An Overview of Paradoxical Breathing

Symptoms, Causes, and Treatment

In This Article

Table of Contents

Paradoxical breathing is the term for a sign of respiratory distress associated with damage to the structures involved in breathing. Instead of moving out when taking a breath, the chest wall or the abdominal wall moves in. Often, the chest wall and the abdominal wall move in opposite directions with each breath.

To understand the significance of paradoxical breathing, it's important to know why it's a paradox in the first place. Paradoxical breathing is often called paradoxical respiration and refers to a rare sign of respiratory distress or respiratory failure that essentially looks like the opposite of what one would expect to see while breathing.

The physiology of breathing consists of two distinct parts: ventilation and respiration. Ventilation refers to air movement in and out of the lungs. Respiration refers to the exchange of gases that occurs between the lungs and the bloodstream.

Paradoxical respiration refers to changes in the mechanics of breathing, which is ventilation rather than respiration. Learn more about the symptoms, causes, diagnosis, and treatment of this condition.


Paradoxical breathing is a sign (or symptom) itself. The presence of paradoxical breathing points to various types of respiratory distress or respiratory failure. The manifestation of paradoxical breathing depends on its cause.

Trauma can cause movements in the middle of the chest wall or on the back that do not match what is happening along the rest of the chest wall. Medical causes of paradoxical breathing are more likely to lead to a "seesaw" motion between the abdomen wall and the chest wall when the patient is breathing.

In each of the causes below, we will discuss how the breathing pattern looks and why it is called paradoxical breathing.


Traditionally, one traumatic and one medical cause is attributed to paradoxical breathing. Almost any cause of shortness of breath, however, can lead the patient to exhibit paradoxical breathing if severe enough. In only one cause, flail chest, is paradoxical breathing a diagnostic sign all by itself.

Flail Chest

The most common cause for paradoxical breathing noted in the literature is called a flail chest, which consists of a segment of the free-floating chest wall from multiple rib fractures. It takes a minimum of four complete rib fractures to develop a flail segment, which is defined as two or more consecutive ribs each broken in two or more places. Some sources suggest that at least three adjacent ribs must be broken in order to qualify as a flail segment. It's not as much about the number of ribs involved as it is about the size of the segment.

The larger of an area the flail segment covers, the more severe the patient's shortness of breath will be.

Flail chest is a very rare condition. In one study of 25,467 trauma patients admitted over a six-year period, only 85 patients had a flail segment, about 1/3 of a percent. The amount of force needed to cause a single rib fracture is significant. To create a flail segment, that level of force must be applied over a much larger area of the chest to be sufficient to break an entire section of ribs apart from its neighboring ribcage. Such force is likely to damage much more than just the chest wall. Many patients with flail chest also have associated internal injuries.

Paradoxical breathing in the case of a flail chest is the description given to the movement of the flail segment as the patient inhales and exhales. The flail segment is free-floating, which causes it to suck in when the patient inhales and bulge out when the patient exhales. This is the opposite of the movement of the rest of the patient's chest wall.

The movement of a large flail segment minimizes the efficacy of the patient's attempts to breathe. The patient has a hard time expanding her chest to move air in because the segment moves in and reduces the change in overall chest volume. The same thing happens during exhalation.

In flail chest, paradoxical breathing can lead to complications such as pneumothorax and pneumonia.

Paralysis of the Diaphragm

One cause of paradoxical breathing that can be either traumatically or medically induced is paralysis of the diaphragm. A very rare condition, the diaphragm could be paralyzed or weakened by damage to the spinal cord or by a medical cause affecting the muscle directly (or the nerves running from the brain to the diaphragm).

The diaphragm is a domed muscle found at the base of the chest cavity that separates it from the abdominal cavity. The diaphragm is extremely important in breathing. It is the muscle most involved in expanding and contracting the chest cavity to change volume and create inhalation or exhalation.

When the diaphragm is sufficiently weak, the muscles of the chest wall—the intercostal muscles—must do all the work of breathing. Even when the intercostal muscles are engaged during periods of exercise or shortness of breath, the diaphragm acts as a stabilizing force and assists with expansion and contraction of the chest cavity.

If the diaphragm is too weak to stabilize the base of the chest cavity, movement of the chest can lead to the abdominal organs being pulled toward the chest during inhalation and pushed away from the chest during exhalation.

Paradoxical breathing during weakness or paralysis of the diaphragm is described as a "seesaw" motion between the chest wall and the abdominal wall.

As the chest expands, abdominal organs move up and seemingly behind the sternum, causing the abdominal wall to contract. When the chest contracts for exhalation, the organs are pushed away and the abdominal wall expands.

Paradoxical breathing from a weak or paralyzed diaphragm is often made worse when the patient lies flat on his back (supine). Paradoxical breathing when a patient is lying supine that appears to resolve when the patient stands is an indication of weakness of the diaphragm.

Respiratory Failure

As noted above, if a patient suffers severe shortness of breath for a long enough period of time, fatigue of the intercostal muscles or the diaphragm can lead to the seesaw type of paradoxical breathing. This is likely the most common cause of paradoxical breathing in both adults and children.

Respiratory failure is defined as fatigue from shortness of breath—also known as respiratory distress—that results in a patient no longer being able to compensate. Without treatment, a patient with respiratory failure is likely to continue to decline. As her condition worsens, the patient with severe fatigue develops paradoxical breathing as one of many signs indicating increased work of breathing and decreased ventilation.


Paradoxical respiration can usually be spotted visually. As mentioned, it is recognizable by its characteristic opposition to normal breathing patterns. You can see the chest/stomach move in or toward the body upon inhalation, and out or away from the body upon exhalation.

A doctor may perform a number of tests including X-rays, imaging tests, ultrasounds, and blood tests to diagnose the underlying condition. He/she will want to see how much oxygen is getting through to your lungs since paradoxical breathing indicates a decrease in the amount of air that is able to move through the airways.

Of course, it is crucial to get to a healthcare professional upon realizing these symptoms so that a proper diagnosis can be made and the underlying condition can be treated.


In the case of flail chest or a weakened diaphragm, treatment includes stabilization of the paradoxical movement to allow the chest to expand and contract as fully as possible. Stopping the flail segment or the abdominal wall from moving helps the chest and lungs to move air more efficiently.

The most important treatment in all cases of paradoxical breathing involves reversing the root cause, which is only done in the emergency department. This could involve the use of an oxygen mask, fixing any damage to the chest, and/or restoring a clear path in your airway to make sure normal breathing is reinstated.

A Word From Verywell

Paradoxical breathing from paralysis of the diaphragm or from flail chest is uncommon enough that many caregivers can have a long career—even in emergency medicine—and possibly never encounter it. However, it is such an important sign to help diagnose flail chest that every EMT and paramedic learns to look for it. If you are faced with a traumatic event likely to cause flail chest, it's best to call 911. On the other hand, if you recognize the seesaw motion of paradoxical breathing combined with a feeling of shortness of breath, even if there's no obvious injury, it's worth going to the emergency department for an evaluation. Weakness or paralysis of the diaphragm is treatable if noted in time.

Was this page helpful?
Article Sources
  • Pereira, M., Mussi, R., Massucio, R., Camino, A., Barbeiro, A., Villalba, W., & Paschoal, I. (2006). Paresia diafragmática bilateral idiopática. Jornal Brasileiro De Pneumologia32(5), 481-485. DOI:10.1590/s1806-37132006000500017

  • Saraya T, Shimoda M, Hirata A, Takizawa H. Paradoxical respiration: 'Seesaw' motion with massive pulmonary consolidation. BMJ Case Rep. 2016;2016:bcr2015213449. Published 2016 Jan 19. DOI:10.1136/bcr-2015-213449

  • Beom JY, Seo HY. The Need for Early Tracheostomy in Patients with Traumatic Cervical Cord Injury. Clin Orthop Surg. 2018;10(2):191-196.

  • Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. Eur J Trauma Emerg Surg. 2016;43(2):163–168. DOI:10.1007/s00068-016-0721-2

  • Veysi VT, Nikolaou VS, Paliobeis C, Efstathopoulos N, Giannoudis PV. Prevalence of chest trauma, associated injuries and mortality: a level I trauma centre experience. Int Orthop. 2009;33(5):1425–1433. DOI:10.1007/s00264-009-0746-9