Episode 88 - EVALI - a podcast by Rio Bravo Family Medicine Residency Program

Episode 88: EVALI. 

Nugdeep and Jeffrey present E-cigarette and Vaping Associated Lung Injury (EVALI), including symptoms, diagnosis, and treatment. Introduction includes a word of advice for matching and not matching students in 2022. 

 

Introduction: The Match 2022 is over.  
By Hector Arreaza, MD. Read by Valeri Civelli, MD. 

Another Match season is behind us. It’s time to celebrate and prepare for a new stage of your career. As an interesting fact, the American Association of Family Physicians announced that in 2022 the highest number of family medicine residents matched.

Positions for family medicine residencies have been steadily growing for the last 13 years in a row. There are 756 family medicine categorical and combined residency programs, that’s 15 more programs than in 2021. 

Also, in 2022, osteopathic medical schools had the historic highest number of students matching into family medicine, to be exact 1,496 DO seniors matched to family medicine this year, that’s 58 more students than 2021.

During this season, the number of U.S. medical grads matching into family medicine “did not increase despite a larger number of positions available.”[1]

If you did not match this year, the Match can also be a time of reflection and goal setting as you prepare with optimism for the next season. To increase your chances to match next year, Dr. Margarita Loeza advised in an AMA article[2] to stay in touch with your medical school, find a job in a clinical setting, take Step 3, and try a new approach during next season. For example, you may consider applying to a higher number of programs or even more than one specialty. 

Residency training is the primary way to get licensed to see patients, but there are hundreds of alternative ways to pursue your passion for medicine. Do not give up on your goals. “Never give up on something that you can’t go a day without thinking about.” ―Winston Churchill.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

Page Break

EVALI.

By Nugdeep Singh, MS4; and Jeffrey Nguyen, MS4. Ross University School of Medicine. Participated in the discussion: Hector Arreaza, MD.

 

N: Good afternoon listeners. My name is Nugdeep Singh, and I am a fourth-year medical student. 

J: Hello, and I’m Jeffrey Nguyen, also a fourth-year medical student. Thank you for having us today Dr. Arreaza. 

N: Today we will be talking about E-cigarette and vape-associated lung injury (EVALI), also known as vaping-associated pulmonary injury (VAPI). But, before we get into the medical pathology of E-cigarettes and vapes, why don’t we give a little background on them.

Arreaza: EVALI and VAPI sound like another Indian holiday or an Italian dessert, but EVALI and VAPI are certainly no joke. 

J: Sure, let’s get started. So, E-cigarettes are battery-operated devices that heat liquids containing nicotine to produce an aerosol that the user inhales. Long-term health effects and whether they help an individual quit smoking has been controversial, as there has not been much research on it. 

These E-cigarettes have raised public health concerns on smoking prevalence and their potential use by children. In 2019, over 5 million children and adolescents were using 3-cigarettes. This represented an increase in e-cigarette use by high school students from 12% in 2017 to 28% in 2019. In fact, Massachusetts legislation bans the sale of all flavored tobacco products starting in June 2020. Nicotine is the main ingredient in the liquid, however, there are other constituents that are carcinogenic potential. Nugdeep, can you go over some of these ingredients? 

N: Yea, let’s start with nicotine. The level of nicotine varies between 0 to 36mg/mL, though it can be higher in some. Nicotine salt is another variant that can provide a different sensation in a user’s throat. Next is propylene glycol, which are humectants, and they are the main component of most E-cigarette liquids. 

Arreaza: When you mentioned proPYlene glycol, I immediately thought of “PEG”. PolyEthylene Glycol, does it ring a bell? Yes, it’s a common laxative, but besides that it’s used in the mRNA COVID-19 vaccines. Having allergy to PEG is one of the few contraindications of the COVID-19 vaccine. But you are not talking about PEG, you are talking about propylene glycol, which is a lightly sweet substance used in e-cigarettes, which can cause chemical conjunctivitis or respiratory irritation.  The consequences of chronic inhalation of propylene glycol are still unknown.

N: Finally, there are flavorings and there are about 7000 flavors available. Some examples include candy, fruits, sodas, and alcohol flavors. 

J: Can I add something real quick? 

N: Yea, of course. 

J: Although these flavorings do add taste to the experience, it attracts E-cigarettes in the youths, especially those who do not already smoke. So, kids, don’t start smoking these just because of the different flavors. Sorry for interrupting you, you can continue. 

N: It’s all good. To continue where I left off, metals such as tin, lead, nickel, chromium, and arsenic have also been found in these liquids. In addition to these, people can also use aerosolized THC or cannabinoid oils with these E-cigarettes. 

J: Wow, there are so many ingredients found in these liquids that the public is not aware of. Now that we know a little more about E-cigarettes, let’s talk about how they affect the lungs. 

N: Yea, let’s get to it. E-cigarette and Vape Associated Lung Injury was first recognized in the summer of 2019 and to date, there are more than 2800 cases that have been reported to CDC as of February 2020. Among those, 68 deaths have been recorded.  Approximately 66% are male users and nearly 80% are under the age of 35. Unfortunately, 22% of the patients have underlying asthma. 

J: Currently, we still don’t fully understand how E-cigarettes affect the lungs. Reported cases have hypothesized that lung diseases are associated with acute eosinophilic pneumonia, diffuse alveolar hemorrhage, acute and subacute hypersensitivity pneumonitis, respiratory bronchiolitis-associated pneumonitis, and interstitial lung disease, suggesting that more than one mechanism of injury may be involved. It is important to understand that there is no evidence of an infectious etiology. 

N: One interesting fact is that when they took fluid samples from the lungs (called bronchoalveolar lavage) from patients with lung injury from E-cigarettes, they noticed that the sample contained THC and/or Vitamin E acetate. Of course, other additives were included, however, these two were in the majority of fluid samples. In fact, the product Juul® was recently found to have a strong association with EVALI. 

Arreaza: JUUL was a commercial success, compared to Uber and Airbnb, but it has been involved in a lot of controversies around the world. 

J: Vitamin E acetate? But isn’t that found in many other products that we use on a daily basis? 

N: Definitely, Vitamin E is found in many foods including vegetable oils, cereals, meats, fruits, and vegetables. It is also available as dietary supplements and is in cosmetic products such as skin creams. There are no known harms when Vitamin E acetate is ingested or applied to the skin, however, research suggests that it interferes with normal lung functions. 

J: Interesting, who knew something as simple as Vitamin E can cause harm to the lungs when used differently. To continue, let’s talk about symptoms that patients present with. Respiratory symptoms include shortness of breath, cough, chest pain, pleuritic chest pain, and hemoptysis. Patients may have subjective fever and chills. GI symptoms include abdominal pain, nausea, vomiting, and diarrhea. Vital signs can be remarkable for tachycardia, tachypnea, and hypoxemia that may progress to respiratory failure. Nugdeep, are there any criteria to meet the diagnosis of E-cigarette and Vape Associated Lung Injury? 

N: Before I talk about how to make the diagnosis, I want to mention that CDC recommends obtaining detailed information on the type of vaping device used, type of substance used, frequency of vaping, and where these devices were obtained. To answer your question, in order to make the diagnosis, you need:

Use of e-cigarettes in the past 90 days.

Chest x-ray or CT chest showing lung opacities without any signs of lung infection.

Negative influenza PCR, respiratory viral panel, and other respiratory infections like urine antigen test for legionella. (COMMENT: COVID-19?)

 

Once the diagnosis has been made, what are the treatment options? 

J: Since this is a new and upcoming problem, there are no known treatments to date. The most important thing is to rule out infectious processes, such as community-acquired pneumonia. However, patients diagnosed with EVALI can be started on antibiotics empirically to cover pathogens of community-acquired pneumonia. Systemic glucocorticoids have been used; however, the efficacy has not been formally studied. The decision to initiate systemic glucocorticoids is challenging due to various presentations, but it has been suggested to initiate systemic glucocorticoids for patients who meet the criteria for EVALI and have progressively worsening symptoms and hypoxemia. So, what does supportive care entail?

N: 95% of patients with this diagnosis will require hospitalization for supportive care, such as supplemental oxygen with a target pulse oxygen saturation of 88-92%. If hypoxemia worsens, management follows that for acute respiratory distress syndrome. In order to discharge a patient, it is important to ensure vital signs, oxygen saturation and exercise tolerance are stable for 24-48 hours prior to discharge. Jeffrey, to conclude this podcast, can you talk about the prognosis of EVALI? 

J: Sure. When comparing fatal vs nonfatal cases of EVALI, the proportion of fatal cases was higher among patients over the age of 35 and those with a history of asthma, cardiac or mental health conditions. Case reports among adolescents suggest residual lung dysfunction, like short-term diffusion abnormalities. However, it remains unclear whether abnormalities persist in the long term. We would need to wait while they do more research about this condition. 

Arreaza: E-cigarette use is increasing, and we need to be aware of the signs and symptoms of E-cigarette and vape-associated lung injury (EVALI) to start treatment appropriately. Remember to include e-cigarettes and vaping when you ask questions about smoking. 

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Now we conclude our episode number 87 “EVALI.” EVALI stands for E-cigarette and vape-associated lung injury. The medical community has been increasingly concerned about the safety and health consequences of e-cigarettes and vaping. When you encounter a patient with respiratory complaints, remember to ask about any form of tobacco use, including e-cigarettes and vaping. If you suspect a patient has EVALI, confirm the diagnosis with a chest x-ray or CT scan and rule out any infectious etiology. Consider hospital admission if symptoms are severe, for example, if the patient has shortness of breath or requires oxygen. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email at RioBravoqWeek@clinicasierravista.org. This podcast was created for educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Valerie Civelli, Nugdeep Singh, and Jeffrey Nguyen. Audio edition: Suraj Amrutia. See you next week! 

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References:

Mitchell, David, Family Medicine Welcomes Largest Class of Residents Ever, American Association of Family Physicians, aafp.org, March 18, 2022, https://www.aafp.org/news/education-professional-development/2022-match-day.html.

 

Smith, Timothy M., What if you don’t match? 3 things you should do, American Medical Association (ama-assn.org), https://www.ama-assn.org/residents-students/match/what-if-you-don-t-match-3-things-you-should-do.

 

Kaplan, Sheila, Andrew Jacobs, and Choe Sang-Hun, The World Pushes Back Against E-Cigarettes and Juul, The New York Times, nytimes.com, March 30, 2020 https://www.nytimes.com/2020/03/30/health/vaping-juul-international.html.

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