E-Cigarette or Vaping Product Use-Associated Lung Injury (EVALI): Perioperative Management

Electronic cigarettes, called “e-cigarettes,” “e-cigs,” “vapes,” “e-hookahs,” “vape pens” and “electronic nicotine delivery systems (ENDS),”¹ are drug-containing devices that may resemble regular cigarettes, cigars, pipes, pens, USB sticks or other everyday items.² E-cigarettes produce an aerosol by heating a liquid that usually contains nicotine, the addictive ingredient in tobacco products.² Users inhale this aerosol into their lungs, and bystanders may also breathe in the chemical through the user’s exhalations.² E-cigarettes can also be used to deliver marijuana and other drugs.² E-cigarettes can benefit adults who use them to substitute or wean off of regular cigarettes and other smoked tobacco products,¹ which are harmful to almost all body systems.³ Because they were invented in the early 2000s, scientists know little about e-cigarettes’ long-term effects on health or prevention and cessation of tobacco use.⁴ Some studies have found that e-cigarettes impair air quality,⁵ are poorly regulated⁶ and may influence youth to engage in nicotine use.⁷ Recently, reports of severe vaping-related pulmonary disease and deaths have drawn researchers’ attention to the unknown health effects of e-cigarettes.⁸ Due to the rising popularity of e-cigarettes, health care providers should be familiar with their potential health consequences. Additionally, anesthesia providers must take special perioperative considerations for patients with e-cigarette-related lung disease. 

Recent reports have brought to light a serious consequence of e-cigarettes known as e-cigarette or vaping product use-associated lung injury (EVALI).⁹ EVALI was first recognized by the Centers for Disease Control and Prevention (CDC) in August 2019 after health departments across the United States encountered cases of severe, sometimes fatal, lung infections arising in otherwise healthy people.⁹ Emergency department visits related to e-cigarette or vaping products peaked in September 2019 and have declined since.¹⁰ Though scientists lack the evidence to conclude which exact chemicals contribute to EVALI, it is clear that vitamin E acetate is strongly linked to EVALI outbreaks.¹¹ Vitamin E acetate has been found in product samples tested by FDA and state laboratories and in patient lung fluid samples tested by the CDC; it has not been found in lung fluid of people who do not have EVALI.¹¹ As an additive in some THC-containing e-cigarettes, vitamin E acetate may be responsible for the higher rates of EVALI in THC-containing—as opposed to nicotine-containing—e-cigarette users.^12,13 EVALI can be difficult to diagnose because its signs and symptoms may be similar to those of other illnesses, such as pneumonia or the flu.⁹ Symptoms include respiratory issues such as cough, chest pain and shortness of breath; gastrointestinal distress such as abdominal pain, nausea, vomiting, stomach pain and diarrhea; or nonspecific constitutional symptoms such as fever, chills and weight loss.¹¹ Analysis of lung biopsies shows signs of acute lung injury ranging from inflammation to alveolar damage to pneumonia.¹² As of February 18, 2020, a total of 2,807 hospitalized EVALI cases or deaths have been reported to the CDC from the United States, the District of Columbia, Puerto Rico and the U.S. Virgin Islands.¹³ Sixty-eight deaths have been confirmed in 29 states and the District of Columbia.¹³ EVALI is a significant public health problem not only in its associated morbidity and mortality, but also in the lack of knowledge about its pathology and long-term effects.¹² 

Along with a lack of knowledge about EVALI comes a lack of data on its perioperative implications. However, current research suggests that e-cigarette use can cause damage to the respiratory, cardiovascular, immune and musculoskeletal systems in ways that are similar to and different from the effects of cigarette smoking.¹⁴ It is well-known that smoking during the perioperative period leads to worse surgical outcomes, and that nicotine increases risk of surgical site infections and necrosis.¹⁵ In a recent study by Troiano et al., animal models showed impaired wound healing after exposure to either e-cigarette vapor or cigarette smoke.¹⁶ Thus, the authors conclude that smoking and vaping are equally detrimental to wound healing.¹⁶ Additionally, nicotine can lower the effectiveness of certain medications or interfere with anesthetic drugs.¹⁷ This applies surgery for all patients who use e-cigarettes, even those who are not affected by EVALI. Meanwhile, patients with EVALI may need thoracic surgery to address lung injury.¹⁸ In a patient with EVALI, intraoperative ventilation may be challenging, and high levels of FiO₂ (percentage of inhaled oxygen) and PEEP (positive end-expiratory pressure) may be required to maintain adequate gas exchange.¹⁸ In severe EVALI cases, clinicians may need to perform venovenous extracorporeal membrane oxygenation (ECMO), which entails oxygenating blood with an artificial lung and returning it to the patient’s body.¹⁸ The respiratory and wound-healing issues associated with e-cigarette use and EVALI may complicate anesthesia administration and perioperative care. 

E-cigarette use is highly prevalent in the United States, especially among youth.¹⁹ Though researchers know little about the long-term health effects of e-cigarettes, they have associated vaping with a syndrome called EVALI. EVALI is marked by a variety of symptoms ranging from shortness of breath to fever, and it can even cause death. In perioperative settings, e-cigarette use and EVALI are associated with ventilation complexities and impaired wound healing. Future research is needed to explore the impact of EVALI on anesthetic management and surgical outcomes.²⁰ 

1.Centers for Disease Control and Prevention. Electronic Cigarettes. Smoking & Tobacco Use 2020; https://www.cdc.gov/tobacco/basic_information/e-cigarettes/index.htm. 

2.Centers for Disease Control and Prevention. About Electronic Cigarettes (E-Cigarettes). Smoking & Tobacco Use 2020; https://www.cdc.gov/tobacco/basic_information/e-cigarettes/about-e-cigarettes.html. 

3.Centers for Disease Control and Prevention. Health Effects. Smoking & Tobacco Use 2020; https://www.cdc.gov/tobacco/basic_information/health_effects/index.htm. 

4.Grana R, Benowitz N, Glantz Stanton A. E-Cigarettes. Circulation. 2014;129(19):1972–1986. 

5.Schober W, Szendrei K, Matzen W, et al. Use of electronic cigarettes (e-cigarettes) impairs indoor air quality and increases FeNO levels of e-cigarette consumers. International Journal of Hygiene and Environmental Health. 2014;217(6):628–637. 

6.Zhu S-H, Sun JY, Bonnevie E, et al. Four hundred and sixty brands of e-cigarettes and counting: Implications for product regulation. Tobacco Control. 2014;23(Suppl 3):iii3–iii9. 

7.Ambrose BK, Rostron BL, Johnson SE, et al. Perceptions of the Relative Harm of Cigarettes and E-cigarettes Among U.S. Youth. American Journal of Preventive Medicine. 2014;47(2, Supplement 1):S53–S60. 

8.Marsden L, Michalicek ZD, Christensen ED. More on the Pathology of Vaping-Associated Lung Injury. The New England Journal of Medicine. 2020;382(4):387–388. 

9.Yale Medicine. E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI). Conditions 2020; https://www.yalemedicine.org/conditions/evali/. 

10.New Cases in Outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injury (EVALI) On the Decline [press release]. December 20, 2019. 

11.Centers for Disease Control and Prevention. For Healthcare Providers. Smoking & Tobacco Use February 25, 2020; https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease/healthcare-providers/index.html. 

12.Butt YM, Smith ML, Tazelaar HD, et al. Pathology of Vaping-Associated Lung Injury. New England Journal of Medicine. 2019;381(18):1780–1781. 

13.Centers for Disease Control and Prevention. Outbreak of Lung Injury Associated with E-cigarette Use, or Vaping. Smoking & Tobacco Use February 25, 2020; https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html. 

14.Wang W. Vaping And Anesthesia. University of New England; June 2019. 

15.Fracol M, Dorfman R, Janes L, et al. The Surgical Impact of E-Cigarettes: A Case Report and Review of the Current Literature. Archives of Plastic Surgery. 2017;44(6):477–481. 

16.Troiano C, Jaleel Z, Spiegel JH. Association of Electronic Cigarette Vaping and Cigarette Smoking With Decreased Random Flap Viability in Rats. JAMA Facial Plastic Surgery. 2019;21(1):5–10. 

17.American Association of Nurse Anesthetists. Vaping ‘no better’ than smoking when surgery is needed. ScienceDaily. Web: ScienceDaily; November 15, 2017. 

18.Dodick T, Greenberg S. A Patient With E-Cigarette Vaping Associated Lung Injury (EVALI)—Coming to an Operating Room Near You! APSF Newsletter. February 2020;35(1):1, 4. 

19.Cullen KA, Gentzke AS, Sawdey MD, et al. e-Cigarette Use Among Youth in the United States, 2019. JAMA. 2019;322(21):2095–2103. 

20.Gricourt Y, Ghezal H, Claret PG, et al. Preoperative vaping prevalence and behavior of French surgical patients: A multicentre study. Tobacco Induced Diseases. 2019;17:84.