(1199) Acute Respiratory Failure Secondary to Suspected Naloxone-Induced Pulmonary Edema

Introduction: Narcan – induced pulmonary edema (NPE) is an underreported adverse effect of naloxone and is believed to occur in 0.2-3.6% of administrations. When utilized in acute opioid reversal, NPE can arise from sympathetic surge, release of central catecholamines, and increased pulmonary blood flow and capillary permeability.

Description: A 32-year old male presented with altered mental status, hypoxia, and diaphoresis after being found down at his work. He had turned in a bag of white powder to his supervisor prior to being found. Based on this, first responders administered a total of 12 mg of intravenous naloxone due to suspected overdose despite no response. His oxygen saturation upon arrival was 75%. He became more alert on a non-rebreather, reporting feeling ill all week and had been utilizing amphetamine-dextroamphetamine and energy drinks for lethargy. Due to worsening hypoxia, he was intubated for airway protection and copious amounts of bright red blood were suctioned from his lungs. Despite maximized sedatives, he required paralytics for synchronization. CT chest showed widespread bilateral upper and lower lobe alveolar consolidations with concerns for diffuse alveolar hemorrhage. Medical history significant for severe childhood asthma and consistent vape smoking. Antibiotics and high-dose steroids were also initiated. He was extubated on day 5 and discharged home on day 10.

Discussion: Patient populations associated with NPE in case studies include acute or chronic opioid users, wide age ranges, co-ingestion overdoses, and pre-hospital or ED reversal. Comorbidities include congestive heart failure, obstructive sleep apnea, and obesity. Illicit substances such as cocaine and methamphetamine have been linked to NPE. Treatment is similar to sympathetic crashing acute pulmonary edema (SCAPE) with nitroglycerin boluses and high-rate infusions with non-invasive or invasive ventilation for airway support. Due to the patient’s ingestion of stimulants prior to high doses of naloxone, it is possible this led to NPE based on his rapid respiratory decline. While a vape-induced lung injury may have contributed to earlier respiratory symptoms, it has not been linked to SCAPE-like symptoms. NPE requires increased education for healthcare providers due to severity of illness.