Drug overdose and SOB

Case: The Rapid Response Team (RRT) has been called for a 32-year-old male with a history of IV drug abuse (IVDA) who is now in inpatient rehab  - for an acute episode of shortness of breath. CXR showed bilateral pulmonary edema. The patient failed a noninvasive ventilation mask and required intubation. Echocardiography is reported to be normal, with good right and left ventricular funtions. Critical Care fellow floated the swan with normal wedge pressure. 

Answer: Noncardiogenic pulmonary edema of opioid overdose 

Well known for the last 150 years but often undiagnosed is the independent noncardiogenic pulmonary edema due to opioid overdose. Any of the opioids or related agents can be responsible, including fentanyl, morphine, or heroin.

In the above question, the patient may have developed noncardiogenic pulmonary edema from methadone OVERDOSE while in the treatment!

Although the exact mechanism is unknown, the probability is the combination of two factors: the drug's direct toxicity and hypoventilation-induced respiratory acidosis, which causes cerebral and pulmonary edema. Naloxone can be tried, but pulmonary edema is usually resolved once the hypoventilation is managed. Usually, the response is very rapid. 

#pulmonary

#toxicity

References:

1. Osler W. Oedema of the left lung—morphia poisoning. Montreal General Hospital Reports Clinical and Pathological, vol 1, Dawson Bros Publishers, Montreal 1880. p.291.

2. Dezfulian C, Orkin AM, Maron BA, et al. Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e836.

3. Farkas A, Lynch MJ, Westover R, et al. Pulmonary Complications of Opioid Overdose Treated With Naloxone. Ann Emerg Med 2020; 75:39.

Radke JB, Owen KP, Sutter ME, et al. The effects of opioids on the lung. Clin Rev Allergy Immunol 2014; 46:54.

4. Sporer KA, Dorn E. Heroin-related noncardiogenic pulmonary edema : a case series. Chest 2001; 120:1628.