Paradoxical Breathing


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.

Paradoxical Breathing


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.

Paradoxical Breathing

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.

Paradoxical Breathing


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.

Paradoxical Breathing


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.1

Different breathing patterns cause different types of paradoxical breathing.

Paradoxical Breathing

Paradoxical Breathing

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, often called paradoxical respiration, 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.