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E-cigarette, or vaping, product use associated lung injury

An update

Huey, Sally DNP, APRN, FNP-BC; Granitto, Margaret MS, APRN, ANP-BC, CNL; Brien, Lori MS, APRN, ACNP-BC; Tierney, Catherine DNP, APRN, ACNP-BC

Author Information
doi: 10.1097/01.CCN.0000654800.17371.09
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The use of vaping devices (e-cigarettes) in the US has been reported widely across various age groups, socioeconomic backgrounds, and ethnicities.1 Of concern is the use of e-cigarettes in adolescent and young adult “never before smokers.” This has brought an outcry from the public health sector, sounding the alarm on the growing concern for potential harm and unknown health effects from long-term use of these products.2 E-cigarettes deliver aerosols that may contain nicotine, tetrahydrocannabinol (THC), or cannabidiol (CBD) to the user by heating up a liquid component (which may contain nicotine, THC, or CBD along with additives and flavoring) with a heating coil powered by a battery. These devices are particularly popular among teens due to various candy-like flavors available; sleek designs that look like flash drives, pens, perfumes, or electronic devices; and the convenience of use, with no odor or smoke.3

The rapidly changing technology of e-cigarettes and the identified patterns of use have informed the guidelines as research and anecdotal reports are collected. To date, several public health organizations have made recommendations pertaining to e-cigarette use. This article summarizes the latest recommendations.

Physiologic effects

Reported effects of vaping on the pulmonary system are found in both the conducting airways and alveolar spaces. These include inhibition of ciliary function, cellular toxicity, increased cytokine secretion, altered gene expression, impaired gas exchange, and impaired macrophage function.4 With the identification of a growing number of patients with lung injuries associated with vaping, nurses across all disciplines should become familiar with these products, the reported signs and symptoms identified with this injury, and nursing implications when caring for patients presenting with vaping-associated illness.

Currently, the CDC, FDA, local health departments, and public health agencies are investigating an outbreak across all 50 states, the District of Columbia, and two US territories of a respiratory illness linked to e-cigarettes. Known as EVALI (e-cigarette, or vaping, product use associated lung injury) or sometimes vaping-associated pulmonary injury, the case reports have ranged from patients with mild illness managed in the outpatient setting to those requiring ventilatory support in critical care settings. Of note, hospitalized patients have been predominantly male and under age 35. Of the 2,502 probable cases reported, there have been 57 deaths associated with EVALI to date.5

Although no clear evidence points to one product, the CDC is getting closer to discovering the cause of EVALI. A recent research study analyzed a convenience sample of 51 patients with EVALI across 16 states with collection of bronchoalveolar lavage (BAL) fluid. Vitamin E acetate was identified in 48 of the 51 patients studied. It was not found in any patients in the control group. THC was detectable in 94% of the BAL fluid with nicotine detectable in 64%.6 Vitamin E acetate has been identified as a “toxin of concern,” but the CDC investigation is ongoing.7

The CDC has issued guidelines to assist US healthcare providers caring for patients with known or suspected EVALI in diagnosing and treating this emerging threat. The guidelines address initial clinical evaluation, suggested criteria for hospital admission and treatment, patient follow-up, and special considerations for groups at high risk.5 (See CDC EVALI guidelines.)

Prevention

First and foremost, prevention should be emphasized when addressing concerns about patients' use of e-cigarettes. Inform patients and families about the potential harms from vaping and ask about their habits and product use with a nonjudgmental approach to ensure patient-centered care. Become familiar with the terminology related to e-cigarettes to correctly identify potential risks for patients. (See Glossary of terms.) Currently, the CDC recommends that patients should not use any vaping product, including e-cigarettes or products containing THC. If adult patients are using e-cigarettes for smoking cessation, they should not return to smoking and should carefully weigh the risk/benefit profile of e-cigarette use with their healthcare provider.5

Recognition

Rapid recognition of patients presenting with EVALI is the first step to decrease the morbidity and mortality associated with this pulmonary disorder. Obtaining an accurate health history is crucial, and this information will translate into actionable data as the CDC continues to gather evidence to track this disorder. Types and other specifics of products used, duration and frequency of use, product source, and method of delivery (aerosolization, drabbing, dripping) are all areas of potential interest to investigators. The review of systems should go beyond respiratory complaints because gastrointestinal (GI) complaints have been present and recognized in over 70% of patients with EVALI to date.8,9 The associated GI signs and symptoms, such as nausea, vomiting, and diarrhea preceding the respiratory illness in case reports of EVALI, may assist the clinician in differentiating EVALI from seasonal influenza. Cardiopulmonary comorbidities (chronic obstructive pulmonary disease [COPD], asthma, heart failure [HF], obstructive sleep apnea, and coronary artery disease) that put patients at higher risk should be important determinants in calculating risk assessment for patients with potential or diagnosed EVALI.6

Physical assessment findings in a patient with suspected EVALI may include fever, tachycardia, tachypnea, and hypoxemia. However, many patients may present with an unremarkable physical assessment. Vital signs that include pulse oximetry on room air should be included in patients undergoing assessment for EVALI.5 Lab markers demonstrating leukocytosis with neutrophil predominance and no eosinophilia, as well as elevated inflammatory markers (such as C-reactive protein and erythrocyte sedimentation rate), have been identified across many patients with EVALI.8 Urine toxicology may also be considered in order to recognize exposure to THC. Many other respiratory illnesses may present with similar clinical findings; for now, EVALI remains a diagnosis of exclusion. Obtaining the appropriate history and physical data will help the clinician determine ongoing surveillance and management.6

The CDC recommends a chest X-ray (CXR) for all patients with a history of vaping who present with respiratory or GI symptoms, especially in conjunction with a decreased oxygen saturation (<95% on room air).5 Many of the patterns identified on CXRs demonstrate bibasilar predominant consolidation and ground-glass opacities with lobular and subpleural sparing.10 More sophisticated imaging with chest CT may be considered on a case-by-case basis. Some reports have suggested that vaping-related lung injury may represent lipoid pneumonia.8 However, the pathophysiology is still poorly understood, and no histologic findings have supported this theory. Chemical pneumonitis from the vaped oils and substances is another possible etiology, but the agents responsible are still unknown.11

A pulmonary specialist consultation should be made to perform bronchoscopy or BAL and optimize pulmonary management.

The decision to admit a patient for suspected EVALI should be considered for patients with hypoxemia, respiratory distress, or comorbidities that increase the risk of poor outcomes. Almost half of all patients admitted to the ICU for respiratory distress from suspected EVALI required endotracheal intubation and mechanical ventilation.5 Careful multidisciplinary management is needed as high-risk patients with comorbidities such as HF, COPD, and advanced age are more likely to need endotracheal intubation, mechanical ventilation, and longer hospitalizations. These patients are also more likely to have prolonged hypoxemia and require home oxygen therapy upon discharge.12 Aggressive treatment with antimicrobials and corticosteroids is recommended and has been used in patients admitted with suspected EVALI. The use of antimicrobials is recommended to treat community-acquired pneumonia until it is ruled out as the source of pulmonary compromise.6 Caution must be used with corticosteroids as their use may worsen outcomes for patients with fungal pneumonia.6

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Table:
Glossary of terms

The need for close follow-up after hospitalization is critically important to maximize outcomes for patients with EVALI. Recent investigations of EVALI readmissions and deaths showed correlations between patient comorbidities and older age, and EVALI relapse and death, with most readmissions occurring within 4 days of discharge and most post-discharge deaths occurring within 3 days.12 The CDC updated their discharge guidelines to advise that patients remain hospitalized until they have had 24 to 48 hours of normal hemodynamic parameters and that the discharge plan includes extensive medication reconciliation, e-cigarette cessation counseling, mental health and addiction screening, and coordination of outpatient care to include scheduled primary care and specialist appointments. All patients hospitalized for EVALI are recommended to have a medical follow-up visit within 48 hours of discharge.12 Annual vaccination for seasonal influenza is particularly important in patients post hospitalization to protect them from further compromise in respiratory function. Pneumococcal vaccination should follow current recommended guidelines.6

Nursing implications

Nurses working in the hospital setting may encounter patients at risk for EVALI in all phases of care. It is important that e-cigarettes are identified as a risk factor for pulmonary illness upon admission. Nurses must ask about e-cigarette use in their initial patient interview and enter complete information into the electronic medical record so it is available for other healthcare team members and researchers attempting to identify patients with EVALI.5

Nurses at the bedside are most likely to be the first to recognize a decline in respiratory status in patients. Pulmonary signs and symptoms such as shortness of breath, tachypnea, accessory muscles of respiration use, and increased supplemental oxygen requirements as well as mental status changes, tachycardia, and diaphoresis should be evaluated as signs of respiratory deterioration. Patients at risk for EVALI should be assessed frequently for changes in clinical status. Recognizing the signs and symptoms of respiratory failure early and notifying a provider can greatly contribute to a patient's likelihood of recovery.13

Inhalation injury is one of the risk factors for acute respiratory failure and acute respiratory distress syndrome. These syndromes are characterized by cell-mediated alveolar damage, which impedes the lungs' ability to exchange oxygen and carbon dioxide at the alveolar capillary membrane.14 When a patient with EVALI develops respiratory failure, it may be necessary to place him or her on mechanical ventilation. The ventilator settings chosen are important because although mechanical ventilation may improve oxygenation, it poses risks for ventilator-induced lung injury and can result in pulmonary edema, barotrauma, and worsening hypoxemia that can prolong mechanical ventilation, lead to multisystem organ dysfunction, and increase mortality.14,15

Guidelines to mitigate further injury (lung protective strategies or protective ventilatory strategies) are used along with mechanical ventilation. These strategies include low tidal volume ventilation (4 to 8 mL/kg predicted body weight); plateau pressures of 30 cm H2O or below; positive end-expiratory pressure (PEEP) of at least 5 cm H2O; and increasing as needed to decrease the FiO2 required to maintain PaO2 of 55 to 80 mm Hg, and allowing acidosis to a pH of 7.3.14,16(See Lung protective strategies.)

Table
Table:
Lung protective strategies16

Another way nurses can protect their patients is to follow bundles designed to limit mechanical ventilator use and prevent the adverse reactions associated with endotracheal intubation.17 The ventilator-associated event bundle includes keeping the head of bed elevated at least 30 degrees (unless medically contraindicated), managing subglottic secretions, providing twice-daily oral care with chlorhexidine mouthwash, and adhering to the ABCDEF bundle.17

The ABCDEF bundle, developed by the Society of Critical Care Medicine, clusters evidence-based interventions shown to reduce the long-term sequelae of prolonged intensive care. The components include: A: assessment of pain, B: both daily reduction of sedation with awakening trial and daily breathing and ventilator weaning trials, C: choice of analgesia and sedation, D: delirium screening and management, E: early mobilization, and F: family involvement and engagement in care.17

After recovery

As a patient recovers and moves toward discharge from the hospital, nurses should counsel and support them to avoid tobacco and e-cigarette use in the future. Nurses should never encourage a patient trying to quit smoking tobacco to use e-cigarettes. Instead, they should suggest FDA-approved therapies such as nicotine gum or patches, support groups, or a discussion with a primary care provider about other pharmacologic therapy.18 By opening up the conversation, advising the patient to cease vaping, assessing a patient's desire to quit, and providing resources as well as nonjudgmental support, nurses can make a difference for patients attempting to stop using e-cigarettes and tobacco products.19

CDC EVALI guidelines6

Initial clinical evaluation

  • History of e-cigarette use. Identify type, frequency, and method
  • Physical assessment findings: tachycardia, oxygen saturation <95% on room air
  • Lab findings: respiratory viral panel, white blood cell count, erythrocyte sedimentation rate, C-reactive protein, liver function test, consider urine toxicology screen
  • Imaging: CXR—pulmonary infiltrates, chest computed tomography (CT): pulmonary opacities
  • Consultation: pulmonology consult recommended

Criteria for hospital admission/treatment

  • Decreased oxygen saturation (<95% on room air)
  • Respiratory distress
  • Comorbidities that impact respiratory reserve
  • Treatment: consider corticosteroids, antimicrobials for community-acquired pneumonia, and antivirals if during influenza season

Patient follow-up

  • Follow up within 1-2 weeks with pulse oximetry and CXR
  • 1-2 months: measure spirometry and diffusion capacity; consider CXR
  • Pulmonary follow-up as indicated
  • Advise discontinuation of all vaping products
  • Influenza vaccine
  • Consider pneumonia vaccine

Special considerations for high-risk patients

  • High-risk groups include age >50; cardiopulmonary comorbidity, pregnancy
  • Early identification of EVALI, introduction of corticosteroids; pulmonary consultation is imperative

REFERENCES

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2. Huey SW, Granitto MH. Smoke screen: the teen vaping epidemic uncovers a new concerning addiction. J Am Assoc Nurse Pract. [e-pub Jul. 30, 2019].
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5. Centers for Disease Control and Prevention. Outbreak of lung injury associated with e-cigarette use, or vaping. 2019. www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html.
6. Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: interim guidance for health care providers evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung injury—United States, October 2019. MMWR Morb Mortal Wkly Rep. 2019;68(41):919–927.
7. Blount BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N Eng J Med. 2019;Dec 20. [epub ahead of print].
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12. Evans MF, Twentyman E, Click ES, et al. Update: Interim guidance for health care professionals evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung injury and for reducing the risk for rehospitalization and death following hospital discharge—United States, December 2019. MMWR Morb Mortal Wkly Rep. 2020; 68(5152):1189–1194.
13. Shebl E, Burns B. Respiratory failure. Stat Pearls. 2019. www.ncbi.nlm.nih.gov/books/NBK526127.
14. Thompson BT, Chambers RC, Liu KD. Acute respiratory distress syndrome. N Engl J Med. 2017;377(6):562–572.
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16. Grasso S, Stripoli T, De Michele M, et al. ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am J Respir Crti Care Med. 176(8):761–767.
17. Health Research & Educational Trust. Preventing Ventilator-Associated Events (VAE) Change Package: 2018 Update. Chicago, IL: Health Research & Educational Trust; 2018.
18. Schunur MB. Vaping epidemic: a public health crisis? Lippincott's Nursing Center. 2019. www.nursingcenter.com/ncblog/september-2019/vaping-epidemic.
19. Prochnow JA. E-cigarettes: a practical, evidence-based guide for advanced practice nurses. J Nurse Pract. 2017;13(7):449–455.
20. Carroll County Health Department. Vaping and dabbing: facts for parents. 2019. https://cchd.maryland.gov/wp-content/uploads/sites/26/2019/09/Vaping-Dabbing-Advisory-Update-9.2019.pdf.
    Keywords:

    cannabidiol; e-cigarettes; EVALI; lung injury; nicotine; pulmonary illness; tetrahydrocannabinol; vaping; vitamin E acetate

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