INDEX

    E-cigarette or Vaping product use Associated Lung Injury

    Respiratory, Toxicology

    Last Updated Feb 10, 2020
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    Context

    • Vaping is the act of inhaling liquid vaporized by an electronic device. Vaping liquid typically contains nicotine or tetrahydrocannabinol (THC), as well as other diluents including artificial flavours, propylene glycol and glycerin. Vaping is generally performed for recreational use or used as a smoking cessation aid.
    • E-cigarette or Vaping product use Associated Lung Injury (EVALI) is an outbreak of acute severe respiratory illness associated with vaping.
    • As of January 2020, 2711 cases have been reported in the USA to the Centre for Disease Control (CDC) with 60 deaths confirmed. In Canada, 17 cases have been reported with no deaths. Emergency department visits related to EVALI are declining, after peaking in September 2019.

    Signs and Symptoms

    • EVALI should be considered in patients with a history of vaping who present with respiratory complaints, such as cough, chest pain and shortness of breath.
    • Patients may present with hypoxia, tachypnea and tachycardia. They may or may not have fever.
    • Many patients also report constitutional and gastrointestinal symptoms that may precede their respiratory symptoms.

    Pathophysiology

    • A clear mechanism behind EVALI has not been confirmed, though several leads have been identified.
    • The majority of samples associated with EVALI contained THC and were acquired through informal sources (ie. friends, family, online dealers).
    • Vitamin E acetate is strongly associated with EVALI. It is an adulterant added to THC oil products as a thickening agent, and it may disrupt lung surfactant and induce an inflammatory response.

    Diagnostic Process

    • There is no official recommended decision aid, but the CDC has defined specific case criteria as follows:
      • Reported use of vaping products within the last 90 days
      • Bilateral pulmonary infiltrates on chest imaging
      • Negative work-up for pulmonary infections
      • No plausible alternative diagnosis – cardiac, rheumatologic and neoplastic causes ruled out
    • Recommended approach in the emergency department:
      • Basic laboratory investigations: leukocytosis, elevated inflammatory markers (CRP and ESR) and elevated transaminases are common.
      • Chest x-ray: diffuse bilateral infiltrates.
        • If severe presentation, condition worsening or x-ray findings do not match clinical presentation, a CT chest is warranted. CT findings consistent with EVALI are nonspecific bilateral ground glass opacities and diffuse lung nodules.
      • Investigations to rule out other causes:
        • Troponin, ECG
        • Blood cultures, sputum cultures, nasopharyngeal swab for extended viral panel (influenza, RSV)
        • Consider atypical infections: Legionella urine antigen, mycoplasma NAAT
        • Consider autoimmune work-up
    • A diagnosis of EVALI requires ruling out other causes with investigations that are often beyond the scope of the emergency department, such as bronchoalveolar lavage. If considering EVALI as a potential diagnosis, patients should be referred or admitted for further work-up.

    Management

    • If clinically concerned, cover for potential infection with antibiotics and/or antivirals.
    • Treatment with steroids has resulted in rapid clinical improvement in many cases. Exact dosing and length of treatment is determined on a case-by-case basis and should be discussed with respirology.
    • If a potential EVALI patient has mild symptoms and is suitable for discharge, outpatient respirology follow up should be arranged within 24-48 hours.
    • Any suspected cases should be strongly advised to stop vaping.
    • Confirmed cases in British Columbia should be reported to the local medical health officer.

    Quality Of Evidence?

    Justification

    The quality of evidence on this topic is currently low. Due to the novel and rapidly evolving nature of the EVALI outbreak, guidelines and recommendations are based on available case literature.

    Low

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