Fentanyl Induced Chest Wall Rigidity and Negative Pressure Pulmonary Edema

October 2015, Vol 148, No. 4_MeetingAbstracts

Signs and Symptoms of Chest Diseases | October 2015

Fentanyl Induced Chest Wall Rigidity and Negative Pressure Pulmonary Edema Maliha Khan, MD; Abhishek Agarwal, MD; Wissam Abouzgheib, MD Cooper University Hospital, Hamilton, NJ Chest. 2015;148(4_MeetingAbstracts):1025A. doi:10.1378/chest.2271026

Abstract SESSION TITLE: Signs and Symptoms of Chest Diseases Student/Resident Case Report Posters SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM INTRODUCTION: Fentanyl, a rapid onset potent narcotic, is associated with serious side effects. Fentanyl-induced chest wall rigidity, although not very common could lead to serious respiratory complications. We report a case of fentanyl-induced chest wall rigidity causing negative pressure pulmonary edema. CASE PRESENTATION: A 49 year old healthy male admitted with neck pain after playing soccer; he is found to have a C6-C7 epidural hematoma on MRI. He is admitted to the trauma intensive care unit for neurovascular monitoring and started on a fentanyl PCA after receiving 50 mcg bolus. Several minutes afterwards, he developed respiratory distress, audible wheezing with a SaO2 of 88%. He also developed a cough associated with pink, frothy, mucus, along with back pain and chest tightness. He “was unable to take a deep breath.” Patient was started on BiPaP with minimal improvement until fentanyl was stopped. Patient’s symptoms and clinical status improved shortly thereafter. Same day chest x-ray and CT scan showed findings consistent with pulmonary edema. Cardiac workup was completely negative including a normal echocardiogram. His Chest x-rray went back to normal after diuresis, he was taken off oxygen 2 days afterwards. DISCUSSION: It is well reported that rapid infusion of fentanyl may result in increased chest wall muscle tone leading to reduced total lung compliance and functional residual capacity. It is more common in younger patients and with use of large doses of fentanyl and rapid infusion. The spectrum of clinical manifestation varies from mild coughing to severe chest wall and laryngeal rigidity impairing oxygenation and ventilation. In our patient, this was further complicated by negative pressure pulmonary edema. We hypothesize this complication was due to increased respiratory effort against low compliant chest and possible laryngeal rigidity. CONCLUSIONS: This case is unique considering the unusual presentation of negative pressure pulmonary edema caused by increased respiratory efforts in the setting of fentanyl induced chest wall rigidity. Reference #1: Coruh, Basak; Tonelli, R.Mark, Park, R. David. Fentanyl-Induced Chest Wall Rigidity. Chest. 2013;143 (4): 1145-1146. Reference #2: Hamilton WK and Cullen SL. Effect of levallorphan tartrate upon opiate induced respiratory depression. Anes. 1953. 14:550-554.

Reference #3: Vaughn, L. Robert; Bennett, C. Richart. Fentanyl Chest Wall Rigidity Syndrome-A Case Report. Anesthesia Progress. 1981;50-51. DISCLOSURE: The following authors have nothing to disclose: Maliha Khan, Abhishek Agarwal, Wissam Abouzgheib No Product/Research Disclosure Information