Case report: Intrapulmonary tidal volumes in a preterm infant with chest wall rigidity

Endotracheal intubation of newborn infants is a mandatory competence for many pediatric trainees. The Neonatal Resuscitation Program recommends a 20-second limit for intubation attempts. Intubation attempts by junior doctors are frequently unsuccessful, and many infants are intubated between 20 and 30 seconds without apparent adverse effect. Little is known about the proficiency of more senior medical staff, the time taken to determine endotracheal tube (ETT) position, or the effects of attempted intubation on infants' heart rate (HR) and oxygen saturation (Spo2) in the delivery room (DR). The objectives of this study were to determine (1) the success rates and duration of intubation attempts during DR resuscitation, (2) whether experience is associated with greater success rates and shorter time taken to intubate, (3) the time taken to identify ETT position after intubation, and (4) the frequency with which infants deteriorated during intubation attempts and the time at which this occurred. We reviewed videos of DR resuscitations; identified whether intubation was attempted; and, when attempted, whether intubation was attempted by a resident, a fellow, or a consultant. We defined the duration of an intubation attempt as the time from the introduction of the laryngoscope blade to the mouth to its removal, regardless of whether an ETT was introduced. We determined the time from removal of the laryngoscope to the clinicians' decision as to whether the intubation was successful and noted the basis on which this decision was made (clinical assessment, flow signals, or exhaled carbon dioxide [ETCO2] detection). We determined success according to clinical signs in all cases and used flow signals that were obtained during ventilation via the ETT or ETCO2 when available. When neither was available, the chest radiograph on admission to the NICU was reviewed. For infants who were monitored with pulse oximetry, we determined their HR and Spo2 before the intubation attempt. We then determined whether either or both fell by > or =10% during the attempt and, if so, at what time it occurred. We reviewed 122 video recordings in which orotracheal intubation was attempted 60 times in 31 infants. We secondarily verified ETT position using flow signals, ETCO2, or chest radiographs after 94% of attempts in which an ETT was introduced. Thirty-seven (62%) attempts were successful. Success rates and mean (SD) time to intubate successfully by group were as follows: residents: 24%, 49 seconds (13 seconds); fellows: 78%, 32 seconds (13 seconds); and consultants: 86%, 25 seconds (17 seconds). Of the 23 unsuccessful attempts, 13 were abandoned without an attempt to pass an ETT and 10 were placed incorrectly. The time to determine ETT position in the DR was longer when clinical assessment alone was used. Infants who were monitored with oximetry deteriorated during nearly half of the intubation attempts. Deterioration seemed more likely when HR and Spo2 were low before the attempt. Intubation attempts often are unsuccessful, and successful attempts frequently take >30 seconds. Greater experience is associated with greater success rates and shorter duration of successful attempts. Flow signals and ETCO2 may be useful in determining ETT position more quickly than clinical assessment alone. Infants frequently deteriorate during intubation attempts. Improved monitoring of infants who are resuscitated in the DR is desirable.

Fentanyl and other opiates used in procedural sedation 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 elective 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 compounds. Management includes ventilatory support and reversal with either naloxone or a short-acting neuromuscular blocking agent. This reaction does not appear to be a contraindication to future use of fentanyl or related compounds. Chest wall rigidity causing respiratory compromise should be readily recognized and treated by bronchoscopists.

To assess the occurrence of muscle rigidity after fentanyl administration in premature and term neonates. Prospective case series, observational study. A university hospital neonatal intensive care unit. 8/89 preterm and term infants (25-40 wks gestational age) who received fentanyl for perioperative analgesia and sedation or intensive care procedures. Mechanical or bag mask ventilation and antagonization with naloxone. We observed chest wall rigidity in 8 patients after low dosage of fentanyl (3-5 microg/kg body weight). All patients presented with respiratory distress, hypercapnia, and hypoxemia leading to bradycardia. In two patients, laryngospasm was noted and associated with muscle rigidity, thus making intubation impossible. Naloxone (20-40 microg/kg body weight) reversed the laryngospasm and muscle rigidity immediately, allowing restitution within 1 min. In our patient population, we found fentanyl-induced chest wall rigidity in 4% of neonates after fentanyl administration. Even low doses of fentanyl can lead to thoracic rigidity in neonates. Additionally, we observed laryngospasm in two patients and speculate that it might be a variant of muscle rigidity.