What are the injuries associated with nicotine (Nicotine) vaping?

From the Guidelines

Nicotine vaping can cause severe injuries, including e-cigarette or vaping product use-associated lung injury (EVALI), and the most effective treatment involves stopping vaping immediately and providing supportive care for symptoms, as recommended by the most recent guidance from the Morbidity and Mortality Weekly Report 1.

Key Injuries Caused by Nicotine Vaping

• Respiratory injuries, such as EVALI, bronchitis, pneumonia, and exacerbation of asthma
• Cardiovascular injuries, including increased heart rate, elevated blood pressure, and potential increased risk of heart attack and stroke due to blood vessel damage
• Nicotine poisoning, with symptoms like nausea, vomiting, increased heart rate, and in severe cases, seizures

Treatment and Management

• Stopping vaping immediately
• Supportive care for symptoms
• Oxygen therapy if needed
• Hospitalization in severe cases
• Nicotine replacement therapies, medications like varenicline or bupropion, and counseling for nicotine addiction

Importance of Recent Guidance

The most recent guidance from the Morbidity and Mortality Weekly Report 1 emphasizes the importance of careful hospital discharge and transition planning to prevent rehospitalization or death, particularly among patients with cardiac or chronic respiratory comorbidities.

Key Recommendations

• Confirming stability of clinical parameters without clinically significant fluctuations in vital signs before discharge
• Ensuring outpatient primary care or pulmonary specialist follow-up within 48 hours of discharge
• Planning for discharge care, early follow-up, and management of any comorbidities
• Arranging posthospitalization specialty care
• Following best practices for medication adherence
• Ensuring social support and access to mental and behavioral health and substance use disorder services, as highlighted in the study by Mary E. Evans et al. 1.

From the FDA Drug Label

OVERDOSAGE Signs and Symptoms of Nicotine Toxicity Signs and symptoms of an overdose of the NICOTROL Inhaler would be expected to be the same as those of acute nicotine poisoning including: pallor, cold sweat, nausea, salivation, vomiting, abdominal pain, diarrhea, headache, dizziness, disturbed hearing and vision, tremor, mental confusion, and weakness The effects of using several cartridges in rapid succession are unknown. Doses of nicotine that are tolerated by adult smokers during treatment may produce severe signs and symptoms of poisoning in children and may prove fatal Suspected nicotine poisoning in a child should be considered a medical emergency and treated immediately

The answer to nicotine vaping injuries is not directly addressed in the provided drug labels. However, the labels do describe the signs and symptoms of nicotine toxicity and overdose, which may be relevant to vaping injuries.

• Key symptoms of nicotine toxicity include pallor, cold sweat, nausea, salivation, vomiting, abdominal pain, diarrhea, headache, dizziness, disturbed hearing and vision, tremor, mental confusion, and weakness.
• Severe poisoning in children can occur with doses of nicotine that are tolerated by adult smokers.
• Medical emergency should be considered in cases of suspected nicotine poisoning in children. 2

From the Research

Nicotine Vaping Injuries

• Nicotine vaping injuries, also known as e-cigarette or vaping product use-associated lung injury (EVALI), have been recognized as a public health crisis worldwide 3.
• The use of electronic nicotine delivery systems has increased in popularity over the past decade, with over 40 million people in the United States vaping, and youth and young adults representing over half of this population 3.
• EVALI was first recognized in the summer of 2019 and resulted in more than 2800 hospitalizations and 60 deaths per the Centers for Disease Control and Prevention (CDC) 3.

Clinical Presentation and Diagnostic Evaluation

• Patients with EVALI typically present with dyspnea, cough, and hypoxemia, with bilateral airspace opacities on chest imaging 4.
• A comprehensive diagnostic evaluation, including a standardized vaping questionnaire, is necessary to diagnose EVALI and rule out other cardiopulmonary conditions 3.
• The clinical algorithm for EVALI focuses on key signs and symptoms, and the importance of ruling out infection and other conditions before making a presumptive diagnosis of EVALI 4.

Treatment and Outcomes

• Patients with EVALI often require management in the intensive care unit, with respiratory support, including intubation and extracorporeal membrane oxygenation in severe cases 5.
• The majority of patients with EVALI survive to discharge, with a median hospitalization duration of 7 days 4.
• Cessation of vaping, supportive care, and steroid therapy are often effective in treating EVALI, with most patients recovering and remaining symptom-free at follow-up 4.

Long-term Consequences and Public Health Implications

• The long-term consequences of EVALI and chronic vaping on respiratory health are not yet fully understood, and further research is needed to establish clear public policy guidance and regulation 6.
• The 2019 EVALI outbreak highlighted the potential harms of vaping, and the role of vaping as a tool of smoking cessation and tobacco harm reduction remains controversial 6.
• The impact of vaping on respiratory health, including the effects of chronic vaping on respiratory health and COVID-19 outcomes, requires further investigation 6.