What is the treatment for vaping-induced lung injury?

Treatment for Vaping-Induced Lung Injury

The cornerstone treatment for vaping-induced lung injury (EVALI) includes immediate discontinuation of all e-cigarette/vaping products, systemic corticosteroids, and appropriate respiratory support, with hospitalization for patients with oxygen saturation <95% or respiratory distress. 1

Initial Assessment and Triage

Hospitalization Criteria

• Oxygen saturation <95% on room air 2, 1
• Presence of respiratory distress 2, 1
• Comorbidities that could compromise cardiopulmonary reserve 2
• Inability to discontinue e-cigarette/vaping product use 2, 1
• Inadequate social support or unreliable access to care 2, 1

Outpatient Management Criteria

• Oxygen saturation ≥95% on room air 2
• No respiratory distress 2
• No significant comorbidities 2
• Reliable access to care and strong social support 2

Clinical Evaluation

• Vital signs with pulse oximetry to evaluate respiratory status 2, 1
• Focused history, including specific vaping products used 2, 1
• Rule out other possible etiologies (influenza, community-acquired pneumonia) 2
• Chest radiograph for all patients; consider CT scan even if CXR is normal 2, 3
• Laboratory testing including urine toxicology and infectious disease testing as clinically indicated 2

Inpatient Management

Primary Interventions

• Immediate discontinuation of all e-cigarette and vaping product use 2, 1
• Systemic corticosteroids - shown to be beneficial in many cases 1, 4
• Supplemental oxygen for patients with hypoxemia to maintain SpO2 ≥95% 1, 5
• Consider empiric antimicrobial therapy according to community-acquired pneumonia guidelines until infection is ruled out 2, 1

Specialty Consultations

• Consider pulmonary, critical care, medical toxicology, infectious diseases consultations 2
• Consider psychiatry consultation for patients with mental health or substance use disorders 2

Additional Measures

• Administer routine annual influenza vaccination if not previously received 2
• Consider bronchoalveolar lavage or lung biopsy if clinically indicated, in consultation with pulmonary specialists 2

Discharge Planning

• Ensure clinical stability for 24-48 hours before discharge 2, 1
• Screen for mental health, substance use disorders, and social care needs 2
• Conduct medication reconciliation and patient counseling by inpatient pharmacist, particularly for patients on corticosteroid taper 2
• Schedule initial outpatient follow-up appointment within 48 hours of discharge 2
• Arrange follow-up with a pulmonologist within 2-4 weeks 2
• Evaluate patients who received prolonged corticosteroid courses for risk of secondary adrenal insufficiency 2, 1
• Counsel patients about signs and symptoms of adrenal insufficiency (fatigue, decreased appetite, gastrointestinal distress, myalgia, joint pain, salt craving, dizziness, postural hypotension) 2, 1

Follow-up Care

Initial Follow-up (within 48 hours)

• Assess for stable vital signs, resolution of symptoms, and normalized laboratory tests 2
• Ensure adherence with medication regimens, particularly corticosteroid taper 2
• Reinforce the importance of abstinence from e-cigarette/vaping product use 2
• Connect patients to needed social, mental health, and substance use disorder resources 2

Pulmonary Follow-up (2-4 weeks)

• Assess pulmonary function and resolution of radiographic findings 2
• Consider spirometry, diffusing capacity of the lung for carbon monoxide, and chest x-ray 2

Long-term Follow-up (1-2 months)

• Additional pulmonary function testing as indicated 2
• Consider physical therapy for patients who experienced prolonged immobilization 2
• Continue engagement with addiction medicine and mental health services as needed 2

Special Considerations

• Patients with cardiac disease, chronic pulmonary disease, diabetes, and older age have higher risk for rehospitalization and death 1, 5
• Use corticosteroids with caution in outpatients due to risk of worsening respiratory infections 2, 1
• Offer cessation services to all patients and facilitate connection to these services 2, 1
• For patients on corticosteroids, consider a taper schedule and follow-up with an endocrinologist if prolonged course was required 2, 1

Common Pitfalls to Avoid

• Failing to recognize EVALI in young, otherwise healthy patients with respiratory symptoms 6, 7
• Discharging patients before ensuring 24-48 hours of clinical stability 2
• Not scheduling prompt follow-up within 48 hours of discharge (associated with increased risk of rehospitalization and death) 2
• Inadequate patient counseling about the importance of completely abstaining from all e-cigarette/vaping products 2, 1
• Not evaluating for potential adrenal insufficiency in patients who received prolonged corticosteroid treatment 2, 1