Journal of Pulmonary Medicine & Respiratory Research Category: Medical Type: Review Article
Popcorn Lung and E-Cigarettes the Risk of Post OP Anesthesia Complications
- Joseph Mulligan1, Paul Deitrick1, Shelia Weaver2, Farnaz Valei3, Allen Fred Fielding4*
- 1 Oral And Maxillofacial Surgery, Temple University Hospital, Philadelphia, United States
- 2 Pulmonologist, Temple University Hospital, Philadelphia, United States
- 3 Department Of Oral Maxillofacial Surgery, University Of Maryland School Of Dentistry, Baltimore, United States
- 4 Kornberg School Of Dentistry, Katz School Of Medicine, Temple University Hospital, United States
*Corresponding Author:Allen Fred Fielding
Kornberg School Of Dentistry, Katz School Of Medicine, Temple University Hospital, United States
Tel:+1 2157072871/ 2157073613,
Email:firstname.lastname@example.org / email@example.com
Received Date: Jun 15, 2018 Accepted Date: Dec 12, 2018 Published Date: Dec 20, 2018
The Chinese firm Hon Lik made the first modern electronic cigarettes in the mid-2000s , as a substitute for the conventional smoker, marketed as a healthier alternative. Since the emergence of new generations of e-cigarettes, they have increased in popularity especially among the younger smokers. Presently there are over 7000 different flavoring agents used in e-cigarettes. E-cigarettes are unfortunately not currently regulated by the US Food and Drug Administration. Under the Family Smoking Prevention and Tobacco Control Act (2009) the FDA has issued a proposed rule to include e-cigarettes . Liquid flavoring agents seen in e-cigarettes have been shown to contain diacetyl (2,3-butanedione), diketone and 2,3-pentanedione. Levels of diacetyl and 2,3-pentanedione were found in a large proportion of sweet flavored e-cigarette liquids in concentrations greater than considered conventionally safe. Interestingly, these chemicals were even found in products which are coming from manufacturers who clearly made claim their products didn’t contain them . When used e-cigarettes have been shown to even have levels of these compounds that exceed the exposure levels of factory workers who had reported as having been exposed. The exposure pathways for these flavoring chemicals is through inhalation which is similar for both the users of the e-cigarettes and popcorn factory workers. E-liquids which contain nicotine, propylene glycol, and flavoring agents are heated, vaporized, and then inhaled. Once heated the (2,3-butanedione), diketone and 2,3-pentanedione are released for inhalation [3,5].
Bronchiolitis obliterans is the inflammatory and fibrotic process in which partial or complete obstruction of the bronchioles occurs . In bronchiolitis obliterans, the proliferation of granulation tissue in the bronchiolar epithelium leads to obstruction of the small airways. It is believed generation of reactive oxidative agents also plays a significant role in pathology of diacetyl toxicity producing a reactive oxygen species . The disease can manifest as an obstructive, restrictive, or mixed pattern of a pulmonary disfunction .
Prolonged exposure to diacetyl (2,3-butanedione), diketone and 2,3-pentanedione can lead to fixed airflow obstruction, gas exchange impairment, obstructive lung disease. Bronchiolitis obliterans is an irreversible loss of pulmonary function. The disease process can become so severe that the only treatment may be a lung transplant . Exposure has been shown to decrease the Forced Expiratory Reserve Volume (FEV1) and Functional Vital Capacity (FVC). Studies by Fedan et al., suggested the epithelial cell is adversely affected by flavoring in e-cigarettes.
The pathophysiology of the popcorn lung is believed to be initiated by the epithelial damage caused by diacetyl (2,3-butanedione) diketone and 2,3-pentanedione [11,12]. The airway surface liquid and mucocilliary clearance is regulated in epithelial cells through absorption of Na+ and Cl- secretion in epithelial cells . These chemicals cause disruption of the transepithelial Na+ transporters which can eventually lead to pulmonary edema [14,15], and airway obstruction [16,17]. Fedan et al., revealed transepithelial depolarization and altered tight junction integrity was adversely affected in guinea-pigs after perfusing physiological salt solution containing diacetyl into the lumen .
It is believed diacetyl and 2,3-pentanedione are metabolized by the enzyme dicarbonyl/l-xylulose reductase to acetoin and 2-hydroxy-3-pentanone respectively [18,19], releasing their metabolites into the submucosal medium. These metabolites were able to change the Na+ ion transporter function in much lower doses than needed to alter the morphologic shape of the epithelial cells that can be visible. It is important to recognize e-cigarettes have not been around in the market for long enough, so the health effect of the exposure to e-cigarettes aerosol has only been investigated in a few articles and the long term biological effects of e-cigarette aerosol exposure are not yet fully investigated.
As a rule, adequate preoperative evaluation of patients with pulmonary dysfunction by a pulmonologist is recommended before any anesthetic induction to avoid Postoperative Pulmonary Complications (PPCs). Smoking and lower FEV1 are identified as risk factors as PPCs. In patients with PPCs after non-cardiothoracic surgeries, the values of FEV1 and FVC were lower than those who had normal FEV1 and FVC rates suggesting FEV1 is an important factor for predicting postoperative complications after surgeries. Committed vapers may be at higher risk of PPCs after general anesthesia. Using neuromuscular blocking agents during GA may also exacerbate respiratory complications or post-operative hypoxemia .
Hypercapnia and desaturation can both happen because of “popcorn lung” as a result people should be screened for the possible effects of vaping to avoid these post-anesthesia pulmonary complications . Studies by Hinrichs et al., demonstrated patients with bronchiolitis obliterans had a significant lower SO2 venous saturation. Lower venous oxygen saturations can be further exacerbated due to anesthesia as general anesthesia disrupts central regulation of breathing, which can ultimately result in hypoventilation . The majority anesthetic agents that we use like midazolam, Propofol, and fentanyl have depressive effect on the respiratory system, so careful attempt should be directed towards administrating these drugs to the patients with these conditions.
E-cigarettes were thought to be a safe alternative to traditional tobacco smoking; however popcorn lung can be caused by inhaling the flavoring agents present in E-cigarettes. This condition can lead to patients being hypoxic and hypercapnic, and this can lead to a higher chance of having post anesthesia complications. In our study we would like to emphasize the importance of patient’s education on respiratory effects of e-cigarettes and investigate if there are any necessary actions that should be done in pre-op evaluations of the population of e-cigarettes smokers before providing anesthesia. In previous studies, Continuous Positive Airway Pressure (CPAP) has been suggested as one way of reducing post-operative anesthesia complications by improving respiratory failure. CPAP can improve respiratory failure by recruiting alveoli, reducing airway resistance, and improving lung expiration, leading to improved gas exchange and decreased hyperinflation . We would like to investigate if spirometry tests or other available methods of preoperative screening would be efficient in the oral surgery settings for evaluation of long-term e-cigarettes smoker’s respiratory function, before determining if they are good candidates for sedations. We would also like to evaluate CPAP as a post-operative therapy in these patients to help reduce respiratory events. At this time there are no guidelines regarding e-cigarette smoking length and respiratory function depression during anesthesia, since e-cigarettes have not been available and in wide use for a long period of time. We think further studies need to be directed towards this important topic.
- Farsalinos KE, Romagna G, Tsiapras D, Kyrzopoulos S, Spyrou A, et al. (2013) Impact of flavour variability on electronic cigarette use experience: An internet survey. Int J Environ Res Public Health 10: 7272-7282.
- Grana R, Benowitz N, Glantz SA (2013) Background paper on e-cigarettes (electronic nicotine delivery systems). UCSF Center for Tobacco Control Research and Education, San Francisco, USA.
- Allen JG, Flanigan SS, LeBlanc M, Vallarino J, MacNaughton P, et al. (2016) Flavoring chemicals in e-cigarettes: Diacetyl, 2,3-pentanedione, and acetoin in a sample of 51 products, including fruit-, candy-, and cocktail-flavored e-cigarettes. Environ Health Perspect 124: 733-739.
- Farsalinos KE, Kistler KA, Gillman G, Voudris V (2015) Evaluation of electronic cigarette liquids and aerosol for the presence of selected inhalation toxins. Nicotine Tob Res 17: 168-174.
- Holden VK, Hines SE (2016) Update on flavoring-induced lung disease. Curr Opin Pulm Med 22: 158-164.
- Lockey JE, Hilbert TJ, Levin LP, Ryan PH, White KL, et al. (2009) Airway obstruction related to diacetyl exposure at microwave popcorn production facilities. Eur Respir J 34: 63-71.
- Kreiss K, Gomaa A, Kullman G, Fedan K, Simoes EJ, et al. (2002) Clinical bronchiolitis obliterans in workers at a microwave-popcorn plant. N Engl J Med 347: 330-338.
- Ryu JH, Myers JL, Swensen SJ (2003) Bronchiolar disorders. Am J Respir Crit Care Med 168: 1277-1292.
- Kovacic P, Cooksy AL (2010) Electron transfer as a potential cause of diacetyl toxicity in popcorn lung disease. Rev Environ Contam Toxicol 204: 133-148.
- Markopoulo KD, Cool CD, Elliot TL, Lync DA, Newell JD Jr, et al. (2002) Obliterative bronchiolitis: Varying presentations and clinicopathological correlation. Eur Respir J 19: 20-30.
- Fedan JS, Dowdy JA, Fedan KB, Hubbs AF (2006) Popcorn worker’s lung: In vitro exposure to diacetyl, an ingredient in microwave popcorn butter flavoring, increases reactivity to methacholine. Toxicol Appl Pharmacol 215: 17-22.
- Hubbs AF, Battelli LA, Goldsmith WT, Porter DW, Frazer D, et al. (2002) Necrosis of nasal and airway epithelium in rats inhaling vapors of artificial butter flavoring. Toxicol Appl Pharmacol 185: 128-135.
- Hollenhorst MI, Richter K, Fronius M (2011) Ion transport by pulmonary epithelia. J Biomed Biotechnol 174306.
- Egli M, Duplain H, Lepori M, Cook S, Nicod P, et al. (2004) Defective respiratory amiloride-sensitive sodium transport predisposes to pulmonary oedema and delays its resolution in mice. J Physiol 560: 857-865.
- Zaccone EJ, Goldsmith WT, Shimko MJ, Wells JR, Schwegler-Berry D, et al. (2015) Diacetyl and 2,3-pentanedione exposure of human cultured airway epithelial cells: Ion transport effects and metabolism of butter flavoring agents. Toxicol Appl Pharmacol 289: 542-549.
- Danahay H, Atherton H, Jones G, Bridges RJ, Poll CT (2002) Interleukin-13 induces a hypersecretory ion transport phenotype in human bronchial epithelial cells. Am J Physiol Lung Cell Mol Physiol 282: 226-236.
- Eisenhut M (2006) Changes in ion transport in inflammatory disease. J Inflamm (Lond) 3: 5.
- Nakagawa J, Ishikura S, Asami J, Isaji T, Usami N, et al. (2002) Molecular characterization of mammalian dicarbonyl/L-xylulose reductase and its localization in kidney. J Biol Chem 277: 17883-17891.
- Ebert B, Kisiela M, Maser E (2015) Human DCXR - another ‘moonlighting protein’ involved in sugar metabolism, carbonyl detoxification, cell adhesion and male fertility? Biol Rev Camb Philos Soc 90: 254-278.
- Lawrence VA, Cornell JE, Smetana GW (2006) Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: Systematic review for the american college of physicians. Ann Intern Med 144: 596-608.
- Duggappa DR, Rao GV, Kannan S (2015) Anaesthesia for patient with chronic obstructive pulmonary disease. Indian J Anaesth 59: 574-583.
- Thia LP, McKenzie SA, Blyth TP, Minasian CC, Kozlowska WJ, et al. (2008) Randomised controlled trial of nasal Continuous Positive Airways Pressure (CPAP) in bronchiolitis. Arch Dis Child 93: 45-47.
Citation: Mulligan J, Deitrick P, Weaver S, Valei F, Fielding AF (2018) Popcorn Lung and E-Cigarettes the Risk of Post OP Anesthesia Complications. J Pulm Med Respir Res 4: 019.
Copyright: © 2018 Joseph Mulligan, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.