Pneumotox » Drug » E-cigarette - E-vaporizers - ENDS - Vaping - Dabbing

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

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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.

Last update : 30/06/2021

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

5

I.b Pneumonitis (ILD)

5

I.c Eosinophilic pneumonia (pulmonary infiltrates and eosinophilia)

1

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

1

I.e Acute eosinophilic pneumonia (AEP)

1

I.j Exogenous lipoid pneumonia (subacute, acute)

1

I.m ILD with a granulomatous component

1

I.u Relapsing or migrating pneumonitis/pneumonia (see also Id)

1

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

1

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

1

I.ax Chronic pneumonitis

1

II.b ARDS - Acute lung injury

2

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

1

III.a Alveolar hemorrhage (AH), diffuse AH (DAH)

1

III.c Hemoptysis

1

III.m Coagulopathy

1

IV.a Bronchospasm - Wheezing - Asthma

2

IV.d Cough (lone)

2

IV.f Severe or catastrophic bronchospasm or asthma attack (can be fatal)

1

IV.k Bronchiectasis

1

IV.n Obstructive airway dysfunction (see also IVc, XVx)

1

IV.p Thermal, chemical or caustic airway injury

1

IV.q Reactive airway dysfunction syndrome (RADS)

1

IV.t Sptutum production - Bronchorrhea - 'Bronchitis'

1

IV.v Deterioration/exacerbation of preexisting asthma or COPD

1

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

1

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

1

V.f Pneumothorax

1

VII.a Lymphadenopathy (intrathoracic)

1

VII.e Granulomatous mediastinal lymphadenopathy

1

VII.h Pneumomediastinum

1

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

1

VIII.al Epiglottitis

1

VIII.an Facial/labial/buccal/oral/dental trauma

1

VIII.ap Airway foreign body

1

VIII.at Gross tracheal inflammation on endoscopy

1

IX.h Dyspnea, unexplained otherwise

1

IX.af Seizures

1

X.b Antiphospholipid antibodies w/wo the APL syndrome

1

X.k Sarcoid-like granulomatosis (endo-/extrathoracic)

1

X.aq Relapse or flare of preexisting ulcerative colitis

1

XI.b Chest pain (acute or subacute), lone or prominent

1

XI.r Death following exposure or poisoning

1

XI.ac Thermal skin/dermal injury

1

XI.ay Chest tightness

1

XI.bc Polycythemia

1

XI.bd Nicotine poisoning

1

XI.be Burns

2

XII.a Left or biventricular dysfunction/failure

1

XII.l Cardiac arrhythmias or dysrhythmias (AF, VT, VF, TdP)

1

XII.ag Bradycardia

1

XIV.a Methemoglobinemia

1

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

1

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

1

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

1

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

1

XV.g Path: Alveolar hemorrhage (see also IIIa)

1

XV.p Path: Exogenous lipoid pneumonia

1

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

1

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

1

XV.ab Path: Pulmonary capillaritis

1

XV.ba Path: Granulomatous lymphadenopathy

1

XV.bi Path: Giant-cell interstitial pneumonia (GIP)-pattern

1

XVI.a Imaging: Diffuse haze

1

XVI.b Imaging: Ground-glass opacities (GGO) / shadowing

1

XVI.d Imaging: Alveolar opacities or haze with a batwing or butterfly distribution

1

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

2

XVI.k Imaging: An area or areas of consolidation

1

XVI.v Imaging: Centrilobular micronodules (can be diffuse)

1

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

1

XVI.ai Imaging: A 'tree-in-bud' pattern

1

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

1

XVII.a Respiratory tract infection incl. pneumonia

1

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

1

XVII.h Nontuberculous pulmonary mycobacterial infection/superinfection

1

XVIII.x Eye catcher: A batwing pattern on imaging

1

XIX.a BAL: An excess proportion of lymphocytes

1

XIX.b BAL: An excess proportion of neutrophils

1

XIX.c BAL: An excess proportion of eosinophils

1

XIX.d BAL: Gross or microscopic bleeding/hemorrhage

1

XIX.f BAL: Foamy macrophages

1

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

1

XIX.n BAL: Brown-pigmented macrophages

1

Diagnosing DIRD

1

Drug and radiation history

2

Drug singularity - Correct identification of the drug

3

Consistent timing of exposure v. onset of symptoms

4

Clinical, imaging, BAL, pathological pattern consistent with the specific drug

5

Careful exlusion of another cause

6

Remission of symptoms with removal of drug

7

Recurrence with rechallenge (rarely advisable)

8

Causality assessment

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