Chronic disease, mental health conditions may increase risk for worse outcomes in EVALI
Several characteristics, including mental health conditions and chronic conditions, were associated with a higher risk for severe outcomes in patients with e-cigarette- or vaping- associated lung injury, or EVALI, researchers reported in The New England Journal of Medicine.
The EVALI outbreak, which began last year, triggered numerous questions about the effects of e-cigarettes on the lungs and why certain patients who developed the illness had more severe consequences than others. After the outbreak peaked in September, researchers began reviewing cases to gain more insight into who may be at greater risk for hospitalization and death.
“CDC, FDA and state health authorities have made progress in identifying the cause of EVALI. National and state data from patient reports and product sample testing show THC-containing e-cigarette or vaping products, particularly from informal sources like friends, family or in-person or online dealers, are linked to most EVALI cases and play a major role in the outbreak,” Angela K. Werner, PhD, MPH, health scientist with the Environmental Public Health Tracking Program, National Center for Environmental Health, CDC, wrote in an email to Healio Pulmonology.
Werner also noted that researchers were able to identify vitamin E acetate, which was found in many of the e-cigarette or vaping product samples provided by patients, as one culprit behind the outbreak. And, although new cases of EVALI have declined, she said it remains important that clinicians be aware of and on the lookout for risk factors associated with more severe disease.
“Although clinical presentations and outcomes of EVALI patients have been reported, data on patients who died are more limited. This article fills a gap by reporting on a national study assessing detailed demographics, substance use and clinical characteristics of EVALI patients who have died, and comparing them to the characteristics of EVALI patients who survived. The findings can help inform clinicians’ awareness of the risk factors associated with more severe outcomes of EVALI,” Werner said.
Characteristics of fatal vs. nonfatal EVALI cases
For the study, Werner and colleagues analyzed 2,558 nonfatal cases of EVALI in hospitalized patients from 50 states, the District of Columbia, Puerto Rico and the U.S. Virgin Islands and 60 fatal cases in patients from 27 states and the District of Columbia that were reported to CDC by Jan. 7. Medical records served as the primary data source and were supplemented by patient or proxy interviews when necessary or available.
In both fatal and nonfatal cases, patients were predominantly men (53% and 67%, respectively) and white (80% and 61%, respectively). Patients in fatal cases, however, tended to be older, with a median age of 51 years vs. 24 years for patients in nonfatal cases. Patients who died were also more likely than those who did not to have a history of any respiratory disease (44% vs. 26%), cardiac disease (47% vs. 10%) and any mental health condition (65% vs. 41%).
More than half of patients in fatal cases also had obesity (52%), the researchers noted.
Additionally, the researchers found that more patients in fatal cases than in nonfatal cases initially presented in an outpatient setting, such as a primary care physician location, urgent care center or ED, without being admitted for symptoms associated with EVALI (46% vs. 21%).
This last finding, Werner noted, was particularly interesting.
“Those who died from EVALI were at least two times as likely as those who did not die from EVALI to have visited an outpatient setting without being admitted for symptoms,” she said. “This brings up the question of symptom severity when visiting the outpatient setting, when they visited the outpatient setting in the context of the EVALI outbreak timeline and clinicians’ knowledge of what to look for in terms of earlier admissions for those who may have ended up with more severe outcomes.”
The data also highlighted some areas for future research, according to Werner.
“Our study showed that the percentage of patients who had obesity was higher among those who died from EVALI than in the general population. While we only had data on body weight for those who died from EVALI and not for those who did not die, more studies could be helpful to determine if there is an association between obesity and development of EVALI as well as whether obesity contributes to the severity of outcomes for those who develop EVALI,” she said.
Further research on the effect of early glucocorticoid administration, which was used in 78% of fatal cases and 88% of nonfatal cases, will also be important in these patients, Werner added.
Looking ahead
Overall, this study underscores the importance of identifying EVALI, according to Werner.
“It is important for all clinicians, both those working in outpatient and hospital settings, to recognize that patients may have EVALI early so that they can provide appropriate clinical care and potentially reduce deaths,” she told Healio Pulmonology. “Patient characteristics that may help identify EVALI cases at higher risk for serious consequences, including death, are older age, non-Hispanic white, current or former tobacco smoking, and history of chronic disease and mental health conditions.”
In an accompanying editorial, Matthew B. Stanbrook, MD, PhD, associate professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto, and Jeffrey M. Drazen, MD, from the NEJM Group, reflected on the outbreak and the findings from this study while also noting that reports of pulmonary disease related to vaping date back to 2012. The presentation of the disease in these reports varies widely, they noted, ranging from organizing pneumonia and diffuse alveolar disease to interstitial lung disease. Consequently, although vitamin E acetate and THC from illicit sources have been implicated in the 2019 outbreak, they are likely not the only source of toxins or chemicals causing vaping-related lung injuries.
“This evidence suggests that we are witnessing more than one syndrome of vaping-induced lung disease: an acute, severe syndrome that affects a large number of e-cigarette users and another, more subtle syndrome that either affects a much smaller proportion of users or requires a longer time to manifest itself in most users,” Stanbrook and Drazen wrote. “We will only learn whether the latter is the case going forward, but we must address this possibility proactively with much more attention and concern.” – by Melissa Foster
Disclosures: The study authors report no relevant financial disclosures. Drazen reports he is editor of the NEJM Group. Stanbrook reports no relevant financial disclosures.