Sedation challenges in patients with E-cigarette, or vaping, product use-associated lung injury (EVALI)

Abstract

E-cigarette, or vaping, product use-associated lung injury (EVALI) has become an epidemic that is increasingly affecting patients across USA. Recently, over 2100 cases have been reported in 49 states, resulting in at least 42 deaths. We present a case of rapid respiratory failure in an otherwise healthy and young patient who used a vaporiser containing tetrahydrocannabinol (THC) during the month prior to admission. The patient eventually required mechanical ventilation. There were significant challenges in achieving the appropriate level of sedation during intubation and mechanical ventilation. As more EVALI cases are being diagnosed in recent months, we highlight an aspect that may be unique to the population of patients who vaporise THC-high sedative and analgesic requirements during intubation and mechanical ventilation.

Keywords: anaesthesia; mechanical ventilation; medical management; smoking and tobacco; toxicology.

Figure 1

Chest X-ray on admission non-specific peripheral infiltrates without effusions or hilar abnormalities.

Figure 2

Coronal CT thorax with contrast patchy subpleural ground-glass opacities with sparing of majority of central parenchyma. No effusions noted.

Figure 3

Axial CT thorax with contrast bilateral lower lobe ground-glass opacities in a posterior distribution. No honeycombing or bronchiectasis noted.

Figure 4

(A–C) Pathology slides from transbronchial biopsies. A: 100×; B: 200×; C: 400× features show severe acute lung injury consistent with diffuse alveolar damage. The interstitium is mildly expanded by oedema and there are a moderate number of eosinophilic hyaline membranes in alveolar spaces constituting diffuse alveolar damage. There are no eosinophils, evidence of haemorrhage, granulomas or giant cells. Grocott’s methenamine silver (GMS) stains did exclude the possibility of pneumocystis or fungal infection. Additional hematoxylin and eosin (H&E) stains did not reveal any additional features.

Figure 5

Chest X-ray on two different admissions (A) First admission (2 days into admission): patchy bilateral subpleural ground glass opacities. (B) Second admission (7 days post discharge): diffuse subcutaneous emphysema with pneumomediastinum and large left apical blebbing in the background of diffuse fibrotic parenchymal lung changes.