Have you ever had a drug seeker present with pulmonary edema

[Kaisu]

This one was a new one for me. I was on my clinicals at the ED. All h*** was breaking loose so none of the nurses were at the desk. A respiratory tech comes out of room 2 and is near panic - says the patient is in big trouble. I go into the room and there is a 40ish woman in the bed with a non-rebreather on. I can hear wet lungs without my stethescope BUT.. the patient is exhibiting a wierd breathing pattern - sort of a hiccup - no accessory muscle use, skin pink and warm, vitals normal, O2 sat at 100% - She says she's having difficulty breathing and I tell her we may need Bipap. ABSOLUTELY NOT she says - she claims claustrophobia and PTSD. Now its even wierder because any pulmonary edema I have ever seen is so happy to get help breathing that once they've had CPAP they are reaching for the mask.

Her husband is standing beside her, rolls his eyes at me and says "Would you like to try and work through it hon"? I try and coach her breathing to get rid of the aforementioned wierd pattern but she is not cooperating.

I leave the room and go check her history. She has the usual drug seeker mile long list of previous visits and extensive bronchoscopy less than a month before. At the hospital she was treated primarily for pain management and her tolerance was so high that they extrapolated this huge dose that was likely her daily intake of narcotics - dilaudid being her drug of choice.

My question - definately drug seeking, definately nothing wrong with her lungs BUT what causes the fluid? How is she doing that? I'm thinking some narcotic induced parasympathetic sludge thing happening but I am puzzled.

What do you think?

[chbare]

As far as I know, the exact mechanisms are not known. The pulmonary edema related to narcotic use is non cardiogenic in nature however. It is known that increased pulmonary capillary permeability is noted in patients who develop this problem.

I have also herd of flash pulmonary edema developing when apneic patients are given reversal meds and experience sudden changes in airway pressures following narcotic reversal.

Take care,

chbare.

[VentMedic]

A respiratory tech

WTF? Thread after thread of complaining that the public doesn't know what a Paramedic is and Paramedics still can not identify other professionals correctly. Respiratory Therapist: Certified (CRT) or Registered (RRT). Didn't everyone get the memo stating that the "tech" term is not used anymore for the RT profession in the U.S?

What was the BNP? Did the CXR show pulmonary edema? Which regions of the lung field were the crackles in?

Singultus and ineffective breathing can give a presentation of crackles which can be indicative of atelectasis from ineffective breaths. This is usually seen post operatively on some patients recovering from anesthesia or with inadequate pain management.

Crackles or Rales can be heard in a variety of lung diseases states. That is why PNA and CHF are very often treated the same in the field because it is difficult to differentiate by breath sounds alone. In the hospital we have the chance to differentiate between the two before overly aggressive treatment which may worsen the underlying disease process.

I can hear wet lungs without my stethescope

I usually use my stethoscope before making an educated guess.

Upper airway and glottic noise can also be deceiving on assessment. That is why there are various assessment techniques to help differentiate or filter out the noise. I distract a person while listening with my stethoscope to see if the quality of the sound suddenly differs.

Not everyone can tolerate CPAP or BIPAP. This is especially true in people with some obstructive component or claustrophobic issues. In the hospital we also have strict guidelines as to who BIPAP/CPAP devices are used for since it can create as many problems as it can solve.

[Just Plain Ruff]

Just because she has an extensive history of drug seeking behaviour does not mean she's not in an emergent situation this time.

It's thinking like that among providers, oh they are a drug seeker so let's not treat her agressively that leads to patients dying.

Your assessment and your physicians assessment will make the differential diagnosis, not the fact that her chart shows extensive drug seeking behaviour. It should give you pause but it should not guide your emotions or treatment.

[Ridryder 911]

WTF? Thread after thread of complaining that the public doesn't know what a Paramedic is and Paramedics still can not identify other professionals correctly. Respiratory Therapist: Certified (CRT) or Registered (RRT). Didn't everyone get the memo stating that the "tech" term is not used anymore for the RT profession in the U.S?

.

I have to admit I would still be ignorant, as we still have tech.'s They have never went to school other than OJT and never attended a therapist program. we have one therapist that is charge of the department. They actually wear the name tag as respiratory technician, unfortunately this is not at one of the hospitals.

R/r 911

[VentMedic]

I have to admit I would still be ignorant, as we still have tech.'s They have never went to school other than OJT and never attended a therapist program. we have one therapist that is charge of the department. They actually wear the name tag as respiratory technician, unfortunately this is not at one of the hospitals.

R/r 911

Your "tech" better get their butt in gear. The credentialing (NBRC) organization was kind enough to grant them another year to credential. They had a 5 year notice of the change which ended 12/07. After this final grace period, they could find themselves cleaning vents in the equipment room instead of managing them. If your state does not recognize the changes, it may put RT in your state in the same boat as EMS in some states in terms of advancing the profession. The educational degree has spoken for entry to licensure. The OJTs were granted a 20 year stay from being abolished from the profession. It is now time to get with the rest of the herd.

[brock8024]

First why was she at the ER for in the first place. You never said what her C/C was. That will solve a lot of this problem of trying to figure out what may be wrong with her.

Second Who cares is she is a drug seeker? She is in trouble at the moment and needs help.

So she could be in acute pulmonary edema, pneumonia, or be having a AMI. If I remember right AMI affecting the left ventricle could cause acute pulmonary edema? If I am wrong please correct me. I am not perfect and always willing to learn.

She is in her 40's? Is she overweight? Any hx of chest pain or having this before. She said no to the bipap and c-pap fast, so has she ever had one on before or did you explain what it was to her. She is tolerating a NRB mask but not c-pap or bipap mask?

Did you go get a nurse or go see the patient and then go tell the nursing staff?

I would think she needs a stat EKG, Chest XRAY, Full set of labs.

[Kaisu]

thanks for all who answered. As I mentioned, this was not my patient, but it was interesting enough for me to follow up on as I had not encountered narcotic induced pulmonary edema before. For those of you incensed at what you perceive to be a lack of care you can rest easy. The woman was in very good hands. I just wanted input into the mechanism involved in the phenomena. The very first reply gave me what I was looking for. Thanks again.

[brock8024]

So you are not going to answer our questions or anything. Just thanks I got what I needed???

[Kaisu]

yep.. pretty well