Discussion:
The use of e-cigarettes has been found to be associated with significant
pulmonary pathology. Although e-cigarettes have been marketed to assist
with smoking cessation, they have gained traction in the adolescent
population for recreational use. One study found a significant increase
in prevalence of e-cigarette use among eighth, tenth, and twelfth
graders from 2017 to 2019 (3). In addition to the concern for increased
and earlier nicotine addiction in the pediatric population, there are
more acute consequences such as EVALI/VALI and spontaneous pneumothorax.
EVALI is acute lung injury that has significant morbidity and mortality
among e-cigarette users (2). EVALI may present in different ways.
Diffuse alveolar damage and organizing pneumonia are most frequently
found on radiographic imaging (4).
Primary spontaneous pneumothorax, or pneumothorax in an individual
without underlying lung pathology, has historically occurred in
individuals who smoke cigarettes. Until recently (5-9), there had been
no reports of spontaneous pneumothoraces in individuals who use
e-cigarettes. Newer literature on otherwise healthy people with regular
e-cigarette usage has emerged relating to pneumothoraces. One study
describes the mechanism of injury as inflammation within the lung tissue
from e-cigarette chemicals that results in alveoli damage, formation of
blebs, and resultant rupture after a coughing event or with no trigger
(5). Other reports consider that breathing techniques during inhalation
could be the culprit (6).
Comprehensive clinical evaluation, including a thorough history, is
fundamental in such cases due to lack of public awareness of e-cigarette
impact on health. One case report demonstrated that specific questions
regarding e-cigarette use was required to attain discloser of this
potential cause of a pneumothorax (7). Therefore, it is advised that
providers assess for e-cigarette use along with traditional cigarettes,
smokeless tobacco, and marijuana. E-cigarettes seem to be linked with
recurrence of pneumothoraces. One case involved a patient who had
recurrent right-sided pneumothoraces following episodes of e-cigarette
use which resolved following smoking cessation (6). It is reported that
the interval to pneumothorax reoccurrence may be faster in patients who
use e-cigarettes compared to traditional cigarettes and non-smokers (5).
Treatment for spontaneous pneumothorax is variable. According to the
American College of Chest Physicians, a large pneumothorax, defined as
≥3 cm, should undergo lung expansion with placement of a chest tube or
catheter (10). In one study, all e-cigarette using patients with
spontaneous pneumothorax required tube thoracostomy (11). VATS is a
minimally invasive technique that can be used with blebectomy and/or
pleurodesis. Blebectomy is a procedure to remove air blebs from the lung
while pleurodesis adheres the lung tissue to the chest wall. VATS is
often used for patients with recurrent pneumothoraces (7). Other
indications for surgical intervention are bilateral pneumothoraces or
failed expansion with tube thoracostomy. There is no specific treatment
for pneumothorax related to e-cigarettes. Close follow up and patient
education are recommended to prevent recurrent pneumothoraces.
E-cigarette use is an emerging cause of spontaneous pneumothorax, with a
predominance to the adolescent population. In this case, ongoing use of
e-cigarettes contributed to recurrent pneumothoraces. Initial treatment
varies depending on severity, but typically consists of supplemental
oxygen and/or tube thoracostomy. Recurrent episodes may require surgical
intervention. Additionally, providers should be cognizant and provide
education to patients and families about known adverse outcomes
secondary to e-cigarette use.