The most common symptoms reported in our study were cough, shortness of breath, and vomiting, each occurring separately in five patients. Three patients presented with chest pain. Two patients presented with altered mental status in the form of unresponsiveness, with one patient requiring intubation. The other unresponsive patient, a 16-year-old male, returned to a normal mentation with bag-valve-mask ventilation and naloxone but required high-flow nasal cannula for shortness of breath. On physical examination, accessory muscle use was the most common finding, reported in four patients. Rales were appreciated in two patients, while no patients were found to have wheezing . In our study, six patients presented with respiratory failure. Four required HFNC. One patient was intubated; one patient required simple nasal cannula oxygen at two liters per minute; and one patient maintained normal oxygen saturations in room air during his ED visit and was discharged home. A brief clinical presentation, summary of findings on imaging, and type of respiratory support needed are summarized in Table 2. Five patients were admitted to the pediatric intensive care unit, and one patient was admitted to the normal pediatric unit. The median hospital length of stay was six days . All patients were discharged with no comorbidities or deaths reported. Six patients were treated with steroids. The median duration of treatment with steroids during admission and after discharge was nine days.
Our patients had a variety of laboratory tests ordered. Most common were complete blood count, respiratory virus panel, respiratory cultures, and urine drug screen. All patients had a complete blood count,grow trays and the median for white cell count was 16 thousand cells per cubic millimeter . A respiratory virus panel was collected from five patients and it was negative in all of them . Respiratory cultures were collected from two patients and both resulted negative. A urine drug screen was performed for six patients and was positive for cannabinoids in all six . Three patients followed up at different intervals in the pulmonology clinic . Spirometry showed normal results in all three patients at that time. Case 1 followed up one week after discharge, at which time spirometry showed evidence of obstructive lung disease, which returned to normal at three-month follow-up visit. No repeat imaging was performed for that patient. Case 2 followed up six weeks after discharge with near-complete resolution of ground-glass appearance on repeat CT and normal spirometry. Case 4 followed up two weeks after discharge with improvement in lung opacities on repeat radiograph and normal spirometry. All three patients had received steroids for 10 days when they were originally diagnosed with EVALI. No follow-up data was available for the remaining four patients.EVALI was an emerging disease entity in 2019. In our case series, we describe adolescents diagnosed with EVALI and their clinical course in the ED and the hospital. In our study, the most common symptoms of cough, shortness of breath, and vomiting presented with an equal frequency of 71%. In a study by Layden et al, shortness of breath and cough was noticed in 85% of patients and vomiting in 61%; whereas, according to Belgaev et al, 90% of patients in their study presented with gastrointestinal and respiratory symptoms.In a report by the CDC, 85% of the EVALI population had respiratory symptoms and 57% had GI symptoms.
The results of our study are similar to previous literature in suggesting that respiratory and GI symptoms are common in patients with EVALI. According to Balgaev et al, 67% of patients had clinical and radiological improvement with residual findings on radiological and pulmonary function tests at time of followup.10 In our study, the three patients who had documented follow-up visits had normal spirometry without residual deficits. Only two of those patients had repeat imaging, and both showed improvement without residual abnormalities. E-cigarette liquids and aerosols have been shown to contain a variety of chemical constituents including flavors that can be cytotoxic to human pulmonary fibroblasts and stem cells.Exposure to heavy metals such as chromium, nickel, and lead has also been reported.None of our patients were tested for heavy metal exposure. Most of the delivery systems have nicotine in them, with one cartridge providing the nicotine equivalent to a pack of cigarettes.In addition to nicotine, e-cigarette devices can be used to deliver THC-based oils.According to Trivers et al, one-third of the adolescents who used e-cigarettes had used cannabinoids in their e-cigarettes.In our patients with EVALI, urinary drug screen was positive for cannabinoids in all patients. One caveat is that we do not know whether our patients used only THC-containing products or a combination of nicotine and THC-containing products. In our case series, the majority of patients presented with pulmonary disease requiring respiratory support and intensive care unit admission. None of these patients developed acute respiratory distress syndrome . We likely did not see this disease process due to our small sample size, as Layden et al reported ARDS development in several of their examined cases.6 In our series, we did not evaluate the pathologic pulmonary changes in different patients. In other case reports, different pathophysiologic patterns of pulmonary involvement, in the form of diffuse alveolar hemorrhage, exogenous lipoid pneumonia, acute eosinophilic pneumonia, or hypersensitivity pneumonitis have been identified.Although the mechanism of EVALI is not clearly understood, the CDC suggests the use of steroids for treatment.
According to a series of patients in Illinois, 51% of those patients had improvement in symptoms after the administration of steroids.6 In another study, patients showed clinical and radiological improvement following the use of antibiotics and steroids.In our study, six patients received steroids and six patients received antibiotics; three of those patients followed up in clinics with normal spirometry. But this evidence is not sufficient to establish that use of steroids or antibiotics is beneficial in EVALI. There are several limitations of our study. First, because it was a retrospective chart review we could not establish causation. Second, all data may not have been recorded on all patients . We might have missed some if the ICD-10 codes were not correct on the chart. Only three had documented follow-up,pruning cannabis so we don’t know whether the other four had any comorbidities after their hospitalization. Third, we had a small number of patients. Fourth, this was a single-center study; so results may not be generalizable to other hospitals with different patient demographics.At baseline, intervention patients received a face-to-face brief intervention during their clinician visit. Clinicians followed a paper scripted protocol “Summary to Clinician” provided by research staff based on the patients’ HSD; the majority of clinicians reported on our post-visit “Intervention Plan” that their intervention lasted 3–4 minutes and all clinicians reported that they had counseled the patient on their HSD. The message covered drug addiction as a chronic brain disease , the need to quit or reduce using drugs to prevent this disease, the physical and mental consequences of drug use, and the potential accelerated progression towards addiction caused by poly-substance use. Clinicians also told patients that they would receive telephone calls 2 and 6 weeks later from a health educator. Patients subsequently received a Drug Health Education Booklet with a Report Card for their HSD, and viewed a video doctor reinforcing the clinician message . Patients were enrolled on their HSD, and it was that drug that the clinician focused on ; they would also briefly mention the benefits of reducing risky use of alcohol or tobacco if the patient screened positive on the ASSIST for risky use of these substances. The 2- and 6-week telephone drug-use coaching sessions reinforced the clinicians’ message, and followed a patient-centered protocol, focusing on HSD use reduction.
As previously described , lay health educators were trained in motivational interviewing and cognitive behavioral techniques. Weekly meetings with the PIs and project director fostered a HE “Learning Community,” where every case was discussed to maintain fidelity to the protocol. All 32 intervention patients received clinician brief advice , and 22 had at least 1 telephone session and 15 had both sessions. Control patients completed the ASSIST but did not receive clinician brief intervention or coaching sessions; they did receive a video doctor and information booklet on cancer screening. At study exit, control patients received the intervention components of the video doctor and informational booklet.Urine drug testing was conducted at baseline and follow-up to validate self-reported drug use. The Confirm BioSciences, San Diego, Integrated QuickScreen™ CLIA cup was used since it reliably tests for drugs of interest to this study . At baseline, 58/65 patients provided urine specimens and 47/51 did so at follow-up. Thirty two patients tested positive for marijuana at baseline and all 32 disclosed past month marijuana use. Similarly, 2 patients tested positive for cocaine and both self-reported its use. At follow-up, 18 patients tested positive for marijuana; all of these patients reported recent marijuana use. Three control patients tested positive for cocaine and/ or amphetamines – 1 for cocaine, 1 for amphetamines and 1 for both; all 3 disclosed their use of these drugs. Thus, for all intervention and control patients with urine tests, self-reports of drug use were confirmed by the tests at both baseline and follow-up. Finally, to complement the assessment of a group difference in degree of self-reported reduction in HSD use over the study period, chi-square and logistic regression analyses were conducted to determine whether there was a group difference with respect to the objective measure of testing positive for HSD use via urine analysis at follow-up.The outcome measure was reduction in number of days of drug use in the past 30 days of the patients’ HSD between baseline and 3-month follow-up. For this study, we employed self-reported use of substances for the past 30 days that provides similar results as the timeline follow-back method . Patients self-administered the questionnaires and recorded their responses on the tablet computers at baseline and followup . The Behavioral Model for Vulnerable Populations guided selection of variables used as potential covariates in analyses . Key characteristics are shown in Table 1. Perceived general health status was assessed by a five-point Likert scale item from the SF-12 ; for analysis, responses were dichotomized to fair/poor health versus good, very good, or excellent health. Physical health was measured by self-reported history of 8 chronic medical conditions. Readiness to change drug use was assessed . Baseline and follow-up questionnaires were identical.Reduction in past month HSD use between baseline and follow-up was approximately normally distributed and was assessed with linear regression analysis. Baseline variables in Table 1 associated with reduction in HSD use at the 0.05 level were candidate covariates. A parsimonious final model was obtained by manually removing covariates one at a time in descending order of p values until only those associated with reduction in HSD use at the 0.10 level remained and multi-collinearity was not a problem , 2015. A priori power testing for efficacy was not conducted for this pilot study. Since 14 of the total sample of 65 patients were lost to follow up, intention-to-treat analysis was performed using multiple imputation to impute their missing outcome values rather than carrying forward the last observation to accommodate the very real possibility of change over time . Baseline variables in Table 1 related to loss-to-follow-up were included in the imputation model , along with analytic variables. Twenty sets of imputed values were produced. Two separate regression analyses were compared to check the sensitivity of our estimates of the effects of QUIT on drug use reduction. One was the intent-to-treat analysis including all 65 cases . The other used the 51 complete cases with both baseline and follow-up data . Additionally, to investigate whether patients might have compensated for reducing their HSD use by increasing their use of alcohol and tobacco, we assessed changes in use of these substances among patients who reduced their HSD use by 1 day or more. Baseline characteristics show that 94% were Latino; on average had used their HSD for 12.9 years; had a mean HSD ASSIST score at baseline of 14.4 ; and their most common HSD was cannabis , followed by stimulants . Intervention and control groups did not differ on baseline characteristics. For the 51 patients with follow-up data, the mean number of days of HSD use in the past 30 days was balanced at baseline .