Recent data on vaping-associated respiratory distress syndrome (VARDS) has sparked a growing interest in guidance on how to rapidly identify and manage these patients. A chief concern about the growing number of reports of VARDS is that some victims experience rapid progression to hypoxemic respiratory failure and death. “Most clinicians will only rarely be confronted with vaping-related respiratory illness, but it is important for us to be prepared with strategies to identify patients at highest risk for developing respiratory failure,” explains Craig M. Lilly, MD. “Many patients who have died of VARDS were sent home from their doctor’s office or emergency room.”

The CDC recently labeled electronic cigarette- or vaping-associated lung injuries as EVALI, but Dr. Lilly says VARDS is different in that it is the most severe and life-threatening form of EVALI. The CDC defines EVALI as possibly occurring in patients who used an e-cigarette during the past 90 days before symptom onset, have a pulmonary infiltrate, and have no clinical evidence of a pulmonary infection. Patients who could have VARDS meet the EVALI criteria but also have a chest imaging study with new and otherwise unexplained lung abnormalities and/or acute hypoxemia. This expanded definition of VARDS can help clinicians confirm and assess exposure and provide more effective treatment.

Risk Stratification

A multi-disciplinary task force led by Dr. Lilly issued guidance for VARDS that was published in Critical Care Explorations. The guidance, which is applicable nationwide, recommends that patients seeking medical care who have vaped or been exposed to vaping fumes in the last 90 days be divided into 3 groups. “Patients should be stratified into low-, medium-, and high-risk Worcester groups,” says Dr. Lilly (Table). “Each group has an intuitive recommended management and follow up strategy. This guidance provides a useful starting point from which great we can tailor recommendations that include vaping avoidance.”

Low-risk patients fall into Worcester Group 1. These patients do not have VARDS symptoms, such as chest pain, cough, fatigue, shortness of breath, or weight loss. Worcester Group 1 patients should be asked if they need help with quitting. If so, they should be referred to a nicotine or THC-focused addiction medicine program.

Medium-risk patients are categorized into Worcester Group 2. These individuals have VARDS symptoms and should undergo a chest X-ray. If results are abnormal, patients are at higher risk for developing respiratory failure. Patients with VARDS symptoms and normal blood oxygen levels (defined as 95% at rest or 88% during exercise) should be evaluated and managed on an outpatient basis.

The highest-risk patients fall into Worcester Group 3. These patients have VARDS symptoms and abnormal blood oxygen levels. They should be hospitalized for monitoring, offered spirometry when dyspnea is present, and referred to a specialist when symptoms are severe and when infiltrates are extensive or have a fibrotic pattern.

Vigilance Required

According to the new guidance, clinicians are urged to ask targeted questions to determine if any symptoms patients are experiencing are related to vaping. Questions should focus on vaping exposure, type of vaping device, and intensity of use. From there, clinicians should consider the possibility that some cases may cluster with a particular vaping solution. Cases that do not involve vaping suggest that an infection is the cause. Management approaches should be guided by symptoms, physical findings, gas exchange, radiographic abnormalities, and preferences.

Ultimately, Dr. Lilly says it is imperative that patients at risk for acute respiratory failure be identified, monitored, evaluated, and treated. “Physicians should ensure strict vaping avoidance and hospitalize hypoxemic patients,” says Dr. Lilly. “These suggestions are made without geographic restriction. In the future, researchers should aim to better understand how vaping devices create toxin bearing droplets and how vaping use affects deposition in the respiratory tract.”

References

Lilly CM, Khan S, Waksmundzki-Silva K, Irwin RS. Vaping-associated respiratory distress syndrome: case classification and clinical guidance. Crit Care Explor. 2020;2(2):p e0081. Available at: https://journals.lww.com/ccejournal/Fulltext/2020/02000/Vaping_Associated_Respiratory_Distress_Syndrome_.4.aspx.

Miech R, Johnston L, O’Malley PM, et al: Adolescent vaping and nicotine use in 2017-2018 – U.S. National estimates. N Engl J Med. 2019; 380:192-193.

Gravely S, Thrasher JF, Cummings KM, et al: Discussions between health professionals and smokers about nicotine vaping products: Results from the 2016 ITC Four Country Smoking and Vaping Survey. Addiction. 2019;114(Suppl 1):71-85.

Hswen Y, Brownstein JS: Real-time digital surveillance of vaping-induced pulmonary disease. N Engl J Med. 2019;381:1778-1780.

Siegel DA, Jatlaoui TC, Koumans EH, et al; Lung Injury Response Clinical Working Group; Lung Injury Response Epidemiology/Surveillance Group: Update: Interim guidance for health care providers evaluating and caring for patients with suspected e-cigarette, or vaping, product use associated lung injury. MMWR Morb Mortal Wkly Rep. 2019; 68:919-927.