SPONTANEOUS PNEUMOTHORAX SECONDARY TO VAPING

Abstract

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Over the past decade the use of e-cigarettes has risen dramatically, particularly among teenagers. They have been proven to cause lung injury and hypoxic respiratory failure. A less commonly studied pulmonary effect of vaping is significant bullous disease with the potential to cause a spontaneous pneumothorax. CASE PRESENTATION: This is a 22 year-old male with no significant medical history presented due to sudden onset left-sided pleuritic chest pain that was unprovoked and associated with dyspnea. He smokes 1 joule every 4 days and has been smoking for 4 years. On arrival, he was found to be tachycardic and appeared uncomfortable. Electrocardiogram showed normal sinus rhythm. Computed tomography was done and revealed a large left sided pneumothorax and left lung collapse. He had a chest tube placed to suction with improvement in his symptoms. Repeat chest radiography showed significant improvement in the pneumothorax with a small apical left sided pneumothorax.The chest tube remained to suction with a continuous leak observed without resolution of the apical pneumothorax that remained stable in size. On day 8 of hospitalization, he underwent a video-assisted thoracoscopic surgery (VATS) with left upper lobe wedge resection and talc pleurodesis. A new chest tube was placed intra operatively and repeat chest radiography showed resolution of the pneumothorax with no air leak observed. Intra operative findings were suggestive of significant bullous lung disease with blebs. On day 11, the chest tube was removed successfully without recurrence of pneumothorax. He was discharged home breathing comfortably on room air. DISCUSSION: E-cigarettes contain propylene glycol and vegetable glycerin, which decompose when exposed to high temperatures generating harmful carbonyl compounds. These compounds have been shown to cause oxidative stress and release of inflammatory markers causing airway epithelial injury and impaired gas exchange. The addition of flavoring agents further causes epithelial injury and reduction in ciliary beat frequency leading to decreased mucociliary clearance and increased colonization. The indications for VATS include recurrent pneumothoraces, large bullae, incomplete expansion of the lung, and bilateral involvement. VATS has been associated with decreased hospital length of stay and rehabilitation time. CONCLUSIONS: This case highlights the need for thorough exposure history in patients with an unclear etiology for respiratory symptoms, particularly among young adults. Early recognition of candidates for VATS also leads to improved outcomes. Vaping has been associated with bullous disease, although there have not been many cases of rapidly progressing bullous disease causing pneumothorax. REFERENCE #1: Fuentes, X Fonesca, et al. "VpALI-Vaping-Related Acute Lung Injury: A New Killer Around the Block." Mayo Clinic Proceedings, U.S. National Library of Medicine, 22 Nov. 2019 REFERENCE #2: Kalra, Saminder Singh, et al. "Rapid Development of Bullous Lung Disease: a Complication of Electronic Cigarette Use." Thorax, BMJ Publishing Group Ltd, 1 Apr. 2020 REFERENCE #3: Paliouras, Dimitrios, et al. "Video-Assisted Thoracic Surgery and Pneumothorax." Journal of Thoracic Disease, AME Publishing Company, 7 Feb. 2015 DISCLOSURES: No relevant relationships by Nourhan Kika, source=Web Response No relevant relationships by Nisha Patel, source=Web Response No relevant relationships by Anthony Saleh, source=Web Response