Overview
Definition:
Vaping-associated lung injury (VAPI), also known as E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI), is an acute, severe pulmonary illness linked to the inhalation of certain substances contained in e-cigarettes or vaping products
It is characterized by rapid onset of respiratory symptoms and evidence of lung inflammation.
Epidemiology:
While initially observed in adults, a significant rise in VAPI cases has been reported among adolescents and young adults
Prevalence data is evolving rapidly, but studies indicate a strong association with the use of tetrahydrocannabinol (THC)-containing vaping products, particularly those obtained from informal sources
The CDC reported thousands of cases and dozens of deaths primarily in this age group.
Clinical Significance:
VAPI poses a serious threat to adolescent respiratory health, potentially leading to acute respiratory failure, prolonged hospitalization, and long-term pulmonary sequelae
Understanding its presentation, diagnosis, and management is critical for pediatricians and residents preparing for DNB and NEET SS examinations, enabling timely intervention and preventing adverse outcomes.
Clinical Presentation
Symptoms:
Onset typically occurs within days to weeks of vaping
Common symptoms include progressive dyspnea, cough (often non-productive initially, then may become productive), chest pain (pleuritic or diffuse), fever, chills, and malaise
Gastrointestinal symptoms such as nausea, vomiting, abdominal pain, and diarrhea are also frequently reported.
Signs:
Physical examination may reveal tachypnea, tachycardia, hypoxemia (SpO2 < 90% on room air), and diffuse crackles or wheezes on lung auscultation
Some patients may present with signs of shock
Cyanosis may be present in severe cases
Abdominal tenderness can occur.
Diagnostic Criteria:
The CDC has established case definitions for EVALI
Key elements include: 1) History of vaping or e-cigarette product use within 90 days before symptom onset
2) Pulmonary signs and symptoms consistent with VAPI
3) Chest imaging showing bilateral opacities consistent with VAPI
4) Exclusion of other infectious or alternative causes of pulmonary infiltrates
5) No alternative physician-diagnosed condition sufficiently explaining the clinical presentation.
Diagnostic Approach
History Taking:
A detailed history is paramount
Inquire about: type of vaping device used (e-cigarette, vape pen, e-hookah)
specific liquids or substances vaped (nicotine, THC, CBD, flavorings)
source of vaping products (legal retail, informal market)
frequency and duration of use
recent changes in vaping habits
any associated symptoms
Red flags include recent initiation of vaping, use of illicit or black-market products, and co-use of other substances.
Physical Examination:
A thorough respiratory examination is essential, focusing on respiratory rate, presence of accessory muscle use, auscultation for adventitious sounds (crackles, wheezes), and assessment for hypoxemia using pulse oximetry
General assessment for signs of systemic illness, dehydration, and shock is also crucial.
Investigations:
Laboratory investigations may include complete blood count (CBC) with differential, basic metabolic panel (BMP), liver function tests (LFTs), creatine kinase (CK), urinalysis, and inflammatory markers (e.g., C-reactive protein, erythrocyte sedimentation rate)
Arterial blood gas (ABG) analysis is crucial for assessing oxygenation and ventilation
Imaging includes chest X-ray (CXR) and CT scan of the chest, which typically show bilateral reticular or ground-glass opacities, often with a predilection for the bases
DPLs may show a lymphocytic or neutrophilic exudate
Viral and bacterial etiologies should be ruled out through sputum cultures, blood cultures, and respiratory viral panels.
Differential Diagnosis:
Differential diagnoses include infectious pneumonia (bacterial, viral, fungal), acute respiratory distress syndrome (ARDS) from other causes, hypersensitivity pneumonitis, lipoid pneumonia, eosinophilic pneumonia, drug-induced lung disease, and interstitial lung diseases
Careful exclusion of these conditions based on clinical, laboratory, and imaging findings is necessary.
Management
Initial Management:
Immediate discontinuation of all vaping products is the cornerstone of management
Patients with hypoxemia require supplemental oxygen to maintain adequate saturation
Severe cases may necessitate intensive care unit (ICU) admission for close monitoring and respiratory support.
Medical Management:
Corticosteroids are the mainstay of medical therapy, often initiated empirically in moderate to severe cases
A typical regimen involves intravenous methylprednisolone (e.g., 1-2 mg/kg/day) followed by a slow oral taper, guided by clinical response and imaging
Broad-spectrum antibiotics should be considered if infection is suspected, but stopped if cultures are negative
Bronchodilators may be used for wheezing.
Surgical Management:
Surgical intervention is generally not indicated for VAPI
However, in extremely severe and refractory cases leading to respiratory failure, extracorporeal membrane oxygenation (ECMO) may be considered as a bridge to recovery or lung transplantation in select patients.
Supportive Care:
Supportive care includes meticulous fluid management, nutritional support, and continuous cardiorespiratory monitoring
Patients may require mechanical ventilation if respiratory failure progresses
Careful management of electrolyte imbalances and pain control is also important.
Complications
Early Complications:
Acute respiratory failure requiring mechanical ventilation, pneumothorax, pulmonary edema, ARDS, sepsis, electrolyte disturbances, and multi-organ dysfunction syndrome.
Late Complications:
Long-term sequelae may include persistent pulmonary fibrosis, reduced lung function (e.g., decreased diffusing capacity), chronic cough, and increased susceptibility to respiratory infections
Psychological impact and nicotine dependence also warrant consideration.
Prevention Strategies:
Public health initiatives aimed at educating adolescents about the risks of vaping and the potential for VAPI are crucial
Stricter regulation of vaping products, including ingredient disclosure and prohibition of certain additives, is essential
Healthcare providers should routinely screen adolescents for vaping use and counsel them on cessation.
Prognosis
Factors Affecting Prognosis:
Prognosis is variable and depends on the severity of illness, promptness of diagnosis and treatment, underlying health status, and the specific agents involved
Patients with milder disease and prompt treatment generally have a good prognosis
Severe ARDS, delayed treatment, and extensive lung involvement are associated with poorer outcomes.
Outcomes:
Most adolescents with VAPI experience significant improvement with appropriate medical management and cessation of vaping
However, a subset may develop chronic respiratory issues
Mortality rates, though concerning, have decreased with increased awareness and improved management protocols.
Follow Up:
Adolescents recovering from VAPI should have regular follow-up appointments to monitor for resolution of symptoms, assess lung function, and address any long-term sequelae
This includes pulmonary function tests and imaging as indicated
Continued counseling and support for vaping cessation are vital.
Key Points
Exam Focus:
Recognize VAPI as a diagnosis of exclusion in adolescents with acute respiratory illness and a history of vaping
Emphasize the role of THC-containing products and illicit sources
Recall the CDC diagnostic criteria and the importance of corticosteroid therapy.
Clinical Pearls:
Always ask adolescents about vaping history during respiratory complaints
A high index of suspicion is needed, especially with a rapid onset of symptoms after starting new vaping products
Early initiation of steroids in appropriate cases is key to a better outcome.
Common Mistakes:
Failing to inquire about vaping history, attributing symptoms solely to infection without considering VAPI, delaying steroid initiation, or discharging patients with persistent hypoxemia without adequate follow-up
Overlooking GI symptoms associated with VAPI.