\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Recurrent Spontaneous Pneumothorax in a 15-Year-Old Female Associated
with Electronic Cigarettes}



\author[1]{Seth Deskins}%
\author[1]{Samuel  Luketich }%
\author[1]{Saif  Al-Qatarneh }%
\affil[1]{West Virginia University}%


\vspace{-1em}



  
  \date{May 19, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Pneumothorax as a sequalae of vaping is a relatively recent complication
being described in the literature. Smoking has classically been
associated with increased risk of pneumothorax, and emerging evidence is
showing that electronic cigarettes (e-cigarettes) likely carry some of
the same risks. Since electronic cigarettes increased in popularity,
especially among the adolescent population, there has been reported
increased incidence of lung injury, including pneumothorax. We present a
case of a 15-year-old female with a history of e-cigarette use admitted
for recurrent pneumothorax with failure to re-expand requiring surgical
intervention.%
\end{abstract}%



\sloppy


\textbf{Title:}

Recurrent Spontaneous Pneumothorax in a 15-Year-Old Female Associated
with Electronic Cigarettes

\textbf{Authors:}

Seth J Deskins, MD\textsuperscript{1}; Samuel K Luketich,
MSIII\textsuperscript{1}; Saif Al-Qatarneh, MD\textsuperscript{2}

\textbf{Conflict of Interest:}

None to disclose

\textbf{Abstract:}

Pneumothorax as a sequalae of vaping is a relatively recent complication
being described in the literature. Smoking has classically been
associated with increased risk of pneumothorax, and emerging evidence is
showing that electronic cigarettes (e-cigarettes) likely carry some of
the same risks. Since electronic cigarettes increased in popularity,
especially among the adolescent population, there has been reported
increased incidence of lung injury, including pneumothorax. We present a
case of a 15-year-old female with a history of e-cigarette use admitted
for recurrent pneumothorax with failure to re-expand requiring surgical
intervention.

\textbf{Keywords:}

Pneumothorax, electronic cigarettes, vaping, case report

\textbf{Introduction:}

E-cigarettes are a popular alternative to traditional nicotine
containing cigarettes. The operational mechanism for e-cigarettes
involves heating a liquid to produce an aerosol that can be inhaled into
the lungs (1). A potential draw to e-cigarettes is the capability of the
liquid to contain various chemical compounds ranging from nicotine to
tetrahydrocannabinol (THC) and cannabinoids (CBD) oils that can be mixed
with additives and flavors (1). However, there are potential
consequences though that need to be considered. A now commonly
recognized pathology is e-cigarette/vaping associated lung injury
(EVALI/VALI). This was first described in 2019 and by the end of that
year, a reported 2807 patients were admitted for EVALI with a total of
68 deaths (2). EVALI is an important consideration in the pediatric
realm as adolescents have easy access to electronic cigarettes. The
median age of admitted patients was 21 years old with a male
predominance (2). Since this is a relatively new diagnosis, there are no
prospective studies on the long term impacts on pulmonary health. Recent
issues have started to take precedence and to be more recognized in
literature, such as spontaneous pneumothorax related to e-cigarette use.
Here we present a case of recurrent complicated pneumothorax requiring
surgical intervention in an otherwise healthy 15-year-old female with a
significant vaping history.

\textbf{Case:}

A 15-year-old female with a significant past medical history of
recurrent spontaneous pneumothorax presents as a direct admission after
development of sudden onset left-sided chest pain with radiation into
her left shoulder. Her pain is worse with deep inspiration, and she
endorses a bubbling feeling below her ribs with associated numbness and
tingling of the left upper extremity. She denies recent illness,
preceding trauma, or history of connective tissue disease. Family
history is non-contributory, and social history is positive for daily
e-cigarette use containing nicotine and cannabinoid cartridges.

Initial workup with an electrocardiogram reveals normal sinus rhythm. A
viral respiratory panel, which includes the novel SARS-CoV-2, is
negative, and complete blood count and basic metabolic panel is normal.
Chest x-ray (figure 1) performed on admission reveals a small to
moderate left-sided pneumothorax. Further analysis with CT chest (figure
2) is performed and only demonstrates the pneumothorax. This is the
third episode of pneumothorax in this patient within the past 6 months.
Figure 3 shows her chest radiograph from initial hospitalization. She is
placed on 100\% FiO2 via non-rebreather for nitrogen washout. Pediatric
pulmonology and cardiothoracic surgery are consulted. Given her history
of recurrent pneumothoraces, the patient is planned to have a left sided
partial pleurectomy, blebectomy, and mechanical pleurodesis via video
assisted thorascopic surgery (VATS). A chest tube is inserted
intraoperatively and maintained on negative pressure. Oxygen is weaned
to room air, and her chest tube is placed to water seal. Three days
post-operatively, she remains clinically stable and the chest tube is
removed. Follow-up imaging is stable with minimal residual pneumothorax.
Extensive counseling during the admission is provided to the patient and
family regarding cessation of vaping to minimize the risk of recurrence.

\textbf{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.

\textbf{References:}

(1) Center for Disease Control and Prevention. (2021, August 3). Smoking
and Tobacco Use. Retrieved from Smoking and Tobacco Use Website:
https://www.cdc.gov/tobacco/basic\_information/e-cigarettes/severe-lung-disease.html

(2) Triantafyllou GA, Tiberio PJ, Zou RH, Lynch MJ, Kreit JW, McVerry
BJ, Morris A, Rose JJ. Long-term outcomes of EVALI: a 1-year
retrospective study. The Lancet Respiratory Medicine. 2021 Dec
1;9(12):e112-3.

(3) Miech R, Johnston L, O'Malley PM, Bachman JG, Patrick ME. Trends in
adolescent vaping, 2017--2019. New England Journal of Medicine. 2019 Oct
10;381(15):1490-1.

(4) Kligerman S, Raptis C, Larsen B, Henry TS, Caporale A, Tazelaar H,
Schiebler ML, Wehrli FW, Klein JS, Kanne J. Radiologic, pathologic,
clinical, and physiologic findings of electronic cigarette or vaping
product use--associated lung injury (EVALI): evolving knowledge and
remaining questions. Radiology. 2020 Mar;294(3):491-505.

(5) Sharma M, Anjum H, Bulathsinghala CP, Buch M, Surani SR. A case
report of secondary spontaneous pneumothorax induced by vape. Cureus.
2019 Nov 4;11(11).

(6) Bonilla A, Blair AJ, Alamro SM, Ward RA, Feldman MB, Dutko RA,
Karagounis TK, Johnson AL, Folch EE, Vyas JM. Recurrent spontaneous
pneumothoraces and vaping in an 18-year-old man: a case report and
review of the literature. Journal of Medical Case Reports. 2019
Dec;13(1):1-6.

(7) Skertich NJ, Sullivan GA, Madonna MB, Shah AN. Vaping is a risk
factor for spontaneous pneumothorax: two cases. Journal of Pediatric
Surgery Case Reports. 2019 Nov 1;50:101305.

(8) Adhikari R, Manduva D, Malayala SV, Singh R, Jain NK, Deepika K,
Koritala T. A rare case of vaping-induced spontaneous pneumomediastinum.
Cureus. 2021 Aug 13;13(8).

(9) Kass AP, Overbeek DL, Chiel LE, Boyer EW, Casey AM. Case series:
Adolescent victims of the vaping public health crisis with pulmonary
complications. Pediatric Pulmonology. 2020 May;55(5):1224-36.

(10) Baumann MH, Strange C, Heffner JE, Light R, Kirby TJ, Klein J,
Luketich JD, Panacek EA, Sahn SA. Management of spontaneous
pneumothorax: an American College of Chest Physicians Delphi consensus
statement. Chest. 2001 Feb 1;119(2):590-602.

(11) Shah M, Bryant MK, Mody GN, Maine RG, Williams JB, Upham TC. The
Impact of Vaping on Primary Spontaneous Pneumothorax Outcomes. The
American Surgeon. 2021 Oct 7:00031348211048849.

\textbf{Images:}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

Figure 1: Chest radiograph showing small to moderate pneumothorax at
admission\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}

Figure 2: CT chest showing small to moderate pneumothorax at admission\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

Figure 3: Chest radiograph from prior admission showing moderate sized
pneumothorax

\selectlanguage{english}
\FloatBarrier
\end{document}

