Articles
E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach

https://doi.org/10.1016/S2213-2600(19)30415-1Get rights and content

Summary

Background

Since June, 2019, more than 1000 new cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported in the USA. Patients presented with dyspnoea, cough, and were found to be hypoxaemic with bilateral airspace opacities on chest imaging. Most patients required management in the intensive care unit and steroid therapy. All patients recovered with cessation of vaping, supportive care, and steroid therapy and remained symptom free at follow up. E-cigarette use continues to rapidly escalate in the USA, particularly among youth.

Methods

Cases were defined as patients admitted to the University of Rochester Medical Center (Rochester, NY, USA) who had used e-cigarettes or another vaping device in the 30 days before presentation, and who had bilateral airspace opacification on chest imaging (CT or x-ray). Case details were obtained via medical record review and patient interviews over the past 3 months including symptomatology, physical exam data, imaging studies, laboratory data, vaping history, and subsequent outpatient follow-up data. In collaboration with the New York State Department of Health, our hospital developed a novel clinical practice algorithm based on statewide physician feedback along with input from experts in environmental health, medical toxicology, infectious disease, epidemiology, and chronic disease prevention.

Findings

We report 12 cases treated for suspected EVALI at our medical centre between June 6, 2019, and Sept 15, 2019. Ten (83%) patients had dyspnoea, fever, and emesis and nine (75%) had cough. 11 (92%) patients reported the use of e-cigarette cartridges containing tetrahydrocannabinol oil. Although eight (67%) patients required admission to the intensive care unit for hypoxaemic respiratory failure, no deaths occurred. The median hospitalisation duration was 7 days (IQR 7–8). All patients completing follow up (6 [50%]) had resolution of previous chest CT findings and normal spirometry. The clinical algorithm focuses on the key signs and symptoms of EVALI and the importance of ruling out infection and other cardiopulmonary conditions before making a presumptive diagnosis of EVALI.

Interpretation

Patients with suspected EVALI in our cohort had life-threatening hypoxaemia, with 67% requiring management in the intensive care unit. Despite the severity of presentation, similar to previous reports of patients with EVALI, most patients improved within 1–2 weeks of initial presentation after vaping cessation and administration of systemic corticosteroids when needed. Almost all (92%) patients with suspected EVALI reported vaping a THC product, making THC containing e-liquids or oils a key focus on the ongoing nationwide investigations into the cause of EVALI. Additional research is required to understand the potential toxins, underlying pathophysiological mechanisms, and identification of susceptible individuals at higher risk for hospitalisation due to EVALI. To our knowledge we present the first clinical practice algorithm for the evaluation and management of EVALI, which will be useful for both acute management and improved accurate reporting of this life-threatening respiratory illness.

Funding

None.

Introduction

The use of e-cigarettes has surged worldwide since 2000.1, 2 E-cigarettes are devices that allow users to aerosolise (vape) liquid, which can contain nicotine or other substances, and are sometimes flavoured (e-liquid).3 Since their introduction in 2007, the USA has seen an increase in number of e-cigarette users and in vaping of non-nicotine liquids, such as tetrahydrocannibidiol (THC), cannabidiol (CBD), and other unknown substances.3, 4

Many e-cigarette formulations come in attractive flavours to appeal to young adults and teenagers who tend to experiment and modify the product being vaped and the vaping method itself. New methods of inhalation, such as dabbing, have changed the content and properties of the compounds delivered to the pulmonary system. Dabbing is defined as the “consumption of cannabis whereby a cannabis concentrate is volatilised via application to a hot platform (holder) and the vapour is subsequently passed through a water pipe and inhaled by the end user”.5 The use of a metal platform during dabbing introduces the risk of inhaling solder, rust, and benzene, which are released at higher temperatures.3, 6, 7

Research in context

Evidence before this study

We first searched PubMed on Sept 10, 2019, with the search terms “e-cigarette”OR “e-cigarettes”OR “vaping” AND “pulmonary disease”. We have been repeating this search to ensure we have included the most relevant and up-to-date information. This search revealed several case reports or case series detailing other cases of e-cigarette, or vaping, product use associated lung injury (EVALI). The US Centers for Disease Control and Prevention (CDC) has been tracking cases nationally and provided clinical guidance via its website and series of publications in the Morbidity and Mortality Weekly Report (MMWR). This guidance gave helpful information regarding the presenting symptoms of cases and the types of exposures patients encountered. Current data on EVALI are limited by challenges in accurate patient and provider reporting in part due to a lack of a standardised algorithm for workup and management of this condition. We independently developed a clinical algorithm for the diagnosis, medical management, and reporting of EVALI based upon our case series of 12 patients reported presently, as well as the emerging information on this outbreak available statewide and nationally.

Added value of this study

To our knowledge, this is the first study presenting a clinical practice algorithm meant for direct patient care of EVALI. The current case definition and clinical guidance available from CDC provides useful general principles, which has been enhanced presently through the experience we have gained in the 12 patient case series. We present a practical algorithm for efficient screening, diagnosis, and medical management of EVALI. This case series also highlights the important challenge of post hospitalisation follow up on patients and the degree to which the severe changes in imaging and symptoms can improve with the cessation of vaping and systemic corticosteroids (in severe cases).

Implications of all the available evidence

A significant proportion of the EVALI cases reported here had exposure to aerosolised tetrahydrocannabinol oil, also consistent with national reports by the CDC. Most patients improved within 1–2 weeks of initial presentation after vaping cessation and administration of systemic corticosteroids when needed. Our clinical practice algorithm is similar in content to the recommendations provided by the CDC, though our algorithm focuses on vaping activity within the past 30 days and is arranged to allow for efficient exclusion of cases that bear no similarity to our current understanding of EVALI. Further research is needed to identify the inciting toxins of EVALI, underlying pathophysiology behind acute hypoxaemic respiratory failure, and the susceptibility of hospitalised individuals.

One of the most popular methods of vaping involves a cartridge-based device normally filled with nicotine salts to deliver an aerosol to the user.8 Although cartridge-based systems are normally a closed non-modifiable system, users can modify the liquid composition within the cartridges. For the third-generation and fourth-generation refillable tank-based systems, users can enhance battery power and add any liquid that they choose. Any modification to either the e-liquid or the device itself has the potential to substantially change the chemical profile of the aerosol created.

Lung disease related to vaping has been previously documented mainly via isolated case reports with varied presentations, including mechanical injury (spontaneous pneumothorax), pneumonias (organising, eosinophilic, and lipoid), or hypersensitivity pneumonitis without any single uniting entity.9, 10 Additionally, some additives have been shown to cause oxidative stress on lung epithelium.5

Since June, 2019, health-care professionals have documented 1888 cases of acute lung injury related to vaping in the USA.11 Presentations range from mild dyspnoea to acute hypoxaemic respiratory failure requiring mechanical ventilation, and have been associated with the use of THC-containing e-liquids among other types.11 Despite maximal medical therapy, 37 patients have died.12, 13, 14, 15 The accumulation of cases of e-cigarette, or vaping, product use associated lung injury (EVALI) has attracted the attention of the general public, elected public officials, and law makers.16 Given the recency of these cases, there is no evidence-based approach to the diagnosis and management of patients who present with a history of vaping and dyspnoea. With the vast expansion of available devices and liquids (including THC oil), it is not surprising that the heterogeneity in presentation and case severity has in turn increased in the USA.17 With the strict regulations on e-liquids and e-cigarettes present in other countries, such as the UK, the risk of a similar outbreak of illness is likely to be lower; however, at least one case has been reported of lipoid pneumonia due to vaping.18

The presentation of a respiratory illness without any other known factors except vaping history leaves a broad differential diagnosis to consider. In this article, we summarise the clinical presentations of patients with probable and confirmed EVALI seen at a single academic medical centre, with a focus on diagnostic testing and clinical management. Additionally, we describe how coordination of efforts between multiple departments within the institution, the New York State Department of Health, and the New York City and Upstate New York Poison Control Centers has led to a consensus on testing and work up of patients in New York State.

Section snippets

Case finding and investigations

We present a retrospective case series of patients presenting to a single academic medical centre (the University of Rochester Medical Center [URMC], Rochester, NY, USA]) over a period of 2 months with respiratory failure of unknown origin and history of e-cigarette or vape use. All patients had bilateral ground glass opacities on chest imaging (CT and x-ray) and unrevealing past medical histories (ie, nothing to indicate a potential source of lung injury). An extensive workup was performed

Results

Between June 1, 2019, and Sept 15, 2019, a total of 12 patients were admitted to URMC with suspected EVALI. The median age of these cases was 27 years (IQR 21–35) years and seven (58%) patients were men. All 12 patients were reportedly healthy with no functional deficits before presentation. Only three (25%) had a documented history of pre-existing pulmonary disease (asthma).

Patients typically had symptoms for around 1 week before presentation (median of 7 days [IQR 6·5–10]). The presenting

Discussion

This is a case series of 12 patients presenting with respiratory failure, gastrointestinal symptoms, and evidence of systemic inflammation in the context of vaping, ultimately attributed to EVALI. Patients in this case series had increased oxygen requirements and none had positive results for infectious disease. All patients had bilateral airspace opacification on chest imaging. All patients recovered and were discharged on room air, with a median length of stay in the hospital of 7 days. Of

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