Editor’s Note: Dr. Julie Evans (she/her) is a resident physician in pediatrics at the University of Virginia. She is interested in general pediatrics and global health. -Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
Vapes and e-cigarettes were first introduced in 2007 and have gained popularity, particularly with many middle school and high school children.
However, these products are not without risk. E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI) was first identified in 2019, and although pediatric cases only comprised 15% of cases initially, these cases were alarming. But we don’t know much about what EVALI is and what causes it.
This week, Pediatrics is early releasing a State of the Art review article entitled “The Evolution of a Pediatric Public Health Crisis: E-cigarette or vaping associated lung injury,” by Drs Carrie Barker from the University of Wisconsin, Princy Ghera from the University of Texas Southwestern, and Benson Hsu from the University of South Dakota, who provide us with an overview of how e-cigarettes are affecting children and adolescents (10.1542/peds.2023-063484).
The authors explain there is no formal diagnostic criteria for EVALI, but many use the CDC surveillance criteria:
- Using an e-cigarette or dabbing during the 90 days before onset of illness
- Pulmonary infiltrate
- Absence of pulmonary infection on initial work-up
- No evidence for alternative plausible cause
For pediatric patients, most initial descriptions of EVALI were case reports, making it even more difficult to create definitive diagnostic criteria. In case reports, children and adolescents presented with cough, shortness of breath, chest pain, GI symptoms (more so than adults), fever, chills, night sweats, fatigue, malaise, and myalgias. Nearly half of pediatric patients with EVALI had a history of asthma.
So what causes EVALI? In short, there is no definitive answer yet. The CDC stated that vitamin E acetate–containing vapes and e-cigarettes were strongly linked to the initial cases of EVALI, but there is not sufficient evidence to rule out other chemicals. Studies have shown that exposure to vitamin E acetate can cause damage to lung cells in the lab. However, many other chemicals in vapes and e-cigarettes are known respiratory toxicants and could all be part of the EVALI mechanism.
In 2019, the CDC published guidelines for treatment of EVALI, which include:
- Discontinue use of vapes and e-cigarettes
- Antibiotics/antivirals
- Systemic corticosteroids
- Additional supportive care such as supplemental oxygen, IV fluids, etc.
However, there have been no randomized controlled trials in the clinical management of EVALI, so it is difficult to tell if interventions helped, or if these patients would have improved simply with stopping vaping.
The only data we have about long-term outcomes is from case reports, which describe lingering chest pain, dyspnea, decreased lung function, airflow restriction, and obstruction.
The authors recommend:
- A national EVALI case registry with consistent coding to identify cases, prevalence, and long-term effects, and to help guide future research.
- Improved regulation of e-cigarettes, as 2.55 million children still reported e-cigarette use in 2022.
- A prospective evaluation and diagnostic algorithm, with age-specific recommendations.
Children and adolescents who have been treated for EVALI may need changes in their asthma medicines and may be at increased risk for future lung disease.
Of course, prevention is the best cure. To best protect our pediatric patients, we need to continue encouraging cessation of smoking in all forms.
