E-cigarette or vaping product use-associated lung injury: A review of clinico-radio-pathological characteristics

Respir Investig. 2022 Nov;60(6):738-749. doi: 10.1016/j.resinv.2022.06.011. Epub 2022 Aug 11.


Aggressive, albeit false marketing of electronic nicotine delivery systems (ENDS) or vaping devices as safer alternatives to cigarette smoking, combined with lack of regulations, has led to its mass adoption, especially among youth. A sudden increase in acute lung injuries was noted in 2019 which was linked to ENDS. It was termed by the Centers for Disease Control and Prevention (CDC) as electronic cigarette or vaping product use-associated lung injury (EVALI). Analysis of bronchoalveolar lavage fluid samples linked EVALI to vitamin E acetate (VEA), which is used as a diluting agent for marijuana oils. Patients with EVALI present with a combination of non-specific respiratory, gastrointestinal, and systemic symptoms. Laboratory results may show elevated inflammatory biomarkers. EVALI is a diagnosis of exclusion and must meet the following criteria: i) history of vaping within last 90 days, ii) abnormal chest imaging, iii) negative evaluation for infection, and iv) no other plausible diagnosis. A spectrum of computed tomography (CT) chest findings has been reported in EVALI, ranging from diffuse alveolar damage to organizing pneumonia, characterized by bilateral ground-glass opacities, consolidation, and septal thickening. A similar spectrum is seen on histopathology, characterized by lipid-laden alveolar macrophages, with varying degrees of infiltrative inflammatory cells and fibrin deposition. Early and accurate identification of the EVALI pattern can help optimize patient care. For example, in diffuse alveolar damage (DAD), a lower threshold for ventilation support and corticosteroid may improve outcomes. Here, we review the etiopathogenesis, clinical management, histopathology, and imaging features of EVALI.

Keywords: E-cigarette or vaping product use-associated lung injury; Electronic nicotine delivery systems; Marijuana; Nicotine; Vaping.

Publication types

  • Review

MeSH terms

  • Acute Lung Injury* / diagnostic imaging
  • Acute Lung Injury* / etiology
  • Adolescent
  • Cigarette Smoking*
  • Electronic Nicotine Delivery Systems*
  • Humans
  • Lung Injury* / diagnostic imaging
  • Lung Injury* / etiology
  • Lung Injury* / pathology
  • Tomography, X-Ray Computed
  • Vaping* / adverse effects