Heroin Abuser with Sudden Shortness of Breath, Case of the Week

The correct answer is:

Opioids in an overdose and therapeutic dosing setting may result in noncardiogenic pulmonary edema.

Educational Objective:

Describe the presentation of noncardiogenic pulmonary edema.

Key Point:

Noncardiogenic pulmonary edema is a frequent finding of opioid use and abuse and typically occurs within 4 hours of the original heroin dose. Studies are inconclusive about this phenomenon and its relationship to the administration of naloxone.

Explanation:

This patient is experiencing noncardiogenic pulmonary edema.

Examination of the chest x-ray reveals that this patient's heart size is normal. This makes congestive heart failure clinically unlikely.

In addition, continuous use of heroin and other opioids is associated with cardiovascular toxicity; however, typically this is manifested by bradycardia and hypotension, not congestive heart failure.

Bronchospasm can result from inhalation of opioids (and also from opioids via other routes); however, the chest x-ray shows signs of fluid accumulation rather than bronchoconstriction.

Treatment is mostly symptomatic.

Pearl:

Digoxin and diuretics are NOT recommended because the patient is experiencing a non-cardiogenic cause of pulmonary edema. Diuretics may worsen the hypotension that results from histamine release following some opioid use/overdose. About 40% of patients will require mechanical ventilation.

References:

Nikolaides JK, Thompson ™. Opioids. (Chapter 156) In: Walls R, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice. 9th ed., 2018: 1943 -1946.e2.

Sporer A, Dorn E. Heroin-related noncardiogenic pulmonary edema. Chest. 2001;120:1628-1632.

Bazoukis, G et al. “Non-cardiogenic pulmonary edema, rhabdomyolysis and myocardial injury following heroin inhalation: a case report.” Hippokratia vol. 20,1 (2016): 84-87.