Recurrent Desaturation Events due to Opioid-Induced Chest Wall Rigidity after Low Dose Fentanyl Administration

Ham, Sung Yeon; Lee, Bo Ra; Ha, Taehoon; Kim, Jeongmin; Na, Sungwon

doi:10.4266/kjccm.2016.31.2.118

Cited by 6 publications

(6 citation statements)

References 17 publications

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“…The delay in presentation seen in our experience has been described as well with delayed effects reported up to six hours after administration depending on dosage [7]. The characteristic muscular rigidity seen with difficulty in ventilation and markedly increased airway pressure during these episodes has been extensively described [5,7,12,13]. This rigidity was observed during clinical evaluation of all patients included in our study.…”

Section: Discussionsupporting

confidence: 69%

“…The relationships between CWR, narcotic type, dosing, and duration have all been implicated in its severity. The majority of literature surrounding CWR lists fentanyl as the most common perpetrator [8,9,[11][12][13]. However, in contrast to the literature, in the majority of our study sample, we used morphine during observed episodes, another unique aspect of our findings.…”

Section: Discussionmentioning

confidence: 87%

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Objective Characterization of Opiate-Induced Chest Wall Rigidity

Trujillo¹,

Rudd²,

Ogutcu³

et al. 2020

Cureus

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Introduction Opiate-induced chest wall rigidity is a syndrome that largely goes unrecognized. To date, no study has presented significant objective data to better understand this syndrome. Objective The aim of this study was to explore the correlation between the dosage of opiates and the incidence of chest wall rigidity, ventilatory changes, and effects of naloxone administration. Methods A total of eight patients were identified as having episodes of chest wall rigidity, with half of the population being females, with an average age of 54.8 ± 9 years. Physiological changes, ventilator data, vitals, and opiate dosage prior to chest wall rigidity episodes and after reversal with naloxone administration were analyzed using the Wilcoxon rank sum test for statistical significance. Results Significant changes were observed in dynamic wall compliance without positive end-expiratory pressure (PEEP) (pre-median=5.13; post-median=52.03; p=0.0078), dynamic wall compliance with PEEP (pre-median=6.13; post-median=72.36; p=0.0078), tidal volume (pre-median=110.5; post-median=1006; p=0.0078), and ventilator airflow (pre-median=0; post-median=75; p=0.0078). However, no statistically significant changes were detected in end tidal CO 2 (pre-median=36; post-median=37.5; p=0.4219), respiratory rate (pre-median=9; post-median=10.5; p=0.7188), or peak airway pressure (pre-median=17; post-median=21.5; p=0.4063). Additionally, there is a statistically significant correlation between morphine equivalent potency dosing within 24 hours and the change in tidal volume (r=0.8237; p=0.0439). Conclusions Our study is the first to demonstrate significant objective data on the ventilatory responses seen with opiate-induced chest wall rigidity. These findings may assist clinicians in better understanding the presentation and management of chest wall rigidity.

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Section: Discussionsupporting

confidence: 69%

Section: Discussionmentioning

confidence: 87%

Objective Characterization of Opiate-Induced Chest Wall Rigidity

Trujillo¹,

Rudd²,

Ogutcu³

et al. 2020

Cureus

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“…A rare, yet feared complication is opioid-induced chest wall rigidity, in which patients develop increased thoracic and abdominal muscle tone [27]. Intubated patients who develop chest wall rigidity can develop increased airway pressures and oxygen desaturation [28]. This complication could prove fatal if presenting in a COVID-19 patient with ARDS, on aggressive ventilator settings.…”

Section: Opioidsmentioning

confidence: 99%

Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review

Karamchandani

Dalal

Patel

et al. 2021

Curr Anesthesiol Rep

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Purpose of Review To highlight the challenges associated with providing sedation and analgesia to critically ill patients with coronavirus disease 2019 (COVID-19) and also understand the pathophysiological alterations induced by the disease process as well as the logistical difficulties encountered by providers caring for these patients. We also discuss the rationale and risks associated with the use of common sedative agents specifically within the context of COVID-19 and provide evidence-based management strategies to help manage sedation and analgesia in such patients. Recent Findings A significant proportion of patients with COVID-19 require intensive care and mechanical ventilation, thus requiring sedation and analgesia. These patients tend to require higher doses of sedative medications and often for long periods of time. Most of the commonly used sedative and analgesic agents carry unique risks that should be considered within the context of the unique pathophysiology of COVID-19, the logistical issues the disease poses, and the ongoing drug shortages. Summary With little attention being paid to sedation practices specific to patients with COVID-19 in critical care literature and minimal mention in national guidelines, there is a significant gap in knowledge. We review the existing literature to discuss the unique challenges that providers face while providing sedation and analgesia to critically ill patients with COVID-19 and propose evidence-based management strategies.

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“…[1][2][3][4][5][6][7] The majority of cases reported occurred with high dose administration of fentanyl, often during induction for procedural sedation or general anesthesia, and in neonates and children. 2,4,[8][9][10] Fentanyl induced rigid chest syndrome (FIRCS) is generally described as pronounced thoracic rigidity, respiratory failure, and asynchronous ventilation if intubated. 2 It has historically been associated with large fentanyl doses, 17-19 mcg/kg, and rapid administration, 200 mcg/min, but is also reported with nearly any dose.…”

Section: Introductionmentioning

confidence: 99%

“…Rigidity is also likely induced by activation of spinal motor neurons through fentanyl's action at the locus coeruleus in the pons. 8,9 Glottic and supraglottic closure have also been reported to contribute to opioid induced respiratory failure outside of the presence of thoracic rigidity. 10,11 Recent literature has been published in the setting of fentanyl overdose related to the opioid crisis that describe additional mechanisms of action and possible resistance to reversal with naloxone in toxic doses, leading to higher fatality rates.…”

Section: Introductionmentioning

confidence: 99%

Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients

Tammen

Brescia

Jonas

et al. 2022

J Intensive Care Med

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Background Opioid induced chest wall rigidity was first described in the early 1950s during surgical anesthesia and has often been referred to as fentanyl induced rigid chest syndrome (FIRCS). It has most commonly been described in the setting of procedural sedation and bronchoscopy, characterized by pronounced abdominal and thoracic rigidity, asynchronous ventilation, and respiratory failure. FIRCS has been infrequently described in the setting of continuous analgesia in critically ill adult patients. We postulate that FIRCS can occur in this setting and is likely under recognized, leading to increased morbidity and mortality. Methods Patients admitted to the intensive care unit with suspected FIRCS were included in this retrospective analysis. The objective of this analysis is to describe the clinical presentation and treatment strategies for FIRCS. Results Forty-two patients exhibiting symptoms of FIRCS were included in this analysis. Twenty-two of the forty-two patients with descriptive documentation had evidence of thoracic or abdominal rigidity on examination (52.4%). Twelve of sixteen (75%) patients treated solely with naloxone had documented ventilator compliance following intervention, compared to six of eleven (55%) managed with cisatracurium alone. Nine of twelve patients who ultimately received naloxone after initial treatment with cisatracurium had documented ventilator compliance following naloxone administration (75%). Standard interventions, including sedation optimization and ventilator adjustments were attempted to rule out and treat other potential causes of dyssynchrony. In most cases, the administration of naloxone resulted in appropriate compliance with both ventilator and patient-initiated breaths, suggesting the ventilator dyssynchrony was due to fentanyl. Conclusions This is the largest case series to date describing FIRCS in the intensive care setting. Recognition and prompt management is necessary for improved patient outcomes. Research is needed to increase awareness and recognition, identify patient risk factors, and analyze the efficacy and safety of interventions.

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Recurrent Desaturation Events due to Opioid-Induced Chest Wall Rigidity after Low Dose Fentanyl Administration

Cited by 6 publications

References 17 publications

Objective Characterization of Opiate-Induced Chest Wall Rigidity

Objective Characterization of Opiate-Induced Chest Wall Rigidity

Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review

Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients

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