Vaping and E-Cigarette Use in Children and Adolescents

Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine

Deborah A. Rusy, MD, MBA, FASA; Anita Honkanen, MD; Mary F. Landrigan-Ossar, MD, PhD, FASA, FAAP; Debnath Chatterjee, MD, FAAP, FASA; Lawrence I. Schwartz, MD; Kirk Lalwani, MBBS, FRCA, MCR; Jennifer R. Dollar, MD; Randall Clark, MD, FASA; Christina D. Diaz, MD, FASA, FAAP; Nina Deutsch, MD; David O. Warner, MD; Sulpicio G. Soriano, MD


Anesth Analg. 2021;133(3):562-568. 

In This Article

Clinical Presentation of E-cigarette, or Vaping, Product Use–Associated Lung Injury

E-cigarette, or vaping, product use–associated lung injury (EVALI) is a newly identified lung disease caused by vaping. Initial clinical presentation of EVALI can be varied, but most commonly includes the respiratory and gastrointestinal tracts as well as constitutional symptoms. Respiratory symptoms frequently include hypoxia, tachypnea, shortness of breath, pleuritic chest pain, chest pain, occasionally hemoptysis, and cough. Many patients present with concurrent nausea and vomiting, abdominal pain, diarrhea, anorexia, and weight loss. Occasionally, patients present with gastrointestinal symptoms before noting any respiratory symptoms. Constitutional symptoms include fever, malaise, and fatigue.[14–18] Patients may also present with headache, and 1 episode of seizures has been reported.[15] The majority of patients present with respiratory symptoms, and respiratory failure can progress quickly and may even develop into acute respiratory distress syndrome (ARDS).[19] Radiologic imaging generally demonstrates bilateral diffuse lung opacities on chest radiograph. Computerized tomography (CT) scan shows lower lobe predominant ground glass and consolidative opacities, often with subpleural space or lobular sparing. Pleural effusion is not common.[20,21]

As part of the diagnostic workup, some patients may undergo flexible bronchoscopy with bronchoalveolar lavage (BAL). BAL specimens have demonstrated the presence of neutrophils and lipid-laden macrophages.[22] Bronchoscopy has demonstrated mucosal hypervascularity and erythema, edema, hemorrhage, and lesions in the airway.[17] Flexible bronchoscopy with BAL and the associated anesthesia has led to the prolonged intubation and the progression of respiratory distress in patients and was noted to trigger an increased airway reactivity during the procedure.[19] Some patients have also undergone either an open lung biopsy or a transtracheal lung biopsy as part of their diagnostic workup.[23] While the mechanism of injury is not well defined, EVALI is considered a diagnosis of exclusion and infectious, oncologic, and rheumatologic etiologies need to be considered and ruled out.[24]

The treatment consisted of supportive therapy including supplemental oxygen, noninvasive ventilation, mechanical ventilation, and rarely extracorporeal membrane oxygenation (ECMO).[14,19,22] Empiric antibiotics are typically administered during the diagnostic workup.[14] EVALI is treated with vaping cessation and, when necessary, the initiation of a course of glucosteroids.[14,17,23,25,26] The length and dose of steroid treatment are yet to be determined, as some patients have required a second course or hospital readmission.[17,18]

While most patients recover, a significant portion of patients identified with EVALI require hospitalization and treatment, and some patients have died as a result of the disease.[27] Furthermore, EVALI patients who are older or with preexisting conditions are at a greater risk of death. Although there is a resolution of symptoms and CT scan findings in the patients who were followed up after discharge,[26] 2 other articles described persistent increased airway reactivity and impaired diffusion capacity on pulmonary function tests at 2- to 6-week follow-up.[17,18] The Center for Disease Control published a comprehensive report of pulmonary histopathology from lung tissue from 23 individuals with a history of e-cigarette use.[28] Acute to subacute lung injuries ranging from pneumonia to diffuse alveolar damage were noted in these specimens.