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Key Clinical Updates in E-cigarette- and vaping product-associated lung injury (EVALI)

Diagnosis of EVALI requires reported use of e-cigarette or vaping products within 3 months of symptom onset, compatible chest imaging findings (bilateral pulmonary opacities on chest radiograph, CT findings similar to hypersensitivity pneumonitis, acute respiratory distress syndrome, diffuse alveolar hemorrhage, acute eosinophilic pneumonia, lipoid pneumonia, giant cell interstitial pneumonia, and organizing pneumonia), and an evaluation to exclude infectious etiologies.

In hospitalized patients with EVALI, rapid improvement with corticosteroids has been described.

GENERAL CONSIDERATIONS

An outbreak of e-cigarette- or vaping product–associated lung injury (EVALI) began in the United States in 2019 with reports of over 2000 cases in 49 states. The median age of reported patients is 24 years with 80% being under age 35. Over 95% of reported cases required hospitalization: 47% were admitted to intensive care, 22% were intubated, and many died. Based on the characteristics of these patients, the diagnosis of EVALI requires reported use of e-cigarette or vaping products within 3 months of symptom onset, compatible chest imaging findings, and an evaluation that excludes infectious etiologies.

No single causative agent has been identified. The majority of cases involved vaping products containing tetrahydrocannabinol (THC) or nicotine or both. Postulated factors contributing to the development of EVALI include e-cigarette flavorings, exposure to diacetyl (a popcorn flavoring that has been associated with lung injury), THC, adulteration of THC, adulteration of delivery devices, and vitamin E acetate (used as a thickening agent).

CLINICAL FINDINGS

A. Symptoms and Signs

Patients with EVALI have respiratory symptoms (95%), including cough, shortness of breath, and chest pain; gastrointestinal symptoms (77%), including nausea, vomiting, and diarrhea; and constitutional symptoms (85%), including fever, chills, and weight loss). The illness is usually acute to subacute with patients having symptoms for days to weeks before seeking healthcare.

Tachycardia and tachypnea are present in 55% and 45% of patients, respectively. Of note, 57% of cases have a recorded room air oxygen saturation of < 95%. Given the nonspecific nature of the presentation especially during influenza season and the COVID-19 pandemic, providers must have a high degree of clinical suspicion and ask patients specifically about vaping.

B. Laboratory Findings

There are no laboratory findings specific for the diagnosis of EVALI. There may be leukocytosis, elevated C-reactive protein, and elevated erythrocyte sedimentation rate.

C. Imaging

Case series of chest imaging findings in EVALI show various patterns of lung injury. Chest radiographs typically show bilateral pulmonary opacities. Chest CT has shown patterns seen in other disorders, such as hypersensitivity pneumonitis, acute respiratory distress syndrome (ARDS), diffuse alveolar hemorrhage, acute eosinophilic pneumonia, lipoid pneumonia, giant cell interstitial pneumonia, and organizing pneumonia.

DIFFERENTIAL DIAGNOSIS

The differential diagnosis is broad for a patient with respiratory and gastrointestinal ...

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