Acute Lung Injury Associated With Vaping:
E-cigarette or vaping use-associated lung injury (EVALI), initially known as vaping-associated pulmonary illness (VAPI), is an acute respiratory illness characterized by a range of clinical and pathological findings resembling various lung diseases. Currently, EVALI presents as an epidemic across the United States. The Centers for Disease Control and Prevention (CDC) recommends reporting all cases of EVALI to the concerned health department to review the evaluation and treatment of vaping-associated pulmonary injury.
What Are the Causes of EVALI?
The leading cause behind EVALI is vitamin E acetate (an additive in some tetrahydrocannabinol-containing e-cigarettes), but it cannot be considered the only cause of EVALI. The other substances in vaping materials are currently being examined for a possible correlation. A report from CDC analyzed the bronchoalveolar lavage (BAL) fluid of healthy people and EVALI patients from 16 states and found vitamin E acetate in 48 out of 51 EVALI patients. No traces were found in healthy people.
How Is EVALI Diagnosed?
EVALI is diagnosed based on the following factors in accordance with the CDC criteria:
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History of using an e-cigarette in the past 90 days before the appearance of initial symptoms.
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Presence of pulmonary infiltrates indicate tissue damage (which are hazy spots on plain chest radiograph or chest CT).
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Absence of any other possible causes for the infection.
What Is the Treatment for EVALI?
The first step is to discourage the further use of vapes or e-cigarettes. Providing supportive care is the mainstream treatment of e-cigarette or vaping product use associated with lung injury (EVALI). Based on the presentation and severity of the symptoms, a decision can be made whether the patient requires hospitalization or can be managed in the outpatient ward. Decreased oxygen saturation levels, respiratory distress, and associated comorbidities indicate the requirement for patient hospitalization. Understanding and ruling out any other causes of respiratory infection are essential.
Early treatment intervention is vital in the management of influenza and other infections. Antiviral or antimicrobial drugs are administered in case of infections. Corticosteroids have been employed in treating patients with severe lung injury with the history and symptoms of EVALI ruling out any other infection.
However, in the case of patients with milder symptoms, corticosteroids are not preferred as they may worsen respiratory symptoms. Patients with milder symptoms are managed in the outpatient ward, and a pulmonologist should be consulted before administering corticosteroids. The respiratory symptoms in these patients deteriorate very rapidly, requiring them to get assisted mechanical ventilation.
When discharging the EVALI patient, the patient's clinical stability is assessed by the factors of stable oxygenation and exercise tolerance (for 24 to 48 hours before planned discharge). Within 48 hours, there must be a follow-up with the primary care provider or pulmonologist to assess their condition.
What Is the Prognosis of EVALI?
E-cigarette or vaping product use associated with lung injury (EVALI) is a potentially fatal disease. In most cases, patients require supplemental oxygen, non-invasive ventilation (NIV), intubation, and mechanical ventilation. Many patients inadvertently end up requiring invasive or non-invasive mechanical ventilation.
Factors that worsen the prognosis are patients older than 35 years of age, patients with compromised pulmonary reserve due to comorbidities, and patients with less than 95 % resting oxygen saturation levels. In patients with poor prognosis, the symptoms can rapidly deteriorate, and the patient might develop acute respiratory distress syndrome.
What Are the Complications of EVALI?
The notable complications that may present after e-cigarette or vaping product use associated with lung injury (EVALI) are:
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The need for mechanical ventilation and intubation.
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Acute respiratory distress syndrome.
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Death.
How Can the Patients Be Educated?
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Patients showing signs and symptoms of e-cigarette or vaping-associated lung injury (EVALI) should be counseled to discontinue vaping as the risk of re-hospitalization with potentially severe symptoms exists.
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People with no previous history of smoking tobacco products should not resort to vaping.
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Those trying to quit smoking and use e-cigarettes or vapes as an alternative should not get back to smoking cigarettes.
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The CDC highly condemns THC (tetrahydrocannabinol) -containing vapes or e-cigarettes (Centers for Disease Control and Prevention). If the patient uses vapes or e-cigarettes to help stop tobacco smoking, they should only buy vaping products from commercially authorized vendors.
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Other harmful ways of THC exposure, such as dabbing or dripping (a process that allows the users to inhale a high concentration of THC by aerosolizing a concentrate that has been placed on a hot surface), must be avoided altogether as it increases the risk of lung injury.
What Are the Roles of Healthcare Teams in Managing EVALI Patients?
Treatment for patients with e-cigarette or vaping product use associated with lung injury (EVALI) will require an interprofessional team. To optimize patient care in hospitalized patients, consultations with specialists from pulmonologists, medical toxicologists, critical care specialists, psychologists, infectious disease specialists, addiction medicine counselors, and psychiatric specialists should be considered. Involving a pulmonologist is essential to begin the judicious use of corticosteroids and reduce the dosage in a planned way later. For patients requiring assisted ventilation, intensivists should be onboard.
Addiction medicine specialists, psychiatrists, and psychologists should counsel the patient to quit vaping and provide a cessation strategy using evidence-based interventions for tobacco product cessation. This can also include medications and behavioral counseling. Physical therapy is used for patients who require prolonged hospitalization, especially those admitted to intensive care units. These patients must be provided solid access to mental health and substance use disorder services and social support by healthcare providers.
Conclusion:
As the proverb goes, "prevention is better than cure" it is best if individuals stay away from tobacco or tetrahydrocannabinol involving activities. If you already use these products, it is never too late to seek help to stop this habit.
