Should a patient with a history of vaping be considered high risk for respiratory complications?

Should Patients Who Vape Be Considered High Risk?

Yes, patients who vape should be considered high risk for respiratory complications and cardiovascular disease, and this risk status should influence perioperative planning, monitoring intensity, and clinical decision-making. 1, 2

Cardiovascular Risk Profile

Vaping significantly elevates cardiovascular risk through multiple mechanisms:

• Nicotine has significant cardiovascular effects and may play a major role in the development of coronary artery disease, atherosclerosis, and aortic aneurysms, making vapers high-risk patients for cardiovascular complications 1
• Smoking (including vaping) is associated with a doubling of the relative risk of stroke according to meta-analysis data, with this increased risk specifically linked to nicotine exposure 1
• Electronic cigarettes adversely affect cholesterol metabolism and cardiovascular health, contrary to common misperceptions that they are harmless 1, 2
• Vaping increases systolic blood pressure and negatively impacts lipid profiles, both of which are key components of cardiovascular risk stratification 1

Respiratory Complications Risk

Patients who vape face substantial respiratory risks that warrant high-risk classification:

• Vaping is associated with acute respiratory distress syndrome (ARDS) requiring intensive care admission, mechanical ventilation in up to one-third of cases, and even extracorporeal membrane oxygenation (ECMO) support 3, 4, 5
• Spontaneous pneumothorax occurs with vaping, with documented recurrent episodes directly correlated with vaping use 6, 7
• E-cigarette or vaping product-associated lung injury (EVALI) presents with pulmonary infiltrates and can rapidly progress to respiratory failure requiring ICU-level care 3, 5
• Cigarette smoking (and by extension vaping) is associated with increased susceptibility to and severity of respiratory infections through immune suppression, abnormal ciliary function, oxidative stress, and promotion of inflammation 2

Perioperative Risk Stratification

When evaluating vapers for surgical procedures, they should be classified as high-risk patients:

• Smoking cessation of 4 to 8 weeks is necessary to reduce respiratory and wound-healing complications in surgical patients, and vapers should be counseled similarly 8
• Patients who smoke have documented increased risk of intra- and postoperative complications, and this risk profile should be applied to vapers 8
• Critically ill patients are at high risk for ventilator-associated pneumonia (VAP), with smoking-related factors contributing to this risk 8
• Age >43 years and fraction of inspired oxygen (FiO2) >0.5 are predictors of respiratory deterioration, risks that are compounded in patients with vaping history 8

Clinical Management Algorithm

Immediate Risk Assessment

• Screen for tobacco, nicotine, and electronic cigarette use at every healthcare visit as recommended for routine practice 1, 2
• Document frequency and duration of vaping use (daily use strongly predicts future dependence and complications) 8
• Assess for dual use of combustible cigarettes and e-cigarettes, which compounds risk 1, 9

Preoperative Optimization

• Recommend complete cessation of vaping for at least 4 weeks prior to elective surgery to reduce respiratory and wound complications 8
• Screen for undiagnosed hypertension, diabetes, and anemia—conditions more prevalent or complicated by vaping 8, 1
• Consider enhanced cardiorespiratory assessment given elevated cardiovascular risk profile 1

Perioperative Monitoring

• Classify vapers as high-risk patients requiring enhanced monitoring for respiratory parameters including respiratory rate, oxygen saturation, and early signs of respiratory deterioration 8
• Maintain heightened vigilance for spontaneous pneumothorax, particularly in younger patients 6, 7
• Monitor for signs of acute lung injury or ARDS, which can develop rapidly in vapers 3, 4, 5

Postoperative Care

• Consider semi-recumbent positioning and closed endotracheal suction systems if mechanical ventilation is required, as these reduce VAP risk in high-risk patients 8
• Implement active surveillance for VAP in the days following any transport or procedure requiring mechanical ventilation 8
• Plan for potentially longer ICU and hospital length of stay given increased complication risk 8

Critical Pitfalls to Avoid

The most dangerous pitfall is accepting the common misperception that e-cigarettes are harmless or significantly less harmful than traditional cigarettes 2, 9. This misconception can lead to:

• Failure to classify vapers as high-risk patients
• Inadequate preoperative counseling and optimization
• Insufficient perioperative monitoring
• Missed opportunities for cessation counseling

Do not treat vaping as equivalent to smoking cessation—patients using e-cigarettes to quit smoking should be advised to avoid dual use and develop a plan to eventually quit e-cigarettes as well 1, 9

Special Population Considerations

• Youth and adolescents who vape face particularly elevated cardiovascular disease risk and should be screened starting at puberty 2
• Patients with diabetes who vape have compounded cardiovascular risk and should receive intensive cessation counseling 1, 2
• Older patients and those with underlying cardiac or pulmonary conditions face higher mortality and morbidity from vaping-related complications 5

Evidence-Based Cessation Support

When counseling high-risk vapers:

• Varenicline is the most efficacious pharmacotherapy for smoking cessation and should be considered for vapers attempting to quit 2
• Pharmacotherapy plus counseling improves cessation rates compared with either intervention alone 2
• Behavioral strategies should be integrated to support both smoking and vaping cessation 2
• The benefits of complete nicotine cessation on cardiovascular risk become apparent within 2 to 5 years, with return to non-smoker risk levels 1