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Long-term outcomes of EVALI: a 1-year retrospective study

2021; Elsevier BV; Volume: 9; Issue: 12 Linguagem: Inglês

10.1016/s2213-2600(21)00415-x

2213-2619

G. Triantafyllou, Perry J. Tiberio, Richard H. Zou, Michael J. Lynch, John W. Kreit, Bryan J. McVerry, Alison Morris, Jason J. Rose,

Burn Injury Management and Outcomes

E-cigarette, or vaping, product use-associated lung injury (EVALI) was first described in 2019,1Layden JE Ghinai I Pray I et al.Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—final report.N Engl J Med. 2020; 382: 903-916Google Scholar and according to the US Centers for Disease Control and Prevention (CDC) at the end of 2020, 2807 patients were admitted to hospitals with EVALI and 68 died.2CDCOutbreak of lung injury associated with the use of e-cigarette, or vaping, products.https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html#latest-informationDate: Nov 27, 2020Date accessed: September 9, 2021Google Scholar The long-term respiratory sequelae and outcomes in patients with EVALI remain unknown. We previously reported acute findings from patients with EVALI at the University of Pittsburgh Medical Center3Zou RH Tiberio PJ Triantafyllou GA et al.Clinical characterization of e-cigarette, or vaping, product use-associated lung injury in 36 patients in Pittsburgh, Pennsylvania.Am J Respir Crit Care Med. 2020; 201: 1303-1306Google Scholar and here, we report the long-term clinical characteristics and outcomes of patients with EVALI 1 year after initial hospital admission. We retrospectively reviewed electronic medical records of 41 patients diagnosed with confirmed or probable EVALI (on the basis of CDC diagnostic criteria)1Layden JE Ghinai I Pray I et al.Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—final report.N Engl J Med. 2020; 382: 903-916Google Scholar and admitted to any of the University of Pittsburgh Medical Center hospitals between July, 2019, and Sept, 2020. Predefined outcomes of interest were type and duration of symptoms, all-cause mortality, readmissions or emergency department encounters, and chest radiographical and pulmonary function abnormalities. Data are presented as the number of patients with percentages or as medians with IQR. This research was reviewed by the University of Pittsburgh Institutional Review Board and determined to be exempt from informed consent. The funders (National Institutes of Health, Breathe Pennsylvania, and Parker B Francis Foundation) of this research Correspondence had no role in the design, data collection, data analysis, data interpretation, and writing of the report, or the decision to submit for publication. Patient characteristics at the time of initial hospital admission are shown in the appendix (p 2). Median patient age was 21·0 years (IQR 18·5–31·0), patients were mostly men (32 [78%] of 41 patients), and most (28 [68%]) had at least one comorbidity. Eight (29%) of 28 patients had underlying lung disease, specifically asthma, chronic obstructive pulmonary disease, or cystic fibrosis. None of the patients died during initial hospital admission. 33 (80%) of 41 patients had a subsequent health-care encounter (outpatient, emergency department visit, or inpatient). 29 (71%) patients were seen in the clinic. Ten (24%) patients had at least one emergency department visit and ten (24%) required at least one hospital admission in the 1 year following initial hospital admission, with median time to readmission of 23·5 days (IQR 3·7–199·0). Of 33 patients with a documented subsequent health-care encounter, 16 (48%) reported to have stopped vaping, four (12%) continued use of e-cigarettes, and for 13 (39%) patients the vaping assessment was not recorded by the health-care providers. Follow-up patient data are shown in the table. At the outpatient follow-up visit, 13 (45%) of 29 patients reported persistent symptoms (fatigue, dyspnoea, decreased exercise capacity, cough, anorexia, and abdominal pain). Symptoms later resolved in nine (69%) of 13 patients. The median time to documented symptom resolution in these patients was 48·0 days (IQR 15·0–185·0). Eight (28%) of 29 patients were prescribed systemic steroids, and one received corticosteroid inhalers as an outpatient. None of the patients required oxygen supplementation after hospital discharge.TablePatient follow-up dataPatientsSymptoms during outpatient follow-up (n=29)Any symptom13 (45%)Fatigue6 (21%)Dyspnoea6 (21%)Decreased exercise capacity4 (14%)Cough3 (10%)Anorexia2 (7%)Abdominal pain1 (3%)Pulmonary function testing at initial outpatient follow-up*One additional patient with very severe underlying obstructive respiratory disease before EVALI was not included in the median or IQR calculations.Spirometry (n=12)FVC%72·0 (63·5–98·2)FEV1%76·0 (58·5–99·2)FEV1/FVC82·5 (73·0–88·0)FEF25–75%90·5 (63·7–96·7)Diffusing capacity for carbon monoxide corrected for haemoglobin percentage (n=10)68·0 (51·0–87·2)Total lung capacity percentage86·0 (69·0–109·2)Pulmonary function testing at second outpatient follow-up (n=9)*One additional patient with very severe underlying obstructive respiratory disease before EVALI was not included in the median or IQR calculations.Time after first set of pulmonary function testing (days)35·0 (23·7–40·5)Spirometry (n=6)FVC%101·5 (95·5–123·7)FEV1%99·0 (89·7–112·7)FEV1/FVC82·0 (74·0–89·0)FEF25–75%87·5 (73·5–115·0)Diffusing capacity for carbon monoxide corrected for haemoglobin percentage (n=3)90·0 (range 81·0–91·0)Percentage change compared with initial pulmonary function testingFVC41·4 (11·5–50·8)FEV132·1 (0·0–70·7)Diffusing capacity for carbon monoxide51·7 (range 51·0–54·0)Follow-up radiographical imaging (n=18)Resolved12 (67%)Improved4 (22%)Focal scarring2 (11%)Data are n (%), median (IQR), or % (range). FVC=forced vital capacity. FEF=forced expiratory flow.* One additional patient with very severe underlying obstructive respiratory disease before EVALI was not included in the median or IQR calculations. Open table in a new tab Data are n (%), median (IQR), or % (range). FVC=forced vital capacity. FEF=forced expiratory flow. Of the ten inpatient hospital readmissions, six (60%) were due to respiratory diagnoses including persistent or recurrent EVALI, asthma, or bacterial pneumonia. Eight (80%) of the patients who were readmitted had at least one comorbidity. Two patients with substantial underlying medical comorbidities died after hospitalisation, with a 1-year all-cause mortality rate of 4·9%. The cause of death for these two patients was not directly attributed to EVALI. Notably, the baseline death rate of individuals aged 25–34 years in Pennsylvania (USA) in 2019, was 153·8 per 100 000.4Centers for Disease Control and PreventionAbout underlying cause of death, 1999–2019.http://wonder.cdc.gov/ucd-icd10.htmlDate: 2020Date accessed: September 9, 2021Google Scholar 18 (44%) of 41 patients had follow-up radiographical imaging. 12 (67%) of these 18 patients had complete resolution and four (22%) had improvement in initial radiographical abnormalities (appendix p 3). Two (11%) patients showed focal pulmonary scarring (appendix pp 4–5). In patients who had radiological tests, the median time to resolution of radiographical abnormalities was 76 days (IQR 41·5–166·5). 12 (29%) of 41 patients had pulmonary function testing performed after initial hospital admission; nine (75%) of these 12 patients had abnormal results (table). Five patients had a restrictive ventilatory defect and one had a mixed obstructive and restrictive ventilatory defect; none had an obstructive ventilatory defect. Diffusion capacity for carbon monoxide was abnormal in six (60%) of ten patients for whom measurements were available. Three patients had restriction with reduced diffusion capacity and three had an isolated reduction in diffusion capacity for carbon monoxide. Six patients had repeat pulmonary function testing within 1 year after initial hospital admission (table). In all six patients, the pulmonary function testing abnormalities had resolved. To summarise, we assessed 1-year outcomes of patients with EVALI. We found that nearly half of patients remained symptomatic at the time of the first outpatient visit, but most became asymptomatic within the first year. Several patients continued to vape despite admission to hospital and counselling regarding cessation. The importance of vaping cessation is paramount, because the nidus for EVALI is vaping. Beyond EVALI, e-cigarette use has been associated with self-reported chronic cough, phlegm production, and wheezing.5Gotts JE Jordt SE McConnell R Tarran R What are the respiratory effects of e-cigarettes?.BMJ. 2019; 366l5275Google Scholar The 1-year all-cause hospital readmission rate was 24·4%. Most patients who were readmitted to hospital had underlying medical comorbidities and most readmissions were due to respiratory illness. Animal and in vitro studies suggest that vaping could increase airway hyper-reactivity5Gotts JE Jordt SE McConnell R Tarran R What are the respiratory effects of e-cigarettes?.BMJ. 2019; 366l5275Google Scholar or susceptibility to respiratory pathogens.5Gotts JE Jordt SE McConnell R Tarran R What are the respiratory effects of e-cigarettes?.BMJ. 2019; 366l5275Google Scholar Radiographical abnormalities improved within 6 months in most patients who had follow-up imaging. Two patients had focal pulmonary scarring after EVALI. The persistence of radiographic abnormalities has also been shown in patients with acute respiratory distress syndrome (ARDS) after the acute phase.6Masclans JR Roca O Muñoz X et al.Quality of life, pulmonary function, and tomographic scan abnormalities after ARDS.Chest. 2011; 139: 1340-1346Google Scholar We showed that most patients with available pulmonary function testing had abnormal results at short-term follow-up, which is similar to other small studies of patients with EVALI.7Aberegg SK Cirulis MM Maddock SD et al.Clinical, bronchoscopic, and imaging findings of e-cigarette, or vaping, product use-associated lung injury among patients treated at an academic medical center.JAMA Netw Open. 2020; 3e2019176Google Scholar, 8Blagev DP Harris D Dunn AC Guidry DW Grissom CK Lanspa MJ Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study.Lancet. 2019; 394: 2073-2083Google Scholar In all patients with repeat pulmonary function testing, abnormalities resolved within 1 year of hospital discharge. Studies of the acute effects of e-cigarettes on pulmonary function testing remain inconclusive and long-term data are needed.5Gotts JE Jordt SE McConnell R Tarran R What are the respiratory effects of e-cigarettes?.BMJ. 2019; 366l5275Google Scholar Limitations of our retrospective research presented in our study include a small sample size, absence of a control group, and an absence of a standardised algorithm for outpatient follow-up, and radiographical and pulmonary function testing. The small sample size and low incidence of specific abnormalities does not allow for reliable statistical inference; therefore, our findings should be seen as descriptive and hypothesis generating. There was a high rate of patients presenting to the emergency department or readmission to hospital within 1 year of initial hospital admission, particularly when considering the young age of patients with EVALI. The prevalence of persistent physiological and radiographical abnormalities following EVALI still remains unclear. Given the high readmission rates, rate of death, and risk of persistent pulmonary deficits, close outpatient follow-up is recommended. Assessment of patients who continue vaping and cessation counselling is paramount because redevelopment of EVALI occurred in one patient who continued vaping. Future studies on long-term effects of EVALI would allow for a prospective study design and standardised follow-up protocols to better characterise long-term consequences and potentially improve outcomes of EVALI. JJR is supported by the Breathe Pennsylvania and the Parker B Francis Foundation. JJR, AM, and BJM are supported by grants from the National Institutes of Health : K08 HL136857 (JJR), R01 HL140963–S1 (AM, BJM), R01 HL136143–03S1 (BJM), and 2 P01 HL114453–06 (BJM). JJR is a cofounder of Omnibus Medical Devices and a shareholder, officer, and director of Globin Solutions, outside of the submitted work. JJR is a coinventor on patents and applications related to using carbon monoxide scavenging molecules as therapies for carbon monoxide poisoning, licensed to Globin Solutions. Globin Solutions have a license for technologies using nitrite as a therapy against cardiovascular disease from the National Institutes of Health and the University of Pittsburgh. JJR is a coinventor on a patent of using nitrite as a treatment for chemical and smoke inhalational injuries. All other authors declare no competing interests. Download .pdf (.37 MB) Help with pdf files Supplementary appendix