Retractions, costal and sternal

A cardinal sign of respiratory distress in infants and children, retractions are visible indentations of the soft tissue covering the chest wall. They may be suprasternal (directly above the sternum and clavicles), intercostal (between the ribs), subcostal (below the lower costal margin of the rib cage), or substernal (just below the xiphoid process). Retractions may be mild or severe, producing barely visible to deep indentations.

Normally, infants and young children use abdominal muscles for breathing, unlike older children and adults, who use the diaphragm. When breathing requires extra effort, accessory muscles assist respiration, especially inspiration. Retractions typically accompany accessory muscle use.

Emergency interventions

 If you detect retractions in a child, check quickly for other signs of respiratory distress, such as cyanosis, tachypnea, tachycardia, and decreased oxygen saturation. Also, prepare the child for suctioning, insertion of an artificial airway, and administration of oxygen.

Observe the depth and location of retractions. Also, note the rate, depth, and quality of respirations. Look for accessory muscle use, nasal flaring during inspiration, or grunting during expiration. If the child has a cough, record the color, consistency, and odor of any sputum. Note whether the child appears restless or lethargic. Finally, auscultate the child’s lungs to detect abnormal breath sounds. (See Observing retractions.)

History and physical examination

If the child’s condition permits, ask his parents about his medical history. Was he born prematurely? Was he born with a low birth weight? Was the delivery complicated? Ask about recent signs of an upper respiratory tract infection, such as a runny nose, cough, and a low-grade fever. How often has the child had respiratory problems during the past year? Has he been in contact with anyone who has had a cold, the flu, or other respiratory ailments? Did he ever have respiratory syncytial virus? Did he aspirate any food, liquid, or foreign body? Inquire about any personal or family history of allergies or asthma.

Medical causes

Asthma attack

Intercostal and suprasternal retractions may accompany an asthma attack. They’re preceded by dyspnea, wheezing, a hacking cough, and pallor. Related features include cyanosis or flushing, crackles, rhonchi, diaphoresis, tachycardia, tachypnea, a frightened, anxious expression and, in patients with severe distress, nasal flaring.

Bronchiolitis

Most common in children younger than age 2, this acute lower respiratory tract infection may cause intercostal and subcostal retractions, nasal flaring, tachypnea, dyspnea, cough, restlessness and a slight fever. Periodic apnea may occur in infants younger than age 6 months.

Croup (spasmodic)

This disorder causes attacks of a barking cough, hoarseness, dyspnea, and restlessness. As distress worsens, the child may display suprasternal, substernal, and intercostal retractions; nasal flaring; tachycardia; cyanosis; and an anxious, frantic expression. Croup attacks usually subside within a few hours but tend to recur.

 Epiglottiditis

This life-threatening bacterial infection may precipitate severe respiratory distress with suprasternal, substernal, and intercostal retractions; stridor; nasal flaring; cyanosis; and tachycardia. Early features include sudden onset of a barking cough and high fever, sore throat, hoarseness, dysphagia, drooling, dyspnea, and restlessness. The child becomes panicky as edema makes breathing difficult. Total airway occlusion may occur in 2 to 5 hours.

Heart failure

Usually linked to a congenital heart defect in children, this disorder may cause intercostal and substernal retractions along with nasal flaring, progressive tachypnea, and—in severe respiratory distress—grunting respirations, edema, and cyanosis. Other findings include productive cough, crackles, jugular vein distention, tachycardia, right-upper-quadrant pain, anorexia, and fatigue.

Laryngotracheobronchitis (acute)

With this viral infection, substernal and intercostal retractions typically follow a low to moderate fever, runny nose, poor appetite, a barking cough, hoarseness, and inspiratory stridor. Associated signs and symptoms include tachycardia; shallow, rapid respirations; restlessness; irritability; and pale, cyanotic skin.

Pneumonia (bacterial)

This disorder begins with signs and symptoms of acute infection, such as high fever and lethargy, which are followed by subcostal and intercostal retractions, nasal flaring, dyspnea, tachypnea, grunting respirations, cyanosis, and a productive cough. Auscultation may reveal diminished breath sounds, scattered crackles, and sibilant rhonchi over the affected lung. GI effects may include vomiting, diarrhea, and abdominal distention.

Respiratory distress syndrome

Substernal and subcostal retractions are an early sign of this life-threatening syndrome, which affects premature infants shortly after birth. Associated early signs include tachypnea, tachycardia, and expiratory grunting. As respiratory distress worsens, intercostal and suprasternal retractions typically occur, and apnea or irregular respirations replace grunting. Other effects include nasal flaring, cyanosis, lethargy, and eventual unresponsiveness as well as bradycardia and hypotension. Auscultation may detect crackles over the lung bases on deep inspiration and harsh, diminished breath sounds. Oliguria and peripheral edema may occur.

Special considerations

Continue to monitor the child’s vital signs. Keep suction equipment and an appropriate-sized airway at the bedside. If the infant weighs less than 15 lb (6.8 kg), place him in an oxygen hood. If he weighs more, place him in a cool mist tent instead. Perform chest physical therapy with postural drainage to help mobilize and drain excess lung secretions. (See Positioning an infant for chest physical therapy, pages 678 and 679.) A bronchodilator or, occasionally, a steroid may also be used.

Prepare the child for chest X-rays, cultures, pulmonary function tests, and arterial blood gas analysis. Explain the procedures to his parents, too, and have them calm and comfort the child.

Pediatric pointers

When examining a child for retractions, know that crying may accentuate the contractions.

Geriatric pointers

Although retractions may occur at any age, they’re more difficult to assess in an older patient who’s obese or who has chronic chest wall stiffness or deformity.

Pictures

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Breathlessness on exertion: Introduction (review 6 causes)
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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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