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Abnormal imaging findings key to EVALI diagnosis

Pulmonary imaging is important in the diagnosis of the acute lung injury associated with vaping, known as electronic cigarette or vaping product use-associated lung injury (EVALI), according to a special review article (Kligerman  et al. Radiologic, Pathologic, Clinical, and Physiologic Findings of Electronic Cigarette or Vaping Product Use-associated Lung Injury (EVALI): Evolving Knowledge and Remaining Questions. Radiology. 2020 Mar;294(3):491-505. doi: 10.1148/radiol.2020192585). The report outlines what is currently known about this condition and discusses remaining questions. Although e-cigarettes have been often marketed as a safer alternative to traditional cigarettes, EVALI has emerged as a serious and sometimes fatal complication of vaping. Radiologists play a key role in the evaluation of suspected EVALI. Accurate identification of the condition allows for prompt medical treatment, which may decrease the severity of injury in some patients. “Rapid clinical and/or radiologic recognition of EVALI allows clinicians to treat patients expeditiously and provide supportive care,” said Dr.  S Kligerman. “Although detailed clinical studies are lacking, some patients with EVALI rapidly improve after the administration of corticosteroids. Additionally, making the correct diagnosis may prevent unnecessary therapies and procedures, which themselves can lead to complications.” Despite ongoing investigations by public health officials, the exact cause of EVALI remains unclear. Over 80% of EVALI patients report vaping tetrahydrocannabinol (THC) or cannabidiol CBD containing compounds.
Chest CT findings in EVALI can be variable but most commonly show a pattern of diffuse lung injury with sparing of the periphery of the lungs. EVALI is a diagnosis of exclusion. The patient must have a history of vaping within 90 days and abnormal findings on chest imaging, but other possible causes for the patient’s symptoms must be eliminated.
If EVALI is not diagnosed in a timely manner, patients may continue vaping after leaving the doctor’s office, clinic or emergency department which could lead to worsening lung injury,” he said. “Right now, we do not know the long-term effects of vaping, as it is still a relatively new method of nicotine and THC delivery, and there are countless variables involved which further confound our understanding of what is happening on a patient-specific level” .

He added that while recent studies have shown an association between vaping and the development of asthma, chronic bronchitis and chronic obstructive pulmonary disease, these studies have only shown an association and not causation.

I would not be surprised if vaping is directly linked to many of the chronic pulmonary and cardiovascular diseases commonly associated with traditional cigarette smoking,” Dr. Kligerman said. “The link between vaping and lung cancer is unknown at this point,” he noted.

doi: 10.1148/radiol.2020192585

Images show electronic cigarette or vaping product use-associated lung injury in a 32-year-old man with history of vaping who presented with fevers and night sweats for 1 week. (a) Coronal maximum intensity projection image shows diffuse centrilobular nodularity. (b) Histologic sections of his transbronchial cryobiopsy showed distinctive micronodular pattern of airway-centered organizing pneumonia, corresponding to centrilobular nodularity seen at CT. Similar imaging and pathologic findings have been described in patients with smoke synthetic cannabinoids. Credit RSNA