A rare case of spontaneous pneumomediastinum secondary to vaping

SESSION TITLE: Mediastinal Challenging Cases SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Electronic cigarettes (E-cigarettes) in the United States have been popular among young people [1]. The respiratory illnesses caused by E-Cigarettes were collectively known as E-cigarettes or vaping-associated lung injury (EVALI). Spontaneous pneumomediastinum is a rare finding of EVALI. CASE PRESENTATION: We present a case of a 22-year-old male visiting the emergency department (ED) due to increased breathlessness and chest tightness for twelve hours. In the ED, he was tachycardic, wheezing, and in respiratory distress; however, he could speak in complete sentences. His oxygen saturation was 93% in room air. Heart sounds were normal, and no subcutaneous crepitus in the thoracic region. He had a medical history of intermittent bronchial asthma, polysubstance abuse, and extensive vaping history. He had been using nicotine-based, flavored, disposable, and rechargeable e-cigarettes almost every 10-20 minutes daily for ten years. He had also been smoking a few rolled marijuana every other day since he was nine. However, he denied smoking cigarettes and using other recreational drugs.The Point-of-care ultrasound in the ED was unremarkable. Wheezing improved dramatically with steroids and bronchodilators; however, he continued to be tachypneic and tachycardic. Electrocardiogram demonstrated sinus tachycardia with QTc prolongation and U waves. Chest X-ray showed hyperinflated lungs with no active infiltrates. The blood workup showed leukocytosis, hypokalemia, and elevated d-dimer. Blood gas demonstrated normal pH with hypoxemia. Rapid COVID and Flu tests were negative. Urine toxicology was positive for cannabinoids. A Computed Tomography of the chest with contrast demonstrated mild pneumomediastinum with air tracing along the esophagus to the right supraclavicular area and negative for pulmonary embolism. He was admitted to the medical floor for acute exacerbation of bronchial asthma and pneumomediastinum. After symptomatic improvement, he was discharged with step-up asthma treatment and counseling about vaping risks. DISCUSSION: Pneumomediastinum means free air within the mediastinum. The pathogenesis of SPM is due to alveolar rupture from increased intrathoracic pressure. E-Cigarettes or vape pens produce vapor by heating a liquid containing various substances such as nicotine, cannabinoids, artificial flavors, and other additives. People like to inhale and exhale more forcefully to eliminate the large quantity of vapor than a regular cigarette. This creates an exaggerated Valsalva Maneuver and hence alveolar rupture and air release into mediastinal space with lower pressure. It can increase the risk of spontaneous pneumomediastinum (Macklin effect) [2].SPM presents a classic triad of retrosternal pleuritic chest pain, subcutaneous emphysema, and dyspnea. Triggering factors for SPM are acute asthma exacerbation and lower respiratory tract infection, coughing, choking, use of e-cigarettes, and illicit inhalation drugs. Our patient has asthma exacerbation which contributes to the SPM.Chest radiography features lucent streaks or bubbles of gas that outline mediastinal structures. SPM is managed conservatively with analgesia, rest, and avoiding triggers such as Valsalva or forced expiration. Most cases resolve without consequences in 2-15 days, and recurrence rates are rare [3]. CONCLUSIONS: Vaping has not yet been regarded as a risk factor for SPM. Therefore, physicians should be vigilant in inquiring about vaping when asking patients about smoking history and counsel them to quit. REFERENCE #1: National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health: E-cigarette use among youth and young adults: a report of the Surgeon General. Centers for Disease Control and Prevention, Atlanta, GA; 2016. REFERENCE #2: Ivan Macia, Juan Moya, Ricard Ramos, Ricard Morera, Ignacio Escobar, Josep Saumench, Valerio Perna, Francisco Rivas, Spontaneous pneumomediastinum: 41 cases, European Journal of Cardio-Thoracic Surgery, Volume 31, Issue 6, June 2007, Pages 1110–1114, https://doi.org/10.1016/j.ejcts.2007.03.008 REFERENCE #3: Spontaneous pneumomediastinum: a rare benign entity. Gerazounis M, Athanassiadi K, Kalantzi N, Moustardas M. J Thorac Cardiovasc Surg. 2003;126:774. [PubMed] [Google Scholar] DISCLOSURES: No relevant relationships by Victor Chen No relevant relationships by Tutul Chowdhury No relevant relationships by Brijesh Ghimire No relevant relationships by Nway Nway No relevant relationships by Ramakanth Pata No relevant relationships by Saphal Subedi