Reviewed by Dr. Shaoyi Zheng

Dr. Zheng specializes in chest wall surgery, with expertise in chest wall deformities, chest wall tumors, chylothorax management, and perioperative critical care.

What causes a barrel chest? This question often arises in the context of Chronic Obstructive Pulmonary Disease (COPD). We may notice that in the late stages of COPD, some patients develop a barrel chest—a common chest wall deformity characterized by a rounded, barrel-like appearance (with elongated ribs and costal cartilages, increased anteroposterior diameter, and a nearly circular cross-section).

However, the cause of barrel chest is not limited to respiratory diseases such as COPD. In many cases, the exact cause of barrel chest remains unclear, and it often begins to develop gradually from childhood. Moreover, people living in high-altitude areas may also develop a barrel-shaped chest due to prolonged exposure to a low-oxygen environment.

What Causes A Barrel Chest? Primary vs. Secondary

(1) Primary Barrel Chest

Primary barrel chest refers to a congenital chest wall deformity that is not caused by underlying diseases. Although the secondary form arising from chronic respiratory conditions is more common, the incidence of the primary form is not rare.

• Causes of Primary Barrel Chest: Unknown

  
  

• Surgical Indications: The main issue is cosmetic deformity, with little physiological impact. Surgery may be considered if the patient is under significant psychological stress and wishes to improve the chest appearance.

  
  

The etiology of primary barrel chest remains unclear, but it may be associated with abnormal growth and development processes. Normally, due to the biomechanics of respiration, the thoracic cage gradually transforms from the cylindrical shape of infancy to a slightly flattened structure where the anteroposterior diameter is less than the transverse diameter. However, under certain influencing factors, this morphological transformation fails to occur, ultimately leading to the development of a barrel chest.

(2) Secondary Barrel Chest

Clinically, most cases fall under the category of Secondary Barrel Chest, which is caused by various underlying conditions. It is most commonly seen in chronic respiratory diseases, but it may also be caused by other diseases or factors.

• Causes of Secondary Barrel Chest

1) COPD,  Especially Emphysema 

Emphysema is a type of COPD and one of the most common causes of a barrel chest. In COPD—particularly in emphysema—the elastic recoil of the lungs decreases, making it difficult to expel all air during exhalation. The retained air leads to persistent lung hyperinflation, which continuously pushes the ribs outward, enlarges the anteroposterior diameter of the thoracic cage, and ultimately results in a permanent barrel-shaped chest.

For patients with COPD, a barrel chest is not merely a cosmetic concern but also a reflection of disease progression and functional decline. As patients age, the long-term lung damage that leads to emphysema and the subsequent development of a barrel chest may indicate severe structural destruction of the lungs.

2) Other Possible Causes of Secondary Barrel Chest

1. Childhood Asthma: Prolonged and severe asthma can cause expiratory limitation, through mechanisms similar to COPD, and may lead to barrel chest even in childhood.

2. Cystic Fibrosis (a genetic disorder): Thick mucus obstructs the airways, resulting in compensatory hyperinflation and chronic lung injury, often manifesting from childhood.

3. Cardiovascular Disorders: conditions like pericardial effusion and cardiomegaly can cause an enlarged thoracic cage.

4. Pleural Diseases: Conditions such as pleural effusion, pneumothorax, and pleural mesothelioma can lead to a barrel-shaped chest. 

5. Osteoarthritis: When the costovertebral joints become stiff, the ribs are fixed in an expanded position, mechanically creating a barrel chest, which is most often seen in older individuals.

6. Calcium/Vitamin D deficiency: Impairs bone and cartilage development, making them fragile and prone to deformity.

7. Environmental Adaptation: Populations living at high altitudes (e.g., in the Andes or Himalayas) may develop a barrel chest over time. This occurs because long-term exposure to a hypoxic environment requires increased respiratory effort to meet the body's physiological needs, which can gradually alter the shape of the thoracic cage.

• Surgical Indications:

1.  Barrel chest caused by chronic respiratory diseases: As the chest wall deformity represents a compensatory pathological change, surgical correction is contraindicated. Management should focus on treating the underlying pulmonary condition.

2.  Barrel chest caused by other diseases or non-pulmonary factors: If no active pulmonary pathology is present and the patient seeks improvement in chest appearance or function, surgical correction may be considered.

Symptoms and Risks of Barrel Chest

Main Impact:The primary impact of barrel chest—whether primary or secondary—lies in the visible structural changes. The barrel-shaped chest is difficult to conceal and often places a significant psychological burden on patients. Many individuals experience heightened self-consciousness, feelings of shame, and low self-esteem. For many patients, the psychological harm caused by body image distortion may outweigh the physical symptoms, potentially leading to anxiety, depression, and other mental health issues.

Physiological Symptoms of Barrel Chest:

• Primary barrel chest: Usually does not cause noticeable symptoms

• Secondary barrel chest: Symptoms are related to the underlying condition and may include chronic cough, shortness of breath, dyspnea, and chest tightness.

Treatment for Barrel Chest

Given that the structural changes of barrel chest are often irreversible, management and treatment of barrel chest primarily focus on two aspects: correcting the appearance in primary cases and addressing the underlying disease that leads to secondary barrel chest.

(1) Conservative Treatment for Respiratory Symptoms

For patients with secondary barrel chest, conservative strategies are essential. Management mainly involves strict treatment of the underlying chronic disease, supplemented by professional pulmonary rehabilitation techniques.

These essential rehabilitation techniques typically encompass breathing exercises (such as pursed-lip and diaphragmatic breathing), physical conditioning (including endurance and strength training), airway clearance, and supplemental oxygen when necessary. They are complemented by key supportive measures, including smoking cessation (if required), proper inhaler use, and nutritional support.

(2) Surgical Correction: Wenlin Procedure

Surgical intervention is reserved strictly for patients who are extremely dissatisfied with the cosmetic appearance of the barrel chest. Importantly, this procedure is cosmetic in nature. Barrel chest resulting from chronic pulmonary disease cannot be surgically corrected and is considered a contraindication for surgery.

Currently, Dr. Wenlin Wang is the only surgeon worldwide who specializes in surgical treatment for barrel chest. The minimally invasive surgical technique—the Wenlin procedure, pioneered by Dr. Wenlin Wang, is considered an effective choice for correcting barrel chest.

The operation involves making a small incision of about 2 cm on each side of the chest wall. Pre-shaped steel bars are then placed on the anterior chest wall, and steel wires are used to pull the bony structures on both sides outward until the anteroposterior diameter of the thoracic cage gradually shortens, achieving a shape closer to normal. Compared with traditional surgery, the Wenlin procedure integrates multiple innovative techniques and concepts, such as the “Wang Technique” (a unique method for securing the bars) and the “Pre-shaping” concept (a method of releasing and reshaping the protruding bone structures before final bar shaping).

The Wenlin procedure is minimally invasive, highly effective, safe, and simple to perform, offering rapid recovery and carrying a low risk of complications. It has become an ideal option for treating barrel chest and other convex chest wall deformities. 

Conclusion

Many people feel distressed about their own or their child’s barrel-shaped chest. Understanding the causes of barrel chest and the available treatment options is essential. ICWS is dedicated to providing specialized surgical solutions for chest wall deformities.

Founded by Dr. Wenlin Wang and his medical team, ICWS has over 15 years of expertise in chest wall research and has successfully performed more than 10,000 chest wall surgeries for patients from around the world.

If you or your loved one is affected by barrel chest or another chest wall deformity, we encourage you to contact or schedule an appointment with ICWS, where a professional team is ready to provide expert support and care.

Reviewed by Dr. Shaoyi Zheng

Dr. Zheng specializes in chest wall surgery, with expertise in chest wall deformities, chest wall tumors, chylothorax management, and perioperative critical care.