Vaping as the Cause of EVALI (E-cigarette or Vaping Product Use–Associated Lung Injury), a pulmonary disease that can be severe and potentially life-threatening. The term was coined at the same time the disease was first recognized in August 2019. It is important to clarify that EVALI is not a clinical diagnosis but a case definition for surveillance.

Vaping can lead to a wide range of severe adverse health effects, including nicotine poisoning, injuries due to battery explosions from these devices, and damage to the gastrointestinal, cardiovascular, and neurological systems. The rapid adoption of this harmful practice, particularly among young people, has made EVALI a serious public health issue. In this blog, we summarize some of the most important points on this topic.

On the other hand, several definitions of EVALI have been proposed based on the combination of clinical characteristics and patient history. The most commonly used definition is based on the CDC guidelines, which were developed to assist in identifying probable and confirmed cases, thus allowing for standardized reporting and monitoring in the context of an outbreak. Clinically, patients develop hypoxemia that requires supplemental oxygen and signs of systemic inflammation indicated by leukocytosis.

Similarly, according to the document "Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association," there are three types of symptoms that are commonly present in cases of EVALI:

Prominent Gastrointestinal Symptoms. These have been a common primary complaint, affecting over 80% of patients.

General Systemic Symptoms. These include subjective fever, chills, and fatigue, which have been frequently reported.

Respiratory Symptoms. Most patients required some form of respiratory support, ranging from supplemental oxygen and non-invasive ventilation to mechanical ventilation and extracorporeal oxygenation.

In addition, the work of Georgios A. Triantafyllou mentions that during outpatient follow-up, the patients presented the following symptoms (remember that only 41 records were reviewed):

The long-term effects of EVALI have been minimally studied, but a cohort of 41 patients with one-year outcomes reported that 24% of them required hospital readmission. The one-year mortality rate was 4.9%, and 45% continued to experience symptoms during outpatient follow-up. Although most imaging findings improved or resolved during follow-up, 75% of patients with pulmonary function tests showed abnormalities after having EVALI.

Due to the novelty of this syndrome, there are no clinical trials for potential therapies yet, so the current treatment is primarily supportive and based on those used for similar diseases. The document from the American Heart Association⁴ mentions the following:

• Most patients diagnosed with EVALI were initially managed in inpatient services.
• More than half presented with severe illness requiring admission to the intensive care unit.
• The majority of patients (78%–100%) required some level of supplemental oxygen during hospitalization.
• Severe respiratory failure is common in these patients, with the highest level of respiratory support including high-flow nasal cannula (up to 47%), non-invasive positive pressure ventilation (up to 30%), and endotracheal intubation and invasive mechanical ventilation (up to 22%).
• Severe cases of EVALI have required venovenous extracorporeal membrane oxygenation, with one case progressing to a lung transplant.
• According to another review of 169 published articles on EVALI, the majority of patients (95%) required hospitalization and most (84%) received glucocorticoids.
• Glucocorticoids were used in many cases and may be beneficial in the treatment of EVALI. Dosage regimens varied widely.
• The administration of glucocorticoids may be justified in severely ill patients when deemed safe and feasible, and when concomitant infection has been ruled out; however, no clinical trials have been conducted to evaluate their effectiveness.
• Patients have recovered without receiving glucocorticoids. Most patients underwent a thorough microbiological and viral infection assessment.
• Between 78% and 100% of patients received empirical antibiotic therapy, at least initially, in the cases.
• Recurrent cases of EVALI have been reported with persistent use of electronic nicotine delivery systems (ENDS), therefore, cessation is essential for these patients.

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[1] Meghan E. Rebuli et al. The E-cigarette or Vaping Product Use–Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report. Ann Am Thorac Soc. 2023 Jan 1; 20(1): 1–17. Published online 2023 Jan 1. doi: https://doi.org/10.1513/AnnalsATS.202209-796ST

[2] Hubert Mado et al. The vaping product use associated lung injury: is this a new pulmonary disease entity? Rev Environ Health. 2020 Dec 7;36(2):145-157. DOI: https://doi.org/10.1515/reveh-2020-0076

[3] Georgios A Triantafyllou et al. Long-term outcomes of EVALI: a 1-year retrospective study. Lancet Respir Med. 2021 Dec; 9(12): e112–e113.

Published online 2021 Oct 25. doi: 10.1016/S2213-2600(21)00415-X

[4] Jason J. Rose et al. Cardiopulmonary Impact of Electronic Cigarettes and Vaping Products: A Scientific Statement From the American Heart Association. Volume 148, Issue 8, 22 August 2023; Pages 703-728 https://doi.org/10.1161/CIR.0000000000001160