fentanyl question-contraindication with COPD

[Dennhop]

Ok, so I'm an EMT-B, and I understand this is completely out of my wheelhouse, however I'm also curious, and I came across a small tidbit of information tonight, and just want to understand it a bit better.

I read that Fentanyl can be contraindicated in pts with advanced stages of COPD...not really finding a lot about it, my uneducated guess would be that fentanyl can lower the HR, in turn relaxing a COPD pt, and making it more difficult for them to breath, especially considering that they may have fluid built up in their lungs.

Am I anywhere near the truth, or am I way out in left field? Again, I know it's out of my wheelhouse, but I was curious.

 

[dutemplar]

A couple of methods, but the quickest version...

First, opoids can act to cause histamine release. Not necessarily the best thing for brittle asthmatics/ COPDers, and also is a bit of a sedative and can depress the respiratory drive.


Taken from the Duragesic (transdermal fentanyl) info book:

Ventilatory Effects
In clinical trials of 357 non-opioid tolerant subjects treated with DURAGESIC, 13 subjects experienced hypoventilation. Hypoventilation was manifested by respiratory rates of less than 8 breaths/minute or a pCO2 greater than 55 mm Hg. In these studies, the incidence of hypoventilation was higher in nontolerant women (10) than in men (3) and in subjects weighing less than 63 kg (9 of 13). Although subjects with prior impaired respiration were not common in the trials, they had higher rates of hypoventilation. In addition, post-marketing reports have been received that describe opioid-naive post-operative patients who have experienced clinically significant hypoventilation and death with DURAGESIC.

Hypoventilation can occur throughout the therapeutic range of fentanyl serum concentrations, especially for patients who have an underlying pulmonary condition or who receive concomitant opioids or other CNS drugs associated with hypoventilation. The use of DURAGESIC is contraindicated in patients who are not tolerant to opioid therapy.

 

[SeeNoMore]

Sort of. The use of sedation for pt's w/ COPD is certainly a concern. The use of opiates of any kind can lead to diminshed respiratory effort. This is a possible side effect of any sedative and is not caused by a lowered heart rate. Instead a patient may have a decreased HR because of the sedation. As for fluid , you may be thinking of congestive heart failure. This may or may not be present in a patient with COPD. This is not the only reason for a patient to have fluid in their lungs.

It's also possible that you are referring to the uncommon phenomeon of chest wall rigidity secondary to fentanyl? If so this would only complicate the situation for a pt w/ COPD. That being said, it is not my understanding that a baseline of COPD necessarily predisposes a patient to fentanyl induced chest wall rigidity. I believe most of the literature available focuses on neonatal and pediatric patients , but I have seen some regarding adult patients in doses similar to those used by many prehopsital agencies (between 1 and 3 mcg/kg).

 

[Dennhop]

Ok, I completely forgot about the respiratory affect, which makes more sense now...and yeah, I was mixing up copd with Chf. As far as chest wall rigidity, I can honestly say I've never heard of that, so I know I wasn't referring to that part, lol

 

[Akulahawk]

Fentanyl use in COPD patients isn't contraindicated but you do have to be careful with it. I'm more concerned with causing hypoventilation than chest wall rigidity. In my ED we tend to go with lower doses in these patients. I generally have seen 25 mcg being used in these patients if Fentanyl is ordered.

 

[Carlos Danger]

Fentanyl does not cause histamine release, but it does decrease chemoreceptor sensitivity to pH and C02.

 

[dutemplar]

OK, I googled. We were taught long long ago it did... which followup studies claim was due to the limits of the plasma testing at the time. I had heard that again at a con-ed some a few years back, but memory was vague...

However, this... "
Fentanyl enhances the excitability of rapidly adapting receptors to cause cough via the enhancement of histamine release in the airways"

https://coughjournal.biomedcentral.com/articles/10.1186/1745-9974-9-3

On a side note, I'm not yelling or being a dork. I copy/paste the title and that's the font it used and I couldn't change it...

 

[Carlos Danger]

OK, I googled. We were taught long long ago it did... which followup studies claim was due to the limits of the plasma testing at the time. I had heard that again at a con-ed some a few years back, but memory was vague...


However, this... "
Fentanyl enhances the excitability of rapidly adapting receptors to cause cough via the enhancement of histamine release in the airways"

https://coughjournal.biomedcentral.com/articles/10.1186/1745-9974-9-3

On a side note, I'm not yelling or being a dork. I copy/paste the title and that's the font it used and I couldn't change it...

This study shows that a small amount of histamine was found in the bronchial fluid of rats who were given a very large dose of fentanyl.

With the exception of the few who have anaphylactic reactions to fentanyl, it does not cause clinically significant histamine release in humans. That's why it doesn't cause the hemodynamic effects, pruritus, and other side effects that morphine and the morphine derivatives do.