Reporting of pneumothorax in association with vaping devices and electronic cigarettes
In October 2019, a 34-four-year-old white male presented to his general practitioner with a 1-day history of back pain, shortness of breath, tightness in his chest, burning pain in his right chest, retrosternal pain and feeling dizzy. Symptoms started after minor exertion during the afternoon on the day before presentation.\nNo specific health problems occurred during adolescence. His previous medical history was otherwise unremarkable apart from a few rib fractures on his right side sustained through a cycling accident 3 years ago. There was no family history of lung disease. As a trained nurse, the patient worked in outpatient palliative care and devoted his free time to strength training and competitive sports. Due to his occupation, he had regular health checks, all negative for infectious diseases. He had no recent sports trauma to his chest. Despite being an active and internationally successful athlete, he smoked 20 cigarettes per day from the age of 21 years to the age of 31 years. Three years ago, he quit smoking by switching to vaping nicotine. He never smoked or vaped cannabis. He reported a pattern of regular deep and slow inhalation with the vaping device throughout the day similar to smoking a pack of cigarettes.\nOn physical examination, we saw an athletic male with normal body mass index (BMI 23.6, 184 cm body height and 80 kg body weight). There were no signs of chronic lung disease such as finger clubbing, chronic cough, wheezing or sputum production. Neurology examination was unremarkable. During the patient’s initial visit to his general practitioner, vitals included a heart rate of 72 beats per minute, blood pressure of 143/91 mm Hg, peripheral oxygen saturation without air supply of 98% and a respiratory frequency of 15 per minute. His ECG demonstrated signs suggestive of myocarditis. The patient arrived at our emergency department 2 hours later with normal peripheral oxygen saturation of 98%, but increasing tachypnoea with 24 breaths per minute. His heart rate and blood pressure remained normal, and there was no enlarged jugular vein pulse or cyanosis. Respiratory frequency returned to normal rates with 3 L of nasal air flow supply. ECG demonstrated again changes in V3–V5 suggestive of myocarditis (). His skin was dry and warm on palpation with a temperature of 36.8°C, and his tongue was of healthy appearance. His heart sounds were regular on auscultation and breathing sounds were absent on the right side of his chest. Percussion revealed tympanitic chest sounds on the right. The patient complained of acute pain in his chest.\nHis chest X-ray demonstrated a large (according to Collins formula) right-sided pneumothorax () and a small right-sided pleural effusion. Immediate insertion of a right-sided chest tube led to pain relief and normalisation of the ECG.\nDiagnostic and therapeutic approaches were discussed with the patient, and a decision was made for a CT thorax scan. The CT scan demonstrated a bilateral inflated lung, the inserted chest tube on the right side, apical bleps of approximately 0.5–1.0 cm in diameter and a small stripe of remaining apical pneumothorax. Blood tests did not reveal any inflammation or other abnormal findings. After successful removal of the chest tube, the patient was discharged and returned for follow-up examination 1 week later in our outpatient department. During the visit, the patient stated his desire to proceed with bullae resection. Being active in martial arts and internationally successful, he feared of another episode of a pneumothorax leading to a further delay in his training.\nThe patient underwent video-assisted thoracoscopic surgery (VATS) resection of the apical bullae and partial apical pleurectomy. Intraoperatively, the apical bullae and a minor clear fluid collection could be demonstrated with no other visible lung pathology. The resection specimen revealed the site of ruptured bullae. The patient made an uneventful recovery. Perioperatively, the patient received routine tyloxapol inhalations four times daily. Standard analgesia contained oral metamizole, ibuprofen and oxycodone/naloxone.