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KEY FEATURES

Essentials of Diagnosis

  • Presentation is nonspecific

  • Illness is usually subacute

  • Respiratory, gastrointestinal, and constitutional symptoms are common

  • Tachycardia and tachypnea may also be present

General Considerations

  • No single causative agent has been identified

  • Most cases involve 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

    • Vitamin E acetate (used as a thickening agent)

  • Given the nonspecific nature of the presentation, especially during the influenza season and the COVID-19 pandemic, providers must have a high degree of clinical suspicion and ask patients specifically about vaping

Demographics

  • An outbreak of EVALI began in the United States in 2019

  • Approximately 66% of patients have been male and 80% are under age 35

CLINICAL FINDINGS

Symptoms and Signs

  • Respiratory symptoms (95%), including

    • Cough

    • Shortness of breath

    • Chest pain

    • Hemoptysis

  • Gastrointestinal symptoms (77%), including

    • Nausea

    • Vomiting

    • Diarrhea

  • Constitutional symptoms (85%), including

    • Fever

    • Chills

  • Tachycardia (55%) and tachypnea (45%)

  • Of note, 57% of patients have a recorded room air oxygen saturation of < 95%

Differential Diagnosis

  • Community-acquired pneumonia

  • COVID-19 (can be detected by reverse-transcription polymerase chain reaction (RT-PCR) testing of respiratory tract secretions, ie, expectorated sputum, nasopharyngeal swab or bronchoalveolar lavage specimens)

  • Acute eosinophilic pneumonia

  • Acute respiratory distress syndrome

  • Hypersensitivity pneumonitis

  • Lipoid pneumonia

  • Organizing pneumonia

  • Influenza (can be detected by RT-PCR testing of respiratory tract secretions, including nasopharyngeal washings, in season)

DIAGNOSIS

Laboratory Findings

  • No laboratory findings are specific for diagnosis of EVALI

  • Leukocytosis

  • Elevated C-reactive protein

  • Elevated erythrocyte sedimentation rate

Imaging

  • Chest radiographs typically show bilateral diffuse pulmonary opacities

  • Chest CT findings are nonspecific and may show bilateral distribution with ground glass densities with subpleural sparing

TREATMENT

  • Published case reports of hospitalized patients with EVALI have described rapid improvement following administration of corticosteroids

OUTCOME

Prognosis

  • Symptoms of fatigue, dyspnea, decreased exercise capacity, and cough may persist for months

  • Over 95% of reported cases required hospitalization: 47% were admitted to intensive care, 22% were intubated and many died

REFERENCES

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Jonas  AM  et al. Vaping-related acute parenchymal lung injury: a systematic review. Chest. 2020;158:155.
[PubMed: 32442559]
+
Park  JA  et al. Vaping and lung inflammation and injury. Annu Rev Physiol. 2022;84:611.
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