COVID’s TWIN WITH SHORTNESS OF BREATH
What is the risk of getting sick for e-cigarette fans?
If you vape, and you have shortness of breath, chest pain, fever, it may not be COVID-19 at all. Radiologists and medical imaging scientists sound the alarm about a new disease spreading across the planet, associated precisely with electronic smoking cigarettes. The first reports on a new disease began to appear at the end of 2019, long before the start of the coronavirus pandemic. The US Center for Disease Control and Prevention (CDC) called the disease EVALI — e-cigarette or vaping use-associated lung injury, in other words, a lung disease caused by electronic cigarettes or vaping. 95% of patients with EVALI initially complain of shortness of breath, severe cough, chest pain. In 85% of cases fever, chills, weight loss is added to the above symptoms. In 77% of cases diarrhea, nausea, and vomiting emerge. As you can see, it looks like pretty much as an ideal picture of symptoms of bilateral pneumonia caused by COVID-19. However, it may have nothing to do with coronavirus at all, but if a person vape or smoke e-cigarettes occasionally, it might be EVALI disease.
Stanislav Samburskiy talked with Viktor Gombolevskiy, MD, Ph.D., Head of Medical Research Department of Moscow Center for Diagnostics and Telemedicine, about symptoms of EVALI, methods of diagnosis and treatment.
Stanislav Samburskiy: Victor, is there a problem of EVALI spreading in Russia?
Viktor Gombolevskiy: So far, the USA is the leader in this disease; that’s why they have the first scientific articles on this subject. There are no studies of a similar caliber published in reputable scientific journals in Russia. It can be explained, first of all, by the lesser spread of vaping in Russia. We should not forget about the legalization of cannabinoids in some US States, which according to some reports, has led to the avalanche-like increase in EVALI cases in the US, as many consumers have switched to using low-quality cannabis-based vaping products.
SS: It turns out that despite such similarity of symptoms with coronavirus infection, EVALI even has the same feature of ground-glass opacity; different factors cause this disease. Tell us how it is developing.
VG: Yes, the causes of the diseases’ development are different. COVID-19 is an infectious disease associated with micro thrombosis and vascular damage. In the case of electronic cigarettes, we are dealing with the deposition of small light drops of vapor on the alveoli walls, created by the evaporation of a special liquid from the surface of the heating element. The suggested leading cause is the oils tetrahydrocannabinol (a psychoactive agent in marijuana) and cannabidiol (a non-psychogenic agent in marijuana) damage lung tissue. The second reason is the inflammation caused by aromatic compounds in cartridges. There are also increasing reports of illegal contamination of cartridges with the oil containing vitamin E acetate as a thinner. Vitamin E oil, which is harmless when applied topically, causes a severe inflammatory reaction in the lung parenchyma (epithelial cells) when inhaled. Another potential factor contributing to disease development is transferring metal ions from heated coils of devices to the vapor solution and then into inhaled aerosols.
SS: Can a radiologist confuse a ground-glass opacity on a chest CT scan in EVALI with the ground-glass opacity in Covid-19?
VG: It is quite possible. Although we know how this feature differs in most cases on CT images (in COVID-19, ground-glass opacities are distributed in the peripheral lung regions, while in EVALI, they are more often found in the central lung regions), there might be cases very similar to each other. For example, ground-glass opacities detected at the early stage of COVID-19 can be identified in the same areas where we would expect to see ground-glass opacities in EVALI. In the later stages of the disease, more significant differences can be noted. So, it might be a various density of ground-glass opacities in COVID-19 — from subtle ground-glass opacities to consolidations, when it is no longer possible to distinguish pulmonary vessels. While smokers of electronic cigarettes more often have subtle and homogeneous ground-glass opacities.
The attending physician still makes the final diagnosis, who takes into account the full picture of the disease development. Lung damage associated with e-cigarettes or vaping is determined by pulmonary infiltrates’ presence on CT images, which are the accumulation of cellular elements, fluids, and other components in tissues that are not inherent to a healthy person. And also, smoking e-cigarette or vaping within the previous 90 days and the absence of other possible causes, such as infectious, cardiovascular, or rheumatological, helps make the correct diagnosis.
SS: In April-May, some doctors’ statements that smokers are generally less likely to get infected with coronavirus were actively discussed. What about vapers?
VG: On the contrary, the accumulated literature data indicate that vaping contributes to the increase in the incidence of COVID-19 due to damage to the alveolar membranes. An additional argument against vaping during a pandemic is the similarity of clinical and CT manifestations of EVALI and COVID-19, which can lead to delay in establishing the correct diagnosis.
SS: Are patients with vaping-associated lung injury also treated with mechanical ventilation and extracorporeal oxygenation, as patients with Covid-19?
VG: Today, it is known that treatment tactics for patients with these diseases are different. In COVID-19, along with antiviral medications, antibiotics are used to prevent bacterial infection and blood thinners from reducing microthromboses. Mechanical ventilation and extracorporeal oxygenation are used in particularly severe cases of the disease. As for EVALI, almost a third of hospitalized patients have required mechanical ventilation. However, they do not need antibiotics or suppression of blood-clotting factors. The cornerstone of treatment is corticosteroids, supportive therapy, and quitting vaping.
SS: What advice would you give to vapers who are experiencing symptoms of Сovid-19?
VG: When visiting a doctor, do not hide the fact of smoking e-cigarettes or vaping. I know that the word “smoking” is not popular in vaper groups. Your life may depend on the correct diagnosis made by a doctor and prescribed treatment. Due to the increased attention of physicians to the problem of smoking vapes, the number of EVALI cases should decrease.