An Overview of Paradoxical Breathing

Paradoxical breathing describes when the chest wall or the abdominal wall moves in when taking a breath and moves out when exhaling. This is the opposite of normal breathing movement. Seen in children and adults, it is a sign of respiratory distress that is associated with damage to the structures involved in breathing.

Paradoxical breathing, also called paradoxical respiration, can be a symptom of trauma or a medical condition. It can also lead to other symptoms, like shortness of breath, weakness, rapid heart rate, and dizziness. Treatment may vary, but typically involves managing the underlying condition.

Learn more about the symptoms, causes, diagnosis, and treatment of paradoxical breathing.

Symptoms

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 don't match what's happening along the rest of the chest wall. Medical causes of paradoxical breathing often lead to a "seesaw" motion between the abdomen wall and the chest wall when you breathe.

Different breathing patterns cause different types of paradoxical breathing.

Causes

Traditionally, one traumatic and one medical cause is attributed to paradoxical breathing. However, almost any cause of shortness of breath, if severe enough, can lead to paradoxical breathing.

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.

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 and break an entire section of ribs apart from its neighboring rib cage.

Such force is likely to damage much more than just the chest wall. Many patients with flail chest also have associated internal injuries.

The movement of the free-floating flail segment is paradoxical because it sucks in when you inhales and bulges out when you exhales. This is the opposite movement of the rest of the chest wall.

The movement of a large flail segment minimizes the efficacy of your attempts to breathe. It's hard to expand the 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

A cause of paradoxical breathing that can be either traumatically or medically induced is paralysis of the diaphragm.

In this very rare condition, the diaphragm could be paralyzed or weakened by damage to the spinal cord or by a medical cause directly affecting the muscle or the nerves running from the brain to the diaphragm.

The diaphragm is a domed muscle at the base of the chest cavity that separates it from the abdominal cavity. The diaphragm is extremely important in breathing. It's the muscle most involved in expanding and contracting the chest cavity to change volume with 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 these muscles are engaged during periods of exercise or shortness of breath, the diaphragm is a stabilizing force and assists with movement of the chest cavity.

If the diaphragm is too weak to stabilize the base of the chest cavity, chest movement can pull abdominal organs toward the chest when you inhale and push them away from the chest when you exhale.

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 often gets worse when you lie flat on your back (supine) and appears to resolve when you stand up.

Respiratory Failure

As noted above, if you have severe shortness of breath for long enough, fatigue of the intercostal muscles or 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 an inability to compensate. Without treatment, respiratory failure is likely to continue getting worse.

As the condition worsens, paradoxical breathing develops as one of many signs of increased work to breathe and decreased effectiveness of breathing.

Diagnosis

Paradoxical respiration can usually be spotted visually and recognized 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 X-rays, ultrasounds, other imaging tests, and blood tests to diagnose the underlying condition. They'll want to see how much oxygen is getting through to your lungs since paradoxical breathing indicates a decrease in the amount of air that can move through your airways.

It's crucial to get medical care when you recognize these symptoms so a proper diagnosis can be made and the underlying condition can be treated.

Treatment

In the case of flail chest or a weakened diaphragm, treatment includes stabilizating the paradoxical movement to allow the chest to expand and contract as fully as possible. Stopping movement of the flail segment or abdominal wall 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 using an oxygen mask, fixing damage to the chest, and/or restoring a clear path in your airway so you can breath normally.

A Word From Verywell

Paradoxical breathing from any cause is uncommon enough that many caregivers can have a long career—even in emergency medicine—and never encounter it. However, it's such an important sign that every EMT and paramedic learns to look for it.

If you experience a traumatic event that may have caused flail chest, call 911.

If you recognize the seesaw motion of paradoxical breathing combined with feeling short of breath, even with no obvious injury, go to the emergency room. Weakness or paralysis of the diaphragm is treatable if it's caught in time.