What is Paradoxical Breathing?
Paradoxical breathing is a term used to describe a sign of respiratory distress. This type of respiratory distress is commonly associated with damage to the organs involved in the breathing process. (1,2,3,4) Paradoxical breathing can cause the chest to expand while exhaling and contract while inhaling, which is the opposite of how it should normally be moving. (5,6,7)
The way normal breathing looks and feels depends on the usual movements of your lungs and diaphragm. The diaphragm is the main muscle that controls your breathing. During inspiration, which is the medical term used for inhaling, the diaphragm muscle pulls down, creating more room in the chest to allow the lungs to expand with air. This makes the chest appear like it is getting bigger. During expiration, which is the medical term used for exhaling air, the diaphragm muscle moves up, which pushes air out of the lungs, and causes the chest to contract. (8,9)
In cases of paradoxical breathing, this regular pattern of breathing gets reversed. This means that during inspiration, the chest contracts, and during expiration, the chest expands. Paradoxical breathing is also typically accompanied by abnormal movements in the abdomen, and it has been observed that the abdomen also moves in when a person inhales and moves out when they exhale.
While paradoxical breathing can be normal in infants, but in the case of children and adults, it is usually taken as a symptom of an underlying medical condition. (10) If paradoxical breathing is accompanied by breathing difficulties also, it is taken as a medical emergency, and you should seek immediate medical help.
What are the Symptoms of Paradoxical Breathing?
The main symptom of paradoxical breathing is the apparent change in the pattern of breathing. To check for paradoxical breathing, a person can lie down on their back and take a deep breath. When they inhale, the abdomen and chest should expand, and they should contract when they exhale. If the abdomen and chest contract when you inhale and expand when you breathe out, there is a chance that you may have paradoxical breathing.
The symptoms of paradoxical breathing are caused due to insufficient intake of oxygen. The common symptoms may include:
- Shortness of breath – a condition known as dyspnea (11)
- Fatigue or exhaustion that refuses to go away even after sleeping
- Excessive sleepiness – a condition known as hypersomnia (12)
- Poorer performance while exercising
- Frequently waking up at night
- Abnormally fast breathing – a condition known as tachypnea (13)
In some cases, paradoxical breathing can also be accompanied by other symptoms like:
- Being unable to take a deep breath
- Difficulty catching a breath
- Having a rapid heart rate
- Tension, pain, or weakness in the stomach or chest
The presence of paradoxical breathing also points to several other types of respiratory distress or sometimes even respiratory failure. The manifestation of paradoxical breathing depends a lot on its cause.
For example, trauma can cause certain movements on the back or in the middle of the chest wall that may not match what is happening along the rest of the chest wall. It has commonly been observed that medical causes of paradoxical breathing often causes a ‘seesaw’ motion between the chest wall and the abdomen wall while breathing. (14)
At the same time, different breathing patterns can cause different types of paradoxical breathing, and therefore the symptoms can vary.
It is recommended that you see a doctor if you experience any of the above-mentioned symptoms because there are some severe conditions also that cause paradoxical breathing, and the earlier you get diagnosed, the earlier you can start treatment.
What are the Causes of Paradoxical Breathing?
Paradoxical breathing is typically the result of a condition known as diaphragmatic dysfunction. Diaphragmatic dysfunction is a complex condition to diagnose. Researchers are not exactly sure what causes paradoxical breathing and the underlying condition, but it is believed that the following conditions can make people more susceptible to develop paradoxical breathing.
- Paralysis of the Diaphragm: One of the leading causes of paradoxical breathing is the paralysis of the diaphragm, which can either be traumatically or medically induced. This is a rare condition in which the diaphragm can be paralyzed or weakened due to damage to the spinal cord. It can also happen due to an underlying cause that directly affects the muscle or nerves running from the brain to the diaphragm. When the diaphragm is weak, the muscles of the chest wall need to do all the work involved in breathing. If the diaphragm becomes too weak to function and provide stability to the base of the chest cavity, chest movement can cause the abdominal organs to pull towards the chest when you inhale and push them away from the chest when you exhale. Paradoxical breathing from a paralyzed or weak diaphragm can worsen when you lie flat on the back and can resolve itself when you stand up.
- Trauma or Injury To The Chest Wall: Trauma or injury to the chest wall can separate your ribs from the chest wall. This separated section is no longer able to expand when you inhale, and sometimes this separated section can begin to push in, leading to paradoxical breathing. (15)
- Obstructive Sleep Apnea: Obstructive sleep apnea causes a disruption in the inflow of oxygen and the exhalation of carbon dioxide. Over a period of time, the chest wall can start turning inwards instead of outwards, which can lead to paradoxical breathing. (16)
- Mineral Deficiency: If you are deficient in certain minerals, such as magnesium, potassium, and calcium, it can have an impact on your breathing. For example, having a low amount of calcium can impair the nervous system and disrupt your breathing. At the same time, malnutrition, diarrhea, vomiting, and metabolic disorders can also lead to imbalances in the body’s electrolytes, which can also cause respiratory problems such as paradoxical breathing.
- Disruption of Nerves: The movement of the diaphragm and other important muscles in the body are controlled by the phrenic nerves. Nerve damage can cause a disruption to the normal movement of muscles in the body and bring about changes in your breathing. This can happen due to a neurodegenerative diseases like multiple sclerosis, Guillain-Barre syndrome, and muscular dystrophy. Injuries to the chest wall and lung cancer can also cause nerve damage. (17)
- Weak Respiratory Muscles: In some cases, the muscles that support the respiratory system and respiratory pathways can become weak. This can disrupt the breathing patterns. Such type of weakness in muscles can also happen in neuromuscular conditions like multiple sclerosis and amyotrophic lateral sclerosis.
- Hormonal Shifts: Hormones are the chemical messengers of the body, and they convey important information to almost all parts of the body, including the respiratory system. Hormonal imbalances can change your breathing patterns, leading to paradoxical breathing.
- Blockage of the Upper Airway: When there is something blocking the upper airway, including the throat, nose, and upper part of the windpipe, it may cause paradoxical breathing. This can happen due to an allergic reaction if the throat swells up, if someone is choking, or if there is a severe respiratory infection.
How Does Paradoxical Breathing Affect Infants and Children?
In many cases, infants’ chests tend to contract when they inhale, which is considered to be normal as long as the stomach expands with it. The chest and lungs are not yet fully formed in children under 2-3 years old, and because the chest is able to move more easily in infants, their breathing pattern can look quite different than it does in adults. (18)
However, parents should be on the lookout for other signs of respiratory distress if there is any concern about their child’s breathing. Shortness of breath, coughing, and any complaints of having difficulty in breathing are signs that warrant a call to your doctor.
Retracting is a medical emergency that may occur in newborns and infants. Retracting happens when the skin sinks into the ribs while breathing because the body struggles to take in enough air. (19) This may also cause your chest to fall.
Some of the other signs of breathing problems in children and infants may include:
- Wheezing or grunting
- Repeated flaring of the nostrils
- Very rapid breathing
- Turning blue
Diagnosing Paradoxical Breathing
To begin with, your doctor will find out about the symptoms you are experiencing and take a detailed medical history. They will also run a variety of diagnostic tests to check the oxygen and carbon dioxide levels in the bloodstream. Your doctor will measure the oxygen level by taking a blood sample or with an oximeter, which is a small device that is attached to the finger to measure blood oxygen levels. (20)
Your doctor may also prescribe some other tests, including:
- Pulmonary function test
- Fluoroscopy, which is a special type of X-ray
- Sniff nasal inspiratory pressure test, also known as the sniff test
- A maximal static inspiratory pressure test, also known as the MIP test
A pulmonologist and radiologist may further prescribe more imaging tests to get a better understanding of what’s going on inside your body. These may include:
- Chest X-ray
- Ultrasound of the chest and surrounding structures
- CT scan
- Electromyography of the diaphragm
How is Paradoxical Breathing Treated?
Most cases of paradoxical breathing can be managed by treating the underlying condition. For example, if the cause of the paradoxical breathing is a nutrient deficiency, you will be prescribed supplements or advised to change your diet.
Doctors may also prescribe treatments that will help relieve your symptoms. If you have problems while sleeping, your doctor may recommend the use of continuous positive airway pressure (CPAP) to manage the symptoms. Nocturnal invasive ventilation is recommended to help people with low oxygen or high carbon dioxide capacity.(21)
If your symptoms continue or you have an extreme case of respiratory distress, you may need surgery. People who have an injury or trauma to their lungs or ribs may also require surgery to treat the condition.
If the diaphragm is paralyzed, a doctor will use a technique known as surgical plication to help improve your lung function. This technique is done by a surgeon and involves flattening the diaphragm to provide the lungs more space to expand.
People who are on a ventilator may find the procedure of phrenic pacing helpful. This procedure involves a device that sends signals to the phrenic nerves in the body, which makes your diaphragm muscles contract.
Other potential treatments for paradoxical breathing may include:
- Use of a tracheotomy, which involves inserting a breathing tube in the windpipe.
- Using an oxygen mask or another form of oxygen delivery system.
- Medication for any underlying medical condition.
- Removing and treating any blockages in the airway.
- Replacing any lost electrolytes with intravenous fluids.
- Repairing any damage caused to the diaphragm or chest.
- Treating sleep apnea
- Monitoring in a hospital setting if the underlying cause of paradoxical breathing remains unclear.
Paradoxical breathing can range from being a temporary symptom in infants and children to a potentially life-threatening condition in people who have experienced a severe injury or paralysis of the diaphragm.
Paradoxical breathing is more of a breathing pattern and symptom, and it alone cannot be enough to diagnose a medical condition. This is why it is important to seek immediate medical assistance and give your doctor a complete medical history. With the correct diagnosis, paradoxical breathing can be treated, and you have a great outlook.
- Korol, E., 1933. Paradoxical Breathing. Archives of Internal Medicine, 51(2), pp.264-278.
- Courtney, R., 2009. The functions of breathing and its dysfunctions and their relationship to breathing therapy. International Journal of Osteopathic Medicine, 12(3), pp.78-85.
- Perri, M.A. and Halford, E., 2004. Pain and faulty breathing: a pilot study. Journal of Bodywork and Movement Therapies, 8(4), pp.297-306.
- Courtney, R., Cohen, M. and Reece, J., 2009. Comparison of the Manual Assessment of Respiratory Motion (MARM) and the Hi Lo Breathing Assessment in determining a simulated breathing pattern. International Journal of Osteopathic Medicine, 12(3), pp.86-91.
- Crosfill, M.L. and Widdicombe, J.G., 1961. Physical characteristics of the chest and lungs and the work of breathing in different mammalian species. The Journal of physiology, 158(1), pp.1-14.
- Liem, K.F., 1988. Form and function of lungs: the evolution of air breathing mechanisms. American Zoologist, 28(2), pp.739-759.
- Benchetrit, G., 2000. Breathing pattern in humans: diversity and individuality. Respiration physiology, 122(2-3), pp.123-129.
- Petit, J.M., Milic-Emili, G. and Delhez, L., 1960. Role of the diaphragm in breathing in conscious normal man: an electromyographic study. Journal of Applied Physiology, 15(6), pp.1101-1106.
- De Troyer, A. and Estenne, M., 1984. Coordination between rib cage muscles and diaphragm during quiet breathing in humans. Journal of Applied Physiology, 57(3), pp.899-906.
- Ferster, A.P.C., Shokri, T. and Carr, M., 2018. Diagnosis and treatment of paradoxical vocal fold motion in infants. International journal of pediatric otorhinolaryngology, 107, pp.6-9.
- Campbell, M.L., 2017. Dyspnea. Critical Care Nursing Clinics, 29(4), pp.461-470.
- Challamel, M.J., 2003. Hypersomnia in children. In Sleep (pp. 457-468). Springer, Boston, MA.
- Yurdakök, M., 2010. Transient tachypnea of the newborn: what is new?. The Journal of Maternal-Fetal & Neonatal Medicine, 23(sup3), pp.24-26.
- Schuurmans, J., Goslings, J.C. and Schepers, T., 2017. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review. European Journal of Trauma and Emergency Surgery, 43(2), pp.163-168.
- Krakow, B., Melendrez, D., Warner, T.D., Dorin, R., Harper, R. and Hollifield, M., 2002. To breathe, perchance to sleep: sleep-disordered breathing and chronic insomnia among trauma survivors. Sleep and Breathing, 6(4), pp.189-202.
- Saeed, M.M., Keens, T.G., Stabile, M.W., Bolokowicz, J. and Ward, S.L.D., 2000. Should children with suspected obstructive sleep apnea syndrome and normal nap sleep studies have overnight sleep studies?. Chest, 118(2), pp.360-365.
- Howard, R.S., Wiles, C.M., Hirsch, N.P., Loh, L., Spencer, G.T. and Newsom-Davis, J., 1992. Respiratory involvement in multiple sclerosis. Brain, 115(2), pp.479-494.
- te Pas, A.B., Wong, C., Kamlin, C.O.F., Dawson, J.A., Morley, C.J. and Davis, P.G., 2009. Breathing patterns in preterm and term infants immediately after birth. Pediatric research, 65(3), pp.352-356.
- Stanfordchildrens.org. 2021. default – Stanford Children’s Health. [online] Available at: <https://www.stanfordchildrens.org/en/topic/default?id=breathing-problems-90-P02666> [Accessed 1 April 2021].
- Millikan, G.A., 1942. The oximeter, an instrument for measuring continuously the oxygen saturation of arterial blood in man. Review of scientific Instruments, 13(10), pp.434-444.
- Duiverman, M.L., Wempe, J.B., Bladder, G., Jansen, D.F., Kerstjens, H.A., Zijlstra, J.G. and Wijkstra, P.J., 2008. Nocturnal non-invasive ventilation in addition to rehabilitation in hypercapnic patients with COPD. Thorax, 63(12), pp.1052-1057.