Smoking and Emphysema
2015; Elsevier BV; Volume: 148; Issue: 5 Linguagem: Inglês
10.1378/chest.15-1454
ISSN1931-3543
Autores Tópico(s)Pleural and Pulmonary Diseases
ResumoThe relation between cigarette smoking and the development of emphysema and COPD has been well documented.1Ford ES Croft JB Mannino DM Wheaton AG Zhang X Giles WH COPD surveillance-United States, 1999-2011.Chest. 2013; 144: 284-305Abstract Full Text Full Text PDF PubMed Scopus (233) Google Scholar, 2Ford ES Mannino DM Wheaton AG Giles WH Presley-Cantrell L Croft JB Trends in the prevalence of obstructive and restrictive lung function among adults in the United States: findings from the National Health and Nutrition Examination surveys from 1988-1994 to 2007-2010.Chest. 2013; 143: 1395-1406Abstract Full Text Full Text PDF PubMed Scopus (113) Google Scholar Although not all smokers develop disease, among long-term smokers nearly 50% will have evidence of obstruction on spirometry.3Lundbäck B Lindberg A Lindström M Obstructive Lung Disease in Northern Sweden Studies et al.Not 15 but 50% of smokers develop COPD?–Report from the Obstructive Lung Disease in Northern Sweden Studies.Respir Med. 2003; 97: 115-122Abstract Full Text PDF PubMed Scopus (487) Google Scholar Other forms of smoke inhalation, such as exposure to biomass smoke from cooking or heating, are also linked to the development of COPD.4Kurmi OP Semple S Simkhada P Smith WC Ayres JG COPD and chronic bronchitis risk of indoor air pollution from solid fuel: a systematic review and meta-analysis.Thorax. 2010; 65: 221-228Crossref PubMed Scopus (312) Google Scholar, 5Lamprecht B McBurnie MA Vollmer WM et al.BOLD Collaborative Research GroupCOPD in never smokers: results from the population-based burden of obstructive lung disease study.Chest. 2011; 139: 752-763Abstract Full Text Full Text PDF PubMed Scopus (383) Google Scholar Although there are several important differences between these exposures, a key one is intent: Cigarette smokers are intentionally exposing themselves to high levels of particulate pollution, whereas those exposed to biomass smoke are not doing this intentionally. Other agents of abuse are also inhaled, some when they are burned, such as crack cocaine or marijuana,6Mégarbane B Chevillard L The large spectrum of pulmonary complications following illicit drug use: features and mechanisms.Chem Biol Interact. 2013; 206: 444-451Crossref PubMed Scopus (85) Google Scholar, 7Tashtoush B Gonzalez-Ibarra F Memarpour R Hadeh A Smolley L Vanishing lung syndrome in a patient with HIV infection and heavy marijuana use.Case Rep Pulmonol. 2014; 2014: 285208PubMed Google Scholar and others without burning, such as cocaine, inhalants, and some narcotics.6Mégarbane B Chevillard L The large spectrum of pulmonary complications following illicit drug use: features and mechanisms.Chem Biol Interact. 2013; 206: 444-451Crossref PubMed Scopus (85) Google Scholar The report by Walker et al8Walker PP Thwaite E Amin S Curtis JM Calverley PMA The association between heroin inhalation and early onset emphysema.Chest. 2015; 148: 1156-1163Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar in this issue of CHEST (see page 1156) is a case series of heroin smokers who developed early onset emphysema. This newly described phenomenon may offer insights into the development of COPD and emphysema in cigarette smokers. What proportion of heroin users develops emphysema? There is no good estimate for this, although a recent case series of 55 deaths among heroin or methadone users found 38% with emphysema on postmortem CT scan.9Winklhofer S Surer E Ampanozi G et al.Post-mortem whole body computed tomography of opioid (heroin and methadone) fatalities: frequent findings and comparison to autopsy.Eur Radiol. 2014; 24: 1276-1282Crossref PubMed Scopus (38) Google Scholar In that series, it was not known whether the decedents were smoking narcotics nor was the smoking history described, although the emphysema prevalence exceeds that which would be expected in the general population. How might narcotic use contribute to the development of COPD and emphysema? There are several possible explanations. One is that these diseases are related to effects of narcotic use in general (rather than their mode of administration). Supporting this are high levels of C-reactive protein10Reece AS High-sensitivity CRP in opiate addiction: relative and age-dependent elevations.Cardiovasc Toxicol. 2012; 12: 149-157Crossref PubMed Scopus (22) Google Scholar and other evidence of immune stimulation in opiate-dependent people.11Reece AS Chronic immune stimulation as a contributing cause of chronic disease in opiate addiction including multi-system ageing.Med Hypotheses. 2010; 75: 613-619Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar However, data from a study of national surveys in the United States do not show a relation between heroin use and either chronic bronchitis or asthma (although radiographic emphysema was not specifically evaluated in that study).12Han B Gfroerer JC Colliver JD Associations between duration of illicit drug use and health conditions: results from the 2005-2007 national surveys on drug use and health.Ann Epidemiol. 2010; 20: 289-297Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Another possible explanation is that the heroin being used is contaminated with other agents. This phenomenon has been well documented; contaminants or other pharmacologic agents such as talc6Mégarbane B Chevillard L The large spectrum of pulmonary complications following illicit drug use: features and mechanisms.Chem Biol Interact. 2013; 206: 444-451Crossref PubMed Scopus (85) Google Scholar or clenbuterol have been cited.13Wingert WE Mundy LA Nelson L Wong SC Curtis J Detection of clenbuterol in heroin users in twelve postmortem cases at the Philadelphia medical examiner's office.J Anal Toxicol. 2008; 32: 522-528Crossref PubMed Scopus (24) Google Scholar Many of these agents can damage either the lungs per se or the pulmonary vasculature.14Milroy CM Parai JL The histopathology of drugs of abuse.Histopathology. 2011; 59: 579-593Crossref PubMed Scopus (59) Google Scholar The most likely explanation, however, relates to how the heroin is being smoked by the user. Smokers of heroin and other illicit substances typically take a deep inhalation, combined with a Valsalva maneuver to enhance absorption of the drug into the body.14Milroy CM Parai JL The histopathology of drugs of abuse.Histopathology. 2011; 59: 579-593Crossref PubMed Scopus (59) Google Scholar This has been described previously in heroin users15Prowse SJ Lima T Irion KL Burhan H Hochhegger B Marchiori E Valsalva manoeuvre effect on distribution of lung damage in heroin inhalation.Br J Radiol. 2011; 84: e200-e201Crossref PubMed Scopus (6) Google Scholar and users of other smoked substances.6Mégarbane B Chevillard L The large spectrum of pulmonary complications following illicit drug use: features and mechanisms.Chem Biol Interact. 2013; 206: 444-451Crossref PubMed Scopus (85) Google Scholar, 16Shyamsunder AK Gyaw SM Pneumomediastinum: the Valsalva crunch.Md Med J. 1999; 48: 299-302PubMed Google Scholar In addition, these agents often burn at a very high temperature, with the potential to cause damage deep within the lung.14Milroy CM Parai JL The histopathology of drugs of abuse.Histopathology. 2011; 59: 579-593Crossref PubMed Scopus (59) Google Scholar The development of early onset emphysema in heroin users is clearly important in its own right, but may also inform the development of emphysema in nonopiate users. For example, the depth of inhalation, dynamic hyperinflation, and barotrauma may be important factors in some patients who develop emphysema related to cigarette smoking or other factors. Physicians should be aware of this problem, and the general and drug-using public must be educated about the dangers associated with the inhalation of these and other burned substances. /cms/asset/68a627cf-0465-4aa7-8fb4-0ba417f7de40/mmc1.mp3Loading ... Download .mp3 (29.73 MB) Help with .mp3 files Supplementary AudioAssociation Between Heroin Inhalation and Early Onset EmphysemaDuration: 33 minModerator: D. Kyle Hogarth, MD, FCCP, Podcast Editor, CHESTParticipants: Paul P. Walker, MD; David M. Mannino, MD, FCCP
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