Training of Core Trainers on
Clinical Practice Guidelines (CPG)
Management of E-Cigarette or
Vaping Product Use-Associated
Lung Injury (EVALI)
Vaping History
1
Learning objectives
1. To learn about types of e-cigarette or vaping products
available in the market
2. To learn about law & legislation that control e-cigarette
usage in Malaysia
3. To learn on history taking of vaping from the patients
2
LIQUID
CONTAINING NICOTINE TOBACCO
First Generation
• Originate from China & brought into Malaysia
since 2013
Types of E- Second Generation • Has evolved into many generations
cigarette • Became phenomenal in Malaysia in 2015
(E-cig) • Latest is Heated tobacco product in which
tobacco is heated instead of burnt for the purpose
Third Generation/ Mod
of smoking
Forth Generation/ Pod
3
Types of E-
cigarette
(E-cig) -
Open
system
4
Types of E-
cigarette
(E-cig) -
Open
system-2
5
Examples of E-liquid for open system
Types of E-
cigarette
(E-cig) -
Open
system-3
6
Types of E-
cigarette
(E-cig) -
Closed
system
7
Types of E-
cigarette
(E-cig) -
Closed
system-2
8
Examples of closed system
Types of E-
cigarette
(E-cig) -
Closed
system-3
9
BASIC CONTENT
E-cigarette 1. Nicotine
2. Propylene Glycol
3. Vegetable Glycerine
(E-cig) 4. Flavour
liquid
10
Contain Nicotine:
Poison Act 1952
E-Cig E-Cig (Liquid)
Without Nicotine:
Regulated under
Law & E-Cig (HTP) E-Cig(Liquid)
New Act
legislation
for e- MOD POD
cigarette
CTPR 2004
Electronic Device:
(HS Code 8543.70.90)
11
History of
vaping
12
Frequency of vaping
Mean frequency of ECV
use per day was Mean puffs per ECV
session was 16
19 sessions
13
Nicotine & flavour usage
No
16%
Yes
84%
• Most preferred nicotine strength
was 6 mg/ml.
• Most preferred flavour of ECV
liquid among current ECV users
was fruity flavour (mango,
strawberry & apple).
14
Take home messages
1. There are many types of E-cig & vaping products available in
the market, & the products are rapidly evolving.
2. History of vaping is important for diagnosis of EVALI & also
for surveillance purpose to help policy makers get better
understanding of vaping behaviour & product preference.
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Thank you
16
DR LILIWATI ISMAIL
PAKAR PERUBATAN KELUARGA
KLINIK KESIHATAN PANTAI REMIS
CONTENTS
01 Introduction
02 Diagnosis
03 Atielogy/Chemical profiling
04 Differential Diagnosis
05 Treatment
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01 Introduction
• E-cigarette – handheld device with aerosol
generator, battery, solution storage area.
• Invented in 2003,gained popularity in msia in
2010
• 2016 – local study estimated 600,000 e-cig
users, increase to 1.1 million – NHMS 2019
• TECMA 2016- 300,000 e-cig users age 10-19
• 2018 – cross sectional study – 73% e-cig users
among secondary school students
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Inhalation of e-cig aerosol could potentially cause: E-cig negative CV effects through various mech:
1. Adverse effects due to acute administration of nicotine, 1. Oxidative stress
flavourants, chemical
2. Inflammation
2. Accidental nicotine overdose
3. DNA damage
3. Developmental effects on brain from nicotine exposure
4. Arterial stiffness
4. Uptake of illicit drug use
5. Altered hemodynamics & platelet activities
5. Gateway to conventional cigarettes/ dual use
6. Negative psychosocial health
7. Battery explosion
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EVALI ARISING
JULY 2019 – Large case series of Until feb 2020
pulmonary illness reported in Illinois & - 2,807 cases reported to CDC USA
Wisconsin USA
- 68 deaths
- History of e-cig use within 90days Sx
onset
Lab data – strong link between vitamin E
- Pulmonary infiltrate on xray
acetate & other potential toxicants
- No other contributary cause
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In Malaysia??
Cases of probable EVALI had been
highlighted before
Could be underreported – lack of
awareness
CPG – Guide to health care provider in the
management of the novel medical
condition
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02
DIAGNOSIS
• EVALI is a diagnosis of exclusion.
• Several observational studies showed that most EVALI patients had elevated inflammatory
markers like:11, 14, 16, 21
o leucocytosis with neutrophil predominance
o high erythrocyte sedimentation rate
o C-reactive protein
o procalcitonin
There was also mild elevation of liver enzymes.
• In a cross-sectional study, none of the EVALI patients had a microbiologically-confirmed
infectious pneumonia.17
• Additional inflammatory serologies (antinuclear antibody, antiglomerular basement
membrane & antineutrophil cytoplasmic antibodies) were also negative. 17
Can be easily missed due to lack of awareness
Symptoms commonly present
HISTORY
CLINICAL Respiratory
• SOB Use of e-cig @ vaping
PRESENTATION • Cough
product
• Chest pain
GIT
• Nausea/vomiting
• Diarrhea
• Abdominal pain
Constitutional Sx
• fever
SIGNS
• HYPOXIA
• TACHYCARDIA
• TACYPNEA
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LAB
INVESTIGATION
S
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IMAGING
FINDINGS:
1. CXR – ground glass opacities & consolidation almost
symmetrical distribution
-lower lobe predominant or diffuse with sparing of heart
border & subpleural region
Septal thickening as kerley B lines
2. CT Scan – features of acute lung injury
- Diffuse alveolar damage
- Symmetrical multifocal ground glass
opacities
- Diffuse alveolar haemorrhage
- Acute eosinophilic pneumonia like
pattern
3. ss
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BRONCHOSCOP
Y
No clear role
No specific diagnostic bronchoscopic findings
May be performed to exclude other diagnosis if
needed
Lung biopsy – diverse pattern of diffuse lung injury
& inflammation but none were pathognomonic,
cannot confirm Dx.
Findings of Vitamin E acetate in Brochoalveolar
lavage – direct evidence of its existence at the
primary site of injury
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03
CASE DEFINITION
2019 Lung Injury Surveillance Primary Case Definitions: 26
CASE DEFINITION OF EVALI
o
RECOMMENDED BY CDC & PREVENTION
Confirmed Case:
Using an e-cig (“vaping”) or dabbing* in 90 days prior to symptom OF USA
onset
AND
Pulmonary infiltrate, e.g., opacities, on plain film chest radiograph
or ground-glass opacities on chest CT Probable Case:
AND Using an e-cig (“vaping”) or dabbing* in 90 days prior to symptom onset
Absence of pulmonary infection on initial work-up. Minimum AND
criteria are: Pulmonary infiltrate, e.g., opacities, on plain film chest radiograph or
1. A negative respiratory viral panel ground-glass opacities on chest CT
AND AND
2. A negative influenza polymerase chain reaction (PCR) or Infection identified via culture or PCR, but clinical team** believes this
rapid test if local epidemiology supports influenza testing infection is not the sole cause of the underlying lung injury OR minimum
AND criteria to rule out pulmonary infection not met (testing not performed) and
All other clinically indicated respiratory infectious disease testing clinical team** believes infection is not the sole cause of the underlying lung
(e.g., urine antigen for Streptococcus pneumoniae and Legionella, injury.
sputum culture if productive cough, BAL culture if done, blood AND
culture, human immunodeficiency virus-related opportunistic No evidence in medical record of alternative plausible diagnoses (e.g.,
respiratory infections if appropriate) are negative cardiac, rheumatologic, or neoplastic process).
AND
No evidence in medical record of alternative plausible diagnoses
(e.g., cardiac, rheumatologic, or neoplastic process).
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04 AETIOLOGY/CHEMICAL
PROFILING
Aerosol from e-cig – may contain different chemical composition
depending on device type, voltage used & e-liquid content
generally contains – vegetable glycerin, propylene glycol, nicotine &
flavour agents
Studies detected - >60 compounds in e-liquid
Metal from e-cig can also leach into e-liquid after repeated heating
& cooling & emitted in aerosol
Recent evidence – Vitamin E acetate had been detected in high
proportion of THC containing product in EVALI cases
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DIFFERENTIAL
DIAGNOSIS
INFECTIOUS PNEUMONIA
- Bacterial
Fungal
viral
Pneumocystis jirovecii
DIFFUSE PARENCHYMAL LUNG DZ
- Acute hypersensitivity pneumonitis
- Acute eosinophilic pneumonia
- organizing pneumonia
- cellular non specific interstitial pneumonia
OTHER DIFFUSE LUNG DZ
- Acute respiratory distress syndrome
- Diffuse alveolar haemorrhage
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05TREATMENT
Symptomatic based Rx
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REFERRAL
21/08/2023 37
• In our local setting, as EVALI is a new entity with an increasing trend of e-cig use,
there is a need to report EVALI cases for surveillance purpose to MoH, Malaysia.
• The surveillance data can be used to plan for policy & guidance in clinical
management.
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THAN
K YOU
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