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.