Making the Diagnosis

To accurately assess and diagnose this patient’s condition, the clinician needs to eliminate other possible causes of her symptoms. Upon further questioning, the patient reports vaping. The chest radiograph images show subtle bilateral interstitial infiltrates, supporting a diagnosis of acute respiratory distress syndrome (ARDS) from vaping-associated lung injury. The next day, the patient feels worse. A repeat chest radiograph shows worsening of the condition (Figure 3).

Figure 3. Repeat chest radiographs performed the next day confirm acute respiratory distress syndrome (ARDS) from vaping. Credit: Brady Pregerson, MD

In addition to vaping history, other important questions to ask include if the patient has a history of injection drug use? This would be more important if there was evidence of septic lung emboli. Does the patient have any new sexual partners? This would be most important if the clinician is worried about a sexually transmitted disease (STD). Chlamydia can cause pneumonia, but not as an STD. If she had either pelvic or right upper quadrant pain, this question would be very important. A history of recent COVID-19 exposure would be more relevant as the PCR is only about 80% sensitive, although the sensitivity is closer to 90% in admitted patients. Test sensitivity is likely lower for the Omicron variant.


E-cigarette or vaping product use-associated lung injury (EVALI) is a syndrome that mimics viral illnesses in many ways. Symptoms may include both gastrointestinal and respiratory symptoms such as vomiting, diarrhea, abdominal pain, and fever as well as cough, dyspnea, chest pain, and/or headache. Unlike viral upper respiratory infections, nasal congestion or sore throat are not typically found in EVALI. The vast majority of patients with EVALI (94%) report vaping within 1 week of symptom onset; the most commonly used substance is tetrahydrocannabinol (THC).

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Signs of EVALI may include fever, hypoxia, rales, and sometimes abdominal tenderness (Table). Of note, clinical presentation can be very similar to acute COVID-19 infection; fortunately, many of the treatments are the same.

Table. Symptoms of Vaping-Associated Pulmonary Injury

SymptomsIncidence, %
Shortness of breath87
Nausea and vomiting70
Chest pain55
Abdominal pain43

Testing will often show elevated white blood cell count and/or sedimentation rate.  Chest radiographs typically show bilateral infiltrates, which are mild initially but gradually progress. A COVID-19 test should be sent as well as blood work to rule out gastrointestinal infection if the patient has significant abdominal pain that is associated with tenderness. 

Treatment typically includes empiric antibiotics because infection cannot be ruled out reliably, as well as steroids, which are also beneficial in admitted COVID-19 cases as well as bacterial pneumonia severe enough to require admission.

The patient in this case gradually became more hypoxic and was admitted to a step-down unit where she was treated with antibiotics and steroids. She eventually progressed to ARDS but did not require intubation.

Brady Pregerson, MD, is an emergency physician at Tri-City Medical Center in Oceanside, California and Scripps Coastal Urgent Care in Oceanside, California.


Farkas J. Vaping associated pulmonary injury (VAPI). Accessed January 18, 2022.