Characterizing E-Cigarette Vaping Associated Lung Injury (EVALI) in the Pediatric Intensive Care Unit

Objective: Adolescent e-cigarette use has risen to epidemic levels in the US, revealing a new phenomenon of e-cigarette associated vaping lung injury (EVALI). It is important to better characterize EVALI in the critically ill adolescent as this is a vulnerable and rapidly growing demographic.

Methods: This was a retrospective case series of patients ≤ 21 years old with confirmed or probable EVALI (as defined by the Centers for Disease Control) that resulted in admission to the pediatric intensive care unit (PICU) of a large tertiary academic children's hospital between August 2019 and January 2020.

Results: There were six eligible patients, with median age of 17 years. All patients reported tetrahydrocannabinol (THC) as well as nicotine e-cigarette use. Half of the patients had a preexisting diagnosis of asthma and four patient had mental health comorbidities. All patients presented with respiratory alkalosis and chest radiography showing diffuse bilateral infiltrates; two patients had pneumomediastinum, subcutaneous air and/or pneumothorax. The lowest documented ratio of oxygen saturation to inspired oxygen (SpO2:FiO2 or S/F ratio) ranged from 146 to 296. Two patients required an arterial line, with lowest ratio of arterial oxygen to inspired oxygen (PaO2:FiO2 or P/F ratio) of 197 and 165. Two patients tested positive for rhinovirus and respiratory cultures were negative for all patients. Four patients underwent chest CT imaging, which showed diffuse ground glass opacities. Every patient required non-invasive positive pressure ventilation, with one progressing to invasive ventilation. All patients received broad spectrum intravenous antibiotics and steroids, though there was considerable variability in dose, frequency and duration of steroids. The hospital length of stay ranged from 5 to 16 days (median 8.3 days) with PICU length of stay ranging from 4 to 10 days (median 5.5 days). Four patients had pulmonary function testing prior to discharge, two of which showed decreased diffusing capacity of lung for carbon monoxide (DLCO). There were no patient deaths.

Conclusions: This single center case series describes the presentation, course and treatment of EVALI in a pediatric intensive care unit setting. Our results show nuanced differences in the presentation and management of the critically ill adolescent, and raise many questions about the long term implications on lung health, morbidity and mortality. Importantly, these cases illustrate the critical care consequences of a public health phenomenon and should spur further research and policy to address the negative health effects of vaping. This article is protected by copyright. All rights reserved.

Keywords: e-cigarette vaping associated lung injury; intensive care; pediatrics.