Vaping Guidance Aids Respiratory Disease Screening and Care

Craig Lilly, MD

Experts have provided a new guidance on initial screening for vaping-associated respiratory distress syndrome (VARDS) in patients who vape or use electronic cigarettes.

The new guidance, presented at the Society of Critical Care Medicine (SCCM) 2020 Critical Care Congress, advised that persons who vaped or used e-cigarettes within 90 days, and are experiencing chest pain, weight loss, cough, fatigue, or shortness of breath, should seek medical care.

The recommendations also provide a three-tiered response to the results of VARDS screening for physicians.

Led by Craig Lilly, MD, of the University of Massachusetts Medical School, a regional team of experts conducted a comprehensive assessment of VARDS-relevant case studies, series, and public health reports verified by at least 2 physicians and in alignment with US Centers for Disease Control and Prevention (CDC) definitions.

They cited the recent CDC advisory which reported up to 2000-plus VARDS cases—and 42 deaths—in 24 states since mid-2019 as motivation for the guidance.

To their knowledge, no formal guidelines for identifying and treating VARDS currently exist.

“The spectrum of the impact of vaping on patients ranges from anxiety about the health risks or costs of addiction to progressive symptoms of a life-threatening disorder,” they wrote. “Our recommendations for management are based on the presence of vaping exposure and clinical findings that allow cases to be placed into three groups with distinct evaluation and management care plan goals and strategies.”

Lilly and colleagues recommended physicians treating patients who fit the above criteria for VARDS risk be divided into 3 groups: Worcester Group 1, 2, and 3. The groups are respectively defined as patients:

• Who do not have VARDS symptoms. Such patients should be asked if they have interest in help quitting ecigarette and/or vaping use, then be referred to a nicotine or THC-focused addiction medicine program.
• Who have VARDS symptoms and normal results from a chest Xray and noninvasive pulse oximetry test. If patient test results are normal, they should be evaluated and managed in an outpatient basis. Abnormal X-rays are indicative of high respiratory failure risk.
• Who have VARDS symptoms and abnormal pulse oximetry test results. Such patients should be hospitalized for monitoring and be provided oxygen therapy, if necessary.

The experts noted that it is fundamental to define a combination of clinical, radiographic, and pathologic details to implicate a specific diagnosis and either prescribe patients immunosuppressive therapy or cessation measures that would best promote respiratory tissue healing.

“We must work with our patients to better identify the substances that they are vaping and develop culturally effective methods for encouraging abstinence,” they wrote. “We must not attribute to vaping respiratory illnesses that are caused by infections.”

The team stressed the importance of identifying, monitoring, evaluating, and treating vape and e-cigarette users at risk of VARDS. Such practices need to be informed by guides such as their own.

“Our approach to the needs of patients who are exposed to vaping fumes should be guided by their symptoms, physical findings, gas exchange, radiographic abnormalities, and preferences,” Lilly and colleagues concluded. “We should use anti-inflammatories when there is evidence of a steroid sensitive condition and avoid steroids when abstinence results in rapid improvement.”

The guidance, “Vaping-Associated Respiratory Distress Syndrome: Case Classification and Clinical Guidance,” was published online in Critical Care Explorations and presented at SCCM 2020.