EVALI ecigarette or vaping associated lung injury

The term vaping has been coined to describe inhalation of various aerosols resulting from heating either a liquid or resin composed of nicotine or other compounds such as a variety of flavorings, various additive agents such as glycerol or propylene glycol, and cannabinoids. A small, portable cartridge or similar device outfitted with a battery (e-cigarettes), or vape pens, are used to deliver the aerosol. Beginning in 2019, a cluster of cases comprising individuals who were vaping was identified. These patients experienced acute to subacute lung injury characterized by shortness of breath, cough, chest pain (often pleuritic in nature), subjective fever and chills, and occasionally hemoptysis. This condition was termed e-cigarette or vaping product use-associated lung injury (EVALI). GI symptoms were common and included nausea or emesis as well as diarrhea and abdominal pain. More than 3,000 cases of EVALI have been reported to the Centers for Disease Control and Prevention, with as many as 75 deaths.

The precise pathogenesis of EVALI is unclear but appears to be a form of acute lung injury with pathologic findings of acute fibrinous pneumonitis, diffuse alveolar damage, or organizing pneumonia that is typically accompanied by bronchiolitis. No evidence of an infectious etiology has been noted, and EVALI may actually represent an array of various insults to the pulmonary parenchyma, as opposed to a discrete entity. Several descriptions have arisen from pathologic specimens in these individuals, such as acute eosinophilic pneumonia, diffuse alveolar hemorrhage, lipoid pneumonia, and respiratory bronchiolitis interstitial lung disease, suggesting that the pathogenesis is multifactorial. The key risk factor for EVALI has been active vaping by the patient. Examination of BAL samples from affected individuals has found tetrahydrocannabinol and/or vitamin E acetate in the majority of those with EVALI, the latter of which has been associated with more severe respiratory compromise in the cohort of patients studied (choice C is correct).

Although various waxes are used in certain e-cigarette devices, liquefied paraffin has not been among the materials associated with EVALI (choice A is incorrect). Hydrated magnesium silicate (talc) has been associated with talc pneumoconiosis and is one of the rarer forms of silicate-induced lung disease. It has been described in workers exposed to talc during its production or its industrial use and reported in IV drug users but has not been noted in cases of EVALI (choice B is incorrect). Volatile organic compounds, such as benzene, ethylene glycol, or formaldehyde, may include a variety of products that may result in eye, nose, and throat irritation; shortness of breath; headaches; fatigue; nausea; dizziness; and skin problems. Higher concentrations may cause irritation of the lungs, as well as damage to the liver, kidney, or CNS. However, volatile organic compound inhalation has not been noted as having a strong association in those individuals developing EVALI (choice D is incorrect).1

Footnotes

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