7-15: Respiratory Retractions

Clinical Summary

Increased respiratory effort may be manifested by increased respiratory rate, increased chest wall excursion, and retractions of the less rigid structures of the thorax. Retractions of the sternum or suprasternal notch, intercostal retractions, and paradoxical abdominal movement reflect increased respiratory effort. This may be due to obstructive disease such as asthma or upper airway obstruction, pneumonia, or restrictive disease. The presence of stridor, wheezing, or rhonchi will help distinguish the cause.

Management and Disposition

An aggressive search for the cause of the retractions is required to direct therapy. Rapid evaluation of the airway for patency and breathing for oxygenation should be done immediately. High-flow oxygen by face mask is administered to patients in respiratory distress. Preparation for intubation is initiated for patients in severe distress or respiratory failure. Bilevel positive airway pressure and high-flow nasal canula therapy may buy time prior to intubation or prevent intubation. Arterial blood gas analysis may help identify impending respiratory failure. Routine measures for the mildly symptomatic patient depend on the cause of the retractions. For asthma or exacerbations of chronic obstructive pulmonary disease (COPD), nebulized β₂ agonists and steroid therapy may be appropriate. Patients with croup may require nebulized epinephrine or dexamethasone as initial therapy. Foreign-body aspiration requires imaging and consultation for confirmation of the suspected diagnosis and removal.

Pearls

1. Retractions are best observed with the patient at rest and the chest exposed.

2. Retractions from obstructive airway disease can be intercostal and supraclavicular and are usually accompanied by nasal flaring, increased expiratory phase, and increased respiratory rate.

3. Other causes of respiratory retractions include vocal cord paralysis, severe metabolic acidosis as seen in diabetic ketoacidosis, and salicylate toxicity.

4. Most patients with airway or respiratory problems should be positioned for their comfort, not ours.