A complex cascade: Wooden chest wall syndrome following low dose fentanyl infusion

Abstract

Wooden chest wall syndrome (WCS) is a rare complication of high-dose synthetic opioids, particularly fentanyl. It is characterized by thoracic muscle rigidity that impairs ventilation and complicates respiratory management, especially in mechanically ventilated patients. WCS may present with respiratory deterioration that appears disproportionate to underlying lung pathology. While the exact pathophysiology is unclear, central μ-opioid receptor activation is implicated. This case underscores that WCS is not strictly dose-dependent and can occur at relatively modest infusion rates. Timely recognition and reversal with naloxone can be both diagnostic and therapeutic. Transitioning to less lipophilic opioids and adopting multimodal analgesia may help reduce risk. This case highlights the importance of recognizing WCS in ICU patients receiving fentanyl. Prompt identification and intervention are critical to improving outcomes. Further studies are needed to elucidate the mechanisms, risk factors, and preventive strategies for WCS.