Identifying E-Cigarette-Related Health Risks

Context

This learning lesson is inspired by a personal experience with a 35-year-old patient who had no prior respiratory issues and was admitted to the intensive care unit due to severe respiratory distress. After extensive investigations, the diagnosis of vaping-related lung injury was established as a diagnosis of exclusion.

E-cigarettes have become increasingly popular in the UK over the past decade, particularly among young adults and adolescents. While marketed as a safer alternative to combustible tobacco and endorsed in certain contexts as a smoking cessation tool, concerns have emerged regarding acute lung injury associated with vaping products.1

Vaping in adolescents has become a growing concern, especially highlighted in regional initiatives like the Go Smoke Free campaign in the Midlands. During my time at City Hospital Birmingham, I personally observed that for a notable period, vaping was promoted at the entrance as a safer alternative to smoking. While this reflected adult-focused harm reduction efforts at that time, the landscape has shifted. Now, adolescent vaping rates have surged, with nicotine dependence developing in a population particularly vulnerable due to ongoing neurodevelopment. As regulatory efforts – like the proposed disposable e-cigarette ban – face implementation hurdles, emergency clinicians must adapt. While clinical presentations such as dizziness, palpitations or anxiety-like symptoms may overlap with adults, the key difference lies in the social context, early intervention and safeguarding. Our focus now must adapt to the unique risks faced by young people.2,3

In 2019, the United States reported a large outbreak of e-cigarette or vaping-associated lung injury (EVALI), with over 2,800 hospitalised cases and 60 confirmed deaths. The majority of cases were linked to tetrahydrocannabinol (THC) – containing products adulterated with vitamin E acetate.4 Although the UK has not experienced an outbreak of similar magnitude – likely due to stricter regulatory controls under the Tobacco and Related Products Regulations (TRPR) 2016 – sporadic cases of severe vaping-associated lung injury have been reported.5

The clinical presentation of EVALI is variable and can mimic infectious pneumonia, acute respiratory distress syndrome (ARDS), or other inflammatory lung diseases, making early recognition challenging. Given the continued rise in vaping prevalence and evolving product formulations, healthcare professionals must remain alert to the potential harms associated with e-cigarette use. This case serves as a reminder of the necessity to consider e-cigarette use in patients presenting with unexplained respiratory symptoms and include as part of social history taking. After receiving appropriate treatment, the patient was successfully transitioned to the respiratory ward for ongoing care.

Definition

Vaping-related lung injury, or EVALI (e-cigarette or vaping-associated lung injury), refers to a spectrum of acute respiratory conditions associated with recent e-cigarette use.6 According to Centers for Disease Control and Prevention (CDC) criteria, EVALI is a clinical diagnosis requiring e-cigarette use within 90 days prior to symptom onset, pulmonary infiltrates on chest radiograph or computed tomography, and exclusion of alternative causes such as infection.

Patients commonly present with cough, dyspnoea, and chest pain, with imaging frequently demonstrating bilateral infiltrates or ground-glass opacities.5 Pathological patterns may include hypersensitivity pneumonitis, organising pneumonia, or chemical pneumonitis related to exposure to constituents of vaping products.5

Early recognition and reporting are important for ongoing surveillance and public health monitoring.6

The pathophysiology of vaping-related lung injury involves several mechanisms.6 Exposure to harmful substances in e-cigarettes, such as nicotine, flavouring agents, and additives, can lead to direct lung damage and inflammation.5

In hypersensitivity pneumonitis, an immune response occurs due to inhalation of specific antigens, causing inflammation in the alveoli.6 This inflammation can result in the accumulation of immune cells like macrophages and eosinophils, leading to tissue damage and impaired gas exchange.5

Chemical pneumonitis may occur when inhaled vapours irritate the lung tissue, resulting in inflammation and increased permeability of the alveolar-capillary membrane.6 This can cause fluid to accumulate in the lungs, leading to symptoms of respiratory distress.5 Overall, the exact mechanisms are still being studied, and the interplay between various chemicals and individual susceptibility plays a crucial role in the development of vaping-related lung injury.5

Infographic courtesy of the author

Learning bite

Vaping-related lung injury is caused by harmful substances that can lead to inflammation and causes direct or indirect damage in the lungs.

Clinical Assessment

When evaluating a patient suspected of having vaping-related lung injury, a thorough clinical assessment is essential.6 This includes:

History Taking

• Detailed inquiry about vaping habits, including duration, frequency, and types of substances used (nicotine, THC, flavourings).5
• Assessment of symptoms such as cough, dyspnoea, chest pain, and any associated gastrointestinal symptoms like nausea or vomiting.6

Physical Examination

• Focus on respiratory signs, including respiratory rate, oxygen saturation, lung auscultation for wheezing or crackles, and signs of respiratory distress.5

Investigations

• Bedside investigations like ABG (arterial blood gases) in hypoxic patients.6
• Radiological imaging, such as chest X-rays or CT scans, to identify patterns like ground-glass opacities or pulmonary infiltrates.5
• Laboratory tests, including inflammatory markers (e.g., C-reactive protein) and cultures to rule out infections.6

Risk Stratification

Risk stratification helps determine the severity of the condition and guides management.6 Factors to consider include:

Severity of Symptoms

• Assessing the extent of respiratory distress and the need for supplemental oxygen or mechanical ventilation.5
• Early involvement of other teams (outreach, Intensive care team).6
• Most patients are young and can compensate for some time before suddenly deteriorating.5

Underlying Health Conditions

• Identifying comorbidities such as asthma, chronic obstructive pulmonary disease (COPD), or cardiovascular diseases that may complicate the clinical picture.6

Response to Initial Treatment:

• Monitoring the patient’s response to bronchodilators, corticosteroids, and other interventions to evaluate the need for escalated care or admission to intensive care.5
• By systematically assessing and stratifying risk, healthcare providers can tailor management plans effectively, ensuring timely intervention and optimal outcomes for patients with vaping-related lung injury.6

Learning bite

Many patients may not disclose their vaping history unless specifically asked, as they often do not consider themselves smokers.

Bedside tests: ABG

Arterial blood gas is an important bedside test in suspected EVALI, providing objective assessment of oxygenation, ventilation, and acid–base status. It typically demonstrates hypoxaemia and helps guide oxygen therapy and escalation decisions.

Imaging Studies:

Chest X-ray: Initial imaging to identify lung abnormalities such as infiltrates or opacities.6

CT scan of the Chest: Offers detailed visualization, revealing patterns like ground-glass opacities or consolidations indicative of hypersensitivity pneumonitis or chemical injury.5

Laboratory Tests:

• Blood Tests: Including complete blood count (CBC) to assess for inflammation and inflammatory markers such as C-reactive protein (CRP).6
• Microbiological Testing: Sputum cultures and bronchoalveolar lavage (BAL) fluid analysis to identify potential infectious agents contributing to respiratory symptoms.5

Outside the Emergency Medicine Department

Detailed Pulmonary Function Testing: Conducted in a respiratory clinic, these tests provide a comprehensive assessment of lung function, including total lung capacity and diffusion capacity, to evaluate for any ongoing respiratory impairment.5

Allergy Testing: Skin prick tests or serum specific IgE testing to investigate potential allergic reactions to components in e-cigarette liquids.6

Biopsy (if indicated): If the diagnosis remains unclear after non-invasive testing, a lung biopsy may be performed to assess lung tissue for signs of inflammation or injury.5

Learning bite

Chest X-ray and ABG are valuable bedside tools.

In the Emergency Medicine Department

Supportive Care:

• Oxygen therapy: Provide supplemental oxygen and titrate according to clinical response, aiming for target saturations of 94–98% in most patients, or 88–92% in patients at risk of hypercapnic respiratory failure (e.g. COPD), in line with British Thoracic Society guidance.6
• Bronchodilators: Administer short-acting bronchodilators like salbutamol to alleviate bronchospasm and enhance airflow.5

Corticosteroids:

• Dosing: In patients with severe disease, intravenous corticosteroids may be considered. Regimens described in case series commonly include methylprednisolone (e.g. 0.5–1 mg/kg IV twice daily), followed by an oral prednisolone taper. There is no standardised dosing protocol for EVALI.
• Duration: Treatment typically spans 5 to 14 days, depending on severity and response.5

Antibiotic Coverage:

Since many patients may present with chest X-ray findings suggesting consolidation, initiating empirical antibiotic therapy is advisable while awaiting further diagnostic results. This approach helps address the possibility of concurrent bacterial pneumonia.6

Monitoring:

Continuously monitor vital signs, oxygen saturation, and respiratory effort to assess the patient’s condition and treatment response.5

Treatments as an Inpatient:

Depending on the severity, patients can be admitted initially to the ICU if they need respiratory support before stepping down to a respiratory ward.6

Further Respiratory Management:

• Pulmonary Rehabilitation: Referral to rehabilitation programs to improve lung function and overall health will be needed after recovering from the critical status.5
• Long-term Corticosteroid Therapy: For patients with ongoing symptoms, a tapering regimen of oral corticosteroids may be required.6

Education and Support:

• Educate patients about the risks associated with e-cigarette use and emphasize the importance of avoiding further exposure to vaping products.5
• Provide resources for counselling and support groups to assist with smoking cessation if needed.6

Follow-up Care

Regular respiratory clinic follow-up appointments to monitor lung function and adjust treatment plans are usually necessary; additional pulmonary function tests may be conducted to evaluate recovery.5

Learning bite

The primary treatment is effective oxygenation, leading to rapid improvement in most patients; however, some may require intensive care admission. Fortunately, many are young and tend to recover well, though long-term lung damage is often unavoidable.

• Delayed Recognition: Failing to consider vaping-related lung injury in patients with respiratory symptoms can lead to delays in diagnosis and treatment. Symptoms may mimic other respiratory conditions, making it essential to maintain a high index of suspicion.
• Misinterpretation of Imaging: Chest X-rays or CT scans may show findings consistent with infections or other lung diseases. It’s crucial to differentiate these from vaping-related injury, as initial imaging may not always reveal the specific aetiology.
• Antibiotics overprescribing: While empirical antibiotic treatment may be necessary, over-prescribing can occur if there’s a failure to adequately assess the patient’s history of vaping. This can lead to unnecessary side effects and complications.
• Inadequate Monitoring: Insufficient monitoring of respiratory status and response to treatment can hinder timely interventions. Close observation is vital, especially in severe cases.
• Corticosteroid Management: Improper dosing or duration of corticosteroid therapy can result in inadequate treatment of inflammation or potential complications from excessive use. Adjustments should be based on clinical response.
• Failure to Address Underlying Risk Factors: Not identifying and addressing other risk factors, such as co-existing lung diseases or environmental exposures, can impact patient outcomes and recovery.
• Patient Education Gaps: Lack of effective communication regarding the risks associated with e-cigarette use can lead to continued exposure and worsening of symptoms. Providing thorough education is essential for prevention.

1. Zulfiqar H, Sankari A, Rahman O. Vaping-Associated Pulmonary Injury. [Updated 2023 Jun 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan-.
2. Medicines and Healthcare products Regulatory Agency (MHRA). E-cigarette use or vaping: reporting suspected adverse reactions, including lung injury. Drug Safety Update, MHRA. Gov.UK. 2020.
3. New England Journal of Medicine. E‑Cigarettes and Vaping‑Related Disease. Special Issue. 2019.
4. American Thoracic Society. E‑cigarette or Vaping Product Use‑Associated Lung Injury (EVALI): Clinician Information.
5. Rebuli ME, Rose JJ, Noël A, et al. The E‑cigarette or Vaping Product Use–Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions. Ann Am Thorac Soc. 2023;20(1):1‑17.