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Wooden chest syndrome is a rigidity of the chest following the administration of high doses of opioids during anesthesia.
Wooden chest syndrome describes marked muscle rigidity — especially involving the thoracic and abdominal muscles — that is an occasional adverse effect associated with the intravenous administration of lipophilic synthetic opioids such as fentanyl. It can make ventilation difficult, and seems to be reversed by naloxone. Hypoxemia, hypertension, pulmonary hypertension, respiratory acidosis and increased intracranial pressure may supervene.
One recent study hypothesized that chest wall rigidity might be at least partially responsible for some deaths related to intravenous injection of fentanyl, which increasingly is appearing in samples of heroin[1].
Cause
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The primary cause of wooden chest syndrome (WCS) is the administration of fentanyl. This is a synthetic opioid that is widely used in the medical field. It is known for its rapid onset effects, however, in rare circumstances can lead to WCS which would include severe muscle rigidity regardless of dosage. There are actually cases where a minimal amount of fentanyl is administered to the patient and they still seem to negatively react to this medication. [2][3].
Pathophysiology
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The pathophysiology of WCS involves the binding of fentanyl to the mu-opioid receptors in the central nervous system. This triggers a multitude of events leading to muscle rigidity. Furthering this point, noradrenergic and cholinergic pathways are activated resulting in a decreased in chest wall function and an increase in rigidity resulting in ineffective ventilation[2][4][5]. As a result, lung expansion is reduced and oxygen intake is tampered.In the brainstem of the human body, the effect of fentanyl on the respiratory centers likely contributes to a decreased neural output to the respiratory muscles leading to the infamous rigidity.[2] This, however, is still being investigated.
Diagnosis
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Diagnosis of Wooden Chest Syndrome (WCS) is typically made in a healthcare setting by a doctor (non-emergency or emergency). This syndrome is diagnosed when a patient begins exhibiting a rapid-onset of respiratory distress, typically after fentanyl administration. Key diagnostic indicators that a patient may be suffering from this syndrome are as follows: sudden onset of elevated airway pressures, hypoxia, and even resistance to ventilation despite no apparent airway obstruction[2][4]. Diagnosis, however, can be difficult to establish as it requires a rapid identification of symptoms and opioid knowledge. Although a bronchoscopy and chest X-ray can help rule out any other causes, there are no specific tests (laboratory or imaging) that can totally confirm WCS[2].[5]
Treatment
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Management of Wooden Chest Syndrome (WCS) involves an immediate cease to fentanyl administration followed by the administration of an opioid receptor antogonist such as Naloxone[2][4]. Naloxone, although able to reduce the opioid effects, may not be able to reduce muscle rigidity. This is where respiratory support, such as ventilation is introduced to the patient to help counteract restricted breathing. Neuromuscular blocking agents such as Rucuronium can also be used to alleviate muscle rigidity.[2][4] There are also non-medical measures that can be initiated while the pharmacological agents are taking effect such as manual ventilation and body positioning to increase breathing capabilities.[2]
Prognosis
[edit]The prognosis for Wooden Chest Syndrome (WCS) varies by individual case-to-case basis. If promptness and efficacy are taken into account, patients can recover without long-term complications. However, if treatment and diagnosis are delayed, potential fatal outcomes can arise. This syndrome has a higher reoccurrence rate among individuals with opioid-dependence (recreational use) or those undergoing medical treatment that requires repeated administration of fentanyl.[2] There is currently no genetic risk factors, however prognosis does worsen with age[2]. Older adults are at higher risk for severe respiratory complications more so than younger individuals.[2]
Epidemiology
[edit]Wooden Chest Syndrome (WCS) is a rare condition that is becoming more prevalent with the increased use of fentanyl, both in a medical and recreational setting[2]. Although demographic data is currently scarce, evidence does suggest there is no correlation between geographic or ethnic predispositions.[2] References
- ^ a b Zoorob, Ronza; Uptegrove, Logan; Park, Benjamin L. (2023). "Case Report of Very-Low-Dose Fentanyl Causing Fentanyl-Induced Chest Wall Rigidity". Cureus. 15. doi:10.7759/cureus.43788.
{{cite journal}}: CS1 maint: unflagged free DOI (link) - ^ a b c d e f g h i j k l m Rosal, N.; Thelmo, Franklin L.; Tzarnas, Stephanie; DiCalvo, L.; Tariq, S.; Grossman, C. (2021). "Wooden Chest Syndrome: A Case Report of Fentanyl-Induced Chest Wall Rigidity". Journal of Investigative Medicine High Impact Case Reports. 9. doi:10.1177/23247096211034036.
- ^ Torralva, Randy; Janowsky, A. (2019). "Noradrenergic Mechanisms in Fentanyl-Mediated Rapid Death Explain Failure of Naloxone in the Opioid Crisis". The Journal of Pharmacology and Experimental Therapeutics. 371: 453–475. doi:10.1124/jpet.119.258566.
- ^ a b c d UL HUSNA, ASHMA; NEUPANE, RASIK; HOWSARE, MOLLY M; NIRAULA, NIRAJ (2023-10). "WOODEN CHEST SYNDROME: A RARE COMPLICATION OF FENTANYL INFUSION". CHEST. 164 (4): A2759. doi:10.1016/j.chest.2023.07.1820. ISSN 0012-3692.
{{cite journal}}: Check date values in:|date=(help) - ^ a b Judd, G. I.; Starcher, R. W.; Hotchkin, D. (2021). "Fentanyl-Induced Wooden Chest Syndrome Masquerading as Severe Respiratory Distress Syndrome in COVID-19".
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