Case Presentation: A 22-year-old Hispanic male with PMHx of vaping (since age 11) presented with acute chest pain and dyspnea. He used vaper device with flavored nicotine juice 6 mg/mL (0.6% Nicotine) and contains glycerin and propylene glycol. He vaped heavily (multiple cartridges daily) in the week leading up to admission. The day before, he vaped frequently and deeply for a euphoric effect. He developed sudden central/right side chest pain with dyspnea. Coughing and movement made his pain worse. He had dizziness but no palpitations. In the emergency center, he had Temp 98.5 F, HR 101, RR 22, BP 172/109, SpO2 94% room air. On exam, he was calm, well-developed adult with sinus tachycardia, left lung clear, right lung with decreased breath sounds and no wheezing. Pertinent labs included: WBC 11.3 K/µL, Alk Phos 127 U/L, ALT 82U/L, troponin I normal, D-dimer normal, influenza and COVID-19 PCR negative, EKG sinus tachycardia. CXR showed large right pneumothorax. An urgent right chest tube was placed in ER. Subsequent CT chest showed large bulla right middle lobe 7.1×3.2×5.2 cm, minimal pneumothorax with chest tube. Thoracic surgery and pulmonology were consulted and suspected patient likely had previous bulla that had ruptured. To prevent recurrence, the patient underwent right video assisted thoracoscopy with bullectomy, chemical and mechanical pleurodesis. Post-operatively, he was weaned off of chest tube and oxygen on day 3. The team advised the patient to quit tobacco and vaping before discharge.
Discussion: While vaping was initially marketed as a safer alternative to smoking, it has been linked to various respiratory health problems, including spontaneous pneumothorax (SP). The first reported vaping-related SP was published in 2019 and with approximately a dozen cases been reported since. In Ashraf et al’s case series (4 cases) of SP associated with vaping, they postulated heated-up flavored chemicals in e-cigarettes may contain toxins that impair bronchial epithelial cells and ciliogenesis. Additionally, vaping can alter gene expression of the airway innate immune system, leading to elevated levels of matrix metalloproteinase-9, which can cause parenchymal inflammation and tissue damage. This thinning of the alveolar walls can weaken structural integrity and allow air to dissect through interstitial tissues, forming subpleural blebs. Rupturing of these blebs can cause SP. Another factor contributing to vaping-related SP is the use of deep inhalation and forceful exhalation, which increase positive pressure in the distal airways. Repetitive deep inhalation through high resistance device can lead to negative intrathoracic pressure and increase risk of SP. Our patient reported frequent and long practice of deep inhalation when vaping which likely contributed to rupture of his bullae. While only limited evidence, literature review suggested best management of vaping-associated SP with bullectomy and chemical pleurodesis. The patient reported complete return to normal at the time of follow up phone call 4 months after discharge.
Conclusions: While evidence suggests that e-cigarette use can cause lung injury, growing research indicates an additional risk: spontaneous pneumothorax. This is particularly concerning for adolescents and young adults, as case reports demonstrate. Although further studies are needed to fully understand the harmful effects of vaping, clinicians should be aware of these potential adverse consequences and advise patients accordingly.