The E-cigarette or Vaping Product Use-Associated Lung Injury Epidemic: Pathogenesis, Management, and Future Directions: An Official American Thoracic Society Workshop Report

E-cigarette, or Vaping, Product Use Associated Lung Injury: Epidemiology, Challenges, and Implications With COVID-19

BACKGROUND

E-cigarette, or vaping products produce an aerosol by heating nicotine, or cannabis including tetrahydrocannabinol (THC) and cannabidiol (CBD), mixed with other chemicals that help make the aerosol. They are increasingly popular among teenagers and young adults, with a 2023 survey reporting that 2.13 million middle and high school students in the United States used e-cigarettes within the last 30 days. The use of e-cigarette, or vaping products could lead to an acute pulmonary inflammatory syndrome called e-cigarette, or vaping, product use-associated lung injury (EVALI). We review the challenges in diagnosing and treating EVALI, especially during the COVID-19 pandemic.

METHODS

We conducted a literature search on June 10, 2024 using the PubMed database. We searched for articles, case reports and CDC reports investigating the pathogenesis, treatment, and challenges of diagnosing EVALI during the COVID-19 pandemic.

RESULTS

The exact causes of EVALI are not completely understood, although it has been linked to the use of THC and vitamin E acetate. There are no specific biomarkers to diagnose EVALI and it is typically diagnosed through a process of eliminating other possible conditions. Eight studies detailed cases where pediatric patients were initially diagnosed with COVID-19 or community-acquired pneumonia, despite multiple negative COVID-19 tests, and were later found to have EVALI.

CONCLUSIONS

After alerting the public about the removal of vitamin E acetate from vape liquids in 2020, there has been a decline in cases of EVALI, although they are still detected. Therefore, it is necessary to continue looking for diagnostic markers of EVALI and further investigate the toxicity of vapes and e-cigarettes to prevent the recurrence of another EVALI epidemic, especially among teenagers and young adults.

EAP and ECPCP urge ban on novel nicotine- (NNCPS) and non-nicotine-containing products (NNDS) to youth

AIM

We want to verify the correlation between the increasing use of novel nicotine-containing products (NNCPs) and non-nicotine delivery products (NNDPs) among young individuals and the escalating negative health consequences, necessitating their prohibition.

METHODS

We performed a comprehensive analysis of the most relevant literature about the utilisation of NNCPs and NNDPs among young individuals and their health effects.

RESULTS

Despite being initially seen as less harmful alternatives, for smokers aiming to quit, these products have become more popular due to misleading marketing claims. Teenagers using NNCPs and NNDPs, despite having no smoking history, are more likely to transition to tobacco smoking. Consistent use can lead to health issues like pulmonary damage, asthma, and cardiovascular and ocular problems.

CONCLUSION

The EAP and the ECPCP endorse the WHO's appeal to outlaw these hazardous products. They urge European governments to forbid the sale of NNCPs and NNDPs to children and adolescents in order to safeguard their well-being. They also propose specific recommendations (box 4) to support this cause.

Alveolar macrophage function is impaired following inhalation of berry e-cigarette vapor

In the lower respiratory tract, the alveolar spaces are divided from the bloodstream and the external environment by only a few microns of interstitial tissue. Alveolar macrophages (AMs) defend this delicate mucosal surface from invading infections by regularly patrolling the site. AMs have three behavior modalities to achieve this goal: extending cell protrusions to probe and sample surrounding areas, squeezing the whole cell body between alveoli, and patrolling by moving the cell body around each alveolus. In this study, we found Rho GTPase, cell division control protein 42 (CDC42) expression significantly decreased after berry-flavored e-cigarette (e-cig) exposure. This shifted AM behavior from squeezing to probing. Changes in AM behavior led to a reduction in the clearance of inhaled bacteria, Pseudomonas aeruginosa. These findings shed light on pathways involved in AM migration and highlight the harmful impact of e-cig vaping on AM function.

Indoor air pollution and airway health

Because of the disproportionate amount of time that people spend indoors and the complexities of air pollutant exposures found there, indoor air pollution is a growing concern for airway health. Both infiltration of outdoor air pollution into the indoor space and indoor sources (such as smoke from tobacco products, cooking or heating practices and combustion of associated fuels, and household materials) contribute to unique exposure mixtures. Although there is substantial literature on the chemistry of indoor air pollution, research focused on health effects is only beginning to emerge and remains an important area of need to protect public health. We provide a review of emerging literature spanning the past 3 years and relating indoor air exposures to airway health, with a specific focus on the impact of either individual pollutant exposures or common combustion sources on the lower airways. Factors defining susceptibility and/or vulnerability are reviewed with consideration for priority populations and modifiable risk factors that may be targeted to advance health equity.

Vaping Possible Negative Effects on Lungs: State-of-the-Art From Lung Capacity Alteration to Cancer

Vaping has emerged as a popular alternative to traditional smoking. It produces smokeless vapour by heating an e-liquid mixture in an atomizer. This paper delves into the current state of knowledge surrounding electronic cigarettes, exploring the gap between the perceived safety of e-liquids and the emerging evidence of their harmful effects when inhaled. As we navigate this intricate landscape, it is crucial to unravel the complexities of vaping and its implications for public health. We conducted a three-layer systematic review of the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analyses of Observational Studies in Epidemiology (MOOSE). The search was performed in three layers, including the first layer, the effect of vaping on lung function; the second layer, the effect of vaping on lung structure and inducing lung injury; and the third layer, the physiopathologic effect of vaping on the lung and a possible carcinogenic effect. Exposure to e-cigarette vapour reduced lung ventilation in adult male Long-Evans rats, indicating impaired lung function. In male Wistar rats, vaping was associated with a decrease in lung air volume and denser lung tissue structure. Studies on guinea pigs showed that vaping caused acute bronchoconstriction, contributing to lung function impairment. A case study of a young man with an E-cigarette and vaping-induced lung injury (EVALI) highlighted the detrimental effects of vaping on human lung function. The EVALI outbreak in the USA was linked to harmful substances in vapes, such as vitamin E acetate and THC, leading to serious lung injuries, including pneumonia and bronchiolitis. Vaping poses significant health risks, especially to young adults, and misconceptions regarding its safety persist despite evidence of its potential to cause various lung diseases. While vaping has positioned itself as a smoking cessation aid, the discussion surrounding its impact on lung health requires careful consideration. The lack of conclusive evidence on the long-term effects of vaping underscores the need for further research. However, existing data suggest that vaping is not without risks, and its potential association with respiratory issues and cancer underscores the urgency of public health interventions.

Exploring General Practitioners' Knowledge, Attitudes, and Practices towards E-Cigarette Use/Vaping in Children and Adolescents: A Pilot Cross-Sectional Study in Sydney

(1) Background: The increasing use of e-cigarettes/vaping in children and adolescents has been recognised as a global health concern. We aim to explore the Knowledge, Attitude, and Practice of General Practitioners (GPs) in Sydney regarding the use of e-cigarettes in children and adolescents and identify the barriers to addressing this issue. (2) Methods: This pilot study was a cross-sectional study conducted using an electronic questionnaire with a Likert scale and free-text responses. (3) Results: Fifty-three GPs participated in the study (male = 24 and female = 29) with a mean age of 50 ± 5.5 years. There was strong agreement (mean 4.5) about respiratory adverse effects and addictive potential. However, there was less awareness of cardiac side effects and the occurrence of burns. There is a lack of conversation about e-cigarettes in GP practice and a deficit of confidence in GPs regarding managing e-cigarette use in children and adolescents. (4) Conclusions: Our pilot study has shown that GPs are somewhat knowledgeable about the potential adverse effects of the use of e-cigarettes in children and adolescents, though there is a lack of knowledge of the complete spectrum of adverse effects and more importantly, there is a paucity of a structured approach to discuss the use of e-cigarettes with children and adolescents, and there is a low level of confidence in addressing these issues. There is a need for educational interventions for GPs to increase awareness of the potential adverse effects of using e-cigarettes and build confidence in providing management to children and adolescents regarding the use of e-cigarettes.

Vaping-associated illness: a reassessment

BACKGROUND

In 2019, there was widespread presentation of respiratory distress as well as other organ system involvement in patients with a history of vaping. There continue to be reports of vaping-associated illness (VAI). This has come to be known as e-cigarette and vaping product associated lung injury (EVALI). The mechanism of injury remains unclear.

OBJECTIVES

This study reexamines the clinical characteristics of patients affected by vaping and suggests that lung injury may not be the primary organ dysfunction but be part of a larger systemic illness.

METHODS

This is a retrospective chart review of all patients presenting to one hospital identified as having vaping-associated illness RESULTS: Fourteen patients were identified ranging in age from 15 to 33 years. Patients had a broad range of clinical severity. Respiratory symptoms occurred in 64%, gastrointestinal symptoms in 57%, fever in 78%, neurological symptoms in 15% and other constitutional symptoms in 50%. 35% presented with no respiratory symptoms.

CONCLUSION

While the lungs are certainly involved in vaping-associated illness, recognizing the extent of involvement of other organ systems may provide insight into the pathophysiology of the disease. Providers should be aware that vaping-associated illness presents with a multitude of symptoms outside of lung injury, such as abdominal pain, headache or even fever.

Changing patterns of cigarette and ENDS transitions in the USA: a multistate transition analysis of adults in the PATH Study in 2017-2019 vs 2019-2021

INTRODUCTION

The use of cigarettes and electronic nicotine delivery system (ENDS) has likely changed since 2019 with the rise of pods and disposables, the lung injuries outbreak, flavour bans, Tobacco 21 and the COVID-19 pandemic.

METHODS

Using the Population Assessment of Tobacco and Health Study, we applied a multistate transition model to 28 061 adults in waves 4-5 (2017-2019) and 24 584 adults in waves 5-6 (2019-2021), estimating transition rates for initiation, cessation and switching products for each period overall and by age group.

RESULTS

Cigarette initiation among adults who never used either product decreased from 2017-2019 to 2019-2021, but ENDS initiation did not significantly change. The persistence of ENDS-only use remained high (75%-80% after 1 year). Cigarette-only use transitions remained similar (88% remaining, 7% to non-current use and 5% to dual or ENDS-only use). In contrast, dual use to ENDS-only transitions increased from 9.5% (95% CI 7.3% to 11.7%) to 20.0% (95% CI 17.4% to 22.6%) per year, decreasing the persistence of dual use. The dual to cigarette-only use transition remained at about 25%. These changes were qualitatively similar across adult age groups, though adults ages 18-24 years exhibited the highest probability of switching from cigarette-only use to dual use and from dual use to ENDS-only use.

CONCLUSIONS

The persistence of ENDS use among adults remained high in 2019-2021, but a larger fraction of dual users transitioned to ENDS-only use compared with 2017-2019. Because the fraction of cigarette-only users switching to dual use remained low, especially among older adults, the public health implications of this change are minimal.

Conditions Leading to Ketene Formation in Vaping Devices and Implications for Public Health

The outbreak of e-cigarette or vaping use-associated lung injury (EVALI) in the United States in 2019 led to a total of 2807 hospitalizations with 68 deaths. While the exact causes of this vaping-related lung illness are still being debated, laboratory analyses of products from victims of EVALI have shown that vitamin E acetate (VEA), an additive in some tetrahydrocannabinol (THC)-containing products, is strongly linked to the EVALI outbreak. Because of its similar appearance and viscosity to pure THC oil, VEA was used as a diluent agent in cannabis oils in illicit markets. A potential mechanism for EVALI may involve VEA's thermal decomposition product, ketene, a highly poisonous gas, being generated under vaping conditions. In this study, a novel approach was developed to evaluate ketene production from VEA vaping under measurable temperature conditions in real-world devices. Ketene in generated aerosols was captured by two different chemical agents and analyzed by gas chromatography-mass spectrometry (GC-MS) and liquid chromatography with tandem mass spectrometry (LC-MS/MS). The LC-MS/MS method takes advantage of the high sensitivity and specificity of tandem mass spectrometry and appears to be more suitable than GC-MS for the analysis of large batches of samples. Our results confirmed the formation of ketene when VEA was vaped. The production of ketene increased with repeat puffs and showed a correlation to temperatures (200 to 500 °C) measured within vaping devices. Device battery power strength, which affects the heating temperature, plays an important role in ketene formation. In addition to ketene, the organic oxidant duroquinone was also obtained as another thermal degradation product of VEA. Ketene was not detected when vitamin E was vaped under the same conditions, confirming the importance of the acetate group for its generation.

The role of puff volume in vaping emissions, inhalation risks, and metabolic perturbations: a pilot study

Secondhand vaping exposure is an emerging public health concern that remains understudied. In this study, saliva and exhaled emissions from ENDS users (secondhand) and non-ENDS users (baseline) were collected, firsthand emissions were generated using an automated ENDS aerosol generation system programmed to simulate puffing topography profiles collected from ENDS users. Particulate concentrations and sizes along with volatile organic compounds were characterized. We revealed puffing topography metrics as potential mediators of firsthand and secondhand particle and chemical exposures, as well as metabolic and respiratory health outcomes. Particle deposition modeling revealed that while secondhand emissions displayed smaller deposited mass, total and pulmonary particle deposition fractions were higher than firsthand deposition levels, possibly due to smaller secondhand emission particle diameters. Lastly, untargeted metabolomic profiling of salivary biomarkers of lung injury due to firsthand ENDS exposures revealed potential early indicators of respiratory distress that may also be relevant in bystanders exposed to secondhand vaping scenarios. By leveraging system toxicology, we identified 10 metabolites, including leukotriene D4, that could potentially serve as biomarkers for ENDS use, exposure estimation, and the prediction of vaping-related disease. This study highlights characterization of vaping behavior is an important exposure component in advancing our understanding of potential health effects in ENDS users and bystanders.

Effects of E-Cigarettes on the Lung and Systemic Metabolome in People with HIV

The popularity of e-cigarettes (vaping) has soared, creating a public health crisis among teens and young adults. Chronic vaping can induce gut inflammation and reduce intestinal barrier function through the production of the proinflammatory molecule hydrogen sulfide (H2S). This is particularly concerning for people with HIV (PWH) as they already face impaired immune function and are at a higher risk for metabolic dysregulation, diabetes, and chronic liver disease. Furthermore, PWH experience unhealthy behaviors, making it crucial to understand the systemic metabolic dysregulation and pathophysiological mechanisms associated with vaping in this population. Here, we employed liquid chromatography-mass spectrometry (LC-MS)-based metabolomics to investigate the upper respiratory, circulation, and gut metabolic profiles of PWH who vape (n = 7) and smoke combustible tobacco/marijuana (n = 6) compared to control participants who did not vape or smoke (n = 10). This hypothesis-generating exploratory study revealed systemic alterations in purine, neurotransmitter, and vitamin B metabolisms and tissue-specific changes in inflammatory pathways and cryptic sulfur cycling associated with vaping and combustible tobacco/marijuana smoking in PWH. In addition, this study provides the first link between microbial-derived metabolite 2,3-dihydroxypropane-1-sulfonate (DHPS) and vaping/smoking (tobacco and marijuana)-induced metabolic dyshomeostasis in the gut. These findings highlight the importance of identifying the full biological and clinical significance of the physiological changes and risks associated with vaping.

E-cigarettes and Youth: The Known, the Unknown, and Implications for Stakeholders

ABSTRACT

Despite the decline in the prevalence of e-cigarette use among youth during the coronavirus disease 2019 pandemic, more than 2.5 million of US high and middle schoolers are still using e-cigarettes. Furthermore, those who use e-cigarettes are starting at a younger age and are using them more intensely, reflecting, at least in part, a high addiction liability of modern e-cigarettes. Beyond addiction, accumulating evidence suggests that, in the short-term, e-cigarettes are associated with cardiovascular and pulmonary effects, whereas the long-term effects of e-cigarette use are yet to be established. The aim of this review is to synthesize current knowledge on e-cigarette use among youth, including established and potential risks and efforts to date to curb youth exposure to e-cigarettes. In addition, we provide recommendations for health care providers, researchers, and other stakeholders to address this significant public health issue.

Fruit flavors in electronic cigarettes (ECIGs) are associated with nocturnal dry cough: A population longitudinal analysis

Evidence from in vitro and animal models has identified the pulmonary toxicity of flavors in electronic cigarettes (ECIGs); however, less is known from epidemiological studies about the effects of flavors in the respiratory health. This study examined the longitudinal association between exposure to ECIGs flavors and nocturnal dry cough among ECIGs users. A secondary analysis of data from the Population Assessment of Tobacco and Health Study (2014-2019) was conducted. The study population included adults who provided information (n = 18,925) for a total of 38,638 observations. Weighted-incidence estimates and weighted- generalized estimating equation models were performed to assess unadjusted and adjusted associations. The weighted incidence proportion (WIP) of nocturnal dry cough was significantly higher among current (WIP:16.6%; 95%CI 10.5, 21.2) and former fruit flavored ECIGs users (WIP:16.6%; 95%CI 11.3, 21.9) as compared to non-ECIGs users (WIP:11.1%; 95%CI 10.6, 11.6). Current ECIGs users of fruit flavors showed 40% higher risk of reporting cough than non-ECIGs users (aRR:1.40, 95%CI 1.01, 1.94). Former ECIGs users of multiple flavors and other flavors had 300% and 66% higher risk to develop cough, respectively (aRR:3.33, 95%CI 1.51, 7.34 and aRR:1.66, 95%CI 1.0.9, 2.51), relative to non-ECIGs users. We observed a significantly higher risk of developing nocturnal dry cough in the past 12 months in current and former ECIGs users of fruit flavors and in former ECIGs users of multiple flavors. To the extent that cough may serve as an early indicator of respiratory inflammation and potential disease risk, the association between ECIGs use and cough raises potential concerns.

Mechanistic Rationale for Ketene Formation during Dabbing and Vaping

Ketene is one of the most toxic vaping emissions identified to date. However, its high reactivity renders it relatively challenging to identify. In addition, certain theoretical studies have shown that realistic vaping temperature settings may betoo low to produce ketene. Each of these issues is addressed herein. First, an isotopically labeled acetate precursor is used for the identification of ketene with enhanced rigor in vaped aerosols. Second, discrepancies between theoretical and experimental findings are explained by accounting for the effects of aerobic (experimental) versus anaerobic (simulated and theoretical) pyrolysis conditions. This finding is also relevant to explaining the relatively low-temperature production of aerosol toxicants beyond ketene. Moreover, the study presented herein shows that ketene formation during vaping is not limited to molecules possessing a phenyl acetate substructure. This means that ketene emission during vaping, including from popular flavorants such as ethyl acetate, may be more prevalent than is currently known.

E-Cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) Continues: An Opportunity for Pharmacist Intervention

Electronic cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) was first identified and reported in 2019, but media coverage and reporting of cases drastically decreased when the COVID-19 pandemic started in early 2020. The syndrome has continued to occur since that time and it is critical that pharmacists are aware of how EVALI presents, and when it should be considered as a potential diagnosis. Inpatient and outpatient pharmacists play a vital role in the treatment of EVALI, and should be knowledgeable of the utility of corticosteroids, even though data are extremely limited. Pharmacists should understand the importance of collecting detailed and accurate information about vaping from patient interviews. Pharmacists also play a leading role in cessation counseling and treatment, selecting medications that can be used to treat nicotine addiction from vaping, and assisting with transitions of care and follow-up.

The Evolution of a Pediatric Public Health Crisis: E-cigarette or Vaping-Associated Lung Injury

E-cigarettes and vaping products were first introduced in the United States around 2007, and quickly grew in popularity. By 2014, e-cigarettes had become the most commonly used tobacco product among youth in the United States. An e-cigarette, or vaping, product use-associated lung injury (EVALI) outbreak was identified by the Centers for Disease Control and Prevention (CDC) in 2019, with many cases in the adolescent population. The CDC opened a national database of cases and launched a multistate investigation; reported cases reached a peak in September 2019. The CDC investigation found that a vaping liquid additive, vitamin E acetate, was strongly linked to the EVALI outbreak but determined that the decline in cases was likely multifactorial. Due to decreased cases and the identification of a potential cause of the outbreak, the CDC stopped collecting data on EVALI cases as of February 2020. However, e-cigarettes and vaping products have continued to be the most popular tobacco product among youth, though state and national regulations on these products have increased since 2016. While pediatric case series and studies have shown differences in clinical presentation and medical histories between pediatric and adult EVALI cases, the fact that cases are no longer tracked at a national level limits necessary information for pediatric clinicians and researchers. We describe the available literature on the diagnosis, pathophysiology, treatment, and outcomes of EVALI in the pediatric population, and provide clinical and public health recommendations to facilitate prevention and management of EVALI specific to pediatrics.

The Rising Use of E-Cigarettes: Unveiling the Health Risks and Controversies

The use of e-cigarettes has tremendously increased in recent times due to the widespread availability of e-cigarettes in diverse flavors, reduced cost compared to regular cigarettes, and misconception of being comparatively safe, which have led to around 2.55 million US middle and high school students smoking e-cigarettes. These devices use a nicotine-rich liquid, which is aerosolized electronically, producing vapors that may also include hazardous chemicals and heavy metals. E-cigarettes are associated with e-cigarette or vaping-associated lung injury, which presents as an acute respiratory ailment mirroring various pulmonary diseases. Additionally, it causes endothelial dysfunction, alters blood lipid profile by elevating circulating levels of low-density lipoprotein cholesterol, increases sympathetic tone, and is found to correlate with arterial stiffening, hence negatively affecting respiratory, cardiovascular, and overall health. We aim to provide a comprehensive analysis of the data on e-cigarettes and their harmful effects on health in comparison to conventional cigarette use by highlighting the pathophysiology of e-cigarette-induced adverse effects and critically analyzing the data both in favor and against its use. Our review concludes that no matter how much nicotine an e-cigarette contains, evidence shows that using it increases the risk of cardiovascular disease, albeit maybe not as much as smoking regular tobacco. Nonetheless, it is crucial to note that the long-term effects of e-cigarette usage are still not fully understood, and existing data have provided opposing viewpoints.

Electronic Vapor Products: Alarming Trends in United States Adolescents

Background: The use of electronic vapor products (EVPs) increases the risks of nicotine addiction, drug-seeking behavior, mood disorders, and avoidable premature morbidities and mortality. We explored temporal trends in EVP use among US adolescents. Methods: We used data from the Youth Risk Behavior Survey for school grades 9 through 12 from 2015 (earliest available data) to 2021 (the most recently available data) from the US Centers for Disease Control and Prevention (n=57,006). Results: Daily use of EVPs increased from 2.0% in 2015 to 7.2% in 2019, a greater than 3.5-fold increase. Although the percentage decreased to 5.0% in 2021, it was still a >2.5-fold increase since 2015. In 2015, the percentage of EVP use was significantly higher in boys (2.8%) than girls (1.1%). By 2021, the percentage of EVP use was higher in girls (5.6%) than boys (4.5%), a 1.24-fold increase. In addition, the percentage of EVP use in 2021 was higher in White youth (6.5%) vs Black (3.1%), Asian (1.2%), and Hispanic/Latino (3.4%) youth compared to 2015, but White and Black adolescents had the highest increases of approximately 3.0-fold between 2015 and 2021. Adolescents in grade 12 had the highest percentages of EVP use at all periods. Conclusion: These data show alarming statistically significant and clinically important increases in EVP use in US adolescents in school grades 9 through 12. The magnitude of the increases may have been blunted by coronavirus disease 2019, a hypothesis that requires direct testing in analytic studies. These trends create clinical and public health challenges that require targeted interventions such as mass media campaigns and peer interventions to combat the influences of social norms that promote the adoption of risky health behaviors during adolescence.

E-cigarette attitudes and behaviours amongst 15-30-year-olds in the UK

BACKGROUND

The use of e-cigarettes has been rising in the UK, particularly by young people. This study investigated behaviours, attitudes and beliefs about e-cigarettes amongst 15-30-year-olds in the UK.

METHODS

An online survey was administered to a sample of 1009 15-30-year-olds in the UK.

RESULTS

About one in five participants currently used e-cigarettes at least monthly, with 1 in 10 using them daily. Amongst those using e-cigarettes at least monthly, 90% had used e-cigarettes containing nicotine. E-cigarettes were mainly obtained from vape shops and used at home. Having friends who used e-cigarettes and using them to help quit/reduce smoking were the most common reasons for vaping. About half of participants had been exposed to e-cigarette advertising, especially online, and warning labels on e-cigarettes. Most participants agreed that e-cigarettes are addictive (75%), help people quitting smoking (64%) and are bad for health (63%). Previous or current tobacco smokers were 9 and 22 times more likely to use e-cigarettes than never smokers, respectively. Perceiving e-cigarettes as harmful was associated with a 40% lower likelihood of use.

CONCLUSION

Raising awareness on the uncertain long-term consequences of vaping and regulation of marketing and sales are crucial to protect young people in the UK.

Pediatric Pulmonology 2022 year in review: Rare and diffuse lung disease

The field of rare and diffuse pediatric lung disease continues to evolve and expand rapidly as clinicians and researchers make advancements in the diagnosis and treatment of children's interstitial and diffuse lung disease, non-cystic fibrosis bronchiectasis, and primary ciliary dyskinesia. Papers published on these topics in Pediatric Pulmonology and other journals in 2022 describe newly recognized disorders, elucidate disease mechanisms and courses, explore potential biomarkers, and assess novel treatments. In this review, we will discuss these important advancements and place them in the context of existing literature.

Severe Acute Respiratory Distress Syndrome Secondary to Concomitant Influenza A and Rhinovirus Infection Complicated by Methicillin-resistant Staphylococcus aureus Pneumonia in an Early Pregnancy Patient With Vaping-induced Lung Injury

Acute respiratory distress syndrome (ARDS) is a life-threatening lung injury characterized by rapid onset of widespread inflammation in the lungs. Multiple risk factors, including pneumonia, non-pulmonary sepsis, aspiration of gastric contents or inhalation injury, have been reported, to cause ARDS. We present a case of a healthy young woman in her first trimester with vaping-induced lung injury who presented with spontaneous pneumothorax and acute respiratory distress syndrome with concomitant influenza A and rhinovirus infection followed by methicillin-resistant Staphylococcus aureus pneumonia.

Vaping Induced Cannabidiol (CBD) Oxidation Product CBD Quinone Forms Protein Adducts with KEAP1 and Activates KEAP1-Nrf2 Genes

Cannabidiol (CBD) vaping products have become widely available in the U.S. since their legalization in 2018. However, little is known about their respiratory health effects. Here we show that aerosolization of commercial CBD vaping products generates a reactive CBD quinone (CBDQ) which forms adducts with protein cysteine residues. Using click chemistry and a novel in vitro vaping product exposure system (VaPES), we further demonstrate that CBDQ forms adducts with human bronchial epithelial cell proteins including Keap1 and activates KEAP1-Nrf2 stress response pathway genes. These results suggest that vaping CBD alters protein function and induces cellular stress pathways in the lung.

A Large Lung Abscess in an Electronic Cigarette User: To Drain or Not to Drain

A lung abscess is a walled necrotizing infection involving the lung parenchyma, characterized by a cavitary lesion filled with fluid. It is usually caused by microbial infection with aspiration of oropharyngeal contents being the most common mechanism for primary lung abscesses. Secondary lung abscesses occur in the presence of predisposing lung conditions like bronchial obstruction, vascular or septic emboli or impaired host defenses. Lung abscesses caused by electronic cigarette use have gained relevance in the recent years since the outbreak of EVALI, that is, e-cigarette or vaping product use-associated lung injury, in 2019. First-line therapy involves prompt initiation of antibiotics given their success rate in the treatment of lung abscess in the current potent antibiotic era. Percutaneous aspiration and catheter drainage is considered a second line approach due to concerns for potential complications including catheter blockage necessitating repeat procedures, pneumothorax, hemothorax, hemoptysis, need for surgical intervention, infection of pleural space and bronchopleural fistula. We describe a case of a 21-year-old female with a history of electronic cigarette use presenting with a large left upper lobe lung abscess (14.5 x 8.5 x 13.3 cm) treated successfully with broad-spectrum antibiotics alone resulting in clinical and radiologic improvement.

Electronic Cigarette Use during Pregnancy: Is It Harmful?

Although combustible cigarette smoking rates have declined in recent years, alternative tobacco product use, particularly electronic cigarette use ("vaping"), has increased among young adults. Recent studies indicate that vaping during pregnancy is on the rise, possibly due to the perception that it is a safer alternative to combustible cigarette smoking. However, e-cigarette aerosols may contain several newer, potentially toxic compounds, including some known developmental toxicants that may adversely impact both the mother and the fetus. However, there is paucity of studies that have examined the effects of vaping during pregnancy. While the adverse perinatal outcomes of cigarette smoking during pregnancy are well established, the specific risks associated with inhaling vaping aerosols during pregnancy requires more research. In this article, we discuss the existing evidence and knowledge gaps on the risks of vaping during pregnancy. Studies that investigate vaping-associated systemic exposure and its effects (i.e., biomarker analyses) and maternal and neonatal clinical health outcomes are needed to reach more robust conclusions. We particularly emphasize the need to go beyond comparative studies with cigarettes, and advocate for research that objectively evaluates the safety of e-cigarettes and other alternative tobacco products.