breathe out than to breathe in.
• Fast breathing (tachypnea).
• Whistling or other noises coming from their throat or chest when breathing, like wheezing or stridor.
• Breathlessness, or sounding out of breath when they’re talking.

What’s the difference between intercostal and subcostal retractions?

Intercostal retractions are when the skin in between your ribs pulls in when you inhale. Subcostal retractions (sometimes called “belly breathing”) are when your abdomen pulls in just below your rib cage when you breathe in. Subcostal means “below your ribs.”

Other places where you can see retractions include:

• Substernal: Your abdomen pulls in below your sternum (breastbone), in the middle of your lower rib cage.
• Suprasternal: The middle of your neck pulls in, just above your sternum. This is also called tracheal tug.
• Supraclavicular: The skin above your clavicle (collarbone) pulls in.

Where you see retractions can give you an idea of where a blockage might be. A restriction in your upper airways can cause suprasternal and supraclavicular retractions. A restriction in your lower airways can cause substernal, subclavicular and intercostal retractions.

What are the most common causes of intercostal retractions?

Intercostal retractions happen when your airways are narrowed or blocked (by thick mucus, a foreign object or tumor). Some common causes include:

• Chronic obstructive pulmonary disease (COPD) exacerbations or asthma attacks.
• Respiratory illnesses like respiratory syncytial virus (RSV) and COVID-19.
• Conditions that cause inflammation in your airways, like bronchiolitis, croup and pneumonia.
• An object, growth (tumor) or thick mucus blocking your airways.
• Anaphylaxis, a severe allergic reaction.
• Vocal cord paralysis.
• Severe diabetes-related ketoacidosis.
• Reye’s syndrome/salicylate toxicity.

How are intercostal retractions treated?

Healthcare providers treat intercostal retractions by reducing the load on the muscles you use to breathe. They do this by opening up your airways and making sure you’re getting enough oxygen, or by giving you air or oxygen at higher pressures and/or higher concentrations. How they do this depends on the cause and how hard it is for you to breathe on your own.

Treatments include:

• Oxygen therapy.
• Nebulizer treatments with corticosteroids or bronchodilators.
• Removal of foreign body.
• Positive pressure ventilation. This can be noninvasive (CPAP or BiPAP) or invasive mechanical ventilation, if you can’t breathe on your own.

Tests for underlying conditions

The first thing a provider will do to treat intercostal retractions is to make sure you’re getting enough oxygen. But they also need to know what’s causing your breathing issue. Let them know if you have chronic conditions that affect your airways, like asthma, COPD or diabetes.

To better understand the best way to treat you, they might get:

• Imaging of your chest, like X-rays or CT scans (computed tomography scans).
• A nasal swab to test for viral infections.
• Blood tests.

What are the possible risks of not treating intercostal retractions?

If you don’t treat the underlying cause of intercostal retractions, your condition could get worse. In severe cases, breathing issues can lead to:

• Low levels of oxygen in your tissues (hypoxia).
• High levels of carbon dioxide in your blood (hypercapnia).
• Respiratory failure.

Can intercostal retractions be prevented?

You can reduce your risk of the airway issues that cause intercostal retractions by:

• Managing underlying conditions that can affect your breathing, like asthma, COPD and diabetes.
• Not giving aspirin to children under the age of 16.
• Treating and seeking medical attention for potentially severe allergic reactions right away.

When should I be concerned about intercostal retractions?

If you’re having trouble breathing or you notice intercostal retractions in your child or someone else, call 911 (or your local emergency service number) or seek emergency medical attention.

A note from Cleveland Clinic

Not being able to breathe is scary. Seeing your child struggle to breathe is even scarier. Sometimes, it can be hard to tell when you should seek care. If you can see the outline of someone’s ribs when they breathe in at rest, that’s a sign to get help right away. Fortunately, most causes of intercostal retractions in children are manageable or treatable at a hospital.