Nilanga Aki Bandara, Ricky Jhauj, Jayson Fernando, Vahid Mehrnoush, Namal Wijesinghe

1 University of British Columbia School of Kinesiology Vancouver, Vancouver V6T 1Z1, Canada

2 Department of Physiotherapy, University of Melbourne, Parkville VIC 3010, Australia

3 Hackensack University Medical Center, Hackensack 07601, USA

4 Faculty of Medicine, University of British Columbia, Vancouver V6T 1Z3, Canada

5 General Sir John Kotelawala Defence University, Ratmalana 10390, Sri Lanka

To date, the worldwide death toll from the coronavirus disease (COVID-19) pandemic has rapidly increased.We are in the midst of a global pandemic that poses enormous challenges to our healthcare systems globally.Emergency department (ED) physicians have played a significant role in saving lives of patients infected with severe acute respiratory syndrome coronavirus 2 (SARSCoV-2). Efficient, timely, and accurate diagnosis and application of the most appropriate treatment modality to save lives are important tasks for ED physicians.

The enormous demands of SARS-CoV-2 have put an extreme strain on ED physicians and healthcare systems.[1]There are established therapies used to treat COVID-19 patients, even though information on the optimal patient population, optimal duration of therapy, and the effect on clinical outcomes is yet to be thoroughly researched.[1-3]

We must work towards removing misdiagnosisrelated hurdles by establishing ED environments conducive to efficiency and patient care.[1,2]Working conditions in EDs are chaotic during the pandemic,with multiple interruptions and heavy care demands that can hinder a favorable prognosis. Misdiagnosis will undoubtedly reduce public confidence in ED settings,and some may even perceive it as EDs being too focused on SARS-CoV-2.[3]

During the escalating pandemic, emergency physicians may have a more SARS-CoV-2 focused mindset. Consequently, patients presenting with respiratory complaints including electronic cigarette(e-cigarette) or vaping product use-associated lung injury(EVALI) could be assumed to have SARS-CoV-2 (unless proven otherwise) because this is the most readily available explanation.[1,2]Emergency physicians should be aware of lung injuries caused by vaping and that not all respiratory disease in the ED would be from SARSCoV-2.

Recent accumulating research also shows that EVALI is increasing again, and SARS-CoV-2 is making this harder to diagnose.[4-6]Accordingly, the Centers for Disease Control and Prevention (CDC) of the USA issued a health alert urging the importance of healthcare providers asking patients with symptoms consistent with EVALI about e-cigarette use or vaping (especially from teenagers and young adults) during SARS-CoV-2 evaluations.[5,6]

Accurate diagnosis is important to design appropriate treatment and care in a timely manner. Although no specific clinical manifestation reliably distinguishes between SARS-CoV-2 and EVALI, it will be important to identify the accurate etiology in clinical practice. Most importantly, clinicians should be on the lookout for signs of EVALI, because it may save lives.[5]

EVALI cases comprise heterogeneous patterns of lung pathologies, including acute eosinophilic pneumonia, lipoid pneumonia, hypersensitivity pneumonitis, diffuse alveolar damage, diffuse alveolar hemorrhage, acute respiratory distress syndrome, and pneumonia, which poses a diagnostic and therapeutic challenge.[7]

Conf irming a diagnosis of EVALI has been difficult because there has been no simple lab-test to do so.Therefore, current diagnoses are largely based on patient-reported symptoms, recent vaping product use,lung computed tomography (CT) scan abnormalities, and absence of infection. Direct lung examination requires a bronchoscopy, and most patients are too sick to safely tolerate this invasive exam.[7]

The symptoms associated with EVALI often overlap with SARS-CoV-2 symptoms.[7-9]EVALI can cause symptoms that resemble those of pneumonia or the flu,including the following: possible pneumonia, respiratory distress, coughing, chest pain, shortness of breath,abdominal pain, vomiting, diarrhea, fever, and chills.

Symptoms of COVID-19 can vary from person to person, but resemble those of pneumonia or the flu,including the following: possible pneumonia, respiratory distress, widespread pain, new or worsening cough,shortness of breath or difficult breathing, temperature equal to or over 38 ℃, feeling feverish, chills, fatigue or weakness, muscle or body aches, new loss of smell or taste, headache, gastrointestinal symptoms (abdominal pain, diarrhea, vomiting), and feeling very unwell.

The updated CDC clinical guidelines are available to aid proper diagnosis procedures, which in turn could determine or potentially rule out SARS-CoV-2 infection in the ED.[9]

To increase sensitivity and identify potential EVALI patients sooner, the CDC has developed clinical guidelines for the healthcare community to use, including ED physicians. Based on the most current data, the CDC’s updated interim guidance provides a framework for healthcare providers in their initial evaluation,management, and follow-up of persons with symptoms of EVALI.[9]According to recent clinical reports, the patients suspected of EVALI must f irst test negative for SARS-CoV-2 before being treated for EVALI.[9]In some healthcare settings, clinicians take a median of three days (with a range of 1-8 days) to diagnose patients with EVALI. The majority of conf irmed EVALI patients are very young and often require hospitalization and sometimes even ventilation.[5,9]

Precise data concerning the epidemiology of EVALI are difficult to confirm, but the majority of EVALI patients are otherwise healthy adolescents and young adults.[10]Since being recognized in the summer of 2019 as a serious pulmonary disease with public health implications, more than 2,800 cases have been reported to the CDC with 68 deaths as of February 2020. Among these cases, 66% were male and approximately 76%were under the age of 35 years.[10,11]Among 2,016 EVALI patients with available data on hospitalization status,1,906 (95%) were hospitalized, and 110 (5%) were not hospitalized.[11]This evidence shows that we are witnessing more than one serious respiratory disease with significant symptom overlap. Going forward, we must address both these potentially fatal conditions proactively with much more attention and concern in the EDs.[5,9]

As we have discussed, the clinical presentation of EVALI is fairly non-specif ic and a differential diagnosis is challenging, particularly in the COVID-19 pandemic era. Furthermore, the COVID-19 pandemic has made a differential diagnosis of EVALI even more challenging due to the high rate of SARS-CoV-2 diagnosis in e-cigarette smokers[12]as well as the large overlap of clinical and radiological features of the two conditions.[13]

In the midst of a pandemic, errors in diagnosis can increase in ED settings[1,2]and the COVID-19 pandemic is likely to increase the risk of diagnostic errors of respiratory illnesses. In addition, as signs and symptoms of EVALI and COVID-19 can be similar (e.g., cough,fever, and diarrhea), ED healthcare providers should maintain clinical suspicion for EVALI during the COVID-19 pandemic.[5]Furthermore, the CDC health alert urges everyone to refrain from using all e-cigarette or vaping products during the pandemic.[5]Given the dramatic rise in e-cigarette use, especially among adolescents globally, continued efforts should be made to increase public awareness of the harmful effects of e-cigarettes.[13-15]

It is also important that ED physicians are familiar with the clinical features of EVALI and obtain detailed and proper e-cigarette/vaping history in all patients,especially those within the high-risk groups. The greatest likelihood of successfully distinguishing COVID-19 pneumonia from EVALI lies with open communication between radiologists and ED physicians. Specifically,suggestive imaging findings must be combined with direct patient questioning regarding the recent use of e-cigarettes and SARS-CoV-2 exposures.[15]It should be noted that radiologists are familiar with the unique imaging and clinical characteristics. Therefore,radiologists are well-positioned for an initial diagnosis and to help ED physicians expedite treatment decisions to ensure the best patient outcome.[15,16]

Patients often present multiple times to healthcare facilities as their clinical condition worsens with a considerable mortality risk and this portends a considerable morbidity and mortality risk, as highlighted by 13.5% of EVALI deaths occurring within a median of three days following discharge. The diagnosis of EVALI hinges on obtaining a history of vaping.[17]

Moving forward at this time would require more research into all aspects of COVID-19, including treatment variations for different populations, therapy effects on clinical outcomes, and diagnostic technology.Furthermore, efforts towards public education targeted to specif ic demographics can be benef icial to reduce the incidence of EVALI and reduce congestion in the ED during the escalating COVID-19 pandemic.

Funding:None.

Ethical approval:Not Needed.

Conflicts of interest:The authors confirm that no conflict of interest or any f inancial relationship that relates to the content of the manuscript has been associated with this publication.

Contributors:NAB wrote the first draft of this manuscript in collaboration with co-authors and all authors contributed to and approved the f inal draft of this manuscript.