Researchers at Intermountain Healthcare in Salt Lake City have developed best practice guidelines to help physicians identify and treat e-cigarette or vaping-associated lung injury (E-VALI).
"We think it is very important for clinicians to keep E-VALI in mind when patients present not only with acute injury, but also with constitutional and abdominal symptoms, and to be sure to take a thorough vaping history," Dr. Denitza Blagev of Intermountain told Reuters Health by email.
Vaping. Source: Getty Images
"Complications occur in patients who are critically ill when they present," she noted. For those who are not as ill, "moderate doses of steroids in shorter courses are reasonable...and do not seem to cause readmissions, in our experience."
"Patients who improve do so fairly rapidly - within days - as evidenced by the reduction in steroid dosing by bedside clinicians," she said. "Thus, in the absence of a definitive diagnostic test for E-VALI, we believe clinicians who are considering this diagnosis based on clinical grounds may treat with steroids and assess response based on alternative diagnoses, severity of illness, and other patient factors."
"For patients that are not improving, clinicians should continue to reassess the differential diagnosis and consider other possibilities, especially since this remains, for now, a clinical working diagnosis," she said.
For the observational cohort study, data on all patients with E-VALI seen at Intermountain between June 27-October 4, 2019 were collected, including presentation, treatment, and short-term follow-up (two weeks after discharge) from chart review and patient interviews by the Utah Department of Health.
As reported online November 8 in The Lancet, 60 patients presented with E-VALI at 13 hospitals and outpatient clinics. The median age was 27; 80% were men; and 72%, white.
Thirty-three (55%) were admitted to an intensive care unit (ICU); 53 (88%) presented with constitutional symptoms, 59 (98%) with respiratory symptoms, and 54 (90%) with gastrointestinal symptoms.
Fifty-four patients (90%) were given antibiotics and 57 (95%) received steroids. Six (10%) were readmitted to an ICU or hospital within two weeks; half had relapsed with vaping or e-cigarette use.
Twenty-six patients (43%) were followed up within two weeks. Despite clinical and radiographic improvement in all, 10 of 15 (67%) had residual abnormalities on chest radiographs, and six of 9 (67%), on pulmonary function tests.
Two patients died. E-VALI was thought to be a contributing factor, but not the cause of death, for both.
"We believe our clinical guidelines may be of use to other medical centers," Dr. Blagev said.
"Vaping and e-cigarette use are not safe and we are continuing to learn about the different short-term and long-term consequences of vaping," she added. "As clinicians, we need to be obtaining a vaping history - much as we do other tobacco or drug use history - in all patients, and especially those in whom E-VALI may be present."
Dr. Laura Crotty Alexander of the University of California, San Diego, coauthor of a related editorial, commented by email, "It would be reasonable for other institutions to follow (Intermountain Healthcare's) lead, namely by having a point-person or team of clinicians for all cases to be referred to for review. This likely will lead to standardization of assessments at the time of presentation, during the course of the disease, and then during outpatient follow-up."
"There is a great need to better understand what happens to these patients after the acute period, including following their pulmonary function over time, need for oxygen therapy, and resolution or persistence of inflammation," she added. "Thus, implementation of a team at each institution may help make work-ups consistent across patients, and ensure good data collection and current testing from presentation through to resolution/persistence."
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