CHEST
Fentanyl-Induced Chest bronchoscopy was performed for airway anesthesia and
Wall Rigidity
Bașak Çoruh, MD; Mark R. Tonelli, MD; and David R. Park, MD
Fentanyl and other opiates used in procedural seda-
tion and analgesia are associated with several well-
known complications. We report the case of a man
who developed the uncommon complication of chest
wall rigidity and ineffective spontaneous ventilation
following the administration of fentanyl during an elec-
tive bronchoscopy. His ventilation was assisted and the
condition was reversed with naloxone. Although this
complication is better described in pediatric patients
and with anesthetic doses, chest wall rigidity can
occur with analgesic doses of fentanyl and related com-
pounds. Management includes ventilatory support and
reversal with either naloxone or a short-acting neuro-
muscular blocking agent. This reaction does not appear
to be a contraindication to future use of fentanyl or
related compounds. Chest wall rigidity causing respira-
tory compromise should be readily recognized and
treated by bronchoscopists.
CHEST 2013; 143(4):1145–1146
Case Report
A 76-year-old man was referred for bronchoscopy and
endobronchial ultrasound-guided transbronchial needle
aspiration of an enlarged right paratracheal lymph node.
He had a history of stage IA non-small cell lung cancer with
resection 2 years prior, and was found on follow-up imaging
to have new mediastinal lymphadenopathy. More recently,
he had developed hoarseness and cough. The patient had
received procedural sedation and analgesia previously with-
out difficulty.
The patient was afebrile with normal vital signs and
oxygen saturation of 99% on ambient air. Aside from hoarse-
ness, the physical examination was unremarkable. Initial
Manuscript received August 28, 2012; revision accepted
December 11, 2012.
Affiliations: From the Division of Pulmonary and Critical Care
Medicine, University of Washington, Seattle, WA.
Correspondence to: Bașak Çoruh, MD, Division of Pulmonary
and Critical Care Medicine, University of Washington, Box 356522,
1959 NE Pacific St, Seattle, WA 98195; e-mail: bcoruh@u.washington.
edu
© 2013 American College of Chest Physicians. Reproduction
of this article is prohibited without written permission from the
American College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.12-2131
journal.publications.chestnet.org
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Selected Reports
inspection. The patient received a total of 150 µg IV fen-
tanyl and 4 mg IV midazolam in divided doses during
this 20-min portion of the procedure. Airway examination
revealed right vocal cord paralysis, right arytenoid edema,
and extrinsic compression of the right lateral tracheal wall.
The diagnostic bronchoscope was then withdrawn to insert
the endobronchial ultrasound scope. Because the patient
was awake at this time, he received an additional 1 mg of
midazolam and 100 µg of IV fentanyl. Two minutes after
medication administration, the patient was noted to have
clenched hands and jaw. His chest wall became rigid, and
chest wall movement ceased. The patient developed hyper-
tension to 208/134 mm Hg and oxygen desaturation decrease,
with the lowest observed oxygen saturation being 81%.
The patient lost consciousness and bag-valve-mask venti-
lation was initiated to assist patient breaths. Naloxone,
0.2-mg IV, was administered with rapid resolution of rigid-
ity and return of effective respiratory efforts, followed by
awakening. The remainder of the procedure was aborted
and the patient recovered fully with plans to have a lymph
node biopsy performed under general anesthesia.
Discussion
Opioids and benzodiazepines are frequently used agents
for procedural sedation and analgesia, and their combined
use during bronchoscopy is recommended by the American
College of Chest Physicians because of their synergistic
effects on sedation.1 At our institution, we most commonly
use midazolam to achieve sedation and amnesia and fentanyl
for its analgesic and antitussive effect during bronchoscopy.
Procedural sedation and analgesia with benzodiazepines
and opioids is associated with several potential complica-
tions, including respiratory depression, cardiovascular insta-
bility, and nausea and vomiting with resultant aspiration.
Skeletal muscle rigidity is a much less common adverse
effect whose true incidence is unknown.
Fentanyl-induced rigidity was first described by Hamilton
and Cullen2 in 1953: “on some occasions, a pronounced
degree of rigidity and increased muscle tone were noted.”
Since then, skeletal muscle rigidity has been recognized
increasingly, most commonly with lipophilic synthetic opi-
oids such as fentanyl, alfentanil, remifentanil, and sufentanil.
This rigidity can primarily affect the chest and abdominal
musculature, resulting in the “wooden chest syndrome.”
Chest wall rigidity decreases chest wall compliance and
may result in ineffective spontaneous ventilation and may
also make assisted ventilation more difficult. The mechanism
remains poorly understood but appears to be centrally
mediated and is not caused by depression of ventilatory
CHEST / 143 / 4 / APRIL 2013 1145
 Table 1—Risk Factors for Development of
Opiate-Induced Rigidity
Dose and rapidity of injection of opiates
Extremes of age (eg, newborns, elderly patients)
Critical illness with neurologic or metabolic diseases
Use of medications that modify dopamine levels
drive. The nucleus raphe pontis within the reticular forma-
tion and the caudate nucleus within the basal ganglia have
been implicated mechanistically.3,4 Closure of the glottis
and supraglottic structures may contribute to the difficulty
in ventilating these patients.5 Development of rigidity is
potentiated by both dose and rapidity of injection of fenta-
nyl and similar compounds. The risk factors for the devel-
opment of opiate-induced rigidity are listed in Table 1.6
Management includes supportive care (eg, ventilation)
and reversal with either naloxone or a short-acting neuro-
muscular blocking agent.7 There are no guidelines that
suggest that future use of fentanyl or related compounds
is contraindicated.
Fentanyl-induced chest wall rigidity has been well
described in the neonatal,8-14 pediatric,15 and anesthesia16-20
literature but not, to our knowledge, in the bronchoscopy
setting. The patient received a total of 3.6 mg/kg of IV fen-
tanyl, with 1.4 mg/kg being given rapidly just prior to this
event. Although rigidity was more likely, given the higher
(3-5 mg/kg IV) fentanyl dose and the patient’s older age, we
speculate that the patient’s as-yet-undiagnosed underlying
illness may have contributed to his risk of adverse reaction.
The complication was recognized quickly and the condi-
tion was fully reversed with naloxone. This case highlights
the importance of administering fentanyl and similar com-
pounds in low doses and with slow injection. All bronchos-
copists should be familiar with fentanyl-induced rigidity
and its management.
Acknowledgments
Financial/nonfinancial disclosures: The authors have reported
to CHEST that no potential conflicts of interest exist with any
companies/organizations whose products or services may be dis-
cussed in this article.
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Successful Treatment of Severe
Amiodarone Pulmonary Toxicity
With Polymyxin B-Immobilized
Fiber Column Direct
Hemoperfusion
Nahoko Sato, MD; Keisuke Kojima, MD, PhD; Yuko Horio, MD;
Eisuke Goto, MD, PhD; Aiko Masunaga, MD;
Hidenori Ichiyasu, MD, PhD; and Hirotsugu Kohrogi, MD, PhD
Amiodarone pulmonary toxicity (APT) is the most
serious side effect of amiodarone. Although severe
APT, such as ARDS, is rare, mortality of severe APT
Selected Reports