What are the occurrence rates of chest wall rigidity associated with Fentanyl (fentanyl citrate)?

From the Guidelines

Chest wall rigidity associated with fentanyl occurs at a significant rate, particularly with rapid administration or high doses, and can be as high as 20% in certain cases, although the exact occurrence rate is not explicitly stated in the most recent and highest quality studies provided 1. The phenomenon of chest wall rigidity, also known as "wooden chest syndrome," involves sudden muscle stiffness that can impair ventilation and make intubation difficult.

• Risk factors for chest wall rigidity include:
  • Rapid IV administration, especially boluses over 1-2 minutes
  • High doses, typically greater than 5 mcg/kg
  • Extremes of age, such as the very young or elderly
  • Concurrent use of other central nervous system depressants To minimize the risk of chest wall rigidity, it is recommended to administer fentanyl slowly, over 3-5 minutes when possible, use the lowest effective dose, and have naloxone readily available for reversal if needed.
• In severe cases, neuromuscular blocking agents like succinylcholine or rocuronium may be necessary to facilitate ventilation. The mechanism involves fentanyl's action on mu-opioid receptors in the brain stem and spinal cord, affecting central respiratory drive and skeletal muscle tone regulation, as noted in studies on the use of fentanyl for pain management and sedation 1.
• Healthcare providers should be particularly vigilant when administering fentanyl in emergency situations or procedural sedation where rapid administration might be more common. The most critical consideration is to prioritize the safety of the patient by being prepared to manage potential complications, including chest wall rigidity, and to use fentanyl judiciously based on the patient's specific needs and risk factors.

From the FDA Drug Label

Transient neonatal muscular rigidity has been observed in infants whose mothers were treated with intravenous fentanyl The occurrence rate of chest wall rigidity associated with Fentanyl (fentanyl citrate) is not explicitly stated in the provided drug label. However, it is mentioned that transient neonatal muscular rigidity has been observed in infants whose mothers were treated with intravenous fentanyl.

• The label does not provide a specific occurrence rate for this condition.
• It is also not clear if this condition is the same as chest wall rigidity. 2

From the Research

Occurrence Rates of Chest Wall Rigidity

The occurrence rates of chest wall rigidity associated with Fentanyl (fentanyl citrate) are not explicitly stated in the provided studies. However, the studies report on the incidence of chest wall rigidity in various settings:

• A retrospective analysis of 42 patients with suspected fentanyl-induced rigid chest syndrome (FIRCS) found that 22 patients (52.4%) had evidence of thoracic or abdominal rigidity on examination 3.
• A case report of two infants who developed chest wall rigidity after low-dose fentanyl administration highlights the rare but potential adverse effect of fentanyl in pediatric patients 4.
• A case report of a patient who developed ineffective ventilation during conscious sedation due to chest wall rigidity after intravenous midazolam and fentanyl suggests that low-dose fentanyl may also cause chest wall rigidity 5.
• A case report of a patient who developed fentanyl-induced chest wall rigidity syndrome during a routine bronchoscopy highlights the importance of recognizing and managing this rare complication 6.
• A case report of a man who developed chest wall rigidity and ineffective spontaneous ventilation following the administration of fentanyl during an elective bronchoscopy emphasizes the need for bronchoscopists to be aware of this potential complication 7.

Key Findings

• Fentanyl-induced chest wall rigidity can occur in various settings, including procedural sedation, bronchoscopy, and continuous analgesia in critically ill patients.
• The incidence of chest wall rigidity may be underrecognized, leading to increased morbidity and mortality.
• Naloxone and neuromuscular blocking agents are potential treatment options for fentanyl-induced chest wall rigidity.
• Recognition and prompt management of fentanyl-induced chest wall rigidity are necessary for improved patient outcomes.

Study Limitations

• The studies are primarily case reports or retrospective analyses, which may not provide a comprehensive understanding of the occurrence rates of chest wall rigidity associated with fentanyl.
• The studies may not be generalizable to all patient populations or settings.
• Further research is needed to increase awareness and recognition, identify patient risk factors, and analyze the efficacy and safety of interventions for fentanyl-induced chest wall rigidity 3, 4, 5, 6, 7.