The Silent Threat of Wooden Chest Syndrome: Prompt Management of Fentanyl-Induced Muscle Rigidity in the Intensive Care Unit.

INTRODUCTION

Wooden chest syndrome (WCS) is a rare, potentially fatal complication of high-dose fentanyl therapy, characterized by generalized muscle rigidity, reduced chest wall compliance, and acute respiratory distress. Frequently underdiagnosed in the intensive care unit (ICU), WCS poses a significant challenge due to its rapid onset and potential to cause ventilatory failure if not addressed promptly. This case report examines WCS in a postoperative setting, emphasizing its recognition and management to improve patient outcomes.

CASE PRESENTATION

A 49-year-old female with a history of cervical cancer, hypertension, and recent sigmoidectomy developed WCS 8 hours after starting a fentanyl infusion (50 μg/h, total ~400 μg) following an emergent incision and drainage for a 4 × 3 cm neck abscess. Initially stable on pressure-regulated volume control ventilation (peak airway pressure, Ppeak 20 cmHO, tidal volume 450 ml), she presented with sudden chest wall rigidity, respiratory rate of 28 breaths/min, and Ppeak rising to 35 cmHO, alongside respiratory acidosis (pH 7.28, PaCO 58 mmHg). Fentanyl was stopped, naloxone (2 mg IV) administered, and ventilation shifted to pressure control mode of 25 cmHO above positive end-expiratory pressure. Dexmedetomidine (0.5 μg/kg/h) replaced opioids for sedation. Symptoms resolved within 4 hours, enabling a transition to pressure support mode and extubation on postoperative day 2, with discharge to the floor by day 5.

CONCLUSION

This case highlights WCS as a critical, reversible opioid-related complication in the ICU, necessitating vigilance during prolonged fentanyl use (>8 hours). Early detection via ventilator changes (e.g., Ppeak elevation) and swift intervention with naloxone and non-opioid sedation can prevent adverse outcomes. Increased awareness, staff training, and further research are vital to enhance ICU safety.

LEARNING POINTS

wooden chest syndrome can manifest as sudden muscle rigidity and rising peak airway pressures within 8 hours of fentanyl infusion, requiring prompt recognition to prevent ventilatory failure. elevated peak pressures with stable plateau pressures signal wooden chest syndrome, distinguishing it from lung pathology, and warrant immediate investigation. stopping fentanyl, administering naloxone, and using dexmedetomidine can reverse wooden chest syndrome rapidly, enabling extubation within 48 hours.