What are the different types of chest wall retractions seen in children with respiratory distress?

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Types of Chest Wall Retractions in Children

Children with respiratory distress demonstrate several distinct types of retractions, which can be categorized anatomically: subcostal (chest indrawing), intercostal, suprasternal (tracheal tugging), and accessory muscle retractions (head nodding). 1

Anatomic Classification of Retractions

Subcostal Retractions (Chest Indrawing)

  • Location: Inward movement of tissue below the costal cartilage of the lower anterior chest wall during inspiration
  • Mechanism: Results from increased negative intrapleural pressure needed to maintain tidal volumes when lung compliance decreases
  • Clinical significance: Most commonly assessed sign in WHO guidelines for pneumonia diagnosis 1

Intercostal Retractions

  • Location: Tissue between the ribs pulls inward consistently during inspiration
  • Mechanism: Occurs from retraction of external intercostal muscles combined with more negative intrapleural pressures generated during inspiration
  • Clinical significance: Indicates significant respiratory effort and reduced lung compliance 1

Suprasternal Retractions (Tracheal Tugging)

  • Location: Soft tissue over the trachea immediately above the sternum pulls inward during inspiration
  • Mechanism: Results from bilateral contraction and relaxation of sternocleidomastoid and scalene muscles, combined with increased negative intrapleural pressures
  • Clinical significance: Can occur in both younger and older children with severe respiratory distress 1

Head Nodding

  • Location: Head moves upward and downward in synchrony with respiration
  • Mechanism: Occurs in young children with limited head control due to bilateral retraction and relaxation of sternocleidomastoid and scalene muscles
  • Clinical significance: Most visible in upright position, least visible when head is supported; indicates severe respiratory distress 1

Sternal Retractions

  • Location: Inward movement of the sternum itself
  • Mechanism: Occurs due to poor lung expansion and relatively soft anterior chest wall that caves in under increased negative intrathoracic pressure
  • Clinical significance: More common in premature infants; can be misinterpreted on chest radiographs as pneumomediastinum or cardiac displacement 2

Age-Specific Considerations

Children Under 2 Years

  • Critical caveat: Chest indrawing has lower specificity in this age group and can occur without pulmonary disease
  • Physiologic basis: Chest wall is nearly 3 times more compliant than lungs due to immature bone ossification
  • Clinical implication: These children ventilate at a mechanically disadvantageous state, requiring more negative intrapleural pressures even in healthy states
  • Can be seen with: Upper airway obstruction, nasopharyngeal inflammation, or febrile illnesses without lower respiratory disease 1

Children Over 2 Years

  • Chest wall compliance equilibrates with lung compliance by second year of life
  • Retractions become more specific for pulmonary pathology
  • Presence of retractions more reliably indicates significant respiratory compromise 1

Clinical Assessment Algorithm

When evaluating retractions, follow this hierarchy:

  1. Identify the anatomic location(s) of retractions present
  2. Assess for signs of severe respiratory distress (multiple types of retractions, nasal flaring, grunting)
  3. Consider patient age: If <2 years, retractions alone may not indicate severe disease
  4. Evaluate for hypoxemia: SpO₂ <93% significantly increases specificity for pulmonary disease 3
  5. Check for general danger signs: Inability to drink, vomiting everything, convulsions, lethargy, severe malnutrition 3

Critical Pitfalls to Avoid

  • Do not dismiss isolated subcostal retractions in children <2 years as automatically benign, but recognize they require additional signs (hypoxemia, severe respiratory distress signs) to indicate severe disease 1
  • Multiple simultaneous retraction types (intercostal + suprasternal + head nodding) indicate severe respiratory distress and substantially alter mortality risk, regardless of age 1
  • Agitated children may have distorted respiratory patterns making assessment unreliable; calm the child before assessment 1
  • On chest radiographs, sternal retraction can mimic pneumomediastinum, pneumothorax, or cardiomegaly 2

Physiologic Significance

The presence and severity of retractions directly correlate with:

  • Degree of lung compliance reduction
  • Work of breathing (can range from 94% to 793% of normal work performed on lungs) 4
  • Risk of respiratory decompensation
  • Association with severe hypoxemia (SpO₂ <90%) 1

When retractions occur with signs of severe respiratory distress, they represent the body's compensatory attempt for even greater reduction in lung compliance and indicate higher likelihood of respiratory failure 1.

References

4
Research

Distortion of chest wall and work of diaphragm in preterm infants.

Journal of applied physiology (Bethesda, Md. : 1985), 1987

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