Suggested management of e-cigarette or vaping product use associated lung injury (EVALI)

Exposure to Aldehyde Cherry e-Liquid Flavoring and Its Vaping Byproduct Disrupt Pulmonary Surfactant Biophysical Function

Over the past decade, there has been a significant rise in the use of vaping devices, particularly among adolescents, raising concerns for effects on respiratory health. Pressingly, many recent vaping-related lung injuries are unexplained by current knowledge, and the overall implications of vaping for respiratory health are poorly understood. This study investigates the effect of hydrophobic vaping liquid chemicals on the pulmonary surfactant biophysical function. We focus on the commonly used flavoring benzaldehyde and its vaping byproduct, benzaldehyde propylene glycol acetal. The study involves rigorous testing of the surfactant biophysical function in Langmuir trough and constrained sessile drop surfactometer experiments with both protein-free synthetic surfactant and hydrophobic protein-containing clinical surfactant models. The study reveals that exposure to these vaping chemicals significantly interferes with the synthetic and clinical surfactant biophysical function. Further atomistic simulations reveal preferential interactions with SP-B and SP-C surfactant proteins. Additionally, data show surfactant lipid-vaping chemical interactions and suggest significant transfer of vaping chemicals to the experimental subphase, indicating a toxicological mechanism for the alveolar epithelium. Our study, therefore, reveals novel mechanisms for the inhalational toxicity of vaping. This highlights the need to reassess the safety of vaping liquids for respiratory health, particularly the use of aldehyde chemicals as vaping flavorings.

Impact of vaping on respiratory health

Widespread uptake of vaping has signaled a sea change in the future of nicotine consumption. Vaping has grown in popularity over the past decade, in part propelled by innovations in vape pen design and nicotine flavoring. Teens and young adults have seen the biggest uptake in use of vape pens, which have superseded conventional cigarettes as the preferred modality of nicotine consumption. Relatively little is known, however, about the potential effects of chronic vaping on the respiratory system. Further, the role of vaping as a tool of smoking cessation and tobacco harm reduction remains controversial. The 2019 E-cigarette or Vaping Use-Associated Lung Injury (EVALI) outbreak highlighted the potential harms of vaping, and the consequences of long term use remain unknown. Here, we review the growing body of literature investigating the impacts of vaping on respiratory health. We review the clinical manifestations of vaping related lung injury, including the EVALI outbreak, as well as the effects of chronic vaping on respiratory health and covid-19 outcomes. We conclude that vaping is not without risk, and that further investigation is required to establish clear public policy guidance and regulation.

Puff bars: a dangerous trend in adolescent disposable e-cigarette use

PURPOSE OF REVIEW

Puff Bars, a brand of disposable e-cigarettes, have skyrocketed in popularity recently, presenting significant health and safety risks to adolescents. Puff Bars and other disposable e-cigarette products are attractive to children and teenagers because of their vibrant colors and flavors, low cost, and ease of access. This review examines the rise in Puff Bar popularity, describes notable health and safety concerns, and provides advice for parents and pediatricians in identifying and preventing adolescent Puff Bar use.

RECENT FINDINGS

Puff Bars have increased in popularity as their product design evaded strict regulations imposed on alternate e-cigarette products, such as Juul. In addition, Puff Bars' sweet and fruit flavors and marketing on social media have made their use pervasive among youth. Puff Bar use can lead to increased risk of e-cigarette product use-associated lung injury (EVALI) and potential exposure to carcinogens. Furthermore, the developmental risks of nicotine use during adolescence include negative effects on cognitive function and detriments to short-term memory.

SUMMARY

Puff Bars present a significant danger to adolescents, and it is imperative that parents and pediatricians are aware of the health risks involved with vaping. Pediatricians should explore e-cigarette use during patient visits, and parents must communicate these dangers to their children and be able to identify these products to regulate their use.

COVID or Not COVID? A Great Mimicker Behind the Smoke Screen

Vaping is becoming increasingly popular as an alternative to cigarettes. However, vaping does not come without risks; electronic cigarette (e-cigarette) and vaping-associated lung injury (EVALI) is one of the most severe consequences. Coronavirus disease 2019 (COVID-19) and bacterial pneumonia cases often present with almost identical features. We present a case of a young man who presented with pneumonia that was initially thought to be related to COVID-19 infection but later diagnosed as EVALI. Clinicians should have a high suspicion of EVALI in patients who present with hypoxemia and negative infectious workup, particularly during the COVID-19 era. Administration of corticosteroids has shown remarkable efficacy in improving hypoxemia; however, many patients may have chronic lung injury and may require oxygen long-term. Cases of EVALI should continue to be reported and followed up long term for monitoring disease outcomes.

Extracorporeal Life Support for Respiratory Failure in Patients With Electronic Cigarette or Vaping Product Use-Associated Lung Injury

OBJECTIVES

Electronic cigarette or vaping product use-associated lung injury is a clinical entity that can lead to respiratory failure and death. Despite the severity of electronic cigarette or vaping product use-associated lung injury, the role of extracorporeal life support in its management remains unclear. Our objective was to describe the clinical characteristics and outcomes of patients with electronic cigarette or vaping product use-associated lung injury who received extracorporeal life support.

DESIGN

We performed a retrospective review of records of electronic cigarette or vaping product use-associated lung injury patients who received extracorporeal life support. Standardized data were collected via direct contact with extracorporeal life support centers. Data regarding presentation, ventilatory management, extracorporeal life support details, and outcome were analyzed.

SETTING

This was a multi-institutional, international case series with patients from 10 different institutions in three different countries.

PATIENTS

Patients who met criteria for confirmed electronic cigarette or vaping product use-associated lung injury (based on previously reported diagnostic criteria) and were placed on extracorporeal life support were included. Patients were identified via literature review and by direct contact with extracorporeal life support centers.

MEASUREMENTS AND MAIN RESULTS

Data were collected for 14 patients ranging from 16 to 45 years old. All had confirmed vape use within 3 months of presentation. Nicotine was the most commonly used vaping product. All patients had respiratory symptoms and radiographic evidence of bilateral pulmonary opacities. IV antibiotics and corticosteroids were universally initiated. Patients were intubated for 1.9 days (range, 0-6) prior to extracorporeal life support initiation. Poor oxygenation and ventilation were the most common indications for extracorporeal life support. Five patients showed evidence of ventricular dysfunction on echocardiography. Thirteen patients (93%) were placed on venovenous extracorporeal life support, and one patient required multiple rounds of extracorporeal life support. Total extracorporeal life support duration ranged from 2 to 37 days. Thirteen patients survived to hospital discharge; one patient died of septic shock.

CONCLUSIONS

Electronic cigarette or vaping product use-associated lung injury can cause refractory respiratory failure and hypoxemia. These data suggest that venovenous extracorporeal life support can be an effective treatment option for profound, refractory respiratory failure secondary to electronic cigarette or vaping product use-associated lung injury.