E-cigarette or vaping product use-associated lung injury (EVALI) features and recognition in the emergency department

E-cigarette use-associated lung injury (EVALI)

The prevalence of vaping has overtaken conventional cigarettes as the most frequent form of nicotine consumption among 15-24-year olds. There are currently a large number of both legitimate and illegitimate products and suppliers offering more than 8000 different flavors of vape on the market, whose additives are not tested, studied or regulated and whose safety and toxicity profile remains unknown. In vitro studies have demonstrated a dose-dependent decrease in the viability of normal human bronchial epithelial cells after exposure to vapor from electronic vape devices.Short- and medium-term studies to date indicate that vapor-induced pulmonary lesions are the most serious and commonly reported side effect; such lesions include bilateral ground glass opacities in lung bases with subpleural preservation, bilateral infiltrates, pleural effusion, pneumomediastinum and nodular opacities. Cases of EVALI have been described in patients with daily exposure, as well as in users who reported having been exposed to these substances at least once a month. The most frequently inhaled substances are THC, flavored liquids of unknown content, and nicotine.The clinical manifestations of dyspnea and cough are the most frequent respiratory symptomatology, in addition to constitutional manifestations such as fever and chills, and gastrointestinal manifestations such as vomiting, nausea, abdominal pain and diarrhea. To these can be added the presence of tachypnea, tachycardia, elevated blood pressure, hypoxia, leukocytosis with neutrophilia and elevated ESR.

Chemical Interactions and Cytotoxicity of Terpene and Diluent Vaping Ingredients

Vaping devices have risen in popularity since their inception in 2007. The practice involves using a variety of commercially available devices. Internal heating systems in devices aerosolize e-liquid formulations of complex mixtures including an active ingredient (e.g., THC, CBD, and nicotine), diluents (or cutting agents), solvents, and flavoring agents (e.g., terpenes and aldehydes). The vaping toxicology literature consists of cytotoxicity studies of individual chemicals and commercial formulas. Because of the variation of e-liquid composition, there is a limited understanding of the toxicity of ingredient combinations. This study analyzed the cytotoxic effects after exposure to individual and binary mixtures of a representative terpene (+-R-limonene) and diluent (triethyl citrate) on human lung cell models. Data were analyzed to determine the effects of 97:3 and 80:20% v/v (triethyl citrate/limonene) binary mixtures. BEAS-2B cells, a bronchial epithelial cell, and A549 cells, a type II alveolar epithelial cell, served as models for comparison. LC₅₀ values were calculated and isobolograms were used to assess chemical interactions. Results show that limonene was more cytotoxic than triethyl citrate. Isobolographic analyses confirmed that the 97:3% v/v mixture resulted in an antagonistic chemical interaction. The 80:20% v/v mixture resulted in a similar result. Further testing of different ratios of binary mixtures is needed for chemical interaction screening to inform safety assessments.

E-vape and E-Cigarettes-Associated Lung Injury (EVALI) in the COVID-19 Pandemic: A Diagnostic Dilemma and Therapeutic Challenge

E-vape and e-cigarettes-associated lung injury (EVALI) is a diagnostic dilemma and even more obscure during the coronavirus disease 2019 (COVID-19) pandemic. A rise was seen in EVALI cases at the beginning of the COVID-19 pandemic. Still, the non-specific presentation, or the overlapping symptoms of COVID-19 and EVALI, can negate the possible diagnosis of EVALI because of a clinician's predisposition toward infectious etiologies, and it becomes even more challenging during a viral pandemic. The patient's social history remains the key distinctive point in diagnosing EVALI. Systemic steroids are generally used along with supportive care to treat patients with EVALI. This case report demonstrates the dilemma in diagnosing EVALI in a 19-year-old female during the COVID-19 pandemic.

Acute injury or illness related to the inhalation of vaping aerosols among children and adolescents across Canada: A cross-sectional survey of Canadian paediatricians

Background

Vaping prevalence rates have increased among Canadian youth. Evidence suggests that vaping poses significant health risks to children and adolescents.

Objectives

The objectives of the study were to investigate epidemiological characteristics of acute injury/illness cases due to the inhalation of vaping aerosols among children and adolescents across Canada and to explore factors contributing to severe cases.

Methods

Data from the 2019 Canadian Paediatric Surveillance Program cross-sectional survey on vaping-related injury/illness were used. Analyses focused on injury/illness cases (n=71) among children and adolescents aged 0 to 17 years who presented to participating paediatricians for a harm related to the inhalation of vaping aerosols. We conducted descriptive analyses and performed logistic regression to explore associations between severe presentations requiring hospitalization or intensive care unit (ICU) admission and selected case characteristics.

Results

Of the 71 reported injury/illness cases related to inhalation of vaping aerosols, 56% of patients were male, and 68% were aged 15 to 17 years. Nicotine vaping was reported in 42% of cases, and cannabis vaping in 24%. Fifty-four per cent presented with respiratory distress, 18% with symptoms of nicotine toxicity, and 41% required hospitalization and/or admission to the ICU. Cases presenting with respiratory distress were more likely to be hospitalized/admitted to the ICU (odds ratio [OR]=5.37, 95% confidence interval [CI]:1.76 to 16.39).

Conclusions

The inhalation of vaping aerosols among children and adolescents may contribute to acute injury/illness. Clear associations between study variables and severe cases could not be established due to a small sample size. Additional research is needed to determine predictors and preventable risk factors of severe vaping-related injuries.

High COVID-19 morbidity and mortality risk among smoked drug users in Brazil

ABSTRACT

In much of the West, including Brazil, drug use has increased since social distancing began in response to the pandemic. Use of smoked and modified drugs, and their impacts on health, may contribute to aggravate the effects of the pandemic. However, studies on the relationship between use of smoked drugs and the new coronavirus are still scarce and have not received enough attention in global health recommendations. This paper aims to briefly review the relationship between use of smoked drugs and acute respiratory syndrome coronavirus 2 [SARS-CoV-2]. Recent studies also suggest that drug consumption increases the risk of contamination by SARS-CoV-2 and leads to worse prognosis, particularly consumption of drugs that affect lung function. Use of smoked drugs, especially tobacco, is strongly associated with lung diseases that are risk factors for contamination by SARS-CoV-2. It is essential to develop strategies based on specific characteristics of drug users and for mental health professionals to be included in strategic teams. It is also necessary to invest in information campaigns regarding risks and prevention of harm caused by smoked drugs as well as to design strategies that facilitate access to psychosocial treatment during the pandemic.

A 20-Year-Old Man with e-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI) and Thrombotic Coagulopathy

BACKGROUND In 2019, the US Centers for Disease Control and Prevention (CDC) described the criteria for the diagnosis of e-cigarette or vaping product use-associated lung injury (EVALI), which may be caused by contamination of delta-9-tetrahydrocannabinoid (THC) e-liquids with vitamin E acetate. This report describes a case of a 20-year-old man with a history of recreational drug use that included vaping, who presented with EVALI and a coagulopathy associated with thrombotic events. CASE REPORT We present a 20-year-old patient who worked at a cannabidiol (CBD) manufacturing facility with a history of e-cigarette use and polysubstance abuse in remission who presented with respiratory and gastrointestinal symptoms accompanied by 50-pound weight loss over 6 months. The patient had been vaping with nicotine and THC-containing e-cigarettes multiple times per day for 1.5 years. He met the CDC surveillance criteria for EVALI, consisting of respiratory symptoms and infiltrates on imaging within 90 days of vaping, and was found to have eosinophilic pneumonia secondary to THC-containing e-cigarette use. Additionally, thrombi were detected in the pulmonary arteries, right saphenous vein, and right ventricle. A segmental infarct was noted in the inferior pole of the left kidney. CONCLUSIONS We present the second case report potentially linking e-cigarette use with clinically significant thrombogenesis, the first with both arterial and venous thromboses. This report demonstrates the importance of taking a history of e-cigarette use in patients presenting with lung injury. Although EVALI and the diagnostic criteria have only recently been described, systemic effects, including coagulopathy, are now being reported.

Coagulopathy and Acute Respiratory Distress Syndrome: Dual Complications of E-Cigarette-Associated Lung Injury

E-cigarette-associated lung injury (EVALI) is related to the usage of e-cigarettes or a related product (e.g., "vaping" or "dabbing"). It presents mainly with constitutional, respiratory, or gastrointestinal symptoms, and EVALI is currently a diagnosis of exclusion. EVALI patients are more prone to rapid clinical decline requiring close monitoring, with some requiring intensive care unit (ICU) level of care or intubation. Mortality occurs in rare cases. We are presenting an interesting case of a male in his mid-60s who presented to the emergency department with worsening dyspnea and cough for two weeks, preceded by a one-week history of fever, nausea, and diarrhea. He was diagnosed with bilateral pneumonia based on computed tomography (CT) findings. Subsequent CT of the chest showed worsening bilateral diffuse ground-glass opacities (GGOs) correlating with acute respiratory distress syndrome (ARDS). Laboratory workup showed leukocytosis and lactic acidosis. The rest of the laboratory workup was normal. The patient was intubated due to ARDS, developed multiorgan failure, and passed away subsequently.