Pulmonary Complications From Cocaine

Pulmonary Complications From Cocaine

Edward M. Omron MD, MPH, FCCPPulmonary Medicine

Alta Bates Summit

49 yo male found naked running down the freeway. In ER developed tonic-clonic seizure. He is agitated, diaphoretic, and paranoid Fever to 102.8, HR 120, RR 24, BP 170/98.Audible wheezing at bedside

Differential Diagnosis

• Community acquired pneumonia• Septic pulmonary embolism• Pulmonary edema or hemorrhage• Acute interstitial pneumonia• Acute pulmonary syndrome from inhalational

drug abuse

Which of the following should be initially given?

• Labetalol• Haloperidol• Phenytoin• Lorazepam• Acetaminophen

Sympathomimetic Syndrome Cocaine Intoxication

• Tachicardia, hypertension, hyperthermia, midriasis, agitation, and psychosis

• Treatment: – IV midazolam or lorazepam for sedation– IV Fluids to prevent rhabdomyolysis– ECG for myocardial ischemia and ACS markers– CT head to r/o intracranial injury

• Beta Blockers contra-indicated for HTN– Unopposed alpha vasoconstrictor effects– Labetolol preferred agent

• Haloperidol contra-indicated

• Cocaine– Pulmonary complications are a function of

• Dose Size, method of administration, assoc. substances

– Extracted from the leaf of Erythroxylon coca plant– South American shrub– Four forms

• Hydrochloride salt “White powder” inhaled• Crack: Heat stable, preferred form smoked• Bazuco: Extract of coca leaves that is smoked in S.A.

Figure 1.  Photograph illustrates the E coca plant, a shrub that is native to South America and grows in a variety of areas, including Venezuela, Colombia, Ecuador, Peru, Bolivia, Brazil,

and northern Argentina.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Pulmonary Complications of Cocaine Abuse

Acute Respiratory Symptoms

• Cardiorespiratory complaints most common– Particle size from Crack Cocaine 2.3 um deposits in alveoli– Cough , wheezing, dyspnea, CHEST PAIN– Chest Pain 40% after 12 hours– Black sputum– Acute Chest Syndrome

• Patchy alveolar infiltrates upper and lower lobes• SOB• Fever• Hypoxia

• Barotrauma complication– Pneumothorax, pneumomediastinum,

pneumopericardium, or subcutaneous emphysema– Valsalva maneuvers to TLC– Severe cough from inhalation– Accomplice blow into their mouths through

cardboard tube adding PEEP– Injection into internal jugular or subclavian vein

lacerating lung apex

Figure 3a.  Pneumomediastinum in a 28-year-old patient who presented with retrosternal chest pain after smoking crack cocaine.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 4.  Spontaneous left-sided pneumothorax in a 33-year-old man who had been smoking crack cocaine.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Asthma

• Smoked cocaine causes acute bronchospasm in healthy individuals with no history of asthma

• Bronchospasm can be severe and life threatening• Radiographics

– Patchy parenchymal opacities on CXR– GGD on CT chest

Figure 5a.  Crack cocaine–induced asthma in a 38-year-old woman.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Pulmonary Edema and Hemorrhage

• Cardiogenic and noncardiogenic pulmonary edema• 80% of cocaine related deaths in autopsy series• Increased capillary permeability, leakage• Hemoptysis in up 25% of crack users

– Hemorrhage can be severe and life threatening

– Edema and hemorrhage have similar appearances on CT Chest

• Bilateral multifocal opacifications, GGD

Figure 6.  Cardiogenic pulmonary edema in a 36-year-old woman who presented with shortness of breath and chest pain after smoking crack cocaine.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 7.  Acute pulmonary edema in a cocaine abuser.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Eosinophillic Lung Disease

• “Crack Lung” pulmonary syndrome– Inhalation of freebase cocaine– Fever, hypoxia, hemoptysis, ARF, and diffuse

pulmonary infiltrates– Biopsy reveals DAD, alveolar hemorrhage,

infiltration with eosinophils and IgE– BAL eosinophil rich– Corticosteroids are used as treatment

Figure 8a.  Pulmonary eosinophilia in a patient with a history of cocaine abuse.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 8b.  Pulmonary eosinophilia in a patient with a history of cocaine abuse.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 15a.  Advanced emphysema in a relatively young (36-year-old) woman with a history of heavy cocaine abuse and unrelated mitral valve disease.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 15b.  Advanced emphysema in a relatively young (36-year-old) woman with a history of heavy cocaine abuse and unrelated mitral valve disease.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 14a.  Severe pulmonary hypertension in a 43-year-old man with a history of cocaine abuse.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 14b.  Severe pulmonary hypertension in a 43-year-old man with a history of cocaine abuse.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 10a.  Talc granulomatosis in a patient with a history of intravenous cocaine abuse.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

Figure 10b.  Talc granulomatosis in a patient with a history of intravenous cocaine abuse.

Restrepo C S et al. Radiographics 2007;27:941-956

©2007 by Radiological Society of North America

• RadioGraphics July 2007 vol. 27 no. 4 941-956• Chest 1995; 107: 233–240