From Constipation to Intubation: Opiate Induced Constipation Leading to Respiratory Distress

Introduction: Around 20% of the general population is affected by constipation. Etiology is often multifactorial and can lead to significant complications if untreated. We present an adult man with severe constipation that led to respiratory distress requiring endotracheal intubation due to the physical restriction of diaphragmatic movement. Case Description/Methods: A 52-year-old man with a history of chronic obstructive pulmonary disease requiring 2L supplemental oxygen, BMI 54, and opioid use disorder presented to our hospital with abdominal swelling and shortness of breath. His last bowel movement occurred 6 days prior. Vital signs were unremarkable. Physical examination revealed a taught abdomen, hypoactive bowel sounds, and no tenderness to palpation. Labs were unremarkable throughout his stay. Computed tomography (CT) abdomen/pelvis showed a large volume of formed colonic fecal debris and severe fecal impaction (Figure 1). The patient received an aggressive bowel regimen. He began having bowel movements; however, oral laxatives and enemas eventually became ineffective. Gastroenterology assisted, but he remained obstipated, despite using movantik. His respiratory distress did not improve. Arterial blood gas showed CO2 retention. Non-invasive breathing measures were ineffective, and he eventually required endotracheal intubation. Serial manual disimpactions were recommended by general surgery, after which approximately 25kg of stool was evacuated. The patient's abdomen became softer and less distended. He improved clinically and was successfully extubated. Repeat CT abdomen showed interval improvement in stool burden and colonic caliber. He was discharged with an aggressive bowel regimen and was advised to avoid all opioids. Discussion: Only a few cases of respiratory distress secondary to constipation are reported, with most being in the pediatric population (Table 1). Our hypothesis suggests that bowel distention exerts external pressure on the diaphragm, limiting its excursion and causing a restrictive breathing pattern. Our patient's significant improvement with serial manual disimpactions suggests that colonic distention played a significant role in his respiratory distress. He had prior admissions for respiratory distress, but CT abdomens did not reveal abdominal distention at that time. To the best of our knowledge, this is the first known case of severe constipation in an adult causing respiratory distress, which was successfully treated with manual disimpaction and a bowel regimen.Figure 1.: A, B: Extreme fecal impaction throughout the colon. in both axial and sagittal (respectively) sections of Abdomen CT ( before disimpaction) C, D : Decreased colonic stool burden in both axial and sagittal (respectively) sections of Abdomen CT ( after disimpaction). Table 1. - List of case reports in medical literature of patients presenting with respiratory distress secondary to constipation Author(s) Date Published Case A. Milanese, N. L. Schechter, and M. Ganeshananthan 1986 14-year-old boy presenting with a barrel-chested appearance and a complaint of shortness of breath on exertion. The patient had a long history of severe constipation with overflow incontinence. Physical examination suggested limited diaphragmatic excursion. S. Badiani, D. McArthur, D. Bowley, and B. Balasubramanian 2009 17-year-old presenting with acute respiratory distress because of mediastinal shift secondary to chronic constipation. E. S. Mull 2021 13-year-old woman presented acute respiratory distress syndrome and feculent airway casts due to severe constipation.