C48-05 EVALI-induced Acute Respiratory Distress Syndrome

Abstract Introduction E-cigarette or vaping product use-associated lung injury (EVALI) is an acute or subacute respiratory condition linked to vaping. Diagnosis requires a history of e-cigarette use within 90 days, pulmonary infiltrates on imaging, and exclusion of alternative causes such as infection. Though uncommon, EVALI can progress to acute respiratory distress syndrome (ARDS), a severe inflammatory lung injury with high morbidity and mortality. ARDS typically develops within seven days, characterized by bilateral infiltrates and progressive hypoxemia without cardiogenic edema. Case Presentation An 18-year-old male presented with a one-day history of dyspnea. He denied fever, chills, chest pain, cough, palpitations, orthopnea, paroxysmal nocturnal dyspnea, nausea, or vomiting. He reported no significant past medical history but admitted to frequent daily marijuana vaping. On presentation, he was afebrile, with a heart rate in the 140s, a respiratory rate of 32 breaths per minute, blood pressure of 139/86 mmHg, and oxygen saturation of 42% on room air. Supplemental oxygen via a non-rebreather mask improved his oxygen saturation to 78%, and BiPAP with FiO2 100% further increased saturation to 88%, although he remained tachypneic and tachycardic. Initial arterial blood gas demonstrated a pH of 7.20, PaCO2 of 65 mmHg, PaO2 of 78 mmHg, and HCO3− of 25 mEq/L, yielding a PaO2/FiO2 ratio of 78 on BiPAP. A repeat ABG one hour later showed a PaO2/FiO2 ratio of 81, prompting endotracheal intubation for worsening hypoxemia. Chest radiography revealed bilateral pulmonary infiltrates that progressed on repeat imaging four hours later. Chest computed tomography demonstrated multifocal bilateral alveolar infiltrates throughout the lungs. The patient was managed with lung-protective mechanical ventilation, empiric intravenous antibiotics including ceftriaxone and azithromycin, and intravenous hydrocortisone. Endotracheal aspirate cultures and viral respiratory panels were negative, and transthoracic echocardiography revealed no structural abnormalities. Over the following four days, the patient demonstrated significant clinical improvement. Pulmonary infiltrates resolved on follow-up chest radiographs, and he was successfully extubated, transferred out of the intensive care unit, and discharged in stable condition. Discussion This case illustrates severe EVALI manifesting as ARDS. Acute hypoxemic respiratory failure, diffuse bilateral alveolar infiltrates, and a history of marijuana vaping support the diagnosis. Negative cultures and rapid response to corticosteroids suggest a non-infectious inflammatory etiology. Management of severe EVALI focuses on supportive care, including oxygen or mechanical ventilation and corticosteroids for significant inflammation. Early recognition and intervention are critical, as prompt supportive care and corticosteroid therapy can lead to rapid recovery. This abstract is funded by: None