Heroin Insufflation as a Trigger for Patients With Life-Threatening Asthma

doi:10.1378/chest.123.2.510

Chest

Volume 123, Issue 2, February 2003, Pages 510-517

https://doi.org/10.1378/chest.123.2.510 Get rights and content

Study objectives:

To determine the prevalence of self-reported, heroin-associated asthma symptoms among inner-city patients treated for life-threatening asthma, and to compare the rates of drug use between ICU patients with asthma and ICU control patients with diabetic ketoacidosis (DKA).

Designs:

Study 1 was a sequential case series of patients requiring ICU admission for asthma (January to June 1999). Study 2 was a retrospective, case-control study of drug use among asthma patients and control subjects with DKA requiring ICU care (1997 to 1998).

Setting:

Inner-city, public hospital ICU.

Patients:

Twenty-three patients (26 ICU admissions) with asthma (age range, 16 to 50 years) admitted to the ICU from January to June 1999, and 84 patients (104 ICU admissions) with asthma and 42 patients with DKA (age range, 15 to 50 years) admitted to the ICU during 1997 to 1998.

Outcomes studied:

Self-reported, heroin-associated exacerbations, history of heroin or cocaine use, and urine drug screen (UDS) results.

Measurements and results:

In the sequential ICU admissions, 13 of 23 patients (56%) described asthma exacerbations associated with heroin insufflation. In the case-control study, asthmatics were significantly more likely to report heroin use (41.3% vs 12.5%; p = 0.006) and had a significantly higher prevalence of UDS results positive for opiates (60% vs 7%; p = 0.001) compared to subjects with DKA. The rates of cocaine use by history and UDS results did not differ significantly between the two groups.

Conclusions:

At least since 1997, heroin insufflation is a common asthma trigger in this inner-city ICU and should be considered in the care of patients with life-threatening asthma.

Section snippets

Materials and Methods

Cook County Hospital is a public hospital that serves metropolitan Chicago. Approximately 11,000 adult patients per year are treated in the emergency department (ED) for asthma exacerbation, and roughly 4% require hospital admission for > 23 h. Patients requiring ICU admission represent roughly 10% of total asthma hospital admissions; the majority of these are admitted directly from the ED. Patients admitted to the ICU for asthma have either impending or actual respiratory failure, or a severe

Study 1: Case Series

In the first 6 months of 1999, there were 26 admissions for asthma in patients aged 16 to 50 years admitted to the ICU (Table 1). Three patients had two ICU admissions; thus, there were a total of 23 patients. All patients were African American, except one patient who was white. The mean age of the patients was 35 years. Childhood onset of disease was reported by 45%. Fifteen of 22 patients (68.2%) reported using an inhaled corticosteroid. Of the 16 patients for whom the source of asthma care

Discussion

We have observed that heroin insufflation is a common trigger for asthma symptoms among patients requiring ICU admission for asthma in an urban public hospital. This phenomenon has occurred sporadically since March 1997 and may have been operative prior to that date. In the first 6 months of 1999, the majority of persons (13 of 23 patients) admitted with severe asthma to the ICU gave a clear history that heroin insufflation precipitated asthma exacerbations generally, and in some cases, clearly

ACKNOWLEDGMENT

We thank Drs. David Gummin and Paul Bonucci for assistance in data collection, Drs. Henri Frischer and Jay Shannon for review of the manuscript, and Dr. Lawrence Ouellet and the staff of the Community Outreach Intervention Projects for information provided on drug use practices in Chicago.

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L’usage d’héroïne peut causer des complications respiratoires dont l’asthme, la bronchopneumopathie chronique obstructive (BPCO) et les bronchectasies (DDB).
Revue générale de la littérature exposant les données sur la relation entre la consommation d’héroïne et les complications bronchiques les difficultés du diagnostic et de la prise en charge.
Medline, période 1980–2022, mots-clés : « asthma » ou « bronchospasm » ou « COPD » ou « bronchiectasis » et « heroin » ou « opiate » ou « opiates », avec les limites « Title/Abstract ». Concernant l’asthme 26 études ont été retenues, 16 pour la BPCO et 5 pour les DDB.
La prévalence de l’asthme et de la BPCO est plus élevée chez les héroïnomanes ; ces patients sont moins observants de leur traitement. Une association positive existe entre la fréquence des exacerbations d’asthme, l’admission en soins intensifs et l’inhalation d’héroïne. Le diagnostic de BPCO est tardif ce qui aggrave le cours de la maladie ; la présence d’emphysème et de DDB sont des éléments de mauvais pronostic.
Les affections bronchiques doivent être mieux identifiées chez les consommateurs d’héroïne afin d’optimiser leur prise en charge qui comprend l’arrêt de substances toxiques.
Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD).
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Medline, 1980–2022, keywords “asthma” or “bronchospasm” or “COPD” or “bronchiectasis” and “heroin” or “opiate” or “opiates”, with limits pertaining to “Title/Abstract”. Concerning asthma, 26 studies were included, as were 16 for COPD and 5 for BD.
Asthma and COPD are more prevalent among heroin addicts, who are less compliant than other patients with their treatment. The authors found a positive association between frequency of asthma exacerbations, admission to intensive care and heroin inhalation. Late diagnosis of COPD worsens the course of the disease; emphysema and BD are poor prognostic factors.
Bronchial diseases in heroin users can be identified by means of respiratory function exploration and chest CT scans. These tests should be performed frequently in view of optimizing their care, which includes their weaning themselves from addictive substances.
Evaluation and management of the critically ill adult asthmatic in the emergency department setting
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Citation Excerpt :
History may be limited in critically ill patients, but if able to obtain, history should include time of symptom onset, precipitating cause, symptom severity compared to prior exacerbations, and treatments attempted prior to ED presentation [9,10,14,17,27,28]. Clinicians should screen for symptoms that suggest an alternate etiology, such as anaphylaxis, congestive heart failure, pneumonia, and pulmonary embolism, as well as other conditions that may result in wheezing and respiratory distress (Table 1) [29–49]. Increasing use of short-acting beta agonist therapy, recent glucocorticoid use, recent ED visit or hospital admission for asthma, and any prior airway interventions for asthma (e.g., non-invasive positive pressure ventilation [NIPPV] and endotracheal intubation) may suggest a more severe exacerbation [9,10,14,17,27,28].
Asthma is a common reason for presentation to the Emergency Department and is associated with significant morbidity and mortality. While patients may have a relatively benign course, there is a subset of patients who present in a critical state and require emergent management.
This narrative review provides evidence-based recommendations for the assessment and management of patients with severe asthma.
It is important to consider a broad differential diagnosis for the cause and potential mimics of asthma exacerbation. Once the diagnosis is determined, the majority of the assessment is based upon the clinical examination. First line therapies for severe exacerbations include inhaled short-acting beta agonists, inhaled anticholinergics, intravenous steroids, and magnesium. Additional therapies for refractory cases include parenteral epinephrine or terbutaline, helium‑oxygen mixture, and consideration of ketamine. Intravenous fluids should be administered, as many of these patients are dehydrated and at risk for hypotension if they receive positive pressure ventilatory support. Noninvasive positive pressure ventilation may prevent the need for endotracheal intubation. If mechanical ventilation is required, it is important to avoid breath stacking by setting a low respiratory rate and allowing permissive hypercapnia. Patients with severe asthma exacerbations will require intensive care unit admission.
This review provides evidence-based recommendations for the assessment and management of severe asthma with a focus on the emergency clinician.
Asthma and cannabis, cocaine or heroin use
2020, Revue des Maladies Respiratoires
L’usage de cannabis, de cocaïne ou d’héroïne peut être responsable de complications pulmonaires parmi lesquelles figure l’asthme.
L’objectif de cette revue systématique de la littérature est d’exposer les données concernant la relation entre la consommation de cannabis, de cocaïne ou d’héroïne et l’asthme.
L’usage de cannabis, de cocaïne ou d’héroïne par voie inhalée peut être responsable de symptômes respiratoires (toux, sifflements thoraciques), favoriser le développement d’un asthme, augmenter le risque d’exacerbation aiguë d’asthme (pouvant nécessiter une intubation et une ventilation invasive), voire des décès par asthme et diminuer l’observance du traitement de l’asthme. Le cannabis a un effet bronchodilatateur rapide. En revanche, sa consommation chronique provoque une diminution de la conductance spécifique des voies aériennes. Les études portant sur la diminution ou le déclin du volume expiratoire maximal par seconde (VEMS) sont discordantes.
Une consommation de cannabis, de cocaïne ou d’héroïne doit être recherchée devant des symptômes respiratoires survenant chez des sujets jeunes et les praticiens doivent aider les usagers de ces substances illicites à arrêter leur consommation.
The use of cannabis, cocaine or heroin can be responsible for many respiratory complications including asthma.
The aim of this systematic literature review of data was to expose the relations between cannabis, cocaine or heroin use and asthma.
Cannabis, cocaine or heroin use by inhalation may be responsible for respiratory symptoms (cough, wheezing), asthma onset, acute asthma exacerbations (which may require intubation and invasive ventilation) or deaths related to asthma. Lower adherence to asthma treatment is also observed. Cannabis induces a rapid bronchodilator effect. In contrast, its chronic use may induce a decrease in specific airway conductance. Studies on forced expiratory volume in one second (FEV1) reduction or decline are discordant.
Cannabis, cocaine or heroin use must be considered in cases of acute respiratory symptoms or asthma exacerbation in young persons and practitioners must help illicit substance users to stop their consumption.
Relationship between opiates and asthma in the determination of death
2020, Journal of Forensic and Legal Medicine
Several studies have shown an association between asthma and opiate abuse. This retrospective study aims to analyse the demographic, toxicological, and seasonal differences in asthmatic and non-asthmatic subjects who died of opiates. In addition, the relationship between toxicological levels of opiates and histologic grade of lung inflammation is examined.
Deaths from 2013 to 2018 involving opiates as the primary cause of death in Cook County, Illinois (USA) were reviewed. Twenty-six cases of opiate deaths of individuals with a history of asthma and lung histology slides available were identified. In comparison, 40 cases of deaths due to opiates only were analysed. A check-list system for the evaluation of the grade of microscopic inflammation in asthma was developed.
We found statistically significant differences between the asthmatics and the non-asthmatics regarding demography (age and race) and toxicology (6-MAM presence). In particular, the “opiate and asthma group” was mainly composed of African-American subjects, in contrast with the “opiate group”, consisting mostly of Caucasian. The mean age was significantly higher in the “opiate and asthma group” compared with the “opiate group”. A greater presence of 6-MAM was detected in the “opiate group” compared with the “opiate and asthma group”. While we expected to find that low opiate levels would lead to deaths in asthmatics and, in particular, that lower opiate concentrations would cause deaths in subjects with higher grades of histologic inflammation, our study suggests that the quantity of drug and the level of inflammation are not statistically significant in the determination of death. We, therefore, recommend histologic examination of the lungs to evaluate for asthma, particularly in suspected low-level opiate-related deaths, to help further clarify any relationship between asthma and opiate use.
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Chest

Clinical Investigations in Critical CareHeroin Insufflation as a Trigger for Patients With Life-Threatening Asthma*

Study objectives:

Designs:

Setting:

Patients:

Outcomes studied:

Measurements and results:

Conclusions:

Section snippets

Materials and Methods

Study 1: Case Series

Discussion

ACKNOWLEDGMENT

J Psychosom Res

Chest

Life Sci

Forensic Sci Int

Life Sci

Neurosci Res

Chest

Chest

Chest

NIDA Research Report: Heroin abuse and addiction

Epidemiologic trends in drug abuse: Volume I, Epidemiologic trends in drug abuse

Opiate inhalation and occupational asthma [letter]

BMJ

Occupational rhinitis and bronchial asthma due to morphine: evidence from inhalational and nasal challenges

Allergy

Clinical Investigations in Critical Care
Heroin Insufflation as a Trigger for Patients With Life-Threatening Asthma^*