Use of electronic cigarettes, or e-cigarettes, is strongly suspected to have led to bronchiectasis in three young patients, according to a recent report.
The use of e-cigarettes has not yet been well documented in patients with bronchiectasis, and understanding a possible association between the two is essential for guiding effective care, according to the Nationwide Children’s Hospital physicians who conducted the study.
The study, “Bronchiectasis Associated with Electronic Cigarette Use: A Case Series,” was published in the journal Pediatric Pulmonology.
Bronchiectasis involves progressive inflammation, widening, and scarring of the bronchi — the tubes leading air into the lungs — and has been associated with cigarette smoking.
Bronchiectasis without cystic fibrosis (CF) has been increasingly detected among children and adolescents. At the same time, e-cigarettes are rising in popularity among adolescents, who may perceive them as safer than traditional cigarettes.
However, current evidence does not support this belief, the physicians said. In fact, use of e-cigarette or vaping in the U.S. led to approximately 2,800 hospitalizations involving lung injury, as of February. Deaths were reported in all 50 states.
The researchers reported three likely associations between e-cigarettes and non-CF bronchiectasis among adolescents referred to the hospital from January 2018 to March this year.
The patients, two males and one female, reported using e-cigarettes for both nicotine and tetrahydrocannabinol (THC) — the active chemical in cannabis — for at least one year, although the exact frequency of daily use was not recorded.
Both males were referred to the hospital’s pulmonary clinic for chronic cough, while the female patient had a medical history of eosinophilic esophagitis, an immune system disease. All three patients demonstrated widespread bronchiectasis in both lungs with bronchial wall thickening.
The first patient was a 17-year-old boy with chronic cough, nasal congestion, and an abnormal chest X-ray. Further imaging via CT scan revealed mild but widespread bronchiectasis and a lump, or nodule, in the upper portion of his right lung.
His family history included CF in his maternal grandmother and primary tuberculosis in his aunt. He said he had been using e-cigarettes for 2.5 years.
Pulmonary function was normal, as assessed via forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). Laboratory measurements were mostly within reference values, despite altered levels of antibodies.
These findings led to the conclusion that e-cigarette use best explained the patient’s symptoms and X-ray findings.
The second patient was a 16-year-old boy also with a chronic cough and a chest X-ray consistent with mild pneumonia, which did not respond to multiple antibiotic courses. Besides e-cigarette use with THC, his medical history included ulcerative colitis.
Pulmonary function tests showed mild airway obstruction, with FEV1 80% of predicted (which improved with bronchodilator use) and the FEV1 to FVC ratio 79% of predicted. No other abnormalities were found.
This patient was being treated for ulcerative colitis, a form of inflammatory bowel disease. Although past case reports have described bronchiectasis in people with ulcerative colitis, this patient’s gastroenterologist did not believe ulcerative colitis was the cause of the bronchiectasis. As a result, e-cigarette use was strongly suspected to have caused bronchiectasis.
The third patient was an 18-year-old female, who reported using e-cigarettes three to four times per week.
She was seen at an urgent care facility for sudden shortness of breath with facial color changes, a persistent nighttime cough that lasted for one month, as well as audible wheezing over the day before evaluation.
The patient was transferred to the hospital and started on the institution’s asthma care approach and given oxygen, albuterol, and glucocorticoids. Despite a normal chest X-ray, her continued respiratory symptoms prompted doctors to order a CT scan.
The scan showed ground glass opacities — cloudy patches associated with respiratory conditions — and bronchiectasis in the upper lobes of both lungs. Other tests were normal, although blood antibody levels were high. Pulmonary function tests were delayed by the COVID-19 pandemic.
Overall, e-cigarettes are relatively new and their long-term effects remain unknown, the physicians said. More data are needed to provide appropriate interventions and prevent disease progression.
“Through ascertaining and correctly documenting a patient’s social history … a clearer sense of the true prevalence of bronchiectasis associated with e-cigarette use can be determined,” they concluded. “In doing so, this will provide helpful diagnostic information and lead to a more effective treatment plan for each patient.”