Hypoxemia Key Risk Factor for EVALI Death

ORLANDO — Users of vaping products who are at moderate risk of developing e-cigarette/vaping-related lung injury (EVALI) — i.e., those already showing signs of lung damage — should be strongly encouraged to stop, an expert said here.

“For these patients, we think that vaping cessation is absolutely mandatory,” said Craig M. Lilly, MD, of the University of Massachusetts Medical School in Worcester, during a presentation at the Society of Critical Care Medicine (SCCM) annual meeting.

In a paper recently published in Critical Care Explorations, Lilly, who chairs the SCCM vaping task force, offered guidance to clinicians on the risk stratification and medical management of patients who present with respiratory distress that may or may not be related to vaping and may or may not lead to lung injury.

As of Feb. 4, the CDC reported 2,758 e-cigarette and vaping associated lung injury (EVALI) hospitalizations, including 64 deaths, in the U.S.

Emergency department visits related to EVALI peaked in September of last year, though new cases have declined substantially in recent weeks.

Most EVALI cases have occurred among people vaping tetrahydrocannabinol (THC), and vaping fluids containing vitamin E acetate have also strongly been linked to the outbreak.

Increased public awareness regarding the risks associated with THC-containing e-cigarette or vaping products and the dangers of vaping any product containing vitamin E acetate have been cited by the CDC as probable causes for the decline.

In his SCCM presentation, Lilly said patients who vape can be considered to have a low risk for associated respiratory stress if they have no vaping-related respiratory dysfunction.

But he added that even these patients should be encouraged to stop using e-cigarettes or other vaping products.

Moderate-risk patients are those with a recent (90-day) exposure to vape products, symptoms, and abnormal chest imaging with patterns associated with vaping injury, he said.

Unexplained cough, chest pain, unexplained weight loss, fatigue, and dyspnea have all been recognized by the CDC as symptoms of possible vape-associated respiratory distress.

Patients with all those risk factors plus hypoxemia may be considered at high risk for EVALI.

“Most patients who have died from vaping have been sent out of emergency rooms when they were known to be hypoxemic,” he said.

Lilly added that high-risk patients should be hospitalized with supervised vaping abstinence, and at the first sign of at-rest increased respiratory rate, at-rest dyspnea, or at-rest hypoxemia, oxygen and noninvasive ventilation should be given.

“These patients often rapidly improve when they abstain from further exposure,” he said. “We also recommend conservative fluid strategy in patients who are not rapidly improving and then mechanical ventilation when required with low tidal volume strategy.”

With regard to vaping exposure, Lilly said recent exposure, exposure to bootleg or homemade vaping solutions, and dabbing or dripping vaping products are all associated with increased risk.

“Are they a regular user (of commercially-available products) who vapes according to the manufacturer’s recommendation, or do they get advice on vaping through social media?” he asked.

He said users who dab or drip vaping solution directly onto the vape device heating element are exposed to aerosolized particles that are much denser and have a greater diversity in particle size.

“Key questions that are helpful (for assessing risk) are ‘Has anyone else been exposed to the vaping solution?’ ‘Did you share your device with someone else and do they have similar symptoms?’ and ‘Do you know anyone who is sick with similar symptoms who wasn’t exposed to vaping?'” Lilly said. “These questions can help triage cases that are possibly vaping related and those that are not.”

Lilly concluded that clinicians should not miss an opportunity to educate at-risk patients about the potential dangers of vaping, including intensivists who see the most severe cases of vaping-related lung injury.

“I would advise every intensivist when they leave their intensive care unit at night to ask themselves, ‘Have I advised against vaping today?'”