Popcorn lung: Teen first case of life-threatening vaping injury | Commentary

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By  Karen Bosma, Western University and Simon Landman, Western University

E-cigarettes first emerged in North America in 2004 — as a supposedly safer alternative to smoking traditional, carcinogenic, tobacco cigarettes, and as a potential means to help smokers quit smoking altogether.

However, with heavy marketing, an enticing array of flavours and the potential to inhale drugs other than nicotine, vaping has become increasingly popular, particularly among youth, attracting those who have never smoked before.

Read more: Vaping is an urgent threat to public health

We recently published a report in the Canadian Medical Association Journal describing a case of severe, life-threatening airway injury related to vaping that occurred in a Canadian youth.

The 17-year-old, who had been vaping daily using a variety of flavoured cartridges and tetrahydrocannabinol (THC, the psychoactive compound found in cannabis), was hospitalized and required life support in the intensive care unit, including mechanical ventilation and extracorporeal membrane oxygenation (ECMO) — oxygenation of blood outside of the body.

First case of vaping ‘popcorn lung?’

After ruling out other potential causes, we suspected the patient had bronchiolitis obliterans. This condition is also known as “popcorn lung” based on its initial description among microwave popcorn factory workers exposed to chemical flavourants.

He narrowly avoided the need for a double-lung transplant, spent a total of 47 days in hospital and may have suffered long-term damage to his airways.

He is currently recovering from his lengthy intensive care unit stay and is abstaining from e-cigarettes, marijuana and tobacco.

One in four Grade 12 students

Vaping has rapidly increased in popularity in recent years. A study of Canadian youth aged 16 to 19 found that e-cigarette use among this group increased to 37 per cent in 2018.

In 2019, current data estimates that one in four Grade 12 students in the United States have used e-cigarettes in the last 30 days. The recent outbreak of cases of “e-cigarette, or vaping product use associated lung injury” (EVALI) has called into question the safety of vaping, and the risks that e-cigarettes pose, particularly to youth.

Read more: Vaping: As an imaging scientist I fear the deadly impact on people’s lungs

As of Nov. 20, 2019, 2,290 cases of EVALI have been reported in the U.S., with 77 per cent occurring in patients under 35 years of age. To date, there have been 47 deaths confirmed in the EVALI outbreak.

Researchers at the U.S. Centers for Disease Control and Prevention have worked diligently to identify the causative agent(s) responsible, and suspect that vitamin E acetate may play a role. They have not yet ruled out other chemicals of concern and acknowledge that there may be more than one cause of the outbreak.

Despite being branded as a safer alternative, e-cigarettes are known to contain harmful substances including nicotine, vitamin E acetate, volatile organic compounds, heavy metals, ultra-fine particles and carbonyl compounds.

Safe to swallow, not to inhale?

For instance, formaldehyde (group 1 human carcinogen) and acetaldehyde (possible human carcinogen) have been found in e-cigarette aerosols, and their concentrations vary between brands and within samples of the same product.

Of particular concern is the use of flavouring agents in e-cigarettes. There are over 7,700 e-cigarette flavours across 460 brands, with newer marketing practices emphasizing consumer choice and customization of flavours and nicotine content.

While many of these flavours are listed as “generally recognized as safe” under the U.S. Federal Food, Drug and Cosmetic Act, it is important to recognize that this applies to ingestion of these ingredients; aerosolization of flavours safe for swallowing may produce adverse health effects when inhaled into the lungs.

Chemical diacetyl exceeds safety limits

Diacetyl (2,3-butanedione) is one example of such a compound that may be safe for ingestion but toxic when inhaled.

Diacetyl belongs to a class of organic compounds referred to as diketones, α-diketones or α-dicarbonyls, and is known for its characteristic buttery flavour. It is found naturally in some foods and also used as a synthetic flavouring agent in butter, cocoa, caramel, coffee, dairy products and alcoholic beverages.

Occupational diacetyl inhalation is associated with decline in respiratory function and manifested as obstructive lung disease.

Importantly, it is a recognized cause of bronchiolitis obliterans, an irreversible pulmonary disorder of small airways resulting in obstructive physiology not reversible with bronchodilators.

Bronchiolitis obliterans is also known as “popcorn lung” based on its initial description in patient clusters of microwave popcorn factory workers exposed to diacetyl-based flavourants.

Vaping industry needs tighter regulation

Diacetyl has been found in e-cigarette fluid at levels higher than recommended safety limits, including in some products where packaging clearly stated diacetyl was not an ingredient.

By publishing this Canadian case, we hope to raise awareness of the varying types of vaping-related lung injuries and the acute and chronic effects of vaping.

Further research into the safety and toxicity of e-liquid ingredients is essential. We must also push for tighter regulation of the vaping industry.

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Karen Bosma, Associate Scientist at Lawson Health Research Institute and Associate Professor, Schulich School of Medicine and Dentistry, Western University and Simon Landman, Clinical Fellow, Department of Respirology and Sleep Medicine at Schulich School of Medicine & Dentistry, Western University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

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7 Comments

  1. I’m at a loss to understand why governments were so quick to do everything they could to get rid of the tobacco industry and then allow these E Cigarette companies to sell all these chemical compounds that are killing our young people. If they took a look back I think they would find that tobacco did not do much harm until around the 1960’s when they started using chemical fertilizer to grow it I was born in 1940 and most of the men I knew growing up smoked and most lived to around or over 80 and none died of cancer.I was 14 0r 15 before I ever heard of cancer of any kind maybe it was around but nothing like it is today. Now as I see it only one thing has changed and that is the use of chemicals they grow our food with them and we spay them around our homes and cars and all over our bodies and our children are exposed to them from the day they are born. Just something to think about the next time you use air fresheners in your home or car do you really like the smell of chemicals that much.

  2. Well said,Mr. Vowels. Although I agree with you 100%, I can’t seem to think of any other solutions for this evil. My hope is that sentiments like yours, become more popular and men and women with better minds than mine, come up with a solution. Thank you Mr. Vowels.

    • To my way of thinking it’s sad that no one will even check out what all the chemicals are doing to us I e-mailed market place and asked them to look into them but they never even responded to my request so I’m thinking everyone is scared to even suggest looking into the chemical companies. So they can just keep on poisoning us and nothing we can do about it. I try not to use as much chemical free stuff as i can but not much i can do about the food but i use unscented products as much as possible.

  3. Merrill Perret on

    I agree with Ray’s and Stan’s general sentiments, except that our governments were neither quick to do anything about tobacco products, nor effective in stopping them. I shudder to imagine our federal and provincial bureaucrats chasing their tails around courtrooms for 50 years, after 20 or 30 years of thinking about vaping, fighting the industry.
    Here’s a solution: instead of wasting time and money proving vaping is harmful—we already know that!—just ban vaping and vaping products until the industry itself can prove it is safe for our young people. Put the onus on them, for a change.

    • I may be wrong but as I see it tobacco was not to much of a problem until around the 1960s like I said before back in the 40’s most men smoked and during the war our soldiers almost all smoked and I think they were given cigarettes by the Govt I never heard of many of the dying from lung cancer. I started smoking when I was fifteen and the tobacco did not taste anything like it does now in fact it smelled sweet had a very nice smell to it. I quit in 2010 at 70 years old could not stand the smell or the taste any longer. I wish there was a way of knowing what changed but my guess would be Chemical fertilizer and maybe some added to the tobacco after the fact. I also think they should outright ban this vaping before we lose a lot more young people from it.

  4. And it’s not always just government, who are unduly influenced by lobbyists from the multi-nationals, who are to blame. In a parallel, but dissimilar situation, many people of my advanced years suffer from skin cancer. Surely, the medical establishment could have warned us about the dangers of significant exposure to sun, long before they did. Big Pharma would have been all over that, with their myriad of protective products; and the time spent dealing with largely benign tumors could have been devoted to more deadly cancers/diseases.

    • Your right Rob the multi nationals and big companies are so involved with the bottom line and keeping the share holders happy that they don’t care a darn if they are killing people or not so long as the profit is there. What I don’t understand is a lot of this stuff is killing there own children and grand children and they don’t seem to care. I have a site on my home page that tells about all the cancer causing chemicals that go into all deodorants and soaps and it’s crazy that they even make this crap but we keep using it because we think it’s safe. Personally I think these chemicals are the major cause of most cancer but i’m no doctor or scientist so it’s just my opinion.

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