What is Vaping-Associated Pulmonary Injury?
Vaping-related lung damage, also known as VAPI or EVALI, is a condition that affects the respiratory system in a way that looks like many other lung diseases. As per the CDC’s guidelines, EVALI is diagnosed when a patient has used an e-cigarette or vaping device within the past 90 days, has cloudy spots on their lungs seen through X-ray or CT scan, and does not have any other possible causes, such as an infection. In this simplified explanation, we’ll go over what causes EVALI, how it shows up, how doctors check for it, how they treat it, and what complications can arise.
What Causes Vaping-Associated Pulmonary Injury?
Although the exact cause is still unknown, there are some potential causes being examined. One of the most frequently associated substances with lung injury caused by using e-cigarettes or vaping products (known as EVALI) is vitamin E acetate. In support of this, a recent study found vitamin E acetate in fluid samples taken from the lungs (called bronchoalveolar lavage or BAL) of 48 out of 51 patients with EVALI. But this substance was not found in lung fluid samples from healthy people.
It appears that vitamin E acetate was illegally used to thin out low-cost counterfeit cartridges that contain tetrahydrocannabinol (THC, the main active ingredient in cannabis). This practice became common in 2019, which is around the same time as the EVALI outbreak started.
However, it’s possible that other substances, including chemicals in either THC or non-THC vaping products, also play a role in causing this disease. So, the real cause can’t be completely confirmed.
Risk Factors and Frequency for Vaping-Associated Pulmonary Injury
In March 2019, an outbreak began in the USA when a group of people who used e-cigarettes started developing lung injuries. By February 2020, over 2800 individuals had landed in different hospitals in America due to lung damage linked to e-cigarettes or vaping products (referred to as EVALI), with a reported 68 deaths. Canada also had several cases.
Europe saw its first EVALI death in March 2020. There have also been random cases reported among US travelers in other countries. The number of new cases in the US has fallen dramatically due to the banning of various vaping products and the emergence of the COVID-19 pandemic. Moreover, EVALI has been reported to affect children as young as 13.
- Outbreak began in March 2019 when e-cigarette users in the USA started developing lung injuries.
- By February 2020, over 2800 people were hospitalized in the US because of EVALI, with 68 deaths reported.
- Canada, too, reported several cases.
- Europe’s first EVALI death occurred in March 2020.
- Sporadic EVALI cases have appeared among American travelers to other countries.
- The number of new EVALI cases in the US has significantly decreased due to the banning of certain vaping products and the outbreak of the COVID-19 pandemic.
- EVALI has been found in children as young as 13.
Signs and Symptoms of Vaping-Associated Pulmonary Injury
EVALI (E-cigarette or Vaping Product Use-Associated Lung Injury) is a lung condition seen in people who have used vaping products. People with EVALI can experience a variety of symptoms within 90 days of using e-cigarette devices. Symptoms might include:
- Respiratory issues such as cough, chest pain, and shortness of breath
- Gastrointestinal problems like abdominal pain, nausea, vomiting, and diarrhea
- General symptoms, such as fever, chills, or weight loss
Most of these patients are men (79% of cases) around 21 years old. The type of vaping device, the vaping frequency, the substance used, and the location of purchase are all important details to help diagnose EVALI. It was found that most EVALI patients used THC-based products before their symptoms started.
It’s important for doctors to create a trusting environment when interviewing patients about their vaping habits, as some might feel uncomfortable discussing this. On physical examination, the patient might present with fever (33% of cases), rapid heart rate (63% of cases), rapid breathing (43% of cases), and low oxygen levels; 1 in 4 patients could have an oxygen saturation of 88% or less.
EVALI symptoms can be similar to those of COVID-19, making it especially important to consider this diagnosis during the ongoing pandemic.
Testing for Vaping-Associated Pulmonary Injury
When a patient reports using vaping products in the past three months, certain tests should be performed to check their lung health. If their symptoms are mild, an X-ray of the chest is necessary. However, if the patient is having serious trouble breathing and their oxygen saturation (the amount of oxygen in their blood) is under 95%, a chest CT scan might be needed. This is particularly important if there is a high chance the patient has a certain kind of lung injury linked to e-cigarette or vaping use, known as EVALI. It’s worth noting that EVALI is only diagnosed once all other possible causes of lung injury, like pneumonia or chronic lung inflammation, have been ruled out.
Additional diagnostic tests may be conducted depending on the patient’s symptoms. These tests may include checks for respiratory viruses including COVID-19, bacteria often linked to pneumonia, and for any infections commonly found in people with HIV.
Different types of imaging can show different things. An X-ray or a CT scan of the chest can often show unclear shadows on both lungs. These shadows are often seen throughout the lungs but spare some areas, usually around the perimeter and towards the center of the lungs.
Tests like blood tests, liver function tests, and inflammation markers (tests that measure the level of inflammation in the body) should be regularly performed. A test for substance abuse, including testing for THC (the main active ingredient in cannabis), should also be performed, provided the patient consents to this test.
A procedure known as bronchoscopy, which examines the airways of the lungs, can be used to help rule out other conditions, especially when the findings from imaging tests don’t look typical for EVALI. This procedure might be especially useful for patients where an infection is highly suspected, for example in patients with weakened immune systems or those on a ventilator.
Treatment Options for Vaping-Associated Pulmonary Injury
The standard treatment for EVALI, a lung injury related to the use of e-cigarettes or vaping, is centered around managing symptoms in a supportive environment. Typically, this involves providing supplemental oxygen, either through a nasal cannula or specialized high-flow systems, to keep up the patient’s oxygen levels. The severity of the patient’s symptoms helps doctors determine if hospitalization is necessary or if the patient can be treated outside of the hospital.
Conditions like severe difficulty in breathing, other diseases that may strain the lungs, or a decrease in oxygen saturation (if it goes below 95% whilst the patient is breathing normal air) often indicate that hospitalization is necessary. In the most severe cases, the patient might need mechanical assistance in breathing, such as a ventilator. In extremely rare cases, they might need a procedure known as ECMO, which essentially stands in for your lungs to assist with the exchange of oxygen and carbon dioxide in your body.
It’s also crucial to rule out the possibility of any infections causing the symptoms. The patient needs to be evaluated for common respiratory pathogens, which are disease-causing agents like bacteria or viruses. When it’s flu season, doctors will especially consider testing for influenza. Depending on what is common in your area, your doctor might start you on antiviral or antimicrobial medication as a precautionary measure.
Patients showing severe lung damage with no apparent cause, and those who are strongly suspected to have EVALI, have shown positive responses to treatment with corticosteroids, a class of steroid hormones that reduce inflammation. However, this has not been tested formally, so corticosteroids are only recommended for those patients meeting specific EVALI criteria and who have symptoms that are getting worse or low oxygen levels.
For mild cases being managed outside of the hospital, there is limited evidence to suggest the usefulness of corticosteroids. They can actually make a respiratory infection worse, so it’s important that a lung specialist is consulted before starting the patient on corticosteroids. These patients might decline quickly and might end up needing mechanical assistance for breathing.
Before patients with EVALI are discharged from the hospital, doctors need to ensure that the patient’s condition is stable, which is determined by steady oxygen levels and an ability to tolerate exercise for 24 – 48 hours prior to planned discharge. These patients should schedule a follow-up visit with their primary care doctor or a lung specialist within 48 hours after discharge. Depending on the patient’s situation, the lung specialist might recommend follow-up tests such as measuring the lung’s capacity or a chest x-ray.
What else can Vaping-Associated Pulmonary Injury be?
During the ongoing SARS-COV2 pandemic, COVID-19 is the primary condition doctors consider when a patient comes to the emergency room with breathing trouble and show signs of lung infection on a chest X-ray. Community-acquired pneumonia is also an important possibility because it’s a common condition with severe respiratory symptoms. EVALI is a new disease that can look like other lung-related illnesses, making it hard to diagnose, but several common injuries associated with EVALI include:
- Acute eosinophilic pneumonia
- Lipoid pneumonia
- Acute lung injury and acute respiratory distress syndrome
- Acute and subacute hypersensitivity pneumonitis
- Organizing pneumonia
- Diffuse alveolar hemorrhage
- Respiratory bronchiolitis-associated pneumonitis
It’s crucial to understand that the conditions listed can occur in people who don’t use e-cigarettes, so they should also be considered when diagnosing patients with similar symptoms.
What to expect with Vaping-Associated Pulmonary Injury
E-cigarette or vaping product use-associated lung injury (EVALI) is a potentially deadly lung disease. To date, there have been 68 reported deaths. Many patients affected by EVALI may end up needing help with their breathing. In a recent study of 98 patients, up to 76% of people had to use additional oxygen, 22% needed a special form of ventilation that does not involve an invasive procedure (Non-Invasive Ventilation or NIV), and 26% had to be intubated and put on mechanical ventilation, which are more serious measures.
The picture is worse for people over 35, those with existing conditions that make their breathing weaker, and those whose oxygen saturation (the measure of oxygen in the blood) was under 95% when they are resting. These patients can get worse quickly and may even develop acute respiratory distress syndrome, which is a severe lung disease that results in a lack of oxygen in the body.
Possible Complications When Diagnosed with Vaping-Associated Pulmonary Injury
Over half of patients with EVALI, a lung injury associated with vaping, need to be admitted to the intensive care unit. The major health risks from EVALI can include:
- Acute respiratory distress syndrome – a severe lung condition?
- Respiratory failure – inability of the lungs to function correctly
- Requirement for intubation and mechanical ventilation – needing a machine to help with breathing
- Death – in severe cases
Preventing Vaping-Associated Pulmonary Injury
Patients who show signs of EVALI, an illness caused by vaping, are advised to stop vaping immediately. This is due to the high risk of ending up back in the hospital with severe symptoms. Adults who haven’t smoked tobacco in the past shouldn’t start vaping. Similarly, those who have been using e-cigarettes or vapes as a substitute for cigarettes shouldn’t go back to smoking traditional cigarettes.
The U.S. Centers for Disease Control and Prevention, or CDC for short, strongly recommends against using any vaping or e-cigarette products that contain THC, a chemical found in marijuana. Studies have shown that people who use these products more than five times a day face a higher risk of getting EVALI. If adults are using vapes or e-cigarettes as a tool to stop smoking tobacco, they should only purchase these products from officially licensed sellers.
Potentially harmful vaping practices like dabbing or dripping must be avoided. In these practices, people directly apply vape juice onto the heating part of the vape, which produces a much thicker cloud of vapor. This can increase chances of hurting your lungs.
