THE PRICE OF FLAVOR: BRONCHIOLITIS OBLITERANS DUE DIACETYL, VAPING, AND OCCUPATIONAL EXPOSURE

Katarzyna Krupa; Weronika Głowacz; Anna Daniel; Kacper Jankowski; Aleksandra Maciejczyk; Natalia Kraciuk; Alicja Bury; Karol Bartecki; Julia Błoniecka; Małgorzata Piekarska-Kasperska

doi:10.31435/ijitss.3(47).2025.3509

Katarzyna Krupa Wolski Hospital in Warsaw, 01-211 Warsaw, Poland https://orcid.org/0009-0006-3120-8631
Weronika Głowacz Czerniakowski Hospital in Warsaw, 00-739 Warsaw, Poland https://orcid.org/0009-0009-5481-9509
Anna Daniel Regional Specialist Hospital in Wrocław – Research and Development Centre, 51-124 Wrocław, Poland https://orcid.org/0009-0003-8752-6610
Kacper Jankowski Bielanski Hospital named after Father Jerzy Popiełuszko in Warsaw, 01-809 Warsaw, Poland https://orcid.org/0009-0000-3722-7805
Aleksandra Maciejczyk Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, 02-091 Warsaw, Poland https://orcid.org/0009-0008-5709-0269
Natalia Kraciuk Independent Public Healthcare Establishment in Wyszków, 07-200 Wyszków, Poland https://orcid.org/0009-0007-8319-2296
Alicja Bury Orlowski Hospital in Warsaw, 00-416 Warsaw, Poland https://orcid.org/0009-0009-2950-8741
Karol Bartecki University Clinical Centre of the Medical University of Warsaw, 02-097 Warsaw, Poland https://orcid.org/0009-0006-1863-242X
Julia Błoniecka Independent Public Healthcare Facility in Garwolin, 08-400 Garwolin, Poland https://orcid.org/0009-0004-0199-6230
Małgorzata Piekarska-Kasperska Provincial Specialist Hospital of the name Stefan Cardinal Wyszyński in Lublin, 20-718 Lublin, Poland https://orcid.org/0000-0001-5055-4923

DOI: https://doi.org/10.31435/ijitss.3(47).2025.3509

Keywords: Bronchiolitis Obliterans, Popcorn Lung, Diacetyl, E-Cigarettes, Vaping, Occupational Exposure

Abstract

Background. Bronchiolitis obliterans (BO), or “popcorn lung,” is a rare, irreversible obstructive lung disease involving inflammation and fibrosis of small airways. Initially linked to occupational diacetyl exposure in the food industry, BO is now also associated with environmental toxins, post-transplant complications, and e-cigarette use.

Aim. This review presents current knowledge on BO, focusing on pathogenesis, risk factors, clinical presentation, diagnosis, treatment, and public health implications, particularly concerning e-cigarettes and environmental exposures.

Materials and Methods. A narrative review was performed using PubMed, Scopus, ScienceDirect, and Google Scholar, screening English and Polish-language articles from 2000–2025. Keywords included: “bronchiolitis obliterans,” “diacetyl,” “e-cigarettes,” “vaping,” “occupational exposure,” and “BO diagnosis.” Studies involving humans, relevant animal models, or in vitro analyses were included.

Analysis of Literature. BO often presents with nonspecific symptoms and is commonly underdiagnosed. High-resolution CT and histopathology are key diagnostic tools. While immunosuppressive therapy may help post-transplant patients, it is ineffective in toxin-induced BO. Supportive care, including bronchodilators, oxygen therapy, and rehabilitation, remains the mainstay of treatment. Lung transplantation is a last resort. E-cigarettes pose a growing risk due to vaporized compounds like diacetyl and formaldehyde.

Conclusions. BO remains a serious clinical and public health challenge. With no curative treatment and poor prognosis in many cases, prevention is critical. Regulatory oversight of harmful inhaled substances, particularly in vaping products and occupational environments, alongside public education on associated risks, is essential.

References

Schlesinger C, Meyer CA, Veeraraghavan S, Koss MN. Constrictive (obliterative) bronchiolitis: Diagnosis, etiology, and a critical review of the literature. Annals of Diagnostic Pathology 1998;2:321–34. https://doi.org/10.1016/S1092-9134(98)80026-9.

Gutor SS, Miller RF, Blackwell TS, Polosukhin VV. Environmental and occupational bronchiolitis obliterans: new reality. eBioMedicine 2023;95:104760. https://doi.org/10.1016/j.ebiom.2023.104760.

Fixed Obstructive Lung Disease in Workers at a Microwave Popcorn Factory --- Missouri, 2000--2002 n.d. https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5116a2.htm (accessed June 11, 2025).

Carey L, Johnson K, Villalba J, Baqir M. Vaping-associated constrictive bronchiolitis. Respir Med Case Rep 2024;51:102062. https://doi.org/10.1016/j.rmcr.2024.102062.

Bochenek A, Zawistowski S, Reicher M, Łasiński W, Hiller S, Zegarska Z, et al. Anatomia człowieka. T. 2: Trzewa. Wyd. 10. Warszawa: Wydawnictwo Lekarskie PZWL; 2014.

Flake GP, Morgan DL. Pathology of diacetyl and 2,3-pentanedione airway lesions in a rat model of obliterative bronchiolitis. Toxicology 2017;388:40–7. https://doi.org/10.1016/j.tox.2016.10.013.

Harvey RR, Blackley BH, Korbach EJ, Rawal AX, Roggli VL, Bailey RL, et al. Case Report: Flavoring-Related Lung Disease in a Coffee Roasting and Packaging Facility Worker With Unique Lung Histopathology Compared With Previously Described Cases of Obliterative Bronchiolitis. Front Public Health 2021;9:657987. https://doi.org/10.3389/fpubh.2021.657987.

LeBouf RF, Ranpara A, Fernandez E, Burns DA, Fortner AR. Model Predictions of Occupational Exposures to Diacetyl and 2,3-Pentanedione Emitted From Roasted Whole Bean and Ground Coffee: Influence of Roast Level and Physical Form on Specific Emission Rates. Front Public Health 2022;10:786924. https://doi.org/10.3389/fpubh.2022.786924.

Rincon-Delgadillo MI, Lopez-Hernandez A, Rankin SA. Short communication: Reactivity of diacetyl with cleaning and sanitizing agents. J Dairy Sci 2013;96:105–11. https://doi.org/10.3168/jds.2012-5893.

Rom O, Pecorelli A, Valacchi G, Reznick AZ. Are E-cigarettes a safe and good alternative to cigarette smoking? Ann N Y Acad Sci 2015;1340:65–74. https://doi.org/10.1111/nyas.12609.

Syamlal G. Electronic Cigarette Use Among Working Adults — United States, 2014. MMWR Morb Mortal Wkly Rep 2016;65. https://doi.org/10.15585/mmwr.mm6522a1.

Vas CA, Porter A, McAdam K. Acetoin is a precursor to diacetyl in e-cigarette liquids. Food and Chemical Toxicology 2019;133:110727. https://doi.org/10.1016/j.fct.2019.110727.

Allen JG, Flanigan SS, LeBlanc M, Vallarino J, MacNaughton P, Stewart JH, et al. 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 2016;124:733–9. https://doi.org/10.1289/ehp.1510185.

Azimi P, Keshavarz Z, Lahaie Luna M, Cedeno Laurent JG, Vallarino J, Christiani DC, et al. An Unrecognized Hazard in E-Cigarette Vapor: Preliminary Quantification of Methylglyoxal Formation from Propylene Glycol in E-Cigarettes. Int J Environ Res Public Health 2021;18:385. https://doi.org/10.3390/ijerph18020385.

Landman ST, Dhaliwal I, Mackenzie CA, Martinu T, Steel A, Bosma KJ. Life-threatening bronchiolitis related to electronic cigarette use in a Canadian youth. CMAJ 2019;191:E1321–31. https://doi.org/10.1503/cmaj.191402.

Hariri LP, Flashner BM, Kanarek DJ, O’Donnell WJ, Soskis A, Ziehr DR, et al. E-Cigarette Use, Small Airway Fibrosis, and Constrictive Bronchiolitis. NEJM Evid 2022;1:10.1056/evidoa2100051. https://doi.org/10.1056/evidoa2100051.

Weerakkody Y, Knipe H, Farhadi M, et al. Obliterative bronchiolitis. Reference article, Radiopaedia.org (Accessed on 11 Jun 2025) https://doi.org/10.53347/rID-11010

Schlesinger C, Veeraraghavan S, Koss MN. Constrictive (obliterative) bronchiolitis. Curr Opin Pulm Med 1998;4:288–93. https://doi.org/10.1097/00063198-199809000-00008.

Callahan SJ, Vranic A, Flors L, Hanley M, Stoler MH, Mehrad B. Sporadic Obliterative Bronchiolitis: Case Series and Systematic Review of the Literature. Mayo Clin Proc Innov Qual Outcomes 2019;3:86–93. https://doi.org/10.1016/j.mayocpiqo.2018.10.003.

Chen I-C, Hsu J-S, Chen Y-W, Liu Y-C, Wu Y-H, Hsu J-H, et al. Post-infectious Bronchiolitis Obliterans: HRCT, DECT, Pulmonary Scintigraphy Images, and Clinical Follow-up in Eight Children. Front Pediatr 2020;8. https://doi.org/10.3389/fped.2020.622065.

Jerkic S-P, Brinkmann F, Calder A, Casey A, Dishop M, Griese M, et al. Postinfectious Bronchiolitis Obliterans in Children: Diagnostic Workup and Therapeutic Options: A Workshop Report. Canadian Respiratory Journal 2020;2020:1–16. https://doi.org/10.1155/2020/5852827.

Aguilar PR, Michelson AP, Isakow W. Obliterative Bronchiolitis. Transplantation 2016;100:272–83. https://doi.org/10.1097/TP.0000000000000892.

Krishna R, Anjum F, Oliver TI. Bronchiolitis Obliterans. StatPearls [Internet], StatPearls Publishing; 2023.

Tomikawa SO, Adde FV, da Silva Filho LVRF, Leone C, Rodrigues JC. Follow-up on pediatric patients with bronchiolitis obliterans treated with corticosteroid pulse therapy. Orphanet Journal of Rare Diseases 2014;9:128. https://doi.org/10.1186/s13023-014-0128-2.

Ryu JH, Myers JL, Swensen SJ. Bronchiolar Disorders. Am J Respir Crit Care Med 2003;168:1277–92. https://doi.org/10.1164/rccm.200301-053SO.

Association AL. Popcorn Lung: A Dangerous Risk of Flavored E-Cigarettes n.d. https://www.lung.org/blog/popcorn-lung-risk-ecigs (accessed June 11, 2025).

Products C for T. FDA Issues Marketing Denial Orders for Approximately 6,500 Flavored E-Cigarette Products. FDA 2024.

Dyrektywa Parlamentu Europejskiego i Rady 2014/40/UE z dnia 3 kwietnia 2014 r. w sprawie zbliżenia przepisów ustawowych, wykonawczych i administracyjnych państw członkowskich w sprawie produkcji, prezentowania i sprzedaży wyrobów tytoniowych i powiązanych wyrobów oraz uchylająca dyrektywę 2001/37/WE Tekst mający znaczenie dla EOG. vol. 127. 2014.

Jawad M, Charide R, Waziry R, Darzi A, Ballout RA, Akl EA. The prevalence and trends of waterpipe tobacco smoking: A systematic review. PLoS ONE 2018;13:e0192191. https://doi.org/10.1371/journal.pone.0192191.

Rubio DP. EU TPD implementation report: the countdown has started. ECigIntelligence 2021. https://ecigintelligence.com/eu-tpd-implementation-report-the-countdown-has-started/ (accessed June 11, 2025).

Marques P, Piqueras L, Sanz M-J. An updated overview of e-cigarette impact on human health. Respir Res 2021;22:151. https://doi.org/10.1186/s12931-021-01737-5.

THE PRICE OF FLAVOR: BRONCHIOLITIS OBLITERANS DUE DIACETYL, VAPING, AND OCCUPATIONAL EXPOSURE

Abstract

References

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