Vaping and Lung Injury (EVALI)

Vaping appears across our library only as a risk-factor line — in chronic bronchitis and alongside smoking cessation. Given a young regional workforce and a service already engaged with occupational lung exposure, it warrants its own page.¹

Definition

EVALI — e-cigarette or vaping product use-associated lung injury — is an acute or subacute lung injury occurring in a person who has used a vaping product within the preceding 90 days, with pulmonary infiltrates on imaging, and in whom infection and other causes have been excluded. It is a diagnosis of exclusion, which is the single most important practical point: pneumonia, influenza and COVID-19 must be ruled out first.^1,2

Background and cause

A large outbreak was identified in the United States in 2019, with over 2,800 hospitalisations and 68 deaths reported to the CDC. Investigation identified vitamin E acetate — a diluting agent added to illicit THC-containing vaping liquids — as closely associated with the outbreak, found in bronchoalveolar lavage fluid in the overwhelming majority of cases sampled. Case numbers fell sharply once this was publicised and the supply chain changed.^2,3

⚠ EVALI is therefore mainly a contaminant problem, not an inevitable consequence of nicotine vaping — a distinction worth making accurately, because overstating it damages credibility with the exact group most likely to be vaping. That said, cases have been reported with nicotine-only products, and Australian regulatory changes have altered the supply landscape in ways that may not map onto the American experience. Two changes matter for a cessation conversation: since 1 July 2024 the importation, manufacture, supply and commercial possession of non-therapeutic vapes has been prohibited, and since 1 October 2024 therapeutic vapes have been supplied through pharmacies under the TGA access scheme rather than through retail.

Co-morbidities

The typical EVALI patient is young and previously well, which is diagnostically useful but means co-morbidity is less about chronic disease than about what else is being used and what else is going on. Asthma is the important respiratory co-morbidity — vaping worsens control, and an exacerbation can be mistaken for EVALI or vice versa.⁷ Concurrent tobacco smoking is common, since vaping frequently does not displace it. Cannabis and other substance use is intrinsic to the illicit-THC route that caused the outbreak. Mental health conditions are over-represented in people who vape, and vaping is more prevalent in socioeconomically disadvantaged groups — relevant to a regional catchment. ⚠ In older patients, pre-existing COPD or interstitial disease makes the picture considerably harder to read.

Prevalence

The 2019 American outbreak produced more than 2,800 hospitalisations and 68 deaths reported to the CDC, with cases peaking in September 2019 and falling sharply once vitamin E acetate was identified and the supply chain changed.³ Australia saw very few cases, reflecting different regulation and a supply route dominated by nicotine rather than illicit THC products. ⚠ That is reassuring about EVALI specifically and says nothing about vaping prevalence, which is substantial and rising in younger age groups — and Australian regulatory change has altered the supply landscape in ways whose respiratory consequences are not yet visible.⁷

Presentation

Respiratory symptoms — breathlessness, cough, sometimes pleuritic chest pain — usually developing over days. Constitutional symptoms (fever, chills, myalgia) and gastrointestinal symptoms (nausea, vomiting, abdominal pain, sometimes preceding the respiratory features) are common enough to be diagnostically useful. Hypoxaemia is frequent, and a substantial proportion require intensive care and ventilatory support. The patient is typically young and previously well, which is itself a clue.⁴

Investigation

Chest imaging shows bilateral infiltrates, most often ground-glass opacification with subpleural sparing on CT. Inflammatory markers are raised. Bronchoscopy with lavage is used to exclude infection and may show lipid-laden macrophages, though these are not diagnostic. A careful, non-judgemental substance history is the most important investigation — including THC-containing and informally sourced products, which patients may not volunteer.

Management

Supportive care with oxygen and, where required, ventilatory support. Corticosteroids are widely used and most reported series describe rapid improvement, though the evidence is observational rather than randomised. Antibiotics are usually given until infection is excluded. Cessation of vaping is essential; continued use is associated with relapse. Follow-up imaging and lung function are recommended, as some patients have persistent abnormality.^2,5

Vaping beyond EVALI

Distinct from the acute syndrome, the longer-term respiratory effects of vaping are an evolving evidence base. Observed associations include increased respiratory symptoms and airway inflammation, worsened asthma control, and — importantly for our population — dual use with tobacco is common and vaping frequently does not displace smoking. Conversely, vaping has a place as a smoking cessation aid, with evidence that it can outperform nicotine replacement therapy for quitting. Both statements are true simultaneously, and holding them together is what honest advice requires.^6,7

Medications

Corticosteroids are the mainstay of reported treatment, with rapid improvement described in most series — but the evidence is observational, not randomised, and the optimal dose and duration are unknown.⁵ Antibiotics are given until infection is excluded, then usually stopped. Oxygen and, where required, ventilatory support are the essential supportive measures. ⏹ On the cessation side, nicotine replacement therapy, varenicline and bupropion all apply, as does behavioural support — the dependence is the same as tobacco dependence. Inhaled therapy may be needed if there is coexisting asthma; see inhaled medications.

Multi-system manifestations

Although the lung injury dominates, EVALI is frequently a systemic presentation. Gastrointestinal symptoms — nausea, vomiting, abdominal pain — are common and may precede the respiratory features, which is a recognised cause of delayed diagnosis and unnecessary abdominal imaging. Constitutional features are near-universal. Beyond the acute illness, nicotine has cardiovascular effects including raised heart rate and blood pressure, and vaping is associated with increased cardiovascular risk markers. Device-related injuries — battery burns and explosions — are a small but genuine harm. Some patients have persistent radiological or physiological abnormality on follow-up, so recovery is not universally complete.

Living with the aftermath

A previously fit young person who spends time in intensive care because of a consumer product is in an unusual position, and the recovery has a strong psychological component. Breathlessness on exertion may persist for months; anxiety and dysfunctional breathing frequently complicate it, and distinguishing the two matters — see dysfunctional breathing. Continued vaping is associated with relapse, so cessation is not optional advice, yet the dependence is real and shame is unhelpful. Peers often continue to vape, which makes cessation socially harder than it looks. ⏹ Family and school or workplace conversations may be difficult, particularly for younger patients whose use was concealed.

Prognosis

Most patients recover well, and the majority improve rapidly — often within days of stopping and starting corticosteroids. But it is not uniformly benign: the CDC reported 68 deaths among more than 2,800 hospitalisations in the American outbreak, and a substantial proportion required intensive care.^3,5 Persistent abnormality on imaging or lung function occurs in a minority, which is why follow-up is recommended rather than optional. Relapse follows resumed use. ⏹ Longer-term outlook for nicotine vaping generally is genuinely unknown — the exposure is too recent for cohort studies to have matured — and honest uncertainty is the correct thing to convey.⁷

Role of the physiotherapist

• Ask about vaping specifically in any respiratory history, especially in younger patients. "Do you smoke?" does not capture it.
• Rehabilitation after acute injury — breathlessness, deconditioning and reduced exercise capacity respond to graded exercise as they would after other acute lung injury; measure with a field test and prescribe accordingly.
• Cessation support alongside our smoking cessation work, recognising that nicotine dependence is the same problem in a different device.
• Breathing pattern — anxiety and dysfunctional breathing frequently complicate recovery from a frightening acute illness in a young person; see dysfunctional breathing.
• Do not moralise. The clinical goal is cessation and recovery, and a lecture reliably produces the opposite.

Warning signs

Part 1 · References

1. Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin — final report. N Engl J Med 2020;382(10):903–916.
2. Blount BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI. N Engl J Med 2020;382(8):697–705.
3. Krishnasamy VP, Hallowell BD, Ko JY, et al. Update: characteristics of a nationwide outbreak of e-cigarette, or vaping, product use-associated lung injury. MMWR Morb Mortal Wkly Rep 2020;69(3):90–94.
4. Kalininskiy A, Bach CT, Nacca NE, et al. E-cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med 2019;7(12):1017–1026.
5. Werner AK, Koumans EH, Chatham-Stephens K, et al. Hospitalizations and deaths associated with EVALI. N Engl J Med 2020;382(17):1589–1598.
6. Hajek P, Phillips-Waller A, Przulj D, et al. A randomized trial of e-cigarettes versus nicotine-replacement therapy. N Engl J Med 2019;380(7):629–637.
7. Banks E, Yazidjoglou A, Brown S, et al. Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence. Med J Aust 2023;218(6):267–275.

References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.