Opioid-induced chest wall rigidity is an uncommon complication of opioids. Because of this, it is often difficult to make a differential diagnosis in a mechanically ventilated patient who experiences increased airway pressure and difficulty with ventilation. A 76-year-old female patient was admitted to the intensive care unit (ICU) after surgery for periprosthetic fracture of the femur neck. On completion of the surgery, airway pressure was increased, and oxygen saturation fell below 95% after a bolus dose of fentanyl. After ICU admission, the same event recurred. Manual ventilation was immediately started, and a muscle relaxant relieved the symptoms. There was no sign or symptom suggesting airway obstruction or asthma on physical examination. Early recognition and treatment should be made in a mechanically ventilated patient experiencing increased airway pressure in order to prevent further deterioration.
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Fentanyl-Induced Rigid Chest Syndrome in Critically Ill Patients Alison J. Tammen, Donald Brescia, Dan Jonas, Jeremy L. Hodges, Philip Keith Journal of Intensive Care Medicine.2023; 38(2): 196. CrossRef
Effects of fentanyl overdose-induced muscle rigidity and dexmedetomidine on respiratory mechanics and pulmonary gas exchange in sedated rats Philippe Haouzi, Nicole Tubbs Journal of Applied Physiology.2022; 132(6): 1407. CrossRef
Challenges in Sedation Management in Critically Ill Patients with COVID-19: a Brief Review Kunal Karamchandani, Rajeev Dalal, Jina Patel, Puneet Modgil, Ashley Quintili Current Anesthesiology Reports.2021; 11(2): 107. CrossRef
A Case of Masseter Muscle Rigidity during Awake Intubation under Remifentanil Infusion Tomoki YAMAGA, Takeshi NEGITA, Masayo SUGIURA, Nobuyuki KIMURA THE JOURNAL OF JAPAN SOCIETY FOR CLINICAL ANESTHESIA.2019; 39(3): 274. CrossRef
Opioids and Chest Wall Rigidity During Mechanical Ventilation Jeffrey P. Roan, Navin Bajaj, Field A. Davis, Natalie Kandinata Annals of Internal Medicine.2018; 168(9): 678. CrossRef
Vocal cord dysfunction is characterized by the paradoxical adduction of the vocal cord during inspiration, causing relapsing wheezing or stridor, chest tightness, shortness of breath, and coughing. If the patient exhibiting symptoms of asthma is not responsive to treatment, there is a need to test whether vocal cord dysfunction is complicated by asthma. Herein, we report a case of vocal cord dysfunction with acute respiratory failure in old age with underlying disease. The patient presented with resting dyspnea, an audible wheeze, and was first diagnosed with acute exacerbation of bronchial asthma. However, her symptoms were not controlled with medical treatment and laryngoscopy showed paradoxical adduction of the vocal cords. Sudden cardiopulmonary arrest occurred after meal on the day of laryngoscopic examination. Although successful cardiopulmonary resuscitation, the patient developed ventilator-associated pneumonia, and multiple organ failure, eventually leading to death. Because the case was fatal, a report is being issued.
Refractory asthma with hypercapnia is a near-fatal disease.
Pumpless Extracorporeal Interventional Lung Assist (iLA) may be considered as an alternative therapy for the disease as it removes the carbon dioxide effectively. Nevertheless, clinical outcome studies regarding iLA in patients suffering from refractory asthma have rarely been applied. Here, we reported our experience with iLA for the treatment of refractory asthma with hypercapnia. In our case, the patient had refractory asthma which was not controlled with medical treatment or mechanical ventilation. We applied iLA since hypercapnia was not resolved despite mechanical ventilation.
After iLA implantation effectively reduced the carbon dioxide, the clinical condition of our patient improved. In conclusion, iLA is a useful tool for patient suffering from refractory asthma with hypercapnia.
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Interventional lung assist and extracorporeal membrane oxygenation in a patient with near-fatal asthma Seok Jeong Lee, Yong Sung Cha, Chun Sung Byun, Sang-Ha Kim, Myoung Kyu Lee, Suk Joong Yong, Won-Yeon Lee The American Journal of Emergency Medicine.2017; 35(2): 374.e3. CrossRef
Pumpless extracorporeal interventional lung assist for bronchiolitis obliterans after allogenic peripheral blood stem cell transplantation for acute lymphocytic leukemia Yeon-Hee Park, Chae-Uk Chung, Jae-Woo Choi, Sang-Ok Jung, Sung-Soo Jung, Jeong-Eun Lee, Ju-Ock Kim, Jae-Young Moon Yeungnam University Journal of Medicine.2015; 32(2): 98. CrossRef
We report a case of severe status asthmaticus in a 3-year-old boy who required mechanical ventilatory support.
He initially presented with rapidly progressing respiratory distress and spontaneous air leaks. Although he was intubated and received mechanical ventilation, dynamic hyperinflation and air leaks were aggravated. We applied the volume control mode, providing sufficient tidal volume (10 ml/kg), a reduced respiratory rate (25/minute), and a prolonged expiratory time (1.8 seconds) to overcome dynamic hyperinflation. After allowing full expiration of trapped air, his over-expanded lung volumes were decreased and the air leaks resolved. He made a complete recovery without sequelae. Dynamic hyperinflation in asthmatic patients occurs from incomplete exhalation throughout narrowed airways. Controlled hypoventilation or permissive hypercapnia is an important lung-protective ventilator strategy and is beneficial in reducing dynamic hyperinflation. We suggest a controlled hypoventilation strategy with a prolonged expiratory time for patients in severe status asthmaticus with dynamic hyperinflation.
Pseudoaneurysm formation in the pulmonary vasculature is a rare but fatal condition. Several etiologies have been described including trauma, complication after cardiac or other surgeries, tuberculosis, necrotizing pneumonia, congestive heart disease, atherosclerosis, cancer and vasculitis. We report a case of pseudoaneurysm found in a patient being treated with status asthmaticus, who developed complications of pneumonia and brain abscess secondary to sepsis.
Ketamine is well known for its analgesic, bronchodilating and sympathetic stimulating effect. Hence, it has been widely used for induction of patients with hypotension or asthma and also for analgesic and sedating purposes in the ICU. We presented a 62 year old female patient with ventilator support in septic shock with refractory asthma whom we managed successfully with continuous intravenous infusion of ketamine postoperatively in the ICU. The patient had a history of asthma but had been asymptomatic recently and was scheduled for an emergent explo-laparotomy under the diagnosis of acute panperitonitis. Before the induction of anesthesia, the patient was in septic shock but no wheezing could be auscultated. After the induction of general anesthesia and endotracheal intubation, wheezing was apparent in both lung fields with a high peak inspiratory pressure. Inotropics, vasopressors and bronchodilators were promptly instituted without any improvement of asthma and the patient had to be transferred to the ICU with intubated after the operation. Clinical symptoms of asthma continued throughout the first day despite using bronchodilators under mechanical ventilation but, after starting the IV infusion of ketamine, there were decrease in the peak inspiratory pressure and wheezing with a subsequent improvement in the arterial blood gas analysis findings. We could also achieve considerable analgesic and sedating effect without any decrease in the blood pressure. The patient's general physical status improved and weaning with extubation was successfully done on the 21st day and was transferred to the general ward on the 28th day.