Fentanyl-induced rigid chest syndrome after low-dose fentanyl: A case report

Ventilator waveforms as a clue to fentanyl–induced rigid chest syndrome

Abstract

Background: Fentanyl-induced rigid chest syndrome (FIRCS) is a rare, life-threatening adverse effect of fentanyl that can cause respiratory compromise and patient-ventilator dyssynchrony and currently lacks definitive diagnostic criteria.

Case presentation: A 73-year-old Thai female with hepatitis C-related cirrhosis was admitted to the intensive care unit with septic shock and acute respiratory failure due to community-acquired multilobar pneumonia. She was intubated and mechanically ventilated in pressure-controlled mode. After receiving a fentanyl bolus of 50 mcg followed by a continuous infusion of 50 mcg/hour, she developed progressive patient-ventilator dyssynchrony with low tidal volume and worsening hypercapnia despite ventilator adjustments. Physical examination revealed a diffuse rigid abdominal wall. Ventilator flow-time waveforms suggested markedly reduced respiratory compliance. FIRCS was suspected. After discontinuation of fentanyl, incremental intravenous naloxone was administered. A total dose of 0.2 mg resulted in rapid improvement in tidal volume, minute ventilation, and ventilator waveform patterns within one minute. Recurrent symptoms occurred one hour later and resolved after an additional naloxone dose.

Conclusions: FIRCS can occur even with relatively low-dose fentanyl infusion. Recognition of characteristic ventilator waveform patterns is helpful in early diagnosis and prompt treatment.