Clinical, Bronchoscopic, and Imaging Findings of e-Cigarette, or Vaping, Product Use–Associated Lung Injury Among Patients Treated at an Academic Medical Center

Abstract

IMPORTANCE e-Cigarette, or vaping, product use-associated lung injury (EVALI) has caused more than 2800 illnesses and 68 deaths in the United States. Better characterization of this novel illness is needed to inform diagnosis and management. OBJECTIVE To describe the clinical features, bronchoscopic findings, imaging patterns, and outcomes of EVALI. DESIGN, SETTING, AND PARTICIPANTS This case series of 31 adult patients diagnosed with EVALI between June 24 and December 10, 2019, took place at an academic medical center in Salt Lake City, Utah. EXPOSURES e-Cigarette use, also known as vaping. MAIN OUTCOMES AND MEASURES Symptoms, laboratory findings, bronchoscopic results, imaging patterns, and clinical outcomes. RESULTS Data from 31 patients (median [interquartile range] age, 24 [21-31] years) were included in the study. Patients were primarily men (24 [77%]) and White individuals (27 [87%]) who used e-cigarette products containing tetrahydrocannabinol (THC) (29 [94%]). Patients presented with respiratory (30 [97%]), constitutional (28 [90%]), and gastrointestinal (28 [90%]) symptoms. Serum inflammatory markers were elevated in all patients. Bronchoscopy was performed in 23 of 28 inpatients (82%) and bronchoalveolar lavage (BAL) revealed the presence of lipid-laden macrophages (LLMs) in 22 of 24 cases (91%). BAL samples tested positive for Pneumocystis jirovecii (3 patients [13%]), rhinovirus (2 patients [8%]), human metapneumovirus and Aspergillus (1 patient each [4%]); all except human metapneumovirus were determined to be false-positives or clinically inconsequential. The exclusive or dominant computed tomography (CT) pattern was organizing pneumonia in 23 of 26 cases (89%). Patients received antibiotics (26 [84%]) and corticosteroids (24 [77%]), and all survived; 20 patients (65%) seen in follow-up showed marked improvement, but residual symptoms (13 [65%]), radiographic opacities (8 [40%]), and abnormal pulmonary function tests (8 of 18 [44%]) were common. CONCLUSIONS AND RELEVANCE In this case series, patients with EVALI characteristically presented with a flu-like illness with elevated inflammatory markers, LLMs on BAL samples, and an organizing pneumonia pattern on CT imaging. Bronchoscopic testing for infection had a high incidence of false-positive results. Patients had substantial residual abnormal results at early (continued) Key Points Question What are the typical clinical, radiographic, and bronchoscopic findings and clinical outcomes of e-cigarette, or vaping, product use-associated lung injury (EVALI)? Findings This case series of 31 patients found that EVALI typically presented as a flu-like illness with elevated inflammatory markers and an organizing pneumonia pattern on computed tomography imaging. Bronchoscopy showed lipid-laden macrophages and had a high rate of false-positive results for infection. Meaning The findings of this study suggest that EVALI has a characteristic clinical and radiographic presentation and that bronchoscopy has limited utility in its evaluation.

Electronic Cigarette Use Is Not Associated with COVID-19 Diagnosis

“…Given the deleterious effects of e-cigarette use on lung function, 12 it is possible that even if e-cigarette use does not increase the risk of developing infection, it could still increase the severity of disease, as may be the case for conventional cigarettes. 2 Although e-cigarettes have the well-documented potential for harm, 13,14 and the COVID-19 pandemic presents an opportunity to reduce e-cigarette use, [15][16][17] our study found that such use does not appear to increase susceptibility to SARS-CoV-2 infection among patients seeking medical care. This result suggests the hypothesis that any effects of conventional cigarette smoking on susceptibility are not mediated by nicotine.…”

CT Findings and Patterns of e-Cigarette or Vaping Product Use-Associated Lung Injury

“…The DAH pattern was defined as patchy or multifocal GGO, consolidation, or both with superimposed acinar ground-glass centrilobular nodules (CNs) filling most of the secondary lobule. 9,11,19,20 Unlike other patterns, DAH could be asymmetrical. All patients with a DAH pattern had to have either bronchoscopic confirmation of DAH or witnessed hemoptysis.…”

Lung Damage Caused by Heated Tobacco Products and Electronic Nicotine Delivery Systems: A Systematic Review

“…Patients with EVALI presented leukocytosis, elevated erythrocyte sedimentation rate, and high C-reactive protein levels in peripheral blood. The BALF showed a predominance of macrophages and neutrophils; chest radiography revealed multifocal, multilobar opacities, variable in extent and distribution, consistent with foci of alveolar consolidation [ 82 ], with the presence of vitamin E acetate in some reports [ 83 ]. The most frequent clinical presentation included shortness of breath, cough, chest pain, gastrointestinal symptoms such as abdominal pain, nausea, and vomiting, and neurologic symptoms including headache, lethargy, and confusion [ 84 ].…”