What pulmonary complications are associated with electronic cigarette (e‑cigarette) or vaping use?

Pulmonary Complications of Vaping

Vaping causes a severe and potentially fatal lung injury known as EVALI (E-cigarette or Vaping Product Use-Associated Lung Injury), characterized by acute respiratory distress, bilateral lung infiltrates, and hypoxemia requiring hospitalization in many cases. 1, 2

Primary Pulmonary Condition: EVALI

EVALI is the most critical vaping-related pulmonary complication, presenting with:

• Respiratory symptoms: Shortness of breath, cough, chest pain, and respiratory distress 1, 3
• Systemic manifestations: Fever, fatigue, muscle aches, nausea, vomiting, and abdominal discomfort 1, 4
• Severe hypoxemia: Oxygen saturation frequently drops below 95% on room air, requiring supplemental oxygen 2
• Acute respiratory distress syndrome (ARDS): Can progress to requiring mechanical ventilation 5, 4

The CDC has documented 2,807 hospitalized EVALI cases as of February 2020, with vitamin E acetate (used as a diluent in THC vaping cartridges) strongly implicated as the causative agent 3. When inhaled, pulmonary tissue cannot metabolize or absorb vitamin E acetate, leading to its accumulation in the lungs 3.

Specific Pathologic Patterns

Four distinct imaging and pathologic patterns have been identified by the New England Journal of Medicine 5:

• Acute eosinophilic pneumonia 5
• Diffuse alveolar damage (the pathologic correlate of ARDS) 5
• Organizing pneumonia 5
• Lipoid pneumonia (from oil-based substances) 5, 4

All patterns demonstrate bilateral ground glass opacifications on chest imaging 3.

Additional Pulmonary Risks

Beyond EVALI, vaping products contain multiple pulmonary toxins:

• Carbonyl compounds: Propylene glycol and glycerin generate formaldehyde, acetaldehyde, and acrolein when heated—all are pulmonary irritants and carcinogens 3
• Diacetyl exposure: This buttery flavoring agent causes bronchiolitis obliterans (irreversible airway scarring) with inhalational exposure 3
• Heavy metal inhalation: Heating coils leach aluminum, chromium, lead, manganese, nickel, and tin into the aerosol 3
• Increased asthma severity: Long-term vaping is predicted to worsen asthma control 6

Critical Clinical Recognition

Immediate radiologic recognition of vaping as a risk factor for ARDS is pivotal in the emergency setting to initiate appropriate respiratory support without delay 5. The condition primarily affects young, previously healthy individuals aged 18-35 years with recent vaping history 4.

Hospitalization Criteria

Patients require hospitalization if they have any of the following 1, 2:

• Oxygen saturation <95% on room air
• Respiratory distress or tachypnea with increased work of breathing
• Comorbidities compromising cardiopulmonary reserve
• Inability to discontinue vaping product use
• Inadequate social support or unreliable access to care

Treatment Approach

Management centers on immediate cessation of all vaping products and supportive care 2:

• Discontinue all e-cigarette and vaping products immediately 2
• Supplemental oxygen to maintain SpO2 ≥95% 2
• Systemic corticosteroids have shown benefit in many cases, though used with caution due to infection risk 2, 3
• Empiric antimicrobials until infectious etiologies are excluded 2
• Mechanical ventilation for severe ARDS cases 4

Long-Term Consequences

The long-term pulmonary effects remain under investigation, but concerns include 7:

• Persistent functional impairment requiring pulmonology follow-up at 2-4 weeks with spirometry and DLCO testing 1
• Potential for chronic lung disease development
• Increased risk for future respiratory infections

Common pitfall: Flavoring agents in vaping products are FDA-approved for ingestion but lack any safety data for inhalational exposures—this creates a false sense of security 3. The absence of long-term safety data for e-cigarettes means the full spectrum of pulmonary complications may not yet be recognized 3, 6.