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Talmy T, Izhaki Z, Gendler S, Aviram E. Spontaneous Pneumomediastinum Resulting From Passionate Cheering at a Soccer Match. Mil Med 2023; 188:e2823-e2825. [PMID: 36242545 DOI: 10.1093/milmed/usac315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 09/19/2022] [Accepted: 09/28/2022] [Indexed: 11/14/2022] Open
Abstract
Spontaneous pneumomediastinum is a rare and self-limiting clinical entity, often triggered by activities causing acute changes in intrathoracic pressure such as childbirth, strenuous exercise, vomiting, and coughing. We present a case of a young male soldier who developed spontaneous pneumothorax following persistent yelling while attending a soccer match. Spontaneous pneumomediastinum may be preceded by a variety of strenuous activities, and clinicians should be aware of this entity when performing the evaluation of patients with nonspecific symptoms such as chest pain and dyspnea. Patients diagnosed with pneumomediastinum but presenting with additional findings such as vomiting and pleural effusion should be thoroughly evaluated to rule out potentially life-threatening mediastinal organ injury. Return to military duty should be determined by clinical reevaluation and follow-up imaging findings.
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Affiliation(s)
- Tomer Talmy
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan 52621, Israel
- Department of Military Medicine, Faculty of Medicine, Hebrew University, Jerusalem 9574869, Israel
| | - Ziv Izhaki
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan 52621, Israel
- Heller Institute of Medical Research, Sheba Medical Center, Ramat Gan 52621, Israel
- Department of Pediatrics "C", Schneider Children's Medical Center of Israel, Petach Tikvah 4920235, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Sami Gendler
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan 52621, Israel
| | - Eliad Aviram
- Israel Defense Forces Medical Corps, Surgeon General's Headquarters, Ramat Gan 52621, Israel
- Samson Assuta Ashdod University Hospital, Ben Gurion University Faculty of Health Sciences, Ashdod 7747629, Israel
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2
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Kartiko M, Miller A. A Case Report of Secondary Spontaneous Pneumomediastinum Induced by Vaping. Cureus 2023; 15:e35153. [PMID: 36949981 PMCID: PMC10027423 DOI: 10.7759/cureus.35153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2023] [Indexed: 02/20/2023] Open
Abstract
We present a rare case of vaping-induced spontaneous pneumomediastinum in a young healthy female. The patient presented to the emergency department with the chief complaint of acute onset chest pain. Imaging studies, chest X-ray, and computed tomography of the chest showed findings of pneumomediastinum. The patient was counseled on vaping cessation and discharged after 48 hours.
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Affiliation(s)
- Michael Kartiko
- Internal Medicine, Piedmont Macon Medical Center, Macon, USA
- Radiology, Creighton University School of Medicine, Omaha, USA
| | - Aisha Miller
- Internal Medicine, Piedmont Macon Medical Center, Macon, USA
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3
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Adhikari R, Manduva D, Malayala SV, Singh R, Jain NK, Deepika K, Koritala T. A Rare Case of Vaping-Induced Spontaneous Pneumomediastinum. Cureus 2021; 13:e17166. [PMID: 34532191 PMCID: PMC8435398 DOI: 10.7759/cureus.17166] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/13/2021] [Indexed: 01/18/2023] Open
Abstract
Vaping is the process of inhaling an aerosol produced by heating a liquid or wax containing substances such as nicotine, cannabinoids (e.g., tetrahydrocannabinol, cannabidiol), flavoring, and additives (e.g., glycerol, propylene glycol). The presence of air or gas in the mediastinum is pneumomediastinum. We present a rare case of vaping-induced spontaneous pneumomediastinum. A young 20-year-old female patient with a history of vaping and no past medical history presented with acute chest pain to an emergency room. The urine drug screen was positive for cannabinoids. Imaging studies - chest x-ray and computed tomography of the chest - showed pneumomediastinum. The patient was discharged after a day of observation and counseling to quit vaping.
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Affiliation(s)
- Ramesh Adhikari
- Hospital Medicine, Franciscan Health, Lafayette, USA.,Geriatrics, Brown University, Providence, USA
| | | | | | | | | | - Keerti Deepika
- Pediatrics/Translational Research, Thomas Jefferson University, Philadelphia, USA
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4
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An isolated spontaneous pneumomediastinum as a rare complication of COVID 19. LA TUNISIE MEDICALE 2021; 99:764-766. [PMID: 35261009 PMCID: PMC8796666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The Coronavirus Disease 2019 (COVID-19) pandemic has displayed heterogeneity in disease manifestations and complications. This case report illustrates a rare issue : the spontaneous pneumomediastinum. A 73-year-old male presented with chills, and respiratory symptoms. A reverse transcriptase polymerase chain reaction (RT-PCR) test- confirmed COVID19. At admission, the patient was in severe respiratory distress. C reactive protein was 54 mg/l (normal: 0-5 mg/l), , troponin were negative, brain natriuretic peptid 55 pg/ml (normal range <100 pg/ml) and D-dimer 700 mcg/l (normal: 0-500 mcg/l). Arterial blood gases showed pH 7.49 (normal: 7.35-7.45), PCO2 33,8 mmHg (normal: 34-46 mmHg) and PO2 56 mmHg (normal: 80-97 mmHg) with 16 liter per minute of oxygen. Computed tomography of the chest (CT chest) showed diffuse groundglass opacities (60-70%) without pulmonary embolism. Diagnosis of acute respiratory distress syndrome (ARDS) was made. Low flow oxygen was provided (Oxygen saturation target ≥ 94%), intermediate dose of low molecular weight heparin and 8mg of dexamethason were administarted daily. On day 10, worsening hemodynamics and blood oxygen levels was noted. CT chest showed moderate bilateral pneumomediastinum, without pneumothorax, persistent groundglass opacities (75%) with early fibrosis elements. The patient recovered with no pulmonary sequelae. This case report encourages health workers to get used with infrequent clinical and radiological manifestations of COVID-19 that is still surprising the world.
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Sreedharan S, Mian M, Robertson RA, Rhodes A. Radiological findings of e-cigarette or vaping product use associated lung injury: A systematic review. Heart Lung 2021; 50:736-741. [PMID: 34130236 DOI: 10.1016/j.hrtlng.2021.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/27/2021] [Accepted: 05/04/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Chest radiology provides an opportunity to better understand the diagnostic characteristics of e-cigarette or vaping product use associated lung injury (EVALI). This systematic review aimed to summarize the radiological findings associated with EVALI reported in the literature. METHODS This systematic review was conducted in accordance with PRISMA guidelines. Electronic searches of MEDLINE®, CINAHL, Embase® and CENTRAL were conducted in February 2020. Included were all English-language studies reporting radiological findings of EVALI. Data was synthesized using descriptive statistics. RESULTS Thirty studies comprising 184 participants were included. Mean patient age was 24.5 years old. The majority (n = 141, 76.6%) of included patients were male. The most common radiological features reported on chest x-ray were bilateral infiltrates (n = 64, 41.3%) and ground glass opacities (n = 17, 11.0%), and on chest CT were bilateral infiltrates (n = 62, 36.9%), bilateral ground glass opacities (n = 56, 33.3%), subpleural sparing (n = 29, 17.3%), pleural effusions (n = 14, 8.3%), and centrilobular nodularity (n = 13, 7.7%). Of patients with follow-up data reported (n = 81), only 28.4% (n = 23) had complete resolution of symptoms or radiological findings. CONCLUSION Chest radiology is the cornerstone of diagnosis and monitoring of EVALI. A wide variety of radiological findings highlight the need for standardisation of terminology in the radiological descriptions of EVALI. Common findings included bilateral infiltrates and ground glass opacities. Higher quality evidence is warranted to help develop evidenced-based guidelines for the diagnosis and management of EVALI.
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Affiliation(s)
| | - Mustafa Mian
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Ross A Robertson
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, 3010, Australia
| | - Alexander Rhodes
- Melbourne Medical School, University of Melbourne, Melbourne, VIC, 3010, Australia; Department of Radiology, Royal Melbourne Hospital, Melbourne VIC, 3010, Australia
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Haberal MA, Akar E, Dikis OS, Ay MO, Demirci H. Spontaneous pneumomediastinum incidence and clinical features in non-intubated patients with COVID-19. Clinics (Sao Paulo) 2021; 76:e2959. [PMID: 34550210 PMCID: PMC8420840 DOI: 10.6061/clinics/2021/e2959] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 06/11/2021] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES To evaluate the presentation characteristics and disease course of seven patients with COVID-19 who spontaneously developed pneumomediastinum without a history of mechanical ventilation. METHODS A total of seven non-intubated patients with COVID-19, of age ranging from 18-67 years, who developed spontaneous pneumomediastinum between 01 April and 01 October 2020 were included in the study. Patients' demographic data, clinical variables, and laboratory values were examined. Spontaneous pneumomediastinum was evaluated using posteroanterior chest radiography and thorax computed tomography. RESULTS During the research period, 38,492 patients reported to the emergency department of our hospital with COVID-19 symptoms. Of these, spontaneous pneumomediastinum was detected in seven patients who had no previous history of intubation. Chronic obstructive pulmonary disease (2/7) and asthma bronchiale (2/7) were determined as the most common causes of comorbidity. CONCLUSIONS In our study, the frequency of spontaneous pneumomediastinum developing without pneumothorax was found to be high in non-intubated patients. Whether this is related to the nature of the disease or it is a result of the increase in cases diagnosed incidentally owing to the increasing use of low-dose computed tomography should be explored in further studies.
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Affiliation(s)
- Miktat Arif Haberal
- Department of Thoracic Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey
- Corresponding author. E-mail:
| | - Erkan Akar
- Department of Thoracic Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey
| | - Ozlem Sengoren Dikis
- Department of Pulmonary Medicine, Bursa Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey
| | - Mehmet Oguzhan Ay
- Department of Emergency Medicine, Bursa Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey
| | - Hakan Demirci
- Department of Family Medicine, Bursa Yuksek Ihtisas Training and Research Hospital, Health Sciences University, Bursa, Turkey
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Gonsalves CL, Zhu JW, Kam AJ. Diagnosis and Acute Management of E-Cigarette or Vaping Product Use-Associated Lung Injury in the Pediatric Population: A Systematic Review. J Pediatr 2021; 228:260-270. [PMID: 32961169 DOI: 10.1016/j.jpeds.2020.09.040] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 09/15/2020] [Accepted: 09/16/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To assess quantitative data on the presentation, investigative findings, patterns of lung injury, and interventions of pediatric cases of e-cigarette or vaping-associated lung injury (EVALI) in the acute care setting. STUDY DESIGN A literature search using keywords was performed on April 17, 2020, in accordance with PRISMA guidelines. Three thousand five hundred fifty-eight articles were retrieved from MEDLINE via PubMed, Embase via OVID, CINAHL via EBSCO, Web of Science, and the Cochrane Library. Studies were evaluated for inclusion based on predetermined inclusion and exclusion criteria by 2 independent reviewers. RESULTS The search yielded a total of 3558 individual results, 145 of which were evaluated by full text review, resulting in 23 articles included in this systematic review. Two of these articles were identified by manual search of article references. A total of 61 cases of EVALI were described, and 10 major patterns of lung injury were identified for which presenting symptoms, diagnostic and laboratory investigations, interventions, and outcomes were synthesized. CONCLUSIONS Cases of EVALI in the pediatric population have been reported in patients as young as 13 years and often present with respiratory, constitutional, abdominal, and cardiovascular signs and symptoms. Diagnostic findings vary based on the underlying lung injury pattern. However, typical patterns of common findings were identified, including the presence of ground-glass opacities on computed tomography scan and leukocytosis. Mainstays of treatment include the use of corticosteroids, antibiotics, and ventilatory support, including extracorporeal membrane oxygenation. Outcomes range from complete or near complete recovery of lung function to death.
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Affiliation(s)
- Clarelle L Gonsalves
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jie Wei Zhu
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - April J Kam
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.
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8
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Gillespie M, Dincher N, Fazio P, Okorji O, Finkle J, Can A. Coronavirus disease 2019 (COVID-19) complicated by Spontaneous Pneumomediastinum and Pneumothorax. Respir Med Case Rep 2020; 31:101232. [PMID: 32989414 PMCID: PMC7510447 DOI: 10.1016/j.rmcr.2020.101232] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/19/2020] [Indexed: 01/08/2023] Open
Abstract
The first reports of severe acute respiratory symptoms from a novel coronavirus called coronavirus disease 2019 (COVID-19) occurred in Wuhan, Hubei Province, China in December 2019.1 The World Health Organization declared COVID-19 a global pandemic by March 2020.1 The COVID-19 outbreak has resulted in a current global health emergency. Clinical information about the findings of COVID-19 and its associated complications are constantly evolving and becoming more widely available. Providers should be familiar with both typical symptoms and image study results for COVID-19 as well as less commonly reported complications of progressive COVID-19, such as spontaneous pneumomediastinum and spontaneous pneumothorax as highlighted in this case.
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Affiliation(s)
- Megan Gillespie
- Department of Emergency Medicine, Jefferson Health - Northeast, Philadelphia, PA, USA
| | - Nathan Dincher
- Department of Emergency Medicine, Jefferson Health - Northeast, Philadelphia, PA, USA.,Department of Critical Care, Jefferson Health - Northeast, Philadelphia, PA, USA
| | - Pamela Fazio
- Department of Internal Medicine, Jefferson Health - Northeast, Philadelphia, PA, USA
| | - Onyinyechukwu Okorji
- Department of Emergency Medicine, Jefferson Health - Northeast, Philadelphia, PA, USA.,Department of Internal Medicine, Jefferson Health - Northeast, Philadelphia, PA, USA
| | - Jacob Finkle
- Department of Emergency Medicine, Jefferson Health - Northeast, Philadelphia, PA, USA
| | - Argun Can
- Department of Critical Care, Jefferson Health - Northeast, Philadelphia, PA, USA
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9
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Ranavaya A, Warren P, Reyes N, Gilene S, Klein M. Clearing the Air: The Importance of Adolescent History Taking in a Modern Medical Age. Clin Pediatr (Phila) 2020; 59:736-739. [PMID: 32059620 DOI: 10.1177/0009922820905868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Aeesha Ranavaya
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Paul Warren
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Natalie Reyes
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Stephen Gilene
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Melissa Klein
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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10
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Burgwardt S, Huskic A, Schwartz G, Mason DP, Tapias L, Podgaetz E. Spontaneous pneumomediastinum secondary to electronic cigarette use. Proc (Bayl Univ Med Cent) 2020; 33:229-230. [PMID: 32313467 DOI: 10.1080/08998280.2020.1717407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 10/25/2022] Open
Abstract
Vaping, the use of electronic cigarettes, involves different mechanics than conventional combustion cigarettes. Consumers who vape tend to overinhale and then forcefully exhale to eliminate the vapor, which is usually produced in much greater quantity than generated by a regular cigarette. Effectively, they are performing an exaggerated Valsalva maneuver. This can increase their risk for developing potential spontaneous pneumomediastinum. Here we present a case of spontaneous pneumomediastinum secondary to electronic cigarette use.
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Affiliation(s)
- Sean Burgwardt
- New York Institute of Technology College of Osteopathic Medicine, Arkansas State UniversityJonesboroArkansas
| | - Arnes Huskic
- Department of Surgery, Baylor University Medical CenterDallasTexas
| | - Gary Schwartz
- Center for Thoracic Surgery, Baylor Scott and White HealthDallasTexas
| | - David P Mason
- Center for Thoracic Surgery, Baylor Scott and White HealthDallasTexas
| | - Leonidas Tapias
- Center for Thoracic Surgery, Baylor Scott and White HealthDallasTexas
| | - Eitan Podgaetz
- Center for Thoracic Surgery, Baylor Scott and White HealthDallasTexas
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Göktekin MÇ. Acil serviste spontan pnömomediastinum tanılı hastaların değerlendirilmesi. CUKUROVA MEDICAL JOURNAL 2019. [DOI: 10.17826/cumj.508742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Landman ST, Dhaliwal I, Mackenzie CA, Martinu T, Steel A, Bosma KJ. Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth. CMAJ 2019; 191:E1321-E1331. [PMID: 31753841 PMCID: PMC6887563 DOI: 10.1503/cmaj.191402] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2019] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Although electronic cigarettes (e-cigarettes) were initially marketed as a potential smoking-cessation aid and a safer alternative to smoking, the long-term health effect of e-cigarette use ("vaping") is unknown. Vaping e-liquids expose the user to several potentially harmful chemicals, including diacetyl, a flavouring compound known to cause bronchiolitis obliterans with inhalational exposure ("popcorn worker's lung"). CASE DESCRIPTION We report the case of a 17-year-old male who presented with intractable cough, progressive dyspnea and malaise after vaping flavoured e-liquids and tetrahydrocannabinol intensively. Initial physical examination showed fever, tachycardia, hypoxemia, and bibasilar inspiratory crackles on lung auscultation. Computed tomography of the chest showed diffuse centrilobular "tree-inbud" nodularity, consistent with acute bronchiolitis. Multiple cultures, including from 2 bronchoalveolar lavage samples, and biopsy stains, were negative for infection. He required intubation, invasive mechanical ventilation and venovenous extracorporeal membrane oxygenation (ECMO) for refractory hypercapnia. The patient's condition improved with high-dose corticosteroids. He was weaned off ECMO and mechanical ventilation, and discharged home after 47 days in hospital. Several months after hospital discharge, his exercise tolerance remained limited and pulmonary function tests showed persistent, fixed airflow obstruction with gas trapping. The patient's clinical picture was suggestive of possible bronchiolitis obliterans, thought to be secondary to inhalation of flavouring agents in the e-liquids, although the exact mechanism of injury and causative agent are unknown. INTERPRETATION This case of severe acute bronchiolitis, causing near-fatal hypercapnic respiratory failure and chronic airflow obstruction in a previously healthy Canadian youth, may represent vaping-associated bronchiolitis obliterans. This novel pattern of pulmonary disease associated with vaping appears distinct from the type of alveolar injury predominantly reported in the recent outbreak of cases of vaping-associated pulmonary illness in the United States, underscoring the need for further research into all potentially toxic components of e-liquids and tighter regulation of e-cigarettes.
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Affiliation(s)
- Simon T Landman
- Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steel), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Inderdeep Dhaliwal
- Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steel), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Constance A Mackenzie
- Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steel), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Tereza Martinu
- Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steel), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Andrew Steel
- Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steel), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Karen J Bosma
- Divisions of Respirology (Landman, Dhaliwal, Mackenzie, Bosma), Clinical Pharmacology and Toxicology (Mackenzie), and Critical Care Medicine (Bosma), Department of Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ont.; Ontario, Manitoba and Nunavut Poison Centres (Mackenzie), The Hospital for Sick Children; Division of Respirology (Martinu), Department of Medicine, Toronto Lung Transplant Program, University Health Network; Interdepartmental Division of Critical Care Medicine (Steel), Department of Anesthesiology, Faculty of Medicine, University of Toronto, Toronto, Ont.
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