What key questions should I ask a patient with vaping‑related bronchiolitis obliterans complicated by pneumomediastinum to obtain a complete history of present illness (HPI)?

Key History Questions for Vaping-Related Bronchiolitis Obliterans with Pneumomediastinum

You must obtain a detailed vaping exposure history including specific products, frequency, duration, and recent changes in use patterns, as this directly impacts both diagnosis and prognosis in this life-threatening condition. 1

Essential Vaping Exposure History

Product-Specific Details

• What specific substances were vaped? Document nicotine-containing e-liquids, tetrahydrocannabinol (THC) oils, cannabidiol (CBD) products, and any flavored e-liquids 2, 3
• Which brands and flavoring agents were used? Diacetyl-containing products are particularly associated with bronchiolitis obliterans 4, 2
• What was the frequency and intensity of vaping? Intensive or heavy use patterns correlate with more severe presentations 2, 3
• When did vaping start and when was the last use? Establish temporal relationship between exposure and symptom onset 2, 5
• Have there been recent changes in vaping products or patterns? New products or increased frequency may trigger acute deterioration 2, 6

Temporal Relationship to Symptoms

• When did respiratory symptoms begin relative to vaping exposure? Acute bronchiolitis typically develops within days to weeks of intensive exposure 2, 3
• Was there a specific event or change in vaping behavior before symptom onset? This helps establish causality 2

Respiratory Symptom Characterization

Primary Respiratory Complaints

• Describe the cough: Onset (acute vs. gradual), character (dry vs. productive), severity, and whether it is intractable or progressive 1, 2
• Quantify dyspnea progression: Rate of worsening, exercise tolerance changes, and whether dyspnea occurs at rest 2, 5
• Any chest pain? Location, character, radiation, and relationship to breathing (pleuritic pain may indicate pneumomediastinum complications) 3, 7

Associated Respiratory Features

• Any wheezing or audible breathing difficulties? Fixed airflow obstruction is characteristic of bronchiolitis obliterans 2, 5
• Hemoptysis or blood-tinged sputum? This may indicate severe airway inflammation 2

Pneumomediastinum-Specific Questions

Symptoms Suggesting Air Leak

• Any subcutaneous emphysema or neck swelling? Palpable crepitus suggests mediastinal air dissection 3, 7
• Voice changes or difficulty swallowing? These may indicate mediastinal air compression 7
• Sudden worsening of chest pain or dyspnea? This could signal progression to tension pneumothorax 3

Constitutional and Systemic Symptoms

Non-Respiratory Manifestations

• Fever, chills, or night sweats? Constitutional symptoms are common in vaping-associated lung injury 2, 3, 6
• Weight loss and timeline? Significant weight loss suggests severe systemic illness 3
• Gastrointestinal symptoms: Nausea, vomiting, diarrhea, or abdominal pain frequently accompany vaping-related lung injury 3, 6
• Malaise or fatigue? General unwellness is characteristic 2

Environmental and Occupational Exposures

Comprehensive Exposure Assessment

• Any occupational exposures to inhaled toxins? Agricultural work, bird exposure, or industrial chemicals can cause hypersensitivity pneumonitis or other forms of bronchiolitis 1
• Home environment exposures: Mold, water damage, hot tubs, humidifiers, or bird keeping 1
• Geographic and cultural factors: Region-specific exposures relevant to hypersensitivity pneumonitis 1
• Recent travel or new environmental exposures? This helps identify alternative etiologies 1

Past Medical and Medication History

Relevant Medical Background

• Any history of lung transplantation or hematopoietic stem cell transplantation? These are major risk factors for bronchiolitis obliterans, though unlikely in this vaping-related context 1, 8, 9
• Previous respiratory diseases: Asthma, COPD, or other chronic lung conditions 1
• Immunosuppression history: Current or past use of immunosuppressive medications 1, 8
• Gastroesophageal reflux disease (GERD) symptoms: Reflux can contribute to airway injury and is relevant for management 1, 8, 9

Medication and Treatment History

• Current medications, particularly corticosteroids or immunosuppressants? Document doses and duration 1, 8
• Any recent antibiotic use? This helps assess for infectious complications 1
• Previous treatments for respiratory symptoms and their response? Lack of response to bronchodilators suggests fixed obstruction 2, 5

Infectious Symptom Screening

Rule Out Concurrent Infection

• Recent infectious symptoms: Upper respiratory infections, pneumonia symptoms, or systemic infections 1
• Sick contacts or known exposures to tuberculosis or other respiratory pathogens? Multiple cultures are typically negative in vaping-related bronchiolitis, but infection must be excluded 2, 3

Functional Status and Quality of Life Impact

Baseline and Current Function

• What was exercise tolerance before symptom onset? Establish baseline for comparison 2
• Current functional limitations: Activities of daily living, work capacity, and mobility 2, 5
• Oxygen requirement: Whether supplemental oxygen is needed and at what flow rate 2, 3

Critical Pitfalls to Avoid

• Do not assume all vaping-related lung injury is the same: Bronchiolitis obliterans (small airway disease with fixed obstruction and air trapping) is distinct from acute alveolar injury patterns (ground-glass opacities) seen in other vaping-associated pulmonary illness cases 2, 3, 6
• Do not overlook alternative diagnoses: Hypersensitivity pneumonitis, infectious bronchiolitis, and other interstitial lung diseases can mimic vaping-related bronchiolitis and require systematic exclusion through exposure history 1
• Do not miss pneumomediastinum complications: Specifically ask about sudden worsening, as progression to tension pneumothorax is life-threatening 3