Pneumomediastinum in marijuana users: a retrospective review of 14 cases

Abstract

Introduction: Inhaled marijuana has been infrequently identified as a potential risk factor for the development of spontaneous pneumomediastinum (SPM), a rare finding of free air in the mediastinum likely caused by barotrauma during breathing manoeuvres. The mechanism of inhalation drug use is often not ascertained by physicians, thus little is known about how different smoking techniques precipitate pulmonary injury. We aimed to evaluate the frequency of marijuana use in patients with non-traumatic pneumomediastinum over a 12-month period, identifying additional relevant clinical features or risk factors, and determining the extent to which clinicians record smoking techniques.

Methods: We performed a retrospective chart review over a 1-year period, identifying patients presenting to the hospital with a diagnosis of pneumomediastinum in the absence of trauma, malignancy or iatrogenic cause.

Results: We identified 21 cases, 14 of which (66.7%) were associated with marijuana use, average age was 22.5 years (range 18-30), with male predominance (64.2%). Daily or more use was reported in 50% of cases. Concurrent risk factors including vomiting (57.1%) and coughing (42.9%) were commonly present. The mechanism of smoking was described in only two cases (14.3%).

Discussion: Inhaled marijuana may be an underappreciated risk factor for the development of SPM, caused by air leakage around the bronchovascular sheaths during successive inhalation through a high-resistance smoking apparatus or forced exhalation against a closed glottis. Physicians should be aware of this association in order to provide appropriate counselling. Further research is needed to direct the safe use of smoking devices and techniques.

Keywords: barotrauma; marijuana; spontaneous pneumomediastinum; subcutaneous emphysema.

Figure 1

(A) Posterioranterior (PA) chest X-ray demonstrates pneumomediastinum in the anterior and middle mediastinum extending into the cervical soft tissues. (B) Lateral chest X-ray view: lucent striations seen in the mediastinum and air is visualised around the pulmonary vasculature. (C) Coronal CT chest with lung windows shows significant air present in middle mediastinum extending into the cervical soft tissues. (D) Axial CT of the chest with lung windows demonstrates air extending into the pericardial cavity.