Supraclavicular and intercostal indrawing of the adult

Specialty: Respiratory.

• adult suprasternal retraction
• use of accessory respiratory muscles

Why it occurs

• Acute obstruction of the upper airway due to a foreign body, epiglottitis or laryngeal edema (vigorous inspiratory effort generates a large negative intrathoracic pressure that sucks the skin and soft tissues over the clavicle and between the ribs)
• Status asthmaticus or extremely severe asthma attack (severe diffuse bronchial obstruction with drastic increase in inspiratory work)
• Very severe exacerbation of COPD with diaphragmatic fatigue (the accessory muscles of the neck such as the sternocleidomastoid and the scalenes assume the work of inspiration)
• Massive or tension pneumothorax (loss of normal ventilatory mechanics in a hemithorax)
• Extensive bilateral pneumonia with acute respiratory distress syndrome (ARDS).

Initial workup

Immediate visual clinical evaluation of the respiratory pattern; pulse oximetry and cardiac monitoring; Urgent portable chest x-ray; Immediate arterial blood gas; Direct laryngoscopy or urgent neck CT if mechanical or tumor obstruction of the upper airway is suspected.

Standard management

• Adrenaline — nebulized, 2 to 5 mL of 1:1000 solution if the cause is laryngeal edema or stridor due to upper airway obstruction
• Methylprednisolone — 125 mg intravenously immediately for asthma or severe COPD
• Magnesium sulfate (magnesium sulfate, 2 g intravenously infused over 20 minutes in refractory asthma attacks).