Pathological findings in suspected cases of e-cigarette, or vaping, product use-associated lung injury (EVALI): a case series

Reagan‐Steiner, Sarah; Gary, Joy; Matkovic, Eduard; Ritter, Jana M.; Shieh, Wun‐Ju; Martines, Roosecelis B; Werner, Angela; Lynfield, Ruth; Holzbauer, Stacy; Bullock, Hannah; Denison, Amy M.; Bhatnagar, Julu; Bollweg, Brigid C.; Patel, M.; Evans, Mary; King, Brian A.; Rose, Dale A.; Baldwin, Grant T.; Jones, Christopher M.; Krishnasamy, Vikram; Briss, Peter A.; Weissman, David N.; Meaney‐Delman, Dana; Zaki, Sherif R.; Jatlaoui, Tara C.; Koumans, Emilia H.; Kiernan, Emily; Petersen, Emily E.; Karwowski, Mateusz P.; Valentín-Blasini, Liza; Blount, Benjamin C.; Cummings, Kristin J.; Ghinai, Isaac; Feder, K.; Wells, Eden V.; Turabelidze, George; Byers, Paul D.; Tanz, Lauren J.; Navarette, Kristen; Ramadugu, Kirtana; Dewart, Courtney; Miller, Jeffrey A.; Squires, Kelly; Marsden, Lily; Fields, Cheryl A.

doi:10.1016/s2213-2600(20)30321-0

Cited by 34 publications

(25 citation statements)

References 29 publications

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“…EVALD is not a single condition, but an umbrella term which covers multiple different pathologies. Furthermore, the requirement to eliminate other causes of diffuse alveolar damage is not straightforward [64,65]. Those with pre-existing lung disease are surely not immune from e-cigarette toxicity; if a teenager with, for example, a surfactant protein C mutation deteriorates after vaping, is that EVALI/EVALD or an acute interstitial lung disease lung attack?…”

Section: Definitions: Evali or Evaldmentioning

confidence: 99%

Unfriendly Fire: How the Tobacco Industry is Destroying the Future of Our Children

Bush

Ferkol

Valiulis

et al. 2021

AML

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Tobacco has long been known to be one of the greatest causes of morbidity and mortality in the adults, but the effects on the foetus and young children, which are lifelong, have been less well appreciated. Developing from this are electronic nicotine delivery systems or vapes, promulgated as being less harmful than tobacco. Nicotine itself is toxic to the foetus, with permanent effects on lung structure and function. Most vapes contain nicotine, but they also contain many other compounds which are inhaled and for which there are no toxicity studies. They also contain known toxic substances, whose use is banned by European Union legislation. Accelerating numbers of young people are vaping, and this does not reflect an exchange of vapes for cigarettes. The acute toxicity of e-cigarettes is greater than that of tobacco, and includes acute lung injury, pulmonary haemorrhage and eosinophilic and lipoid pneumonia. Given the worse acute toxicity, it should be impossible to be complacent about medium and long term effects of vaping. Laboratory studies have demonstrated changes in lung proteomics and the innate immune system with vaping, some but not all of which overlap with tobacco. It would be wrong to consider vapes as a weaker form of tobacco, they have their own toxicity. Children and young people are being targeted by the vaping industry (which is largely the same as the tobacco industry), including on-line, and unless an efficient legislative program is put in place, a whole new generation of nicotine addicts will result.

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Section: Definitions: Evali or Evaldmentioning

confidence: 99%

Unfriendly Fire: How the Tobacco Industry is Destroying the Future of Our Children

Bush

Ferkol

Valiulis

et al. 2021

AML

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“…Since 2018, serious pulmonary adverse effects from use of ENDS have been noted to be the rise. In 2019, the United States Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) began investigating a national outbreak of EC or vaping product use-associated lung injury (EVALI) ( Reagan-Steiner et al., 2020 ). EVALI led to hospitalizations, as a result of serious acute to subacute lung injury, and fatalities.…”

Section: Introductionmentioning

confidence: 99%

A robotic system for real-time analysis of inhaled submicron and microparticles

et al. 2021

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Vitamin E acetate (VEA) has been strongly linked to outbreak of electronic cigarette (EC) or vaping product use-associated lung injury. How VEA leads to such an unexpected morbidity and mortality is currently unknown. To understand whether VEA impacts the disposition profile of inhaled particles, we created a biologically inspired robotic system that quantitatively analyzes submicron and microparticles generated from ECs in real-time while mimicking clinically relevant breathing and vaping topography exactly as happens in humans. We observed addition of even small quantities of VEA was sufficient to alter size distribution and significantly enhance total particles inhaled from ECs. Moreover, we demonstrated utility of our biomimetic robot for studying influence of nicotine and breathing profiles from obstructive and restrictive lung disorders. We anticipate our system will serve as a novel preclinical scientific research, decision-support tool when insight into toxicological impact of modifications in electronic nicotine delivery systems is desired.

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“…Vitamin E acetate (VEA) inside tetrahydrocannabinol (THC) vaping devices was identified as the most likely indicator of injury [ 1 , 2 ]. Acute lung injury has been reported in EVALI lung biopsies and autopsies [ 3 , 4 ], and it has been hypothesized that VEA may have chemically reacted to create toxic ketene (ethenone) in the presence of high temperatures [ 5 ]. Because chemical reactions can be catalyzed on the surfaces of ceramics or metals such as nickel (Ni) or cobalt (Co) [ 6 , 7 ], any ceramics or metals present inside the vaping devices could further enhance these reactions [ 8 ].…”

Section: Introductionmentioning

confidence: 99%

Vaping cartridge heating element compositions and evidence of high temperatures

2020

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Background Identifying the functional materials inside vaping devices can help inform efforts to understand risk. While nicotine E-cigarette components and metals have been characterized in several previous studies, the internal component compositions of tetrahydrocannabinol (THC) cartridge designs are not as well known. The 2019-20 e-cigarette or vaping product use associated lung injury (EVALI) outbreak has been associated with THC devices containing vitamin E acetate (VEA), possibly mediated by chemical reactions with internal cartridge components and high filament temperatures. Methods We investigate the composition and internal components of 2019 EVALI patient-associated THC vaping devices compared to other THC and nicotine devices from 2016-19, specifically the metal, ceramic, and polymer components likely to be exposed to heat. To do this, we have disassembled forty-eight components from eight used and unused vaping devices under a microscope and analyzed them using X-ray fluorescence, scanning electron microscopy, and Fourier-transform infrared micro-spectroscopy. Conclusions The two THC cartridges used by EVALI patients exhibited evidence of localized high temperatures, including charring of the ceramic heating elements and damaged wire surfaces. The newer THC cartridges possessed more ceramic and polymer insulation than older THC or nicotine devices. The combination of ceramics, metals, and high temperatures in newer THC cartridges is consistent with conditions hypothesized to produce VEA reactions during vaping. Nickel and chromium components were detected in all devices, and others contained copper, lead, tin, gold, silicon-rich rubbers, or fluorinated microplastics. These components have the potential to thermally degrade and volatilize if heated sufficiently. These

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Pathological findings in suspected cases of e-cigarette, or vaping, product use-associated lung injury (EVALI): a case series

Cited by 34 publications

References 29 publications

Unfriendly Fire: How the Tobacco Industry is Destroying the Future of Our Children

Unfriendly Fire: How the Tobacco Industry is Destroying the Future of Our Children

A robotic system for real-time analysis of inhaled submicron and microparticles

Vaping cartridge heating element compositions and evidence of high temperatures

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