Intercostal Retractions: Symptoms, Causes and Treatment

Intercostal retractions are a critical clinical sign that often signal significant respiratory distress, especially in children and patients with pulmonary conditions. Recognizing and understanding intercostal retractions can help healthcare providers make swift, life-saving decisions, while also empowering patients and caregivers to identify when urgent care is needed. In this comprehensive article, we'll explore the symptoms, causes, and treatment options for intercostal retractions, drawing on current research and clinical practice.

Symptoms of Intercostal Retractions

Intercostal retractions manifest as visible sinking or “pulling in” of the skin between the ribs during breathing. This sign is especially recognizable during inspiration, when the negative pressure in the chest increases as the body works harder to draw in air. Recognizing the symptoms associated with intercostal retractions is vital for early diagnosis and intervention in potentially life-threatening conditions.

Symptom	Description	Associated Condition	Source(s)
Retractions	Indrawing of skin between ribs	Respiratory distress	1
Dyspnea	Difficulty or labored breathing	Hypoxemia, pneumonia	1
Nasal flaring	Widening of nostrils during inspiration	Severe respiratory effort	1
Grunting	Audible sound during exhalation	Severe pneumonia	1

Table 1: Key Symptoms

Recognizing Intercostal Retractions

Intercostal retractions are easy to spot in patients who are struggling to breathe. The skin between the ribs visibly draws inward with each breath, a sign that the body is working harder to move air into the lungs. This is particularly noticeable in infants and young children, whose chest walls are more flexible.

Other associated symptoms include:

• Dyspnea: This refers to an increased effort to breathe or a feeling of breathlessness. Patients may appear anxious, breathe rapidly, or use accessory muscles of respiration 1.
• Nasal flaring: This is the outward flaring of the nostrils during inspiration, indicating increased respiratory effort 1.
• Grunting: A low-pitched sound heard during exhalation as the body attempts to keep airways open. It often accompanies severe respiratory conditions like pneumonia 1.

Additional Clinical Markers

Intercostal retractions rarely occur in isolation. They are often seen alongside other signs of respiratory distress such as:

• Subcostal retractions (pulling in below the ribcage)
• Suprasternal retractions (at the top of the breastbone)
• Cyanosis (bluish discoloration of the skin, lips, or nails due to low oxygen)

These symptoms, when present, strongly suggest hypoxemia—a state of abnormally low oxygen in the blood—which requires immediate medical attention 1.

Importance in Diagnosis

The presence of intercostal retractions is highly sensitive for identifying hypoxemia in children with pneumonia, meaning that when retractions are seen, there is a high likelihood that oxygen levels are dangerously low 1. This makes retractions a critical marker in settings where advanced monitoring, such as pulse oximetry, is unavailable.

Causes of Intercostal Retractions

Understanding what causes intercostal retractions is crucial for addressing the underlying health issue. Retractions are not a disease themselves, but rather a symptom of a compromised respiratory system.

Cause	Mechanism	Patient Population	Source(s)
Hypoxemia	Low blood oxygen, increased effort	Children with pneumonia	1
Airway Obstruction	Blocked/narrowed airways	Infants, adults	1
Chest Wall Compliance	Flexible thorax increases retractions	Pediatric, post-surgical	1 2 4
Post-Thoracotomy Pain	Intercostal nerve injury/trauma	Surgical patients	2 3 4 5

Table 2: Main Causes

Hypoxemia and Respiratory Distress

Intercostal retractions most commonly occur due to hypoxemia, a state where oxygen levels in the blood are dangerously low. Hypoxemia increases the work of breathing, forcing the patient to use extra muscles to draw air into the lungs. This increased effort causes the soft tissues between the ribs to be sucked inward during inspiration—resulting in visible retractions 1.

Key Triggers for Hypoxemia

• Severe pneumonia: Pneumonia inflames the lungs and impairs oxygen exchange, making breathing more difficult and often leading to hypoxemia and retractions 1.
• Bronchiolitis and asthma: Inflammatory airway diseases can cause airway narrowing, increasing the effort needed to breathe.

Airway Obstruction

Any condition that narrows or blocks the airways—such as foreign body aspiration, swelling, or severe allergic reactions—can cause intercostal retractions. The narrowing increases resistance to airflow, requiring more forceful inspiration and causing the chest wall to retract 1.

Chest Wall Compliance

Children are especially prone to intercostal retractions due to the greater flexibility of their chest walls. In adults, after chest surgery (e.g., thoracotomy), changes in chest wall mechanics or pain may also contribute to abnormal breathing patterns, though retractions are less pronounced than in children 1 2 4.

Post-Thoracotomy and Intercostal Nerve Injury

Patients who have undergone thoracic surgery (thoracotomy) may experience altered respiratory mechanics, pain, and sometimes intercostal nerve injury. This can result in labored breathing and, in some cases, intercostal retractions, especially if pain management is inadequate or if nerve injury disrupts normal muscle function 2 3 4 5.

Other Contributing Factors

• Neuromuscular disorders: Weakness of the respiratory muscles can increase the work of breathing, making retractions more likely.
• Upper airway anomalies: In infants, anatomical issues like laryngomalacia can contribute to airway obstruction and retractions.

Treatment of Intercostal Retractions

Treating intercostal retractions involves both addressing the underlying cause and providing symptomatic relief. Timely intervention can be life-saving, especially in children and critically ill patients.

Treatment	Approach/Intervention	Target Issue	Source(s)
Oxygen Therapy	Supplemental oxygen delivery	Hypoxemia	1
Airway Management	Suction, bronchodilators, intubation	Airway obstruction	1
Pain Control	Analgesics, nerve protection techniques	Post-thoracotomy pain	2 3 4 5 6
Intercostal Muscle Flap	Surgical technique to reduce pain	Post-surgical nerve trauma	2 4 5
Pharmacological	Opioids, gabapentin, bupivacaine	Chronic pain/allodynia	3 6

Table 3: Treatment Strategies

Acute Management

Oxygen Therapy

The first and most urgent step in the management of intercostal retractions due to hypoxemia is the provision of supplemental oxygen. This helps to rapidly correct low oxygen levels, reducing respiratory effort and relieving retractions. Oxygen delivery can be administered via nasal cannula, face mask, or more advanced modalities, depending on severity 1.

Airway Management

When airway obstruction is suspected, interventions may include:

• Suctioning secretions
• Administering bronchodilators (for asthma or bronchiolitis)
• Intubation and mechanical ventilation in severe cases

Prompt clearing of the airway reduces the work of breathing, alleviating retractions 1.

Pain Management and Postoperative Care

Analgesics and Nerve Protection

In post-thoracotomy patients, pain can significantly impair respiratory effort, leading to shallow breathing or even retractions. Adequate pain management with analgesics—such as opioids, gabapentin, or local anesthetics—improves respiratory mechanics and comfort 2 3 4 5 6.

Protecting the intercostal nerves during surgery, using techniques like intercostal muscle flaps and edge closure, has been shown to reduce postoperative pain and improve breathing 2 4 5. These methods prevent nerve compression or injury during rib retraction and chest wall closure.

• Intercostal muscle flap: Harvesting and repositioning the muscle before rib retraction cushions the intercostal nerve, reducing pain and preserving normal breathing 2 4 5.
• Edge closure technique: Carefully closing the ribs to avoid nerve compression also lowers chronic pain risk 4.

Pharmacological Interventions for Chronic Pain

Research in animal models indicates that gabapentin, morphine, clonidine, neostigmine, and bupivacaine can all reduce the risk or severity of chronic pain (allodynia) after thoracotomy, which may contribute to abnormal breathing patterns and retractions 3 6.

Long-Term Management

For persistent or recurrent intercostal retractions, ongoing management focuses on:

• Treating the underlying disease (e.g., antibiotics for pneumonia)
• Pulmonary rehabilitation for chronic lung conditions
• Addressing neuromuscular weakness if present

When to Seek Emergency Care

Intercostal retractions are a red flag for severe respiratory distress. Immediate medical attention is warranted if retractions are accompanied by:

• Cyanosis (blue lips/skin)
• Altered mental status
• Lethargy or unresponsiveness
• Inability to speak or feed (in infants)

Conclusion

Intercostal retractions are a crucial clinical sign of respiratory distress that demand prompt recognition and intervention. Understanding their symptoms, causes, and treatment options can save lives—especially in vulnerable populations like children and post-surgical patients.

Key takeaways:

• Intercostal retractions signal severe respiratory effort and are often accompanied by dyspnea, nasal flaring, and grunting 1.
• Major causes include hypoxemia, airway obstruction, chest wall compliance (especially in children), and postoperative pain or nerve injury 1 2 3 4 5.
• Treatment focuses on correcting hypoxemia with oxygen, managing airway obstruction, and controlling pain—particularly after thoracic surgery 1 2 3 4 5 6.
• Preventive surgical techniques, like the intercostal muscle flap and edge closure, can reduce postoperative pain and complications 2 4 5.
• Chronic post-thoracotomy pain and its impact on breathing may be minimized by medications such as opioids, gabapentin, and bupivacaine 3 6.
• Persistent or severe retractions warrant immediate medical evaluation, as they may indicate life-threatening hypoxemia or airway compromise.

By being vigilant for intercostal retractions and understanding their clinical significance, healthcare providers and caregivers can ensure rapid, effective intervention for those in respiratory distress.