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A 22-year-old Saudi male is brought to the emergency department by his relatives after he loses consciousness. They report that a few hours before fainting, he had been complaining of chest pain and was very short of breath.

His family members note that he is healthy and has never had a similar attack. He has no family history or previous trauma or medical or surgical problems that might explain the symptoms.

The patient is a healthy weight with a body-mass index of 17.3. Examination finds him alert and fully aware of his surroundings. He is hemodynamically stable; with the following clinical findings:

• Heart rate: 76 bpm with normal rhythms

• Temperature: 36.7°C

• Respiratory rate: 22

• Blood pressure: 112/67 mm Hg

• Oxygen saturation: 97% on room air

The patient is in respiratory distress and using his accessory muscles with symmetric chest movement. He has no evidence of pallor, cyanosis, or dysmorphic features. His trachea is central on palpation. He has normal tactile vocal fremitus, equal bilateral chest expansion, and equal chest resonance on percussion. Auscultation notes normal bilateral air entry, with mild wheezing but no crackles. Precordial examination reveals a non-displaced apex beat, muffled first and second heart sounds, without murmurs or added sounds.

On questioning about the symptoms leading up to his loss of consciousness, he says that the chest pain and dyspnea came on suddenly. His shortness of breath worsened when he breathed in or exerted himself, and was accompanied by palpitations and a continuous retrosternal non-exertional, non-radiating chest pain; lying down caused the symptoms to worsen. He said that over the course of 2 hours, he felt increasingly dizzy and began sweating profusely, before losing consciousness.

Laboratory findings are within the normal range for complete blood count, coagulation profile, cardiac enzymes and markers, arterial blood gas, serum electrolytes, and serum antibodies.

Diagnosis

On further questioning, the patient reveals that just prior to his fainting episode, he had tried smoking tobacco in a hookah for the first time.

A chest x-ray is performed. The anterior-posterior view (Figure) reveals linear lucency projecting over the superior mediastinum tracking superiorly to the neck area and inferiorly along the left border of the heart. The continuous diaphragm sign is obvious.

Coronal view of a CT scan confirms pneumomediastinum around the heart extending to the neck area and interstitial emphysema. The sagittal view shows posterior extension of air around the aorta and the esophagus.

On consultation with the thoracic surgery team, a conservative approach to management including rest and analgesia is recommended. The patient is scheduled for weekly follow-up assessments and serial chest x-rays at the clinic.

Within a few days, the patient reports to the clinic with less pain and dyspnea. An x-ray shows no increase in pneumomediastinum. At a subsequent appointment just over 2 weeks later, he reports that he is free of symptoms. Imaging shows that his pneumomediastinum has resolved.

The patient is advised to avoid hookah smoking, and the file is closed.

Discussion

The clinician reporting this ¹ notes that while cigarette smoking is a well-known risk factor for spontaneous pneumomediastinum (SPM), he is not aware of any concrete evidence that identifies hookah tobacco smoking as a risk factor for SPM. However, he suggests that the potential causative mechanism for SPM may be similar to that involved in cigarette smoking.

SPM is a rare, self-limiting pathology, clinically defined as the presence of free air in the mediastinum, without any traumatic cause, the case author notes. SPM develops as due to rupture along the alveolar tree, which suddenly increases intra-alveolar pressure. This results in air leakage along the bronchovascular sheaths toward the pulmonary hila, which ultimately reaches the mediastinum, a pathophysiological mechanism known as the Macklin effect.²

SPM is precipitated primarily by voluntary and involuntary alterations in breathing patterns, which may be related to bronchial asthma, marijuana smoking, cocaine inhalation, and barotrauma occurring, for example, with Valsalva's maneuver.³ It accounts for approximately one in 30,000 visits to the emergency department.⁴

Predisposing factors to consider in making a of possible SPM include tobacco smoking (32%), asthma (18%), interstitial lung disease (14%), emesis (14%), and a recent history of upper respiratory infection (9%).⁵

The condition tends to affect young, thin males – as reflected in this patient – who often present with arbitrary symptoms of chest pain, cough, and dyspnea.⁵ Other common clinical features of SPM include neck pain, difficulty swallowing, weakness, and swelling of the face and neck.⁶

Smoking a hookah or waterpipe involves charcoal-heated air passing through a perforated aluminum foil wrapping and across tobacco to become smoke, the case report author notes. That the smoke is filtered through water and a hose so that it is generally better filtered and cooled than cigarette smoke⁴ would seem to make it less prone to causing SPM.

Despite a widespread belief among more than half of hookah smokers that the practice is less harmful than cigarette smoking,⁷ 40 to 100 times more tobacco is consumed in a typical session compared with cigarette smoking,⁸ the author writes.

Specifically, a typical hookah session delivers significantly higher levels of smoke, tar, and nicotine compared with cigarettes, according to a 2019 American Heart Association News .⁹ The report cites a 2016 study showing that charcoal briquettes deliver additional toxins, especially carbon monoxide – possibly as much as nine to 10 times as much as cigarettes – in part because hookah sessions last about 30 minutes to an hour compared with a 5-minute cigarette break.⁹

Research has linked hookah smoking to numerous short- and long-term cardiovascular health effects. These include acute increases in heart rates from 4.1 to 16 bpm, and increases in blood pressure of 6.7 to 15.7 mm Hg systolic and 2.0 to 14 mm Hg diastolic pressure. Long-term cardiovascular effects include ischemic heart disease and heart failure.¹⁰

Hookah smoking also increases the risk of addiction, and due to the toxic substances it contains, it can cause cardiovascular disease and many other diseases, including cancer.¹¹

While the author reporting this case opines that the health hazards are related to the large amounts of tobacco and toxic substances consumed,¹¹ rather than to the pipe itself, the author of the 2016 study suggests that the whole waterpipe apparatus acts as a connection between the charcoal to the smoker's deepest airways.⁹

The case author notes that hookah smoking is increasingly popular, and is in fact part of a global tobacco-abuse epidemic, second only to tobacco smoking.⁶ Among U.S. high school students, the CDC reported that cigarette use has dropped by 33%, while use of non-cigarette combustible tobacco products, including waterpipe use, has increased by 123% as of 2012.¹²

The case report author notes that the hookah is also commonly used to smoke "shisha," a generally "fruit-flavored" substance. While hookah establishments claim to sell non-tobacco shisha, it is typically not tobacco-free, and even non-tobacco shisha contains many toxic agents found in cigarette smoke, according to a recent New York City-based study.¹³

The case report author suggests that this is the second documented instance of SPM from hookah (shisha) smoking, and points to a 2017 report of an 18-year-old hookah smoker with a dramatic onset of symptoms. That patient presented with dysphagia, cough with purulent expectoration, dyspnea on exertion, chest pain, clear rhinorrhea, and sneezing, which eventually was determined to be due to spontaneous mediastinum pneumonitis.¹⁴

Conclusion

SPM is a rare pathology, diagnosed through the correlation of chest radiography findings with clinical findings. The author concludes that SPM should be suspected in individuals presenting with chest pain and shortness of breath after hookah use.

References

1. Alaska YA "Spontaneous Pneumomediastinum Secondary to Hookah Smoking" Am J Case Rep 2019; 20: 651-654.

2. Park DR, Vallières E, In: Murray & Nadel's Textbook of Respiratory Medicine. Mason R, et al (eds), Philadelphia, Toronto, Saunders, Pneumomediastinum and Mediastinitis 2010; 1836-1858.

3. Wong KS, et al "Spontaneous pneumomediastinum: Analysis of 87 pediatric patients" Pediatr Emerg Care 2013; 29(9): 988-991.

4. Maziak W, et al "The global epidemiology of waterpipe smoking" Tob Control 2015; 24(Suppl 1): i3–i12.

5. Sahni S, et al "Spontaneous pneumomediastinum: time for consensus" N Am J Med Sci 2013; 5(8): 460–464.

6. Ward KD "The waterpipe: An emerging global epidemic in need of action" Tob Control 2015; 24(Suppl 1): i1–i2.

7. Aljarrah K, et al "Perceptions of hookah smoking harmfulness: Predictors and characteristics among current hookah users" Tob Induc Dis 2009; 5(1): 16.

8. Tucktuck M, et al "Waterpipe and cigarette tobacco smoking among Palestinian university students: A cross-sectional study" BMC Public Health 2017; 18(1): 1.

9. "Hookah smoking gains popularity amid growing evidence of health risks" American Heart Association News, January 15, 2019.

10. El-Zaatari ZM, et al "Health effects associated with waterpipe smoking" Tob Control 2015; 24(Suppl 1): i31–i43.

11. Blachman-Braun R, et al "Hookah, is it really harmless?" Resp Med 2014; 108: 661-667.

12. Haddad L, et al "Waterpipe Smoking and Regulation in the United States: A Comprehensive Review of the Literature" .

13. Roods K, et al "Trends in Hookah Use Among New York City Middle and High School Students, 2008-2014" .

14. Neino AM, et al "Asthma discovered accidentally and subcutaneous emphysema associated with a spontaneous mediastinum pneumonitis in shisha smoker: About one case" J Lung Pulm Respir Res 2017; 4(6): 00146.

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