What are the health risks and treatment options for a young adult with a history of vaping and potential nicotine addiction, presenting with symptoms of respiratory distress?

Vaping Health Problems: Assessment and Management

For a young adult with vaping history presenting with respiratory distress, immediately assess oxygen saturation and hospitalize if <95% on room air, as this represents potential E-cigarette or Vaping product use-Associated Lung Injury (EVALI) requiring urgent intervention. 1

Immediate Clinical Assessment

When evaluating any patient with respiratory symptoms and vaping history, perform the following:

• Measure vital signs with pulse oximetry to determine oxygen saturation status 2
• Obtain focused history specifically documenting which vaping products were used (nicotine-only vs THC-containing products) 1
• Rule out infectious etiologies including influenza and community-acquired pneumonia before attributing symptoms to vaping 2
• Order chest radiograph (CXR) for all patients, and strongly consider CT scan even if CXR appears normal, as imaging abnormalities may not be visible on plain films 1

Hospitalization Criteria

Admit the patient if ANY of the following are present:

• Oxygen saturation <95% on room air 1
• Any respiratory distress 1
• Comorbidities compromising cardiopulmonary reserve (cardiac disease, chronic pulmonary disease, diabetes) 1, 3
• Inability to discontinue vaping product use 1
• Inadequate social support or unreliable access to follow-up care 1

Inpatient Management Protocol

For hospitalized patients with suspected EVALI:

• Immediately discontinue all e-cigarette and vaping products - resuming use can cause recurrence of lung injury 2, 1
• Initiate empiric antimicrobial therapy according to community-acquired pneumonia guidelines until infection is definitively ruled out 1
• Consider systemic corticosteroids, as they have demonstrated benefit in many EVALI cases 1
• Provide supplemental oxygen to maintain SpO2 ≥95% 1
• Perform urine toxicology and infectious disease testing as clinically indicated 2
• Administer influenza vaccination if not previously received 1

Substance Use and Mental Health Evaluation

All patients require comprehensive screening for addiction and psychiatric comorbidities:

• Use validated screening tools: WHO Alcohol, Smoking, and Substance Involvement Screening Test for adults or CRAFFT-N for adolescents 2
• Implement behavioral interventions including cognitive-behavioral therapy, contingency management, and motivational enhancement therapy 2
• For adolescents, consider multidimensional family therapy 2
• Note: No FDA-approved medications exist for e-cigarette cessation in children and adolescents 2
• Arrange evaluation by behavioral health professionals, social workers, or psychiatrists to determine post-discharge support needs 2

Discharge Planning

Patients may be discharged when:

• Clinically stable for 24-48 hours with no significant vital sign fluctuations 1
• Adequate oxygenation maintained on room air 1

Critical discharge interventions:

• Schedule outpatient follow-up within 48 hours of discharge 1
• Arrange pulmonology consultation within 2-4 weeks 1
• Perform medication reconciliation, particularly for patients on corticosteroid taper 1
• Screen for adrenal insufficiency risk in patients who received prolonged corticosteroid courses; consider endocrinology referral 1
• Counsel patients on adrenal insufficiency signs/symptoms 1
• Connect patients to cessation services and facilitate access to mental health/substance use disorder treatment 1

Outpatient Management

For patients meeting criteria for outpatient management:

• Advise complete discontinuation of all e-cigarette and vaping products 1
• Consider corticosteroids cautiously due to infection risk 1
• Consider CXR for patients with chest pain or dyspnea 1
• Perform influenza testing during flu season 1

Health Risks Beyond Acute Lung Injury

Cardiovascular and respiratory toxicity:

• E-cigarettes contain toxic substances beyond nicotine, including vaporizing solvents, particulate matter, metals, and flavorings 4
• Young adults report respiratory symptoms including phlegm, cough, lung pain, and decreased exercise endurance that they attribute to vaping 5
• Early evidence suggests acute physiological cardiovascular effects, particularly with nicotine-containing products 6

Adolescent-specific concerns:

• Nicotine exposure during adolescence alters neurologic development and brain structure, as the adolescent brain is particularly vulnerable 4
• E-cigarette use increases odds of transitioning to combustible cigarette smoking, even among adolescents with no prior intention to smoke 4
• High-nicotine delivery systems like JUUL have increased addiction potential 4

High-Risk Populations

Patients at increased risk for rehospitalization and death include those with: 1, 3

• Cardiac disease
• Chronic pulmonary disease
• Diabetes
• Older age (median age of EVALI deaths: 54 years vs 23 years for survivors) 3

Critical Pitfall

The most common error is failing to recognize that vitamin E acetate (VEA) in THC-containing vape cartridges is the primary culprit in EVALI cases 7. However, not all EVALI cases are linked to VEA, and nicotine-only products can also cause lung injury 8. Always obtain detailed product history and maintain clinical vigilance regardless of reported product type.