Fentanyl-induced chest wall rigidity syndrome in a routine bronchoscopy Chee Kiang Phua * , Audrey Wee, Albert Lim, John Abisheganaden, Akash Verma Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore article info Article history: Received 18 October 2016 Received in revised form 26 February 2017 Accepted 27 February 2017 Keywords: Lung cancer Bronchoscopy Sedation abstract Combination of sedatives such as fentanyl and midazolam during bronchoscopy is recommended by American College of Chest Physician due to its favourable drug profile. It improves patient comfort and tolerance, and is commonly given unless contraindicated. We describe a rare case of fentanyl-induced chest wall rigidity syndrome during a routine bronchoscopy with endobronchial ultrasound guided- transbronchial needle aspiration (EBUS-TBNA) in a 55 year old male presenting with a lung mass and mediastinal lymphadenopathy. This was effectively managed with neuromuscular blockade, intubation and reversal agents including naloxone. This rare complication should be effectively managed by all bronchoscopist as it carries significant mortality and morbidity if not recognised early. We review the literature on the occurrence of fentanyl-induced chest wall rigidity and its predisposing risks factors. © 2017 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Case report A 55 year old Chinese male presented to the respiratory clinic for chronic cough for 3 weeks duration associated with haemoptysis. Prior to presentation, he was treated in the community with oral antibiotics without improvement. He had no known past medical history and but he had a significant 20 pack year smoking history. There were no relevant contact exposure or other symptoms to suggest pulmonary tuberculosis. A chest radiograph showed a large right lower zone mass, concerning for malignancy. A computed tomography (CT) thorax confirmed a right middle lobe mass with multiple necrotic mediastinal lymph nodes and liver metastasis (Fig. 1a). Sputum acid fast bacilli (AFB) smears and tuberculosis polymerase chain reaction (TB PCR) were negative. A bronchoscopy and endobronchial ultrasound-guided trans- bronchial needle aspiration (EBUS-TBNA) of the mediastinal lymph nodes was arranged. Initial pre-procedural examination was un- remarkable and he was afebrile with normal vital signs and oxygen saturation of 99% on room air. The patient did not have any pre- procedure risk factors for apnoea such as obstructive sleep apnoea (OSA) or short neck. His BMI was 18.9. Topical xylocaine spray 10% was given intra-orally and intra-nasally. Initial 1 mg of intravenous (IV) midazolam and 25 mg of IV fentanyl was given for moderate sedation with cardiac and pulse oximeter monitoring. A flexible bronchoscope was first introduced for airway inspection. Vocal cords was normal in appearance. Except for submucosal infiltration seen in the right middle lobe, there were no other endobronchial lesions seen (Fig. 1b). During inspection, a further 2 mg of IV midazolam was given to maintain adequate sedation. Bronchoalveolar lavage was performed to the right middle lobe with good returns. The flexible bronchoscope was removed and endobronchial ultrasound bronchoscope was introduced. Surveil- lance endobronchial ultrasound screen showed enlarged sub- carinal and right para-tracheal lymph nodes. Because the patient became agitated, a further IV midazolam 2 mg and IV fentanyl 25 mg was given, closely titrated to maintain moderate sedation. Suc- cessful EBUS-TBNA to sub-carinal lymph node was performed. We then proceeded to biopsy the right para-tracheal lymph node but abandoned because patient turned restless again and required a further IV fentanyl 50 mg. 2 minutes later, patient became uncon- scious and apnoeic. He was rigid and his chest wall movement ceased During the apnoea phase, he had desaturated leading to sinus bradycardia on the cardiac monitor. Bronchoscope was immediately removed and bag-valve-mask ventilation was attempted but ineffective due to chest wall rigidity. 100 mg IV suxamethonium was given for muscle paralysis to allow for endo- tracheal intubation and ventilation, followed by naloxone and flu- mazenil to reverse the effects of fentanyl and midazolam respectively. The time interval between the onset of apnoea and * Corresponding author. Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital,11 Jalan Tan Tock Seng, 308433, Singapore. E-mail address: cheekiang.phua@mohh.com.sg (C.K. Phua). Contents lists available at ScienceDirect Respiratory Medicine Case Reports journal homepage: www.elsevier.com/locate/rmcr http://dx.doi.org/10.1016/j.rmcr.2017.02.012 2213-0071/© 2017 The Authors. Published byElsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Respiratory Medicine Case Reports 20 (2017) 205e207