E-Cigarette or Vaping Product Use-Associated Lung Injury: A Severe Case That Responded to Corticosteroid Treatment

Abstract

Vaping is associated with an increased risk of lung injury; however, each case of vaping-associated lung injury leads to varying degrees of lung injury, and the response to therapy can be heterogeneous. Corticosteroid use has been suggested as a treatment for lung injuries associated with vaping. We report a case of e-cigarette or vaping product use-associated lung injury (EVALI) that resulted in acute hypoxic respiratory failure. A 20-year-old woman presented with complaints of sore throat, dry cough, shortness of breath, and pleuritic chest pain. The patient admitted to vaping regularly for the past three years. The patient was found to be severely hypoxemic with respiratory distress and was intubated shortly after her arrival at the emergency department. She was treated with a short course of corticosteroids with tapering of the dose based on her response with significant improvement, and she was extubated on the seventh day of her admission. EVALI is a syndrome associated with severe lung injury that results in acute respiratory failure that is clinically indistinguishable from acute respiratory distress syndrome, and it is largely a diagnosis of exclusion. The use of systemic corticosteroids in treating these patients should be considered after excluding an infectious etiology.

Fundamentals of Vaping-Associated Pulmonary Injury Leading to Severe Respiratory Distress

“…Findings in this report are deliberately intended to reflect severe VAPI that represents a minority of vaping-associated respiratory illness. Modeling severe VAPI consistent with clinical reports (10)(11)(12)(13)(14)(15)(16)(17) provides insight regarding risk factors, biological responses, and cardiopulmonary susceptibility in a dynamic marketplace attracting a diverse user base that will continue to expand for the foreseeable future. Whether vaping 27 technology or avant-garde HTP represent a lower risk for cardiopulmonary complications, respiratory illness, and cardiovascular diseases remains to be seen.…”

“…While most vapers do not experience overt symptoms of VAPI, let alone exhibit pulmonary failure, a small subset of users succumb to this type of injury. (10)(11)(12)(13)(14)(15)(16)(17) Such severe VAPI cases arise in users of commercially available vaping products, unlike the EVALI epidemic in 2019 traced back to black market "Dank Vapes" associated with ill-conceived mixing of Vitamin E acetate and THC into vape juice. (48,49) EVALI syndrome often presented as ARDS with fulminant inflammation in the respiratory tract.…”

“…(4)(5)(6) In comparison, pathological processes culminating in severe VAPI are more obscure and slow to develop, in some cases occurring over months of frequent unrelenting vaping activity. (10)(11)(12)(13)(14)(15)(16)(17) Thus, rather than model lung injury using xenobiotic agents that induce rapid and overwhelming inflammatory activity within hours such as bleomycin or meconium, (77,78) the conceptual framework for this study was to use widely available retail vaping technology and product combined with an extended exposure protocol consistent with topography of a high intensity vaper likely to develop VAPI leading to hospitalization.…”

“…Pathological outcomes of vaping vary dramatically in humans as well as laboratory models, but occurrence of severe VAPI in the clinical setting is a serious and growing concern in society. (10)(11)(12)(13)(14)(15)(16)(17) The VAPI model developed in this report provides an experimental platform for this understudied syndrome, exhibiting a collective set of distinguishing characteristics without precedent in the literature. Foremost, phenotypic manifestations are reminiscent of clinical case reports of individuals hospitalized for severe VAPI including tissue damage, inflammatory responses, and cardiopulmonary failure.…”

“…(7)(8)(9) However, Vaping-Associated Pulmonary Injury (VAPI) in a minority of users is a well documented and growing concern in the clinical setting with multiple independent reports of severe respiratory illness including Acute Respiratory Distress Syndrome (ARDS) including potential pulmonary circulation impairment. (10)(11)(12)(13)(14)(15)(16)(17) Life-threatening consequences of VAPI emphasized by high profile media coverage over the last couple of years have raised public awareness of danger linked to vaping (18)(19)(20)(21) with increased calls for regulatory oversight and expanded research. (22,23) Fundamental unresolved issues using commercial vaping products from reputable sources include 1) why do particular individuals develop VAPI; 2) what is the underlying pathogenesis of VAPI leading to respiratory distress; and 3) how does progression of VAPI precipitate pulmonary circuit failure?…”