-
Sporer KA etal. Heroin-related noncardiogenic pulmonary edema : a case series. Chest 2001;120(5):1628-32. PubMed
| Level of Evidence |
4 |
| Study Design |
Retrospective chart review (case series) from August 1994 through
December 1998 in an urban academic setting
|
| Sample Size |
N = 27
|
| Population |
Adults with heroin-related
noncardiogenic pulmonary edema (NCPE).
- Heroin-related NCPE was defined as the syndrome
in which a patient develops significant hypoxia (room air saturation < 90%
with a respiratory rate > 12/min) within 24 h of a clinically apparent
heroin overdose.
- Per the authors, "this
should be accompanied by radiographic evidence of diffuse pulmonary infiltrates
not attributable to other causes, such as cardiac dysfunction, pneumonia,
pulmonary embolism, or bronchospasm, and which resolve clinically and
radiographically within 48 h."
|
| Inclusion Criteria |
All adult patients who presented to the ED with
diagnosis of heroin overdose
|
| Exclusion Criteria |
Not specifically reported
|
| Interventions |
Prehospital administration of naloxone
|
| Results |
- 27 patients were identified during this 53-month
period, with the majority being male (85%; average age, 34 years).
- Twenty patients (74%) were hypoxic on emergency
department arrival, and 6 patients (22%) had symptoms develop within the first
hour.One patient had significant hypoxia develop
within 4 h.
- Nine patients (33%) required mechanical
ventilation, and all intubated patients but one were extubated within 24 h.
- Eighteen patients (66%) were treated with
supplemental oxygen alone. Hypoxia resolved spontaneously within 24 h in 74% of
patients, with the rest resolving within 48 h.
- Twenty patients (74%) had classical
radiograph findings of bilateral fluffy infiltrates, but unilateral pulmonary
edema occurred in four patients (15%) and more localized disease occurred in
two patients (7%).
|
| Conclusions |
NCPE is an infrequent complication of a heroin overdose. The clinical
symptoms of NCPE are clinically apparent either immediately or within 4 h of
the overdose. Mechanical ventilation is necessary in only 33% of patients.
|
| Location |
Department of Medicine, University of California, San Francisco General
Hospital
|
| Funding |
Not reported
|
-
Sterrett C, et al. Patterns of presentation in heroin overdose resulting in pulmonary edema. Am J Emerg Med 2003;21(1):32-4. PubMed
| Level of Evidence |
4 |
| Study Design |
Retrospective chart review (case series) from 1996 through December 1999
in an urban academic setting
|
| Sample Size |
N = 125
|
| Population |
Adults with heroin-related noncardiogenic
pulmonary edema (NCPE)
|
| Interventions |
Prehospital administration of naloxone
|
| Results |
- One hundred twenty-five charts (78%) were
available for review.
- Of these, 13 (10%) were diagnosed with NCPE and all were
male.In the field, NCPE patients had a Glasgow
Coma Scale of 4, and all needed naloxone.
- The average admitted duration of use was
2.9 years for those who developed NCPE compared with 13.2 years for those who
did not.
- Five (42%) NCPE patients
tested positive for cocaine use and 7 (58%) tested positive for alcohol.
|
| Conclusions |
In this cohort, the NCPE patients were male and less experienced users
with initial low Glasgow Coma Scale, which demanded prehospital naloxone use.
|
| Location |
Department of Emergency Medicine, Keck School of Medicine, University of
Southern California, Los Angeles, CA, USA.
|
-
Osterwalder JJ. Patients intoxicated with heroin or heroin mixtures: how long should they be monitored? Eur J Emerg Med 1995;2(2):97-101. PubMed
| Level of Evidence |
2b |
| Study Design |
Prospective, single center cohort study
|
| Sample Size |
N = 160
|
| Population |
Adults
intoxicated with heroin or heroin mixtures who survived to the hospital from
January 1, 1991 to December 31, 1992
|
| Inclusion Criteria |
GCS < 15 and respiratory depression of <
12 /min, improvement in condition following naloxone, and confirmed drug
intoxication
|
| Interventions |
Naloxone
|
| Primary Endpoint |
To find out the time interval during which delayed life-threatening
complications become manifest, such as pulmonary edema or relapse into
respiratory depression or coma after naloxone treatment.
|
| Results |
- Of the 538 intoxications, 160 outpatients who
lived were assessed.
- The results of our investigation showed no
rehospitalization owing to pulmonary edema or coma, but one death, outside the
hospital, owing to delayed pulmonary edema.
- This delayed complication had an incidence of
0.6% (95% confidence interval 0-3.8%). A reintoxication could be excluded in
this patient. Based on reliable report, the pulmonary edema occurred between
approximately 7.25 and 8.25 hours after intoxication.
- In the literature, only two
cases of delayed pulmonary edema have been reported with reliable time
statements (4 and 6 h after hospitalization).
|
| Conclusions |
"We therefore conclude that surveillance for at least 8 h is essential
after successful treatment to exclude delayed pulmonary edema in patients
intoxicated with heroin or heroin mixtures."
|
| Location |
Department of Emergency Medicine and Surgery, Kantonsspital St Gallen,
Switzerland
|
| Comments |
This study found very low incidence of delayed
onset NCPE following naloxone administration for heroin overdose. The single
delayed presentation (7.25-8.25 hrs) reported here was not observed in
hospital, but at home. Per report from friends and family, he did not
re-ingest, there was no illicit drug use paraphernalia at the scene of death,
and there were no illicit substances other than morphine detected on postmortem
toxicology screen. While none of this definitively rules out repeat ingestion,
it makes it less likely. There is also
no data to refute that were this patient monitored, they would have been
detected earlier.
|
-
Frand UI et al. Heroin-induced pulmonary edema. Ann Intern Med 1972;77:29-35. PubMed
| Study Design |
Single-center, Cohort Study
|
| Sample Size |
N = 16
|
| Population |
Adults with heroin overdose and pulmonary edema
|
| Interventions |
Supplemental oxygen, nalorphine (5 mg IV 1-3
doses)
|
| Other Treatments |
Lung volume assessment using closed-circuit
helium dilution and pulmonary function testing
|
| Results |
- Chronic heroin addiction
results in a slight decrease of diffusing capacity.
- Heroin overdose is
characterized clinically by hypoventilation and coma, moderate to severe
hypoxia, mild reduction in vital capacity, and normal diffusion capacity.
- Heroin-associated pulmonary
edema results in profound hypoxemia, right-to-left shunt, metabolic and
respiratory acidosis, decreased lung volumes, decreased lung compliance, and
moderately decreased diffusing capacity.
- Clinical, radiologic, and
arterial blood gas improvements are rapid and complete within a few days.
- Vital capacity and dynamic compliance improve
slowly and diffusion capacity remains unchanged for several weeks.
|
| Conclusions |
Heroin-induced pulmonary edema is similar to
other forms of pulmonary edema.
|
| Location |
Department of Medicine and Unit for Research in
aging, Albert Einstein College of Medicine and Chest Service, Bronx Municipal
Hospital Center, Bronx, New York
|
| Comments |
Nalorphine was the opioid reversal agent used in
this study.
|
|
