Clinical Findings in Adolescents Hospitalized with E-cigarette or Vaping Product-use Associated Lung Injury; Novel Report on Coagulopathy

Background: E-cigarette or vaping-associated lung injury (EVALI) was first reported in 2019 in the United States. Reported lung findings in this disease commonly include acute respiratory distress syndrome but there are now increasing reports of diffuse alveolar hemorrhage and hemoptysis. Considering these reports, we obtained coagulation studies prior to bronchoscopy and noted increased clotting time in the extrinsic coagulation pathway which caused a procedure delay. This study aimed to investigate whether coagulopathy was an isolated phenomenon or a common characteristic in this population. Secondary aim was to report other clinical and laboratory findings in pediatric EVALI.

Methods: IRB approval was obtained for this retrospective cohort study of adolescents. Patients were selected based on diagnosis codes specific to EVALI (ICD 10: J68, U07) as well as combination codes for pulmonary or gastrointestinal symptoms and marijuana or nicotine use. Individual charts were reviewed for findings consistent with Confirmed or Probable EVALI according to the CDC definition published August 2019.

Results: Twenty-nine patients met criteria for Confirmed (n=22) or Probable (n=7) EVALI. Constitutional and gastrointestinal symptoms were more common at presentation than pulmonary symptoms (Table 1). Aggregate data (Table 2) showed significantly elevated PT 18.6 sec [95% CI 16.3-21.0], INR 1.6 [CI 1.4-1.8], Fibrinogen 820 mg/dL [CI 691-949], and D-dimer 1376 ng/mL [CI 691-2063]. Platelets and PTT were within normal limits. Other significant findings included WBC 14.5 [CI 13.2-15.8] with neutrophilic predominance, CRP 26.6 mg/dL [CI 22.1-31.1], and ESR 61.7 mm/hr [CI 51.3-72.0]. Vitamin K was administered to 8 of 10 patients, whereas steroids were administered to all 10 patients. Clotting time improved in patients who had follow up labs performed within 48-72 hours after either intervention.

Conclusion: Adolescents diagnosed with EVALI showed a significant increase in clotting time in the extrinsic pathway which improves after vitamin K and steroid supplementation. To date, EVALI associated coagulopathy has not been reported in the literature nor mentioned in the CDC diagnosis/treatment algorithm. The novel finding of coagulopathy among adolescents with EVALI in this cohort reveals an opportunity to detect co-morbid clotting deficiencies and initiate therapy due to the potential of developing alveolar hemorrhage, hemoptysis, and further lung damage.