Vaping related lung injury




Vaping is associated with a heterogeneous group of pulmonary disease. 


Vaping-related acute lung injury incidence is increasing. 


The consumption of electronic cigarette products carries potential risks of addiction, initiation of tobacco use in the nonsmoker population, and use of illicit drugs. 


Their  use has been associated with an increased intention to smoke cigarettes in the nonsmoking population.


Approximately 3.7% of US adults are users of electronic cigarettes, with the same prevalence for men and women.


Its aerosol liquid comes from the heating process of a solution called e-liquid or vape juice that may or may not contain nicotine as well as other compounds that include propylene glycol, vegetable glycerin, flavoring agents, and additives.



The electronic devices have a variable-voltage battery, a heating element or heating coil that functions as an atomizer converting the e-liquid into the aerosol, a reservoir or vaporizer chamber for the e-liquid, and a mouthpiece.



The e-liquid is rapidly heated by  exposed coils of metal alloys that can contain iron, chromium, carbon, nickel, or other metals.



The e-liquid is exposed to high temperatures creates a suspension containing fine particles of the e-liquid–aerosol


This aerosol this has been inaccurately called vapor, which is the gaseous state of a substance


E-cigarette use is associated with adverse health consequences of the  lungs but also have a negative effect on the cardiovascular system.


More than 7000 flavorings and 400 brands are available


The aerosol is produced by heating a liquid that contains a solvent-vegetable glycerin, propylene glycol, in one or more flavorings, with or without nicotine. 


The evaporation of the liquid at the heating element is followed by rapid cooling forms the aerosol, which is inhaled or vaped.


Dabbing refers to inhalation of combustion of cannabinoid concentrates resulting in faster hallucinogenic effect due to the high concentration of THC.


Liquid flavoring agents used include aldehydes which have been implicated in bronchiolitis one inhaled.


When  exposed to high temperatures vegetable glycerin and propylene glycol contained within the solvent in the E-cigarettes decompose, generating harmful carbonyl products such as formaldehyde, acid aldehyde, and acrolein: implicating in the development of oxidative stress and release of inflammatory mediators causing airway injury.


Propylene glycol and vegetable glycerin decompose when exposed to high temperatures, generating harmful carbonyl compounds such as aldehydes including acrolein, formaldehyde, and acetaldehyde.


Carbonyl compounds in the aerosol have been implicated in the development of oxidative stress and release of inflammatory mediators increasing cardiovascular risk, and platelet function alteration, airway epithelial injury, and impairing gas exchange function.


Repeated exposure of the heating element to high temperatures allows emission of nanoparticles with a potential harmful effect on the respiratory system.


Estimated that more than 7000 e-liquid flavors are available.


These flavoring agents impair the epithelial barrier and cellular function of the lungs.


E-flavoring agent can reduce ciliary beat frequency leading to diminished mucociliary clearance and impairing mitochondrial function.


Aerosolized components can alter airway cytokines, macrophages and neutrophil antimicrobial function while increasing the virulence of colonized bacteria.


E-cigarettes are associated with the use of tobacco products but also with alcohol and other substances, such as marijuana.

About 80% of reported vaping product associated lung injury cases have involved THC containing e-cigarettes.


The act of inhaling the combustion of these cannabinoid concentrates results in a faster hallucinogen effect as a consequence of a higher concentration of tetrahydrocannabinol (THC) than that of the conventional forms of cannabis. 


The justification to the combination of ECs and cannabis includes better taste, opinion that it is healthier, easier to conceal, lack of strong smell, convenience, and more potent hallucinogen effect.



Exposure to cannabis inhalation has a negative effect on different cellular immune mechanisms.



Exposure to cannabis inhalation increases predisposition for respiratory tract infections including pulmonary aspergillosis, eosinophilic pneumonia, voice disorders, pulmonary barotrauma, cystic lung disease, emphysema and a 2-fold increase in the risk of lung cancer.



States where cannabis is medically legal have a higher likelihood of vaping cannabinoids.



Vitamin E acetate is an additive sometimes used in THC-containing products and is strongly linked to E vaping acute lung injury.


Vitamin E acetate and THC are the only chemicals that have been consistently observed in vaping associated lung injuries.

Vitamin E acetate has been found in up to 94% of bronchoalveolar lavage specimens in patients with vaping lung injury.


Cannabidiol is a chemical found in the cannabis plant that, unlike THC, does not have psychoactive adverse effects. 


Most patients with  acute lung injury related to electronic tobacco are previously healthy teenagers, who develop rapid onset of symptoms, including cough and severe dyspnea, after vaping. 


Most vaping product associated lung injuries have been reported in young men with median ages between 19 and 27 years and 16% of patients under 18 years.

Clinical presentation is characterized by gastrointestinal and respiratory symptoms with shortness of breath, cough, pleuritic chest pain, and rarely hemoptysis.

Gastrointestinal symptoms include nausea and abdominal pain.

78% of patients experience fever and chills.

78% of patients experience fever and chills. And I

Several patients required mechanical ventilation, some of them for several days.

Progression to hypodermic respiratory failure with oxygen saturations below 88% occur in at least 40 to 50% of cases and requirement of mechanical ventilation in 15 to 30% of patients reported.

At least 65 to 70% of patients require ICU hospitalization with the need of high flow oxygen or mechanical ventilation.

Lung biopsies from reveal  nonspecific injury, suspected to be an airway-centered chemical pneumonitis. 


Microscopic findings include:  acute fibrinous pneumonitis, diffuse alveolar damage, organizing pneumonia, interstitial edema, and intraalveolar fibrin accumulation. 


Foamy macrophages and pneumocyte vacuolization were found in all cases.


Vitamin E acetate in the bronchoalveolar lavage (BAL) samples from patients who developed VpALI has been noted.


Pneumonitis patterns identified include: acute eosinophilic pneumonia, organizing pneumonia, lipoid pneumonia, diffuse alveolar l syndrome, diffuse alveolar hemorrhage, hypersensitivity pneumonitis, peribronchiolar granulomatous  pneumonitis, and giant cell interstitial pneumonitis.

The majority of cases have bilateral hazy or consolidative opacities on chest x-ray or CT scans.


Cardiac and respiratory diseases and mental health conditions, are common among patients hospitalized with E vaping acute lung injury.


Vaping illness associated  in 83% of patients with tetrahydrocannabinols or cannabidiol formulated with oils such as vitamin E acetate.


Hypoxemia is a constant finding in VpALI and respiratory symptoms usually include nonproductive cough and shortness of breath.


Cases related to the inhalation of cannabis have been reported, but with more frequent hemoptysis.


The findings of computed tomography are often ground-glass opacities and interlobular septal thickening reflecting emulating crazy paving,

CT of chest parents show bilateral lower lobe predominant ground glass and consolidated opacities


Laboratory findings include: leukocytosis, mild elevation of liver function tests and significant elevation of inflammatory markers, including C reactive protein, and erythrocyte sedimentation rate.


Patients with a higher severity of illness required mechanical ventilation support and even extracorporeal membrane oxygenation  because of progression to ARDS.


Treatment with broad-spectrum antibiotics is encouraged with initial management and subsequent discontinuation if no evidence of respiratory tract or systemic infection is found. 


Hemodynamically stable patients should undergo direct airway examination.


Bronchoalveolar lavage can provide information on the etiology and mechanism of lung injury: lymphocytic, neutrophilic, or eosinophilic cellular patterns can lead to an appropriate diagnosis of the lung injury type. 


Oil Red O–positive macrophages is suggestive of lipoid pneumonia.

Vaping product associated lung injury is a diagnosis of exclusion and consists of a history of vaping within the previous 90 days, bilateral lung opacities, an exclusion of alternative diagnoses and lung infections.

Bronchoscopy with bronchoalveolar lavage should be performed if possible along with transbronchial biopsies.


Initial management is that all patient should receive antibiotics which can be discontinued after infection is excluded.

It is unclear whether systemic steroids are beneficial in treatment.


Mechanical ventilation is often required, especially when there is progression to ARDS. 


Overdistension of the alveoli from either high positive end-expiratory pressure (PEEP) or high tidal volumes can lead to barotrauma, and can result in pneumothorax. 


Likewise, oxygen should be titrated to a minimal arterial oxygen tension of 65 mm Hg to prevent oxygen toxicity.



The prone position needs to be implemented when indicated.



Neuromuscular blockademay be necessary.



Fluid restriction and adequate nutrition are imperative for recovery.



Ventilator-associated pneumonia may occur, and extracorporeal membrane oxygenation may be necessary 



Newer-generation e-cigarettes use nicotine salts, allowing more nicotine to be inhaled.


Patients who died from vaping-induced lung disease were nine times as likely to have COPD,  more than twice as likely to have asthma or history of tobacco smoking, and five times as likely to have cardiovascular disease, mostly manifested by hypertension.



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