Abstract Introduction Life threatening asthma is an acute intractable severe exacerbation characterized by progressive respiratory failure and refractory to standard treatments. Every year approximately 25,000 to 50,000 patients will require intensive care unit (ICU) admission with some requiring mechanical ventilation, and unconventional therapies. A common analgesic and sedative medication used while undergoing mechanical ventilation, is the intravenous opioid fentanyl. Fentanyl induced chest wall rigidity, also known as wooden chest syndrome, is a rare complication of intravenous fentanyl. Case Presentation The patient is a 48 year-old woman with a past medical history notable for asthma, bipolar disorder, and hypertension who underwent a prolonged hospital stay for difficult to treat eosinophilic asthma. She was treated with bronchodilators, steroids, and antibiotics without improvement. Despite being on bilevel positive airway pressure (BiPAP) for 16 hours, the patient required intubation for respiratory failure. She was transferred to our hospital and admitted to the ICU where she remained intubated. Short acting bronchodilators were discontinued after multiple episodes of worsening bronchospasm, elevated peak pressure with low tidal volumes after nebulized treatments. The patient persisted with bronchospasm, acidosis, and elevated dynamic hyperinflation despite high dose of steroids, paralytics (nimbex), ketamine, propofol, fentanyl, montelukast, aminophylline, and epinephrine. Heliox 70:30, and sevoflurane at 4% were given for 3 days, partially decreasing her dynamic hyperinflation that finally resolved after fentanyl was weaned off. Thereafter, nebulized budesonide/formoterol were started without incidents, she was successfully extubated after 14 days and discharged without complications. Discussion Inhaled anesthetics are effective bronchodilators that improve gas exchange and decrease dynamic hyperinflation (DHI). Heliox also decreases DHI and facilitates medication delivery. Both treatments are effective and safe alternatives in refractory cases. Furthermore, paradoxical bronchospasm is a rare side effect of bronchodilators reported in 4.5% of current or former smokers. Chest wall rigidity may present as ineffective ventilation with elevated peak pressures. The mechanism is thought to be caused by a central mediation through a dopaminergic pathway or activation of spinal motor neurons. Management is with the opioid receptor antagonist naloxone, neuromuscular blocking agents, or cessation of fentanyl infusion. Our patient required rocuronium pushes prior to cessation of fentanyl infusion with improvement of ventilation and successful extubation. Conclusion Our case reveals that unconventional therapies are key in the treatment of life-threatening asthma. Chest wall rigidity is rare, but should always be considered in prolonged intubated patients who received intravenous fentanyl. This abstract is funded by: None
Hernandez et al. (Fri,) studied this question.
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