In the months prior to the pandemic, ED visits associated with an e-cigarette or vaping product-associated lung injury (EVALI) had been rising sharply. As of mid-February 2020, a total of 2,807 cases had been reported to the CDC since June 2019. Fifteen percent of hospitalizations were in children under 18 years old and 37 percent in young adults ages 18 to 24. CDC stopped issuing data in February 2020, but there are anecdotal reports of a drop-off in these ED cases during the COVID-19 crisis.
“Previously, physicians weren’t really looking for electronic cigarette use in pediatric patients; we didn’t see our first case here until 2018,” said Jacob Kaslow, M.D., a third-year pediatric pulmonary fellow at Monroe Carell Jr. Children’s Hospital at Vanderbilt. “We’re now being much more vigilant.”
Kaslow says Vanderbilt has seen about twenty suspected and five confirmed cases in teens and young adults in the last 18 months. Some have had severe pneumonia, lung collapse, or complete respiratory failure, placing them in Vanderbilt’s Pediatric Intensive Care Unit requiring mechanical ventilation and life support. “Growing evidence is also pointing towards the involvement of other organ systems, including burns to the back of the throat and oral cavity. It can even affect the inner ear,” he said.
Tracking EVALI Cases
Kaslow says the Vanderbilt pulmonology team is on heightened alert for both adult and pediatric EVALI cases; Vanderbilt researchers recently published a case report of a pneumonia mimic with severe leukocytosis and weight loss in the Journal of the American College of Emergency Physicians Open.
“Previously, physicians weren’t really looking for electronic cigarette use in pediatric patients; we’re now being much more vigilant.”
“With the COVID-19 pandemic we are seeing an additional layer of complexity – EVALI symptoms may resemble COVID-19, influenza, or bacterial pneumonia and become more dangerous or deadly when left untreated,” said Kaitlyn Works, M.D., an emergency physician at Vanderbilt and lead author on the study. “A patient with EVALI may have symptoms that vary and overlap with many illnesses, making it more complicated to diagnose. We now have a high index of suspicion for this disease when patients present to our ED with respiratory complaints.”
Realizing the Health Impact of Teen Vaping
While recent media coverage has precipitated a slight decline in hospital admissions across all age groups, Kaslow fears that teen vaping has not declined as much as expected. In a recent study, the prevalence of self-reported current e-cigarette use was 27.5 percent among high school students and 10.5 percent among students in middle school. “My biggest concern is nicotine addiction,” he said. “We’re talking about the ‘never smokers’ here.”
Whether teens are consuming nicotine or THC-containing products, flavored liquid (the main attraction for younger vapers) is often a combination of dangerous chemicals and may contain vitamin E acetate, a compound that has been strongly linked to the EVALI outbreak. The Vanderbilt pulmonology group has advocated for recent legislation to ban flavored liquids and to raise the smoking age to 21.
“Lack of regulation hindered our early understanding of the health effects of the chemicals in e-cigarettes, as the composition of e-liquids can differ from company to company, and even flavor to flavor,” Kaslow said.
Similarly, e-cigarette vapor is not benign: research has shown that vaping is associated with deregulation of certain genes, especially in the oral epithelial cells, and can increase a person’s susceptibility to development of respiratory infections.
Facilitating Honest Conversation
It is common practice in medical history intake to ask teenagers and young adults about smoking and smoke exposure. Children’s Hospital now includes questions about e-cigarette use to help care teams make informed management choices, particularly for infectious diseases.
“The use of e-cigarettes can make a common infection more severe because the body’s immune system is affected,” Kaslow said. “While some patients don’t want to admit to vaping, especially THC-related products, we approach the topic with sensitivity and encourage them to be truthful.”
Vanderbilt pediatric pulmonologists are conducting educational outreach to ED personnel, pediatricians and primary care physicians through the Cumberland Pediatric Foundation.