The Drug-Induced Respiratory Disease Website and App

E-cigarette - E-vaporizers - ENDS - Vaping - Dabbing

PMID 31990264, 32758560, 34130236. Reached epidemic proportions mid-2019, then declining durably. THC, and vitamin-E acetate at the forefront of possible culprit agents. Substances of toxicological interest include ethylene glycol, glycerine, flavoring agents including diacetyl, cannabis (PMID 26347431), tetrahydrocannabinol THC (PMID 25383564, 31491070), vitamin E acetate, ‘sexual enhancers’ such as tadalafil, poppers (NO), or other drugs of abuse (PMID 30245461, 30835796). There is also the risk of nicotine poisoning if contents of a cartridge is taken orally and swallowed, notably by/in children. Careful differential diagnosis and history taking of exposure to tobacco smoke, inhalants, inhaled stimulants, inhaled drugs and/or substances of abuse is indicated in every patient. E-cigarette in patients on oxygen therapy may produce severe facial burns. Battery explosion and fire can injure the mouth, teeth, face, eye, skin and/or thigh.

Frequency - Incidence

Incidence of respiratory adverse event(s) due to the specific drug as assessed by number of reported/published cases in the literature. Red digits in stars indicate: 0 = Very rare, questionable signal · 1 = < 10 cases · 2 = 10-50 cases · 3 = 50–100 cases · 4 = 100-200 cases · 5 = >200 cases

Evidence level/grade

Evidence level for respiratory adverse event(s) due to the specific drug as estimated using Hill’s (1965), Naranjo’s (1981), and Bégaud’s (1985) criteria applied to published cases. Blue digits in stars indicate: 0 = Questionable · 1 = Low · 2 = Moderate · 3 = Robust · 4 = Definite · 5 = Unquestionable, pathognomonic

I - Interstitial/parenchymal lung disease

I.a

Pneumonitis (ILD)

I.b

Pneumonitis (ILD), acute and/or severe (may cause ARDS)

I.c

Eosinophilic pneumonia (pulmonary infiltrates and eosinophilia)

I.d

Acute eosinophilic pneumonia (AEP)

I.e

Organizing pneumonia pattern (an area or areas of consolidation on imaging)

I.f

Acute fibrinous organizing pneumonia (AFOP)

I.k

Exogenous lipoid pneumonia (subacute, acute)

I.n

ILD with a granulomatous component

I.o

Pulmonary alveolar proteinosis (PAP)

I.v

Relapsing or migrating pneumonitis/pneumonia (see also Id)

I.w

Abnormal lung function/pulmonary physiology (PFTs) without necessarily imaging or clinical evidence

I.ax

Persistent reduction in diffusing capacity for CO upon resolution of the adverse effect

I.ay

Chronic pneumonitis

II - Pulmonary edema - Acute lung injury - ARDS

II.e

ARDS - Acute lung injury

II.u

Acute respiratory failure (e.g. from ARDS, ILD, PIE, OP, pulmonary edema or bronchospasm) requiring ECMO

III - Pulmonary/alveolar./airway hemorrhage/bleeding

III.a

Alveolar hemorrhage (AH), diffuse AH (DAH)

III.c

Hemoptysis

III.m

Coagulopathy

IV - Airway involvement

IV.a

Bronchospasm - Wheezing - Asthma

IV.b

Severe or catastrophic bronchospasm or asthma attack (can be fatal)

IV.e

Deterioration/exacerbation of preexisting asthma or COPD

IV.h

Reactive airway dysfunction syndrome (RADS)

IV.j

Bronchiectasis

IV.l

Large airway inflammation - Tracheitis (w/wo tissue eosinophilia)

IV.p

Thermal, chemical or caustic airway injury

IV.u

Sptutum production - Bronchorrhea - 'Bronchitis'

IV.ab

Cough (lone)

IV.af

Sputum production - Bonchorrhea - ‘Bronchitis’

IV.ag

Obstructive airway dysfunction (see also IVc, XVx)

V - Central-large-upper airway (incl. pharyngeal-nasal) involvement

V.i

Thermal (burns, frostbite), chemical or caustic injury on the face, mouth, tongue, pharynx or upper airway

V.p

Foreign body in the airway

V.am

Epiglottitis

V.ao

Facial/labial/buccal/oral/dental trauma

V.aq

Airway foreign body

V.av

Gross tracheal inflammation on endoscopy

V.ax

Tracheitis including eosinophilic tracheal inflammation

V.az

Tracheal redness/inflammation on gross endoscopic examination

VI - Pleural and/or pericardial involvement

VI.a

Pleural effusion (uni- or bilateral) (can accompany DI-LDs)

VI.f

Pneumothorax

VIII - Mediastinal involvement

VIII.a

Lymphadenopathy (intrathoracic)

VIII.e

Granulomatous mediastinal lymphadenopathy

VIII.h

Pneumomediastinum

IX - Neuromuscular / CNS involvement - Disordered breathing (during sleep)

IX.h

Dyspnea, unexplained otherwise

IX.af

Seizures

X - Systemic/Distant conditions, syndromes and reactions

X.b

Antiphospholipid antibodies w/wo the APL syndrome

X.m

Sarcoid-like granulomatosis (endo-/extrathoracic)

X.s

Systemic inflammatory response

X.as

Relapse or flare of preexisting ulcerative colitis

XI - Miscellaneous

XI.b

Chest pain (acute or subacute), lone or prominent

XI.o

Death following exposure or poisoning

XI.z

Thermal skin/dermal injury

Chest tightness

Polycythemia

Nicotine poisoning

Burns

XII - Cardiovascular involvement / toxicity

XII.a

Left or biventricular dysfunction/failure

XII.n

Cardiac arrhythmias or dysrhythmias (AF, VT, VF, TdP)

XII.ai

Bradycardia

XIV - Hemoglobinopathies - Abnormal hemoglobin states (acquired)

XIV.a

Methemoglobinemia

XVI - Imaging

XVI.a

Imaging: Diffuse haze

XVI.b

Imaging: Ground-glass opacities (GGO) / shadowing

XVI.d

Imaging: Alveolar opacities or haze with a batwing or butterfly distribution

XVI.g

Imaging: Diffuse whiteout/alveolar shadowing (see also under IIb-ARDS)

XVI.k

Imaging: An area or areas of consolidation

XVI.v

Imaging: Centrilobular micronodules (can be diffuse)

XVI.ad

Imaging: Lung cysts or bullae (see also XVI ah/bf)

XVI.ak

Imaging: A 'tree-in-bud' pattern

XVI.bp

Imaging: An area or areas of avid tracer uptake in the lung/chest on 18F-PET scan

XVII - Distinctive patterns - 'Eye-catchers'

XVII.x

Eye catcher: A batwing pattern on imaging

XVIII - Cytological, biochemical features of/in BAL, pleural fluid or FNA

XVIII.a

BAL: An excess proportion of lymphocytes

XVIII.b

BAL: An excess proportion of neutrophils

XVIII.c

BAL: An excess proportion of eosinophils

XVIII.d

BAL: Gross or microscopic bleeding/hemorrhage

XVIII.f

BAL: Foamy macrophages

XVIII.i

BAL: Oil red O-stainable material in BAL macrophages othen than exogenous lipids

XVIII.n

BAL: Brown-pigmented macrophages

XIX - Pathology

XIX.d

Path: Organizing pneumonia (OP/BOOP) pattern (see also Id)

XIX.e

Path: Acute fibrinous organizing pneumonia (AFOP-pattern) (see also If)

XIX.f

Path: ILD with a granulomatous component (see also Im)

XIX.l

Path: Giant-cell interstitial pneumonia (GIP)-pattern

XIX.o

Path: Diffuse alveolar damage (DAD-pattern) (see also IL)

XIX.r

Path: Alveolar hemorrhage (see also IIIa)

XIX.z

Path: Exogenous lipoid pneumonia

XIX.al

Path: Acute/subacute bronchiolitis (see also IVc, IVi)

XIX.ap

Path: Respiratory bronchiolitis (w/wo the RB-ILD-pattern)

XIX.bc

Path: Pulmonary capillaritis

XIX.bx

Path: Granulomatous lymphadenopathy

XX - Infections & related conditions

XX.a

Respiratory tract infection incl. pneumonia

XX.c

Aspergillosis, pulmonary (invasive, allergic [ABPA], or mycetoma)

XX.h

Nontuberculous pulmonary mycobacterial infection/superinfection

XX.ab

Actinomycosis