E-cigarettes and Lung Catastrophes: A Systematic Review of EVALI, Substances, and Radiologic Findings
Sasmayani Eko Winanti, Mohammad Amin, Abdulloh Machin, Arkan Zikri BerlianIntroduction:
E-cigarettes are promoted as safer than conventional cigarettes, yet the 2019 EVALI outbreak caused nearly 3,000 acute lung injuries and many deaths. E-liquid contains THC and/or nicotine, solvents such as propylene glycol, glycerol, and ethylene glycol, and flavorings like diacetyl that generate toxic aerosol. This systematic review analyzes substances in e-cigarettes and imaging (Chest X-ray, CT scan, MRI, and PET) evidence in EVALI to understand injury mechanisms and the role of imaging.
Methods:
A systematic literature search was conducted across multiple databases, including PubMed, Scopus, Web of Science, Embase, and Google Scholar. Included were case reports/ series studies on vaping-related lung injury and imaging, MRI, and PET. Two reviewers assessed eligibility with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist.
Results:
A total 380 articles were identified; 12 articles met the inclusion criteria. Most cases involved adolescents or young adults using THC products with vitamin E acetate; some used nicotine alone. Exposure to vitamin E acetate, propylene glycol, and glycerin was associated with inflammation and epithelial damage. Functional MRI revealed ventilation and perfusion abnormalities, while PET showed increased 18F-NOS uptake.
Discussion:
The findings suggest that EVALI is a multifactorial condition influenced by both active substances and additives in e-cigarette liquids. Conventional imaging findings often overlap with infectious pneumonia, while functional imaging modalities such as MRI and PET provide additional insights into ventilation-perfusion mismatch and inflammatory activity that may persist beyond clinical recovery. These imaging techniques may therefore contribute to earlier detection and improved understanding of EVALI pathophysiology.
Conclusion:
E-cigarettes are not risk-free. Components of e-liquids such as THC, nicotine, vitamin E acetate, and flavorings can trigger EVALI. Functional imaging helps detect ventilation and inflammatory abnormalities early. Long-term prospective studies are needed to evaluate chronic effects and develop preventive interventions.