February 18, 2020
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New guidance for vaping injuries offers screening recommendations

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A multi-disciplinary task force issued guidance for vaping-associated respiratory disease, or VARDS. The guidance, which was presented at the Society for Critical Care’s annual congress and concurrently published in Critical Care Explorations, recommended that physicians focusing on quickly identifying patients at risk for lung injury and familiarize themselves with vaping jargon.

VARDS is not the same as EVALI — the term the CDC has given to electronic cigarette- or vaping-associated lung injuries, Craig M. Lilly, MD, lead author of the VARDS guidance and a professor of medicine at the University of Massachusetts Medical School in Worcester, told Healio Primary Care.

“VARDS is a more severe and life-threatening form of lung injury than EVALI,” he said.

According to Lilly and colleagues, the CDC defines EVALI as potentially occurring in patients who used an e-cigarette during the 90 days before symptom onset, have a pulmonary infiltrate such as opacities on plain film chest radiograph or ground-glass opacities on a chest CT and there is no clinical evidence of a pulmonary infection on the patient’s initial work-up.

E-cigarette 
A multi-disciplinary task force issued guidance for vaping-associated respiratory disease, or VARDS.
Source:Adobe

Patients who could possibly have VARDS meet the CDC’s three EVALI characteristics and also have a chest imaging study with “new and otherwise unexplained lung abnormalities, and have acute hypoxemia, defined as a decrement from baseline to a resting oxygen saturation of less than 95% at rest and or less than 88% with exercise,” Lilly and colleagues continued.

Individuals who have vaped or used e-cigarettes in the previous 90 days and have chest pain, cough, fatigue, shortness of breath or weight loss that started after the use of vaping devices should seek medical attention for possible VARDS, according to a press release from the society. Individuals should also be encouraged to take pictures of the vaping products that they use and be honest about how frequently they use them.

“This can help critical care professionals confirm and assess exposure and provide the most effective treatment,” Lilly said in the release.

The guidance, which can be utilized nationwide, also provides other terms besides vaping, like “Juuling,” “dabbing” and “dripping.” It also recommends that patients seeking medical care who have vaped or been exposed to vaping fumes in the last 90 days be divided into three groups:

  • Worcester Group 1: Patients without VARDS symptoms — chest pain, cough, fatigue, shortness of breath or weight loss — should be asked if need help with quitting and if so, be referred to a nicotine or THC-focused addiction medicine program.
  • Worcester Group 2: Patients with VARDS symptoms should have a chest X-ray. If the results are abnormal, the patient is at higher risk for developing respiratory failure. Patients with VARDS symptoms and normal blood oxygen levels (eg, 95% at rest or 88% during exercise) should be evaluated and managed on an outpatient basis.
  • Worcester Group 3: Patients with VARDS symptoms and abnormal blood oxygen levels should be hospitalized for monitoring, offered spirometry when dyspnea is present and referred to a specialist when symptoms are severe and when infiltrates are extensive or have a fibrotic pattern.

Lilly said that targeted questions can ascertain if a patient’s symptoms are related to vaping.

“Ask about [vaping] exposure, type of vaping device, intensity of use and whether there are cases that cluster with a particular vaping solution. Cases that do not involve vaping suggest that an infection is the cause,” he said.

The VARDS guidance also notes that phenospecificity is helpful for distinguishing cases that are likely to benefit from early treatment with steroids such as acute eosinophilic pneumonia, hypersensitivity pneumonitis and lipoid pneumonia. The authors wrote that treatment should be based on the “tissue injury variants that may be harmed by the immunosuppressive side effects of steroids and phenotypes destined for recovery with avoidance of exposure alone.”

According to the CDC, to date there have been 2,758 hospitalizations or deaths related to vaping injuries reported from all 50 states, Washington, D.C., Puerto Rico and the U.S. Virgin Islands. – by Janel Miller

References:

CDC. CDC, states update number of hospitalized EVALI cases and EVALI deaths. https://www.cdc.gov/media/releases/2020/s0211-Evali-cases-deaths.html. Accessed Feb. 12, 2020.

Lilly C, et al. Crit Care Expl. 2020;doi:10.1097/CCE.00000000000008.

Lilly C, et al. Vaping-associated respiratory distress syndrome (VARDS): New guidance provides first screening recommendations. Presented at: Society of Critical Care Medicine’s Critical Care Congress; Feb. 16-19, 2020; Orlando.

Disclosures: Healio Primary Care was unable to confirm relevant financial disclosures at the time of publication.