enalapril and Respiratory-Insufficiency

To present a case of respiratory depression following the administration of nebulised morphine.. A 74-yr-old, 51-kg woman with a history of hypertension controlled with 5 mg.day-1 enalapril and 50 mg.day-1 atenolol was admitted for evaluation of low back pain, loss of appetite, and weight loss. Investigation revealed advanced metastatic disease with a probable primary in the right lung. The patient's pain was well controlled with 10 mg continuous release morphine p.o. three times daily, and 10 mg immediate release morphine p.o. for breakthrough pain as required. During the two weeks following the commencement of this treatment she occasionally complained of shortness of breath. Examination revealed a fully conscious patient with slight dyspnoea and mild wheezing which responded to oxygen 30% and nebulised bronchodilators. An oncological consultation recommended 4 mg nebulised morphine and 4 mg dexamethasone in saline as treatment for the bouts of breathlessness. Approximately 15 min after the first administration of nebulised morphine the patient became markedly bradypneic (respiratory rate: 4-5 bpm), hypotensive (BP 70/40 mmHg), and responded only partially to command. The pupils were pinpoint. The trachea was immediately intubated and the lungs ventilated with oxygen 40% for four hours. Following this occurrence of respiratory depression nebulised morphine was discontinued and no further events occurred.. Patients receiving inhaled morphine should be closely monitored and resuscitation equipment should be readily available.

Topics: Acute Disease; Administration, Inhalation; Administration, Oral; Aged; Analgesics, Opioid; Angiotensin-Converting Enzyme Inhibitors; Anti-Inflammatory Agents; Antihypertensive Agents; Bone Neoplasms; Bronchodilator Agents; Dexamethasone; Dyspnea; Enalapril; Female; Glucocorticoids; Humans; Hypertension; Intubation, Intratracheal; Lung Neoplasms; Morphine; Nebulizers and Vaporizers; Oxygen Inhalation Therapy; Pain; Palliative Care; Respiration; Respiration, Artificial; Respiratory Insufficiency; Respiratory Sounds

A 37-year-old female with a history of hypertension for 5 years was brought to the emergency room with swelling of the tongue and neck after the second dose of enalapril. After administration of hydrocortisone by her physician, she went to the emergency room. Her dyspnea and dysarthria were relieved. However, she experienced recurrence of the symptoms followed by respiratory arrest. She suffered severe anoxic brain damage and died three days later. Although angioedema is a rare occurrence with the use of enalapril, it is potentially life threatening.

Topics: Adult; Angioedema; Enalapril; Female; Humans; Respiratory Insufficiency

A 65-year-old male with a long history of congestive heart failure presented to the emergency room with facial swelling 7 h after the first dose of enalapril. He was treated with diphenhydramine and hydrocortisone which improved his angioedema. However, there was a profound relapse of the angioedema followed by respiratory arrest. He suffered severe anoxic brain damage and died five days later. It is likely that the long half-life of enalapril lead to this rebound phenomenon. Enalapril induced angioedema is reviewed with suggestions for management.

Topics: Aged; Angioedema; Coronary Disease; Enalapril; Heart Failure; Humans; Hypoxia, Brain; Male; Respiratory Insufficiency

Angiotensin converting-enzyme inhibitors cross the placenta and modify the maternal, foetal and utero-placental renin-angiotensin system. Eight cases of pregnancy in women taking captopril have been published, 7 other cases being reported in this review paper. There were one spontaneous and 2 therapeutic abortions, one of which disclosed a malformation of uncertain diagnosis and imputation. One intrauterine death at 28 weeks was probably due to the severity of the maternal disease. Two children born to mothers also treated with frusemide died of neonatal anuria. Delivery or caesarean section occurred before term in 8 cases, and there were 3 cases of neonatal respiratory distress with a favourable outcome. Finally, one mother gave birth at term to twins of normal weight. The cases with respiratory distress can be attributed to the mother's hypertension, to prematurity and/or to concomitant treatment with beta-blockers, while the cases with anuria seem to be due to inhibition of the effects of angiotensin on renal haemodynamics, with salt depression as a possible aggravating factor. Treatment with angiotensin converting enzyme inhibitors does not seem to warrant therapeutic abortion. However, these drugs are contra-indicated in pregnancy and should only be given to women wishing to become pregnant if they present with resistant and dangerous arterial hypertension. A programme of pharmacovigilance is being set up to follow up such pregnancies.

Topics: Abortion, Spontaneous; Anuria; Captopril; Enalapril; Female; Fetal Diseases; Humans; Hypertension; Infant, Newborn; Pregnancy; Pregnancy Complications, Cardiovascular; Prenatal Exposure Delayed Effects; Product Surveillance, Postmarketing; Renin-Angiotensin System; Respiratory Insufficiency