Pectus Excavatum Shortness of Breath: Causes and Tests

You get winded before your friends do, or a doctor has said it’s probably asthma, and you’re wondering whether the dip in your chest is the real reason. It can be. When pectus excavatum causes breathlessness, it mostly shows up during exercise and mostly in deeper chests, and many people with a sunken chest breathe normally at rest. Breathlessness at rest, lying flat or at night is a different matter, and it needs a doctor rather than a guess.

I was diagnosed with pectus excavatum at 15 and corrected it without surgery over about three years. The change was visible and measurable, but not complete. I’m not a doctor, so every medical point here comes from a study or a hospital source. Many of the numbers come from people already sent to a surgeon, so I say who each one was measured in.

Worried right now? Skip to when to see a doctor. Told you have asthma, or you snore? Jump to asthma or sleep apnea.

Why pectus excavatum can leave you short of breath

Three things can be involved: your lungs, your heart and your fitness.

Your lungs: a little below average at rest

The usual lung function test is spirometry: after a full breath in, you blow out as hard and fast as you can. Its key number is FVC (forced vital capacity), the most air you can blow out, shown as a percentage of what’s predicted for your age, height and sex.

Not everyone with pectus scores low, and some score above average, as the team that developed the Nuss procedure points out in a 2016 review.

In a study of 327 patients at 11 centres who went on to surgery, average FVC was 88% of predicted beforehand. In 310 patients aged 6 to 21 who came to 11 North American centres for repair, 14.5% had a restrictive pattern, meaning the lungs held less air than expected. Abnormal results became more common in deeper chests: at a Haller index of 7, a restrictive pattern was 4 times as likely as at 4. (The Haller index is the severity number from a chest scan, where about 2.5 is average.)

The average shortfall is modest, even in people heading for surgery.

Your heart: filling less during exercise

The right side of the heart sits just behind the breastbone. In deeper chests it can be pressed so it fills less, lowering stroke volume, the blood each beat pushes out. In a study of teenagers with and without pectus, hearts worked the same at rest and differed only during exercise, as I cover in pectus excavatum and heart problems.

Position matters too. In a small study of 13 people with pectus and 20 without, the pectus group had lower peak oxygen uptake (the standard measure of aerobic fitness) and lower stroke volume cycling upright, but near-normal results cycling lying down.

Your fitness: part of the picture

Twelve boys with moderate to severe pectus (average Haller index 3.95) were less fit than 20 boys without, but with “considerable overlap”, enough that the authors found it hard to blame the chest for any one boy’s limits. In a pilot study of 15 teenagers with pectus, aerobic fitness averaged 77% of predicted against 100% in 15 without, and how active they were predicted it. Ninety teenagers with pectus excavatum scored lower than 90 healthy peers on strength, endurance and flexibility, whatever their severity (a study co-authored by Prof. Mustafa Yüksel).

On the other side, 21 patients aged 13 to 50 referred before surgery, 85% of them regular aerobic exercisers, had results the authors called consistent with a heart limit, not lack of fitness. There was no comparison group.

Lack of exercise and anxiety can cause breathlessness on their own, too, says Cleveland Clinic.

My read: in a deeper chest, the heart can set a ceiling during hard exercise, and fitness decides how close you get to it. How you feel can’t tell which one is stopping you. That’s what the exercise test below is for.

How much depends on your chest

Finding	Who it was measured in
Exercise-test changes began above a Haller index of 3.25; peak oxygen uptake fell only above 4.0	99 otherwise healthy patients in Germany, mostly young
About 65% short of breath with exertion	Patients in an 11-centre surgical study, reported in the Nuss developers’ 2016 review
More than 80% reported restricted breathing in normal activity and exercise	432 adults referred for surgery at Mayo Clinic Arizona, median Haller index 4.2
Most cases are mild; in a small number of extreme chests, walking or stairs can be limited, and symptoms can occur at rest	2024 Pectus Care Guidelines, a consensus of specialist surgical societies

Depth matters, but loosely. In that Mayo Arizona referral group, the total symptom score tracked the Haller index at only r = 0.16 (0 is no relationship, 1 a perfect one), and breathing symptoms didn’t track lung test results. People referred to a surgeon skew toward deep, symptomatic chests, the survey had no comparison group, and its first author discloses royalties from the maker of the Nuss bar.

The full list of signs, including whether a mild chest affects breathing, is in pectus excavatum symptoms.

Which kind of breathlessness is it?

The NHS says not to self-diagnose shortness of breath, and to see a GP. Common causes include asthma, chest infections, being overweight, smoking and panic attacks. Use this table to describe your pattern to a doctor.

If you notice	What the research says	What to do
Breathless only with hard exercise	The usual pattern when pectus is involved, mostly in deeper chests, mixed with fitness	Build fitness. Tell a doctor if it’s new, worsening or you can’t keep up with peers
Breathless with light effort or at rest	The guidelines tie this to extreme chests	See a doctor first
Breathless lying flat	I found no pectus study	See a doctor (below)
Wheeze, cough or a tight chest, often worse at night	Classic asthma signs (NHS)	Ask if a breathing test confirmed it (asthma)
Loud snoring, pauses in breathing, daytime sleepiness	Sleep apnea signs (NHS)	Ask about a sleep study (sleep apnea)
Fast breathing with tingling or light-headedness	Over-breathing lowers carbon dioxide (MedlinePlus)	Slow your breathing. Get emergency care if it’s the first time
A child’s ribs or tummy pulling in with each breath	A breathing sign, not a chest shape	Get urgent help (babies and children)

Breathless lying down

Breathlessness lying on your back that eases when you sit or stand is called orthopnea. Cleveland Clinic says it points to an underlying condition in almost every case, such as heart failure, lung disease, fluid around the lungs or a weak diaphragm, though it doesn’t by itself mean heart failure. The NHS says to see a GP if breathlessness gets worse when you lie down.

I couldn’t find a study showing that breathlessness lying flat is a feature of pectus, and the cycling study above points the other way. So don’t put it down to your chest. See a doctor.

When to see a doctor

See a doctor before you start any device, brace or exercise program if any of these apply to you:

• chest pain
• fainting or nearly fainting
• breathlessness at rest or with light effort
• breathlessness when you lie flat, or waking up breathless
• needing your reliever inhaler more often than usual
• loud snoring with pauses in your breathing
• palpitations or an irregular heartbeat
• a diagnosed heart or lung condition
• Marfan syndrome or Ehlers-Danlos syndrome, or a doctor has raised either
• previous chest surgery
• a Haller index above 3.25 together with symptoms
• symptoms that nobody has checked yet

None of these means you’ll need surgery. They mean someone should look at your heart and lungs before you go further. An index above 3.25 is a common referral threshold, not an emergency.

Call 911 (999 in the UK) or your local emergency number now if you have any of these. Don’t drive yourself.

• severe difficulty breathing, such as gasping or not being able to get words out
• blue, grey or very pale lips, skin or nails
• sudden confusion
• an asthma attack that gets worse, or doesn’t ease after the maximum reliever dose in your asthma action plan, or you have no inhaler with you
• a child who is grunting, sucking their tummy in under the ribs with each breath, or floppy
• palpitations that won’t stop
• palpitations with chest pain, shortness of breath, feeling faint or fainting
• sudden chest pain or pressure that doesn’t go away
• chest pain that spreads to your arm, neck, jaw or back
• chest pain with sweating, feeling sick, light-headedness or breathlessness

That list follows NHS and Cleveland Clinic advice on breathlessness, chest pain, palpitations and asthma attacks.

Who to see. Start with your family doctor. If they find something, or your chest is severe and you have symptoms, ask for a referral to a pediatric or thoracic (chest) surgeon who works with chest wall conditions.

Tests that check your breathing and heart

The 2024 Pectus Care Guidelines grade these tests for people being assessed by a specialist pectus service, not for everyone with a dip. Class I is the strongest grade.

Test	What it shows	2024 guideline grade
CT or MRI scan of the chest	The Haller index, and how the breastbone sits against the heart	Class I
Echocardiogram (an ultrasound of the heart)	Other heart causes of breathlessness. Can miss compression	Class IIa
Lung function test (spirometry, sometimes lung volumes)	How much air you move, and other lung causes	Class IIa
CPET (cardiopulmonary exercise test): you cycle or run while your breathing and heart are measured	Whether your aerobic capacity is reduced. Below 85% of predicted counts as abnormal	Class I, for severe pectus with exercise intolerance
Cardiac MRI	Detailed pictures of the heart	Class IIb (optional)

The guidelines add that a normal lung test doesn’t rule out cardiac compression.

The Nuss developers’ review notes that young patients often don’t mention exercise intolerance unless a clinician asks directly. So be specific about when it happens: how far, how fast, compared with whom, and whether lying down changes it.

Can pectus excavatum cause asthma?

Asthma is a common lung condition. The NHS lists wheezing, coughing, shortness of breath and a tight chest, often worse at night and early morning, with triggers such as exercise and cold air. Diagnosis includes a simple breathing test, and it can take time because breathing problems have many causes.

Is asthma more common with pectus? It depends on who you count.

• 7% of 375 surgical patients at UCLA, treated from 1969 to 1999.
• 8.8% of 1,046 patients having minimally invasive repair in Aarhus, Denmark, median age 17. The authors called that comparable to the background population.
• 32% of the Mayo Arizona referral group reported a prior or current asthma diagnosis.

For comparison, the CDC puts current asthma at 8.4% of the US population in 2023. Definitions differ, so treat these as rough.

The Mayo Arizona number comes with a catch. Only 3 of the 139 people with an asthma label had lung tests consistent with asthma, and the authors say most were diagnosed without confirmatory testing. The paper doesn’t say how many of the 139 were tested, so it doesn’t show that only 3 really had asthma.

Unconfirmed asthma isn’t only a pectus problem. Among Canadian adults from the general population diagnosed with asthma in the previous five years, current asthma was ruled out in 203 of 613 fully assessed (33.1%), and 12 (2%) had a serious heart or lung condition instead. The study’s specialists tapered their medicines under supervision.

I couldn’t find a study showing that pectus causes asthma, one testing whether repair changes asthma, or one on how well inhalers work in people with pectus.

So if you were diagnosed with exercise asthma, it’s fair to ask whether a lung function test confirmed it. Keep using your inhaler as prescribed while you ask, and never stop an inhaler without your doctor. For an attack that isn’t easing, use the emergency list above.

Can pectus excavatum cause sleep apnea?

In obstructive sleep apnea (OSA), your breathing stops and starts while you sleep. The NHS lists loud snoring, gasping or choking noises, waking a lot, daytime tiredness and morning headaches. It’s diagnosed with a sleep study, usually at home with devices you wear overnight.

The most direct evidence comes from three small studies:

• Japanese schoolchildren. Among 481 children, average age about 9, drawn from 25,000 screened by questionnaire, those whose parents reported disrupted breathing in sleep on one or more nights a week had roughly 3.7 to 3.8 times the odds of having pectus. Pectus was judged by eye, and a home sleep monitor’s breathing index wasn’t linked to it. The design can’t show cause, and the authors’ hypothesis runs the other way: straining against a blocked airway might help pull the chest in.
• Adults before the Nuss procedure. Thirty-one adults admitted for Nuss surgery in Taipei had an overnight sleep study. All snored, and 8 (25.8%), all men, had OSA. There was no comparison group, and the authors’ idea that OSA may cause or aggravate pectus is a hypothesis.
• Sleep apnea and surgery results. The same Taipei group compared 20 adults with pectus alone and 9 with pectus plus OSA. Two years after Nuss, the gap between breastbone and spine had grown by 19.2% in the OSA group against 42.5% without it. The authors recommend checking for OSA, and treating it, before surgery.

My read: these small studies show an association, and none of them can show which way the cause runs, or whether there is one. I couldn’t find evidence that surgery makes sleep apnea go away.

If you snore loudly or someone has seen you stop breathing, see a doctor and ask about a sleep study. Considering surgery? Tell your surgeon about the snoring. Sleep quality and sleep position are in the best sleeping position for pectus excavatum.

Does treatment help your breathing?

Surgery. The evidence disagrees. A 2006 meta-analysis of 12 studies (313 patients, 1960 to 2005) found repair didn’t significantly improve lung function, possibly because tests were done at rest. A 2012 meta-analysis of 23 studies found lung function tended to improve, similarly after the Ravitch and Nuss procedures at one year, with Nuss ahead several years after bar removal. In the 327-patient multicentre study, FVC rose from 88% to 93% of predicted a year after surgery. Real, and modest.

In 80 Nuss patients in Istanbul, average age 17, FVC fell from 83.2% to 76.5% of predicted six months after the operation, while quality of life rose (a study co-authored by Prof. Yüksel).

For exercise fitness, two 2025 meta-analyses split. One of 15 non-randomized studies, all at serious or critical risk of bias, found no significant gain in peak oxygen uptake. Another of 21 studies and 1,087 patients found a gain, with no change in breathing measurements. Adults retested about 3.4 years after Nuss at Mayo Clinic Arizona (130 of them) had improved peak oxygen uptake, with no comparison group. More in my Nuss procedure guide.

Vacuum bell. In 240 children at a London centre, enrolled only if their chest lifted at the first fitting, self-rated breathing difficulty fell from 3.58 to 2.0 on a 10-point scale over 18 to 24 months. That’s a score the children gave, not a lung test, with no comparison group. I couldn’t find a study testing lung function before and after vacuum bell use. Daily bell use plus structured training was my route, and I’m not claiming it changes breathing. More in vacuum bell therapy.

Exercise and breathing work. In 14 Romanian children with pectus who didn’t need surgery, 12 weeks of supervised exercise improved spirometry and 6-minute walking distance. The Nuss developers recommend breathing, posture and aerobic exercise for mild to moderate pectus, and a vacuum bell in selected patients. Breathing work changes how you breathe, not where your breastbone sits. The drills are in breathing exercises for pectus excavatum.

What to do next

• A red flag, or breathless at rest, lying flat or at night. See a doctor first, before any device or program.
• Breathless only with hard exercise. Work on your fitness with these pectus excavatum exercises. For a sense of how significant your chest is and which route fits, take my free 1-minute quiz.
• An asthma label nobody tested. Ask about a lung function test, and keep your inhaler.
• Snoring or pauses in your breathing. Ask your doctor about a sleep study.
• You want to try without surgery. Every non-surgical route is on the pectus excavatum treatment without surgery page.

Whatever you pick, give it honest time. Structural change takes months and years, not weeks.

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