Fentanyl-Induced Chest Wall Rigidity Causing Recurrent Ventilator Dyssynchrony in the Intensive Care Unit: A Case...

Fentanyl-induced chest wall rigidity represents an important and often overlooked cause of ventilator dyssynchrony in mechanically ventilated patients. Its clinical presentation overlaps with bronchospasm and ventilator malfunction which delays diagnosis and appropriate management.

A 75-year-old male, mechanically ventilated with pneumonia and asthma exacerbation developed ventilator desynchrony, characterized by sudden-onset hypercarbia, decreased lung compliance, and episodic breath-holding. Escalation of bronchodilators, corticosteroids, and sedation failed to improve ventilation. Recurrent episodes of poor ventilation responded only transiently to neuromuscular blockade. After exclusion of dynamic hyperinflation, pneumothorax, and progression of pneumonia; fentanyl-induced chest wall rigidity was suspected. Reduction of the fentanyl infusion resulted in improved lung compliance and resolution of desaturation episodes.

While fentanyl remains a valuable for pain management in the ICU, this case highlights fentanyl-induced chest wall rigidity as a reversible cause of refractory ventilator dyssynchrony that should be suspected when sudden reductions in lung compliance and ineffective ventilation occur without identifiable pulmonary or mechanical causes, particularly in patients receiving continuous opioid infusions. Early recognition and opioid adjustment restore effective ventilation and prevent unnecessary diagnostic or therapeutic interventions.