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.

15
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

21/08/2023 18
 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

21/08/2023 19
 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

21/08/2023 20
 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

21/08/2023 21
 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

21/08/2023 22
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
21/08/2023 25
21/08/2023 26
 LAB
INVESTIGATION
S

21/08/2023 27
 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
21/08/2023 28
 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

21/08/2023 29
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).

21/08/2023 31
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

21/08/2023 33
 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

21/08/2023 34
05TREATMENT
 Symptomatic based Rx

21/08/2023 36
 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.

38
THAN
K YOU

39