电子烟相关肺损伤一例并文献复习

Electronic cigarette use-associated lung injury:a case report and literature review

目的加深对电子烟相关肺损伤这一疾病的认识。方法报道1例北京医院呼吸与危重症医学科救治的67岁男性电子烟相关肺损伤的病例,用超高效液相色谱-质谱联用法(UHPLC-MS/MS)测定患者肺泡灌洗液中维生素E醋酸酯(VEA)和四氢大麻酚(Δ9-THC)浓度,总结该病例诊断及成功治疗经验。以“Vaping-Associated Lung Injury”“vape”“e-cigarette”“electronic cigarette”“EVALI”“electronic nicotine device”“lung”“injury”“case”为检索词,在Pubmed数据库检索2020年7月前报道的EVALI病例文献,并结合文献对目前报道电子烟相关肺损伤病例进行文献复习。结果208例患者中,男149例(71.6%),女59例(28.4%),中位年龄27岁(17~67岁),60岁以上老年人2例(1%),电子烟使用中位时间为90 d(2周~3年);最常见的症状为呼吸困难、发热、胸痛、咯血,伴有消化道症状如恶心、腹痛或腹泻症状者亦多见。胸部CT最多见的表现为双肺磨玻璃影(119例,57.2%);共70例患者完善气管镜检查,肺泡灌洗液分类细胞计数结果巨噬细胞比例为(49.5±29.8)%,肺泡灌洗液泡沫样巨噬细胞阳性者65例(92.9%),中性粒细胞比例为(34.7±28.7)%,淋巴细胞比例为(10.1±7.4)%,嗜酸细胞为(2.4±3.6)%;共计132例(63.5%)患者应用抗菌药物治疗,162例(77.9%)患者应用糖皮质激素治疗,激素治疗的最小初始剂量为甲泼尼龙40 mg,最大初始剂量为甲泼尼龙500 mg,应用机械通气治疗患者共计48例(23.1%),应用体外膜肺氧合(ECMO)治疗患者共计10例(4.8%);202例(97.1%)患者治疗好转,6例(2.9%)死亡。结论临床医生要提高警惕,并加深对电子烟相关肺损伤这一疾病的认识,早期识别该疾病并及时诊治。建议加强对电子烟的规范管理,避免电子烟相关肺损伤相似情况在我国发生。关于电子烟肺损伤的病理生理机制值得我们深入研究。

Objective To improve the clinical recognition of electronic cigarette or vaping product use-associated lung injury.Methods A 67 year old patient with lung injury induced by e-cigarette was reported.The concentrations of vitamin E acetate(VEA)and tetrahydrocannabinol(Δ9-THC)in BALF were measured by UHPLC-MS/MS.A literature review was performed with"Vaping-Associated Lung Injury""vape","e-cigarette","electronic cigarette","EVALI","electronic nicotine device","lung","injury","case"as Mesh terms in PubMed.Results There were 208 cases reported in the literature,71.6%of whom were male,and 28.4%were female,with a median age of 27 years(17-67 years),while 2 patients(1%)were over 60 years old.The median time of using e-cigarette was 90 days(2 weeks-3 years).Of the 208 patients,the most common symptoms were dyspnea,fever,chest pain,hemoptysis,and gastrointestinal symptoms such as nausea,abdominal pain or diarrhea.The most common manifestation of chest CT was bilateral ground glass opacity(n=119,57.2%).A total of 70 patients received bronchoscopy and BALF,which showed that the ratio of macrophages was(49.5±29.8)%,neutrophil(34.7±28.7)%,lymphocytes(10.1±7.4)%,and eosinophils(2.4±3.6)%.The"foamy"alveolar macrophages were positive in 65 cases(92.9%).A total of 132 patients(63.5%)were treated with antibiotics,and 162 patients(77.9%)were treated with glucocorticoids.The initial dose of methylprednisolone was 40 mg and the maximum was 500 mg.48 patients(23.1%)were mechanically ventilated and 10 patients(4.8%)were treated with extracorporeal membrane oxygenation(ECMO).Of the 208 patients,202(97.1%)patients improved and 6(2.9%)died.Conclusion Our case and reported cases should alert physicians to the clinical presentation of vaping-associated lung injury for early diagnosis and prompt management.It is suggested that the standardized management of e-cigarette should be strengthened to avoid similar situation of e-cigarette-related lung injury in China.Additional work is needed to characterize the pathophysiology of this disease.