E‐cigarette or vaping product use‐associated lung injury (EVALI) features and recognition in the emergency department

Abstract

Since August 2019, the pulmonary disease termed e‐cigarette or vaping product‐use associated lung injury (EVALI), has resulted in 2758 hospitalizations and 64 deaths in the United States. EVALI is considered in patients who have vaped or dabbed within 90 days of symptom onset, and have abnormal lung imaging in the absence of any pulmonary infection. The majority of EVALI patients are otherwise healthy adolescents and young adults. The leading etiology of EVALI is contamination of delta‐9‐tetrahydrocannabinoid (THC) e‐liquids with vitamin E acetate. Although the exact pathophysiology of vitamin E acetate‐induced lung injury is unknown, vitamin E acetate may lead to pulmonary lipid accumulation and/or interfere with surfactant functioning. EVALI symptoms are vague but consist of a constellation of constitutional, pulmonary, and gastrointestinal symptoms. Patients often present multiple times to healthcare facilities as their clinical condition worsens with a considerable mortality risk. The diagnosis of EVALI hinges on obtaining history leading to the recognition of vaping/dabbing. Physicians need to be persistent, but nonjudgmental, in obtaining vaping histories, especially in THC‐prohibited states. Radiographical findings of nonspecific bilateral ground‐glass infiltrates are best detected on computed tomography. Management for EVALI requires a multidisciplinary approach focused on supportive respiratory care and ruling‐out infectious causes. Corticosteroids may be of benefit. Most patients who are hypoxic, have comorbidities, or lack appropriate follow‐up within 24–48 hours should be admitted for monitoring. Patients may benefit from substance abuse counseling and should be instructed to avoid vaping. As the outbreak continues, cases should be reported to local health departments and poison control centers.

Coagulopathy and Acute Respiratory Distress Syndrome: Dual Complications of E-Cigarette-Associated Lung Injury

“…The patient met EVALI criteria based on 1) use of an e-cigarette or a related product (e.g., “vaping” or “dabbing”) in the previous 90 days; 2) lung opacities on the chest radiograph or CT scan; 3) exclusion of lung infection; 4) absence of a likely alternative diagnosis (e.g., cardiac, neoplastic, rheumatologic) [ 7 - 8 ]. The diagnosis is further supported by his initial presentation of gastrointestinal symptoms preceding the ARDS.…”

E-vape and E-Cigarettes-Associated Lung Injury (EVALI) in the COVID-19 Pandemic: A Diagnostic Dilemma and Therapeutic Challenge

“…E-cigarettes are devices that aerosolize nicotine-based or cannabis-based concentrates mixed with other solvents. E-vape and e-cigarettes-associated lung injury (EVALI) is an inflammatory response in the lungs from the inhalation of vapes formed from the products in e-cigarettes and should be suspected with use within 90 days of symptom onset [ 2 ]. EVALI is particularly prevalent among the youth [ 2 ].…”

“…E-vape and e-cigarettes-associated lung injury (EVALI) is an inflammatory response in the lungs from the inhalation of vapes formed from the products in e-cigarettes and should be suspected with use within 90 days of symptom onset [ 2 ]. EVALI is particularly prevalent among the youth [ 2 ]. Patients with EVALI may experience life-threatening hypoxemia, requiring critical monitoring [ 1 ].…”

A 20-Year-Old Man with e-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) and Thrombotic Coagulopathy

“…It remains a diagnosis of exclusion, based on symptoms, history of recent e-cigarette use, vital signs, and imaging studies. While not intended for diagnostic purposes, the CDC’s surveillance criteria for confirmed EVALI cases include the following: (1) E-cigarette use within 90 days of symptom onset, (2) presence of pulmonary infiltrates on imaging, and (3) negative workup for pulmonary infections or other disease processes [ 7 – 10 ]. Acute eosinophilic pneumonia, diagnosed by >25% eosinophils on bronchoalveolar lavage (BAL), in addition to characteristic symptoms (febrile illness and hypoxemic respiratory failure), with a detailed history and clinical evaluation, is yet another complication of e-cigarette use, albeit rarely reported.…”