What is the management of vaping-induced lung injury?

Management of Vaping-Induced Lung Injury

The management of e-cigarette or vaping product use-associated lung injury (EVALI) requires immediate discontinuation of all e-cigarette and vaping products, consideration of corticosteroid therapy, and a structured approach to both inpatient and outpatient care based on illness severity. 1

Initial Assessment and Triage

Determining Need for Hospitalization

Patients should be hospitalized if they have any of the following:

• Oxygen saturation <95% on room air 1
• Respiratory distress 1
• Comorbidities that could compromise cardiopulmonary reserve 1
• Inability to discontinue e-cigarette/vaping product use 1
• Inadequate social support or unreliable access to care 1

Initial Clinical Evaluation

• Vital signs with pulse oximetry to assess respiratory status 1
• Focused history including specific vaping products used 1
• Rule out other possible etiologies (influenza, community-acquired pneumonia) 1
• Chest radiograph (CXR) for all patients; consider CT scan even if CXR is normal 1
• Laboratory testing including urine toxicology, influenza, and other infectious disease testing as clinically indicated 1

Inpatient Management

Medical Treatment

• Discontinue all e-cigarette and vaping product use immediately 1
• Consider empiric antimicrobial therapy according to community-acquired pneumonia guidelines until infection is ruled out 1
• Consider systemic corticosteroids, which have shown benefit in many cases 1, 2
  • Use with caution in patients with potential concurrent infections 1
• Administer routine annual influenza vaccination if not previously received 1

Respiratory Support

• For patients with hypoxemia, provide supplemental oxygen to maintain SpO2 ≥95% 1
• For severe cases requiring ICU admission (44% of hospitalized patients):
  • Consider early intubation for progressive respiratory failure 2
  • In severe cases, consider advanced respiratory support including prone positioning and extracorporeal membrane oxygenation (ECMO) for refractory hypoxemia 2

Consultations

• Consider pulmonary, critical care, medical toxicology, and infectious disease consultations 1
• Consider psychiatric consultation for mental health and substance use assessment 1
• Consider bronchoscopy with bronchoalveolar lavage in consultation with pulmonary specialists if diagnosis is uncertain 1, 2

Discharge Planning and Follow-up

Criteria for Discharge

• Clinical stability for 24-48 hours before discharge 1
• No clinically significant fluctuations in vital signs 1
• Adequate oxygenation on room air 1

Discharge Planning

• Screen for mental health, substance use disorders, and social care needs 1
• Ensure access to social/mental health/substance use disorder services 1
• Conduct medication reconciliation and patient counseling by inpatient pharmacist, particularly for patients on corticosteroid taper 1
• Schedule initial outpatient follow-up appointment, optimally within 48 hours of discharge (not 2 weeks as previously recommended) 1
• Arrange follow-up with pulmonologist within 2-4 weeks 1

Outpatient Management

• For patients managed as outpatients:
  • Advise discontinuation of all e-cigarette and vaping products 1
  • Consider corticosteroids with caution due to risk of worsening respiratory infections 1
  • Consider chest radiograph for patients with chest pain or shortness of breath 1
  • Consider influenza testing during flu season 1

Special Considerations

Corticosteroid Management

• Evaluate patients for risk of secondary adrenal insufficiency before hospital discharge if they received prolonged corticosteroid course 1
• Consider corticosteroid taper and follow-up with an endocrinologist for patients who received prolonged steroid treatment 1
• Counsel patients about signs and symptoms of adrenal insufficiency (fatigue, decreased appetite, gastrointestinal distress, myalgia, joint pain, salt craving, dizziness, postural hypotension) 1

Relapse Prevention

• Offer cessation services to all patients and facilitate connection to these services 1
• Consider behavioral interventions for smoking/vaping cessation 1
• Be aware that readmission risk is higher in patients who resume vaping 3

Prognosis

• Most patients with EVALI improve with treatment, with 93% of ICU patients surviving to discharge 2
• Residual abnormalities on chest radiographs and pulmonary function tests may persist despite clinical improvement 3
• Patients with cardiac disease, chronic pulmonary disease, diabetes, and older age have higher risk for rehospitalization and death 1