What is the treatment for lung injury caused by vaping?

Treatment of E-Cigarette or Vaping Product-Associated Lung Injury (EVALI)

The cornerstone of EVALI treatment is immediate cessation of all vaping products, supportive care with supplemental oxygen as needed, and systemic corticosteroids, which should be considered in most hospitalized patients. 1, 2

Initial Assessment and Disposition Decision

When evaluating a patient with suspected EVALI, the decision to hospitalize versus manage outpatient hinges on specific clinical criteria 1, 2:

Hospitalize if ANY of the following are present:

• Oxygen saturation <95% on room air 1, 2
• Respiratory distress 1, 2
• Comorbidities compromising cardiopulmonary reserve (cardiac disease, chronic lung disease, diabetes) 1, 2
• Inability to discontinue vaping products 1, 2
• Inadequate social support or unreliable access to care 1, 2

Outpatient management is appropriate ONLY when ALL criteria are met:

• O2 saturation ≥95% on room air 1
• No respiratory distress 1
• No significant comorbidities 1
• Reliable access to care and strong social support 1

Inpatient Management

Diagnostic Workup

All hospitalized patients require: 1, 2

• Chest radiograph (CXR) - mandatory for all patients 1, 2
• CT scan - should be considered even if CXR appears normal, as CT is more sensitive for detecting bilateral airspace opacities 1, 2
• Urine toxicology screening 1
• Influenza testing and other infectious disease workup as clinically indicated 1
• Vital signs with continuous pulse oximetry 2

Consider specialist consultation: 1

• Pulmonology and critical care 1
• Medical toxicology 1
• Infectious diseases 1
• Psychiatry (given high rates of substance use disorders) 1
• Bronchoalveolar lavage or lung biopsy if diagnosis remains uncertain after initial workup 1

Therapeutic Interventions

Immediate cessation of all vaping products is mandatory - this is the single most important intervention 1, 2, 3, 4

Empiric antimicrobial therapy: 1, 2

• Initiate antibiotics according to community-acquired pneumonia guidelines until infection is ruled out 1, 2
• Early antivirals for possible influenza during flu season 1
• The clinical presentation overlaps significantly with infectious pneumonia, making empiric coverage necessary 3, 4

Systemic corticosteroids: 1, 2, 3, 4

• Should be considered in most hospitalized patients, as they have shown benefit in multiple case series 2, 3, 4
• Use with caution and only after ruling out active infection 1
• In one cohort, 95% of patients received steroids with good outcomes 3
• Most patients improved within 1-2 weeks after corticosteroid administration 4

Respiratory support: 2

• Supplemental oxygen to maintain SpO2 ≥95% 2
• Be prepared for ICU admission - 55-83% of hospitalized patients required ICU care in reported series 3, 4
• Up to one-third may require mechanical ventilation 5

Additional measures: 1

• Administer annual influenza vaccination if not previously received 1
• Offer cessation services to all patients and facilitate connection 1

Discharge Planning

Clinical stability criteria before discharge: 1, 2

• Patient must be clinically stable for 24-48 hours 1, 2
• Adequate oxygenation on room air 2
• No clinically significant fluctuations in vital signs 2

Critical discharge interventions: 1

• Screen for mental health disorders, substance use disorders, and social care needs 1
• Ensure access to mental health and substance use disorder services 1
• Inpatient pharmacist counseling is essential, particularly for patients on corticosteroid tapers, as this reduces rehospitalization 1
• Medication reconciliation by pharmacist 1

Corticosteroid taper management: 1

• Evaluate for risk of secondary adrenal insufficiency before discharge 1
• For prolonged corticosteroid courses, arrange endocrinology follow-up 1
• Counsel patients on adrenal insufficiency symptoms: fatigue, decreased appetite, gastrointestinal distress, myalgia, joint pain, salt craving, dizziness, postural hypotension 1

Follow-up scheduling: 1, 2

• Initial outpatient appointment within 48 hours of discharge 1, 2
• Pulmonology follow-up within 2-4 weeks 1, 2
• Assign patient navigators for those with barriers to care 1

Outpatient Management

For patients meeting outpatient criteria: 1, 2

• Advise immediate discontinuation of all vaping products 1, 2
• Consider CXR if chest pain or shortness of breath develops 1, 2
• Consider influenza testing during flu season 1, 2
• Use corticosteroids with extreme caution due to risk of worsening undiagnosed respiratory infections 1, 2

Critical Pitfalls and Caveats

Readmission risk: 3

• 10% of patients were readmitted within 2 weeks in one series 3
• Half of readmissions occurred in patients who resumed vaping 3
• This underscores the absolute necessity of cessation counseling and support

Residual abnormalities: 3

• Despite clinical improvement, 67% had persistent chest radiograph abnormalities at 2-week follow-up 3
• 67% had abnormal pulmonary function tests at follow-up 3
• This highlights the importance of scheduled pulmonology follow-up

High-risk populations: 2, 5

• Older patients have higher mortality risk 2, 5
• Patients with underlying cardiac disease, chronic pulmonary disease, and diabetes are at increased risk for death and rehospitalization 2, 5
• These patients warrant more aggressive monitoring and lower threshold for hospitalization

Diagnostic overlap: 3, 4

• EVALI remains a diagnosis of exclusion 3, 4
• Symptoms overlap significantly with infectious pneumonia, making empiric antibiotics necessary initially 3, 4
• Maintain high index of suspicion and specifically ask about vaping history, as patients may not volunteer this information