Original Contributions
Acute Alcohol Intoxication in Adolescents: Frequency of Respiratory Depression

Presented at Eastern Society of Pediatric Research, Philadelphia, PA, March 2009, Pediatric Academic Society, Baltimore, MD, May 2009.
https://doi.org/10.1016/j.jemermed.2012.11.041Get rights and content

Abstract

Background

Adolescents and young adults are frequent users of alcohol. Younger patients may be more sensitive to the effects of alcohol than their adult counterparts, and toxicity has been known to occur at lower doses. Respiratory depression is a serious adverse effect of alcohol intoxication; however, current monitoring practices may not adequately detect respiratory depression.

Objective

Our objective was to determine the frequency of hypoventilation as measured by capnography among adolescents with acute alcohol intoxication. Our secondary objective was to determine if an association exists between alcohol levels and incidence of hypoventilation.

Methods

This was a prospective observational pilot study of patients 14–20 years of age with acute alcohol intoxication. Blood or breath alcohol measurements were obtained on arrival. Hourly measurements of vital signs including capnography were recorded.

Results

Sixty-five subjects were analyzed. Mean alcohol level was 185 mg/dL. Twenty-eight percent of subjects had episodes of hypoventilation. Episodes occurred in similar proportions on arrival and during the first 5 h of measurements. There was no difference in alcohol levels between subjects who did and did not hypoventilate (185 mg/dL vs. 186 mg/dL; 95% confidence interval −29 to 25). Oxygen desaturations occurred in 14 subjects and were associated with hypoventilation (p = 0.015).

Conclusions

Hypoventilation is common among adolescents who are acutely intoxicated with alcohol. It is independent of alcohol level and occurs at a steady rate during the first several hours of intoxication. Capnography should be considered as an additional monitoring device to detect these episodes and enhance patient safety.

Introduction

Alcohol is a common drug of abuse among adolescents and young adults. It is estimated that at least 50% of adolescents 12–20 years old have imbibed alcohol during any 30-d period (1). This population also accounts for nearly 20% of all the alcohol consumed in the United States (US) (1). In 2008, the rate of Emergency Department visits related to alcohol alone was 220.7 per 100,000 children age 12–17 years and 596.3 per 100,000 young adults aged 18–20 years (2).

Alcohol is one of the most commonly abused drugs that can induce respiratory failure (3). Respiratory failure from central nervous system depression is a rare but serious consequence of alcohol intoxication. In adults, this has been known to occur in a dose-dependent fashion, as ethanol affects the respiratory center in the medulla oblongata (3). However, the effects of alcohol may be greater in children as compared with adults because children are unlikely to be tolerant to its effects (4).

Signs and symptoms of respiratory depression and impending respiratory failure due to alcohol intoxication can be subtle. Hypoventilation can occur due to changes in either respiratory rate or tidal volume. Bradypneic hypoventilation is due to a decline in respiratory rate and can only be detected by continuous monitoring either via plethysmography or capnography. Hypopneic hypoventilation, which is due to a decrease in tidal volume and concomitant increase in dead space ventilation, cannot be detected with standard monitoring devices and may be difficult to detect on clinical examination as well (5). Pulse oximetry is a continuous monitor of oxygenation, however, it does not adequately assess ventilation. Among patients with apnea, the most extreme form of hypoventilation, pulse oximetry may not begin to decline for several minutes—an unacceptable delay that will be lengthier in patients who are hypoventilating 6, 7, 8.

While the management of acutely intoxicated patients centers around monitoring and supportive care, it is unclear whether standard monitoring devices such as pulse oximetry are sufficiently sensitive in detecting respiratory depression. Capnography, or end-tidal carbon dioxide (ETCO2) monitoring, is a continuous and objective way to monitor ventilation. This monitor can alert a provider within one breath to an airway or respiratory problem, thus demonstrating its superiority as a measure of ventilation (9). Many studies have shown the benefits of this device in the early detection of apnea and hypoventilation 10, 11, 12.

The primary objective of this study was to determine the frequency of hypoventilation as measured by capnography in adolescents and young adults with acute alcohol intoxication. Our secondary goal was to determine if an association existed between alcohol level and the incidence of hypoventilation. We hypothesized that hypoventilation would be detected more frequently by capnography compared with standard respiratory monitoring in adolescents and young adults who were acutely intoxicated. This would provide evidence for the value of continuous capnography monitoring in acutely intoxicated patients. We also hypothesized that subjects who developed hypoventilation would have higher alcohol levels than those who maintained normal ventilatory patterns.

Section snippets

Methods

Between September 2007 and December 2010, a convenience sample of subjects with acute alcohol intoxication was enrolled in a prospective observational pilot study. The Human Investigations Committee approved this study with a waiver of consent. This study took place in the Pediatric Emergency Department of an urban tertiary care hospital. The Pediatric Emergency Department sees approximately 32,000 patients each year.

Subjects were eligible for enrollment if they were between the ages of 14 and

Results

Seventy-one subjects were enrolled and 65 subjects were included in the data analysis. Reasons for exclusion included lack of documentation of alcohol intoxication (n = 4) and alcohol level not indicative of intoxication (n = 2). No subjects removed the nasal-oral cannula because of discomfort or combativeness. Demographic information for the study subjects is presented in Table 1. There were a total of 283 recordings on the subject population, with a median of 4 recordings for each subject

Discussion

This study demonstrated a high frequency of hypoventilation in adolescents and young adults who were acutely intoxicated with alcohol. These episodes were difficult to predict, occurring in similar proportions over the first several hours of intoxication. Furthermore, there was no correlation between initial alcohol level and risk of hypoventilation.

The number of children with acute intoxication has been on the rise 17, 18, 19. Approximately 25% of US high school students report binge drinking,

Conclusions

Hypoventilation, as measured by capnography, occurs frequently in adolescents and young adults who are acutely intoxicated with alcohol, is independent of initial alcohol level and is a risk factor for hypoxemia. These episodes do not steadily decrease over time, but occur in similar proportions throughout the first several hours of intoxication. Capnography should be considered as an additional monitoring device for these patients until their alcohol levels have returned to normal.

Article Summary

1. Why is this topic important?

  1. Alcohol

References (38)

  • S.E. Foster et al.

    Alcohol consumption and expenditures for underage drinking and adult excessive drinking

    JAMA

    (2003)
  • Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality

    Drug Abuse Warning Network, 2008: national estimates of drug-related emergency department visits. USDHHS publication no. SMA 11-4618

    (2011)
  • K.C. Wilson et al.

    Acute respiratory failure from abused substances

    J Intensive Care Med

    (2004)
  • B. Adinoff et al.

    Acute ethanol poisoning and the ethanol withdrawal syndrome

    Med Toxicol Adverse Drug Exp

    (1988)
  • M.L. Langhan et al.

    Detection of hypoventilation by capnography and its association with hypoxia in children undergoing sedation with ketamine

    Pediatr Emerg Care

    (2011)
  • R. Patel et al.

    Age and the onset of desaturation in apnoeic children

    Can J Anaesth

    (1994)
  • F. Verhoeff et al.

    Delayed detection of hypoxic events by pulse oximeters: computer simulations

    Anaesthesia

    (1990)
  • J.H. Burton et al.

    Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices?

    Acad Emerg Med

    (2006)
  • J.R. Lightdale et al.

    Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial

    Pediatrics

    (2006)
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    Financial Disclosure: Equipment on loan and donated from Nellcor Puritan Bennett LLC.

    Conflict of Interest: Melissa Langhan received an honorarium from Oridion for serving on an expert panel after the completion of this study and manuscript.

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