E-Cigarette/Vaping Associated Lung Injury (EVALI) Severity Correlates with Reduced Diffusing Capacity, Need for Lung Biopsy, and Deposition of Titanium in Lung Tissue

Originally marketed as a safer tool for cigarette smoking cessation, electronic cigarettes (e-cigarettes) and vaping devices have now been associated with e-cigarette/vaping associated lung injury (EVALI). Examination of lung tissue from these patients is infrequent. We now report a cohort of nineteen vaping adults hospitalized with EVALI (IRB 20-0094 Feinstein Institutes of Medical Research, Northwell Health). Eight patients were biopsied and one patient’s lung tissue was examined at Brookhaven National Laboratory’s National Synchrotron Light Source II Beam ID-5 for the presence of metals. This sample contained abundant amounts of titanium and small amounts of chromium, iron, zinc, calcium, and copper. Vaping coils contain titanium, which is heated via a battery and aerosolized in the inhaled plume. Titanium is pro-inflammatory and may induce lung scarring. Subjects who vaped more frequently and for a longer duration had a lower DLCO, increased necessity of undergoing a lung biopsy, and a longer duration of hospitalization. Lung volumes and spirometry were normal in all patients. Concurrent cannabis use was self-reported in 95% of subjects, while concurrent tobacco use was 32%. Twenty-six percent were diagnosed with COVID-19 pneumonia during their hospitalization.EVALI may result in hospitalization and respiratory failure. An etiology for EVALI is not yet determined. We report, for the first time, titanium, among other metals, in the biopsy of a patient with EVALI. Titanium may induce lung injury among the 2.55 million adolescents who vape regularly. We earlier reported oxidized titanium in lung tissue of soldiers exposed to burn pits in Iraq and Afghanistan with Iraq Afghanistan War Lung Injury (IAW-LI). Those samples also indicate titanium was burned before inhalation. The role of titanium in both these inhalational lung injuries requires further investigation.Funding: Not funded.Declaration of Interest: Anthony M. Szema, MD has the following grants to disclose: 1. 2022 Site PI and co-investigator CDMRP Congressionally Directed Medical Research Program DOD Department of Defense Peer Reviewed Medical Research Program (PRMRP) PR211133 - “A Wearable Device for Airborne Hazard and Burn Pit Exposure Monitoring” Goal is to test a wearable sensor in simulated burn pit vs. animal and human pathology and physiology. 2. 2021-Present Principal Investigator, New York State A Manufacturing and Technology Resource Consortium (MTRC) Supplemental Award Agreement MTRC Project No. 20211012.1605 Goal is to develop a pulmonary fibrosis drug and medicine for Iraq Afghanistan War Lung Injury (IAW-LI). 3. 2021 U01 OH012264-01 Longitudinal Follow-Up of 9/11 Directly Exposed Children in their Age of Transition: Independence, Occupation and Morbidity (Hoven PI) co investigator. 4. 2020-2024 Consultant, NIH R01 HL152385, Hoven, Amsel (MPIs) 05/01/20-04/30/24, “Childhood Mass Trauma Exposure, Inflammatory Programming, and Psychopathology in Young Adulthood” Goal is to examine blood samples taken from children exposed to the World Trade Center disaster. 5. 2020-Present Principal Investigator, Butterfly Ultrasound Unlimited Cloud Storage Grant for Resource Limited Studies Goal is to save data from ultrasounds of returning soldiers from Iraq and Afghanistan. 6. 2018-Present Site Principal Investigator and Co-Investigator Centers for Disease Control Grant CDC NIOSH U01 OH011308 “9/11 Trauma and Toxicity in Childhood: Longitudinal Health and Behavioral Outcomes” Goal is to assess lung and immune function from children who were exposed to the World Trade Center disaster.Ethical Approval: All methods were carried out in accordance with guidelines and regulations. All experimental protocols were approved by Feinstein Institutes for Medical Research IRB Institutional Review Board Northwell IRB: 20-0094 Feinstein Institute for Medical Research. We obtained patient consent for this study.