Vaping-Associated Lung Disease

Aka: Vaping-Associated Lung Disease, Vaping Associated Lung Injury, E-Cigarette Associated Lung Injury, EVALI

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II. Epidemiology

  1. CDC is reporting 805 Vaping-related severe lung injury cases (and 10 deaths) as of 9/25/2019
  2. Most patients affected are young and otherwise healthy

III. Mechanisms

  1. Inhalants damage lung tissue and their deposits may trigger immune-mediated foreign body reactions
  2. Acute Interstitial Lung Disease
    1. Related to diacetyl, flavorings, and solvents
  3. Lipoid Pneumonia (from oil aspiration) with Alveolar Macrophage infiltration
    1. Vitamin E and diacetyl-induced popcorn lung have also been seen with Vaping

IV. Symptoms

  1. Constitutional Symptoms (85%)
    1. Fever and chills
    2. Fatigue
    3. Weight loss
  2. Respiratory symptoms (95%)
    1. Non-productive cough
    2. Dyspnea
    3. Chest Pain
  3. Gastrointestinal Symptoms (77%)
    1. Nausea
    2. Vomiting
    3. Abdominal Pain
    4. Diarrhea

V. Signs

  1. Vital Sign Abnormalities
    1. Tachycardia (55%)
    2. Tachypnea (45%)
    3. Hypoxia (57%)
  2. Lung Exam
    1. Crackles
    2. Wheezes

VI. Labs

  1. Complete Blood Count
    1. Leukocytosis
  2. Liver Function Tests
    1. Transaminitis
  3. Inflammatory markers
    1. C-Reactive Protein (C-RP) Increased
    2. Erythrocyte Sedimentation Rate (ESR) Increased
  4. Other diagnostics
    1. Respiratory Panel
    2. Covid nasal swab
    3. Influenza nasal swab
    4. Mycoplasma pneumoniae
    5. Streptococcus Pneumoniae urine Antigen
    6. Legionella pneumophila urine Antigen
    7. Consider testing for Fungal Lung Infections, opportunistic lung infections (e.g. PJP)

VII. Imaging

  1. Chest XRay
    1. Infiltrates may be present in Atypical Pneumonia pattern
  2. CT Chest
    1. Ground glass opacities may be present

VIII. Diagnosis: CDC Criteria

  1. E-Cigarette use within 90 days of symptom onset
  2. Pulmonary Infiltrates on Chest XRay or ground glass opacities on CT Chest
  3. Infectious differential diagnosis excluded
  4. No plausible alternative diagnosis

IX. Management

  1. Consult pulmonology
  2. Admission Criteria
    1. Respiratory Distress
    2. Hypoxia
    3. Ill Appearance
    4. Significant comorbidities
  3. Hypoxia
    1. Supplemental Oxygen
    2. Noninvasive Positive Pressure Ventilation (e.g.BIPAP)
    3. Endotracheal Intubation
  4. Adjunctive
    1. High dose IV Corticosteroids
  5. Refractory, Critical Illness (e.g. cardiopulmonary collapse)
    1. ECMO

X. Resources

  1. CDC
    1. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

XI. References

  1. Tomaszekski (2019) Crit Dec Emerg Med 33(10): 23
  2. DeAustin and Sandelich (2023) Crit Dec Emerg Med 37(11): 12-4
  3. Park (2022) Annu Rev Physiol 84: 611-29 [PubMed]
  4. Kligerman (2020) Radiology 294(3): 491-505 [PubMed]

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