WHIPPIT - WHIPPED THE LUNG

Abstract

SESSION TITLE: Medical Student/Resident Disorders of the Pleura Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pneumothorax (PTX) can be a complication of invasive mechanical ventilation due to abrupt changes in pressure within the thoracic cavity. It can also occur due to sudden change in the intra-thoracic pressure as a complication of inhaled illicit substances such as cocaine and 3,4-Methylenedioxymethamphetamine (MDMA) (1,2). The recreational use of inhaled nitric oxide continues to rise, with prolonged inhalation leading to neurological complications (3). Here, we present a case of a PTX after inhalation of pressurized nitric oxide in a patient without any prior lung disease, a complication not previously reported. CASE PRESENTATION: A 25-year-old man with history of cannabis use disorder presented with sudden onset left sided chest pain and dyspnea that started after inhaling two canisters of Whippits (pressurized whipped cream chargers filled with nitric oxide). He was tachycardic and tachypneic upon presentation and was noted to have absent breath sounds over left hemi-thorax. Initial laboratory investigations including a complete blood count and comprehensive metabolic panel were unremarkable. Chest X-ray (CXR) revealed a large left PTX with complete collapse of the left lung. A chest tube was inserted on the left hemithorax with resolution of his symptoms and the PTX on imaging. A computed tomography of the chest showed no underlying lung disease. The patient was discharged with recommendations to abstain from inhaled nitric oxide use. DISCUSSION: PTX due to nitric oxide inhalation is uncommon, and to our knowledge no cases have been previously reported. However, PTX and pneumomediastinum from Valsalva maneuvers after use of inhaled drugs have been reported and have been associated with marijuana use (4,5,6). Although, there is no direct role of marijuana in the development of emphysema, high burden of inflammatory cells leading to lung injury and subsequent emphysema has been described (5). In our patient, who had no prior underlying lung disease, the development of PTX most likely resulted from sudden and rapid change in intra-alveolar pressure secondary to forced lung expansion from a Valsalva maneuver after inhalation of pressurized nitric oxide. CONCLUSIONS: Nitric oxide induced PTX has not been previously reported in the literature. In our patient, PTX in the absence of underlying primary lung disease can be explained by barotrauma from rapid inhalation of nitric oxide via Whippits. Further studies are warranted to evaluate the risk factors and incidence of PTX with pressurized nitric oxide inhalation. Reference #1: Ioannidis G, Lazaridis G, Baka S, et al. Barotrauma and pneumothorax. J Thorac Dis. 2015;7(Suppl 1):S38–S43. doi:10.3978/j.issn.2072-1439.2015.01.31 Reference #2: 2) Jaensch S, Hwang S, Shih-Wei-Kuo T. Spontaneous Pneumomediastinum and Subcutaneous Emphysema following Cocaine Inhalation and Ecstasy Ingestion. Case Reports in Otolaryngology. 2019; doi: 10.1155/2019/6972731 Reference #3: 3) Thompson AG, Leite MI, Lunn MP, Bennett DL. Whippits, nitrous oxide and the dangers of legal highs. Pract Neurol. 2015;15(3):207–209. doi:10.1136/practneurol-2014-001071 4) Hauben M, Hung EY. Pneumothorax as an adverse drug event: an exploratory aggregate analysis of the US FDA AERS database including a confounding by indication analysis inspired by Cornfield's condition. Int J Med Sci. 2013;10(8):965–973. Published 2013 Jun 13. doi:10.7150/ijms.5377 5) Mishra R, Patel R, Khaja M. Cannabis-induced bullous lung disease leading to pneumothorax: Case report and literature review. Medicine (Baltimore). 2017;96(19):e6917. doi:10.1097/MD.0000000000006917 6) Miller, W. Eugene, et al. “Pneumomediastinum Resulting from Performing Valsalva Maneuvers during Marihuana Smoking.” Chest, vol. 62, no. 2, 1972, pp. 233–234., doi:10.1378/chest.62.2.233. DISCLOSURES: No relevant relationships by Moeezullah Beg, source=Web Response No relevant relationships by Tasnim Islam, source=Web Response Consultant relationship with GSK Please note: $5001 - $20000 Added 04/23/2020 by Diego Maselli Caceres, source=Web Response, value=Consulting fee Consultant relationship with AstraZeneca Please note: $5001 - $20000 Added 04/23/2020 by Diego Maselli Caceres, source=Web Response, value=Consulting fee Consultant relationship with Sanofi/Regeneron Please note: $5001 - $20000 Added 04/23/2020 by Diego Maselli Caceres, source=Web Response, value=Consulting fee Speaker/Speaker's Bureau relationship with Sunovion Please note: $5001 - $20000 Added 04/23/2020 by Diego Maselli Caceres, source=Web Response, value=Honoraria Consultant relationship with Novartis Please note: $1001 - $5000 Added 04/23/2020 by Diego Maselli Caceres, source=Web Response, value=Consulting fee