Profile of Acute Asthma Exacerbation in Drug Users

Abstract

The characteristics of patients who use heroin, cocaine, or both and present with acute asthma exacerbations have not been well studied. In this retrospective study, we aimed to study the demographic characteristics of this patient population, the characteristics of their asthma attack, and the risk factors for the need for invasive mechanical ventilation in this patient population. We reviewed the charts of patients discharged from an inner-city hospital with a diagnosis of acute asthma exacerbation. Individuals who used either heroin or cocaine or both within 24 hours of presenting to the emergency department were identified as a cohort of drug users. The rest were classified as non-drug users. Both groups were compared, and a univariate analysis was performed. To assess the predictive value of drug use for the need for intubation in the presence of confounding factors, logistic regression analysis was performed to identify whether using cocaine or heroin or both was an individual predictor for the need for invasive ventilation. Data from 218 patients were analyzed. Drug users (n = 85) were younger (mean age in years 43.9 vs. 50.5, P < 0.01), predominantly male (63.5% vs. 33.8%, P < 0.01), and more likely to be cigarette smokers (90.6% vs. 57.6%, P < 0.01). A medical history of intubation and admissions to the intensive care unit (ICU) was more common among drug users (56.5% vs. 29.3%, P < 0.01 and 54.1% vs. 38.3%, P < 0.03, respectively). Drug use was associated with increased need for invasive mechanical ventilation (35% vs. 23.3%, P = 0.05). Non-drug users were more likely to be using inhaled corticosteroids (48.9% vs. 32.9%, P = 0.03) and had longitudinal care established with a primary care provider (50.6% vs. 68.9%, P < 0.01). After adjusting for a history of mechanical ventilation, history of ICU admission, use of systemic corticosteroids, smoking, and acute physiological assessment and chronic health evaluation 2 score, drug use remained predictive for the need for mechanical ventilation (P = 0.026). Acute asthma exacerbations triggered by cocaine and heroin should be treated aggressively because they represent a cohort with poor follow-up and undertreated asthma as outpatients and are associated with increased need for invasive mechanical ventilation and ICU admission during acute exacerbation.

Asthme et usage d’héroïne

“…Si cette consommation est soupçonnée, une analyse toxicologique des urines pour les opiacés peut confirmer le diagnostic. Une surveillance attentive du patient en unité de soins intensifs est alors impérative en raison du risque de dégradation rapide de l'état respiratoire pouvant nécessiter une intubation et une ventilation assistée [43,47]. Enfin, la consommation d'héroïne a un impact sur le contrôle de l'asthme, ce qui nécessite une prise en charge pluridisciplinaire (médecin généraliste, pneumologue et addictologue) [5].…”

“…Observance du traitement de l'asthme Au cours des maladies chroniques comme l'asthme ou les addictions, la mauvaise observance du traitement est la principale cause d'échec thérapeutique [5,42]. Doshi et al [43] ont montré que, comparativement aux sujets consommant de l'héroïne et/ou de la cocaïne, l'observance thérapeutique était meilleure chez ceux n'en utilisant pas, avec une prise plus fréquente de la corticothérapie inhalée (48,9 % vs. 32,9 % ; p < 0,003) ou systémique (28,6 % vs. 15,3 % ; p < 0,003). De plus, ceux qui en consommaient avaient moins souvent un médecin traitant (50,6 % vs. 68,9 % ; p = 0,007).…”

“…Il s'agit d'un mécanisme direct, non allergique. Il en résulte une bronchoconstriction et un oedème de la muqueuse bronchique [32,43,47,57,58]. D'autre part, Doenicke et al [59] ont montré que l'injection IV de morphine à des sujets sains provoquait une augmentation des concentrations plasmatiques d'histamine 5 minutes après l'injection de morphine, avec pour conséquence une augmentation de la perméabilité capillaire et une vasodilatation pouvant être à l'origine d'un OAP.…”

A primary care database study of asthma among patients with and without opioid use disorders

“…Asthma is amongst the most common long-term health conditions in the UK 1 and represents a significant burden for patients, general practice, emergency medicine and secondary care. Small scale observational studies suggest that people with asthma and opioid use disorder (OUD) experience high rates of acute exacerbations 2 , have more severe symptoms during acute episodes 3,4 and are more likely to need intensive care treatment and intubation 5,6 . The UK has one of the highest rates of death from asthma in Europe 7 and in the 2014 UK National Review of Asthma Deaths, substance misuse was identified as a factor in 6% of the cases 8 .…”

“…More generally, it is recognised that the literature on the pulmonary consequences of heroin use is scant 18 . When assessing asthma outcomes amongst people with OUD, it is important to acknowledge this group are more likely to be male, come from areas of high deprivation and have smoking histories 5 . Factors such as these have been shown to influence asthma outcomes including exacerbation rates [21][22][23][24] .…”