Fentanyl-Induced Wooden Chest Syndrome Masquerading as Severe Respiratory Distress Syndrome in COVID-19

Grace Judd; Rachael Starcher; David Hotchkin

Fentanyl-Induced Wooden Chest Syndrome Masquerading as Severe Respiratory Distress Syndrome in COVID-19

Grace Judd, Rachael Starcher, David Hotchkin

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Abstract

Case Presentation

History •47 yo M with no PMH presented with fever and respiratory distress •Admitted for COVID-19 pneumonia Hospital Course •Intubated for moderate acute respiratory distress syndrome (ARDS) on hospital day 11 •Fentanyl infusion started •Hypoxia improved within 36 hrsbut plateau pressures consistently >30 cm H2O despite minimizing dead space •Trial of airway pressure release ventilation worsened hypercarbia •Bronchoscopy w/o mucous plugging, airway collapse, or purulent secretions •Lung compliance worsened (Pplat=50 on 4 cc/kg) w/o change in oxygenation •Developed suspicion for wooden chest syndrome (WCS) and discontinued fentanyl Outcome •Pplatnadired at 16 within one hour after stopping fentanyl •Pt successfully extubated on VD 10

Takeaway Points

Fentanyl uniquely activates laryngeal and respiratory muscle potentially leading to a fatal syndrome known as Wooden Chest Syndrome (WCS) manifested by poor ventilation •It is likely more common than clinicians realize Implications in practice: •Maintain a high index of suspicion for alternate or overlying physiologies when treating persistent ventilatory failure in ARDS in COVID-19 Recommendation: •Discontinue fentanyl if lung compliance and ventilatory failure seem out of proportion to hypoxia

Original language	Undefined/Unknown
State	Published - May 1 2021

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Fentanyl-Induced Wooden Chest Syndrome Masquerading as Severe Res

http://digitalcommons.psjhealth.org/oaa_ppmc_21/5

Cite this

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title = "Fentanyl-Induced Wooden Chest Syndrome Masquerading as Severe Respiratory Distress Syndrome in COVID-19",

abstract = "Case Presentation History •47 yo M with no PMH presented with fever and respiratory distress •Admitted for COVID-19 pneumonia Hospital Course •Intubated for moderate acute respiratory distress syndrome (ARDS) on hospital day 11 •Fentanyl infusion started •Hypoxia improved within 36 hrsbut plateau pressures consistently >30 cm H2O despite minimizing dead space •Trial of airway pressure release ventilation worsened hypercarbia •Bronchoscopy w/o mucous plugging, airway collapse, or purulent secretions •Lung compliance worsened (Pplat=50 on 4 cc/kg) w/o change in oxygenation •Developed suspicion for wooden chest syndrome (WCS) and discontinued fentanyl Outcome •Pplatnadired at 16 within one hour after stopping fentanyl •Pt successfully extubated on VD 10 Takeaway Points Fentanyl uniquely activates laryngeal and respiratory muscle potentially leading to a fatal syndrome known as Wooden Chest Syndrome (WCS) manifested by poor ventilation •It is likely more common than clinicians realize Implications in practice: •Maintain a high index of suspicion for alternate or overlying physiologies when treating persistent ventilatory failure in ARDS in COVID-19 Recommendation: •Discontinue fentanyl if lung compliance and ventilatory failure seem out of proportion to hypoxia",

author = "Grace Judd and Rachael Starcher and David Hotchkin",

year = "2021",

month = may,

day = "1",

language = "Undefined/Unknown",

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TY - CONF

T1 - Fentanyl-Induced Wooden Chest Syndrome Masquerading as Severe Respiratory Distress Syndrome in COVID-19

AU - Judd, Grace

AU - Starcher, Rachael

AU - Hotchkin, David

PY - 2021/5/1

Y1 - 2021/5/1

N2 - Case Presentation History •47 yo M with no PMH presented with fever and respiratory distress •Admitted for COVID-19 pneumonia Hospital Course •Intubated for moderate acute respiratory distress syndrome (ARDS) on hospital day 11 •Fentanyl infusion started •Hypoxia improved within 36 hrsbut plateau pressures consistently >30 cm H2O despite minimizing dead space •Trial of airway pressure release ventilation worsened hypercarbia •Bronchoscopy w/o mucous plugging, airway collapse, or purulent secretions •Lung compliance worsened (Pplat=50 on 4 cc/kg) w/o change in oxygenation •Developed suspicion for wooden chest syndrome (WCS) and discontinued fentanyl Outcome •Pplatnadired at 16 within one hour after stopping fentanyl •Pt successfully extubated on VD 10 Takeaway Points Fentanyl uniquely activates laryngeal and respiratory muscle potentially leading to a fatal syndrome known as Wooden Chest Syndrome (WCS) manifested by poor ventilation •It is likely more common than clinicians realize Implications in practice: •Maintain a high index of suspicion for alternate or overlying physiologies when treating persistent ventilatory failure in ARDS in COVID-19 Recommendation: •Discontinue fentanyl if lung compliance and ventilatory failure seem out of proportion to hypoxia

AB - Case Presentation History •47 yo M with no PMH presented with fever and respiratory distress •Admitted for COVID-19 pneumonia Hospital Course •Intubated for moderate acute respiratory distress syndrome (ARDS) on hospital day 11 •Fentanyl infusion started •Hypoxia improved within 36 hrsbut plateau pressures consistently >30 cm H2O despite minimizing dead space •Trial of airway pressure release ventilation worsened hypercarbia •Bronchoscopy w/o mucous plugging, airway collapse, or purulent secretions •Lung compliance worsened (Pplat=50 on 4 cc/kg) w/o change in oxygenation •Developed suspicion for wooden chest syndrome (WCS) and discontinued fentanyl Outcome •Pplatnadired at 16 within one hour after stopping fentanyl •Pt successfully extubated on VD 10 Takeaway Points Fentanyl uniquely activates laryngeal and respiratory muscle potentially leading to a fatal syndrome known as Wooden Chest Syndrome (WCS) manifested by poor ventilation •It is likely more common than clinicians realize Implications in practice: •Maintain a high index of suspicion for alternate or overlying physiologies when treating persistent ventilatory failure in ARDS in COVID-19 Recommendation: •Discontinue fentanyl if lung compliance and ventilatory failure seem out of proportion to hypoxia

M3 - Paper

ER -