Vaping-associated lung injury tied to long-term respiratory disability, mood disorders
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Patients with e-cigarette- or vaping-associated lung injury, or EVALI, frequently showed long-term cognitive impairment, respiratory limitations and mood disorders, according to a study published in Annals of the American Thoracic Society.
Further, less than half of the patients had quit vaping or smoking 1 year following this lung injury diagnosis, according to researchers.
“It is important to recognize that patients who have had EVALI do not go back to normal,” Denitza P. Blagev, MD, associate professor in the department of medicine at University of Utah and chief medical officer at Riverton Hospital at Intermountain Healthcare, told Healio. “Asking about long-term consequences — respiratory, cognitive impairment, ongoing vaping — remains important. It also drives home the point that we should be talking to all our patients about their vaping and smoking habits.”
In a prospective cohort study, Blagev and colleagues analyzed 73 patients (mean age, 31 years; 66.7% men; 85% white) with EVALI — which, first identified in 2019, is defined as the presence of bilateral chest infiltrates without an alternative diagnosis in a patient who vaped in the prior 90 days — from two health systems in the Intermountain West, which includes Utah, Idaho and Nevada, between July 20, 2020, and Aug. 15, 2021.
To identify long-term outcomes associated with EVALI, researchers included patients who had completed a 1-year follow-up since their EVALI diagnosis and had screenings or assessments for cognitive function, depression, anxiety, posttraumatic stress, respiratory disability, COVID-19 infection, pulmonary function and vaping behaviors.
Researchers used multivariable regression to identify risk factors associated with vaping after an EVALI diagnosis and to assess whether ICU admission was related to cognitive, respiratory or mood symptoms.
Long-term outcomes
Of the 64 patients who took the Montreal Cognitive Assessment (MoCA), researchers found that 25 (39.1%) had cognitive impairment. Blagev told Healio this finding was surprising because the cohort consisted of a “young and relatively healthy patient population.”
Researchers additionally observed that 30 out of 62 patients (48.4%) who responded to the St. George’s Respiratory Questionnaire (SGRQ) had respiratory impairment, and 38 out of 64 (59.4%) patients evaluated with the Hospital Anxiety and Depression Scale (HADS) had symptoms of anxiety and/or depression.
In a sub-analysis, researchers evaluated 46 patients who had completed the MoCA, SGRQ and HADS. They found that 11 patients (23.3%) had symptoms based on all three assessments, whereas seven (15.2%) had cognitive impairment without dyspnea and/or symptoms related to mood.
Additionally, this analysis showed that dyspnea and anxiety and/or depression were related. Of the 29 patients with dyspnea, 25 (86.2%) had anxiety and/or depression, and of the 35 patients with anxiety and/or depression, 25 (71.4%) had dyspnea, according to researchers.
Regarding PTSD, researchers found 61.9% (n = 39 of 63) of patients had symptoms according to the Impact of Event Scale-Revised.
Out of 64 patients who responded, only four (6.3%) had COVID-19 during follow-up, and none of them were hospitalized.
Of the total cohort, 30 patients (41.1%) had been admitted to the ICU, but ICU admission did not appear associated with long-term symptoms of cognitive impairment, dyspnea or mood.
Vaping practices
Following an EVALI diagnosis, researchers observed decreased rates of both nicotine e-cigarette use (61% to 28%) and THC e-cigarette use (81% to 18.8%; P < .001 for both) in 1 year. However, researchers found that only 24 of 64 patients (37.5%) quit, which Blagev said was surprising.
“People did cut down and modified their habits, but it really drives home the point of the importance of having policies in place that prevent children from getting addicted in the first place,” she said. “Once these habits are established, even an immediate, devastating event such as EVALI is not quite enough to help everyone quit for good.”
When evaluating age, sex, HADS anxiety score, SGRQ total score and MoCA score in multivariable analysis, younger age was significantly associated with reduced vaping/smoking behavior (OR = 0.93; P = .02), but none of the variables were associated with quitting the habit completely.
Looking ahead
Future studies should define different subtypes of EVALI, Blagev told Healio.
“The largest driver of the 2019 outbreak of EVALI was vitamin E acetate in THC e-cigarettes,” she said. “However, since then, we are seeing [other] patients present with EVALI — and even from the start 10% to 15% occurred in nicotine users only — so it is likely that vaping different substances had different subtypes of lung disease. It is still an area we are learning a lot about.
“The key is to prevent children from starting to vape,” Blagev added. “This is not a ‘safe’ thing for kids to do, and once they start, it can have lifelong consequences.”
This study by Blagev and colleagues adds to the literature indicating that e-cigarette use has long-term consequences related to mental health, according to an accompanying editorial by Jason J. Rose, MD, MBA, associate professor of medicine at University of Maryland School of Medicine, and colleagues.
“Screening for mental health disorders and ensuring access to mental health resources is likely an important component of follow-up care for patients with EVALI,” Rose and colleagues wrote. “Despite the limited data on nicotine or cannabis cessation approaches in adolescents and younger adults, outpatient management to follow and address long-term needs regarding pulmonary symptomology, mental health and chemical dependence appears to be critical for EVALI patients.”
They noted, “The work of Blagev and colleagues is a critical addition to the current understanding of the long-term health effects of EVALI.”
For more information:
Denitza P. Blagev, MD, can be reached at denitza.blagev@gmail.com, and her twitter is @mybetterdoctor.