Pneumonitis Due to "Dabbing" Successfully Managed via Extracorporeal Membrane Oxygenation

Abstract

INTRODUCTION: E-cigarette or vaping associated lung injury (EVALI) is an uncommon complication of e-cigarettes or vaping. 96% of these cases require hospitalization. The condition is especially associated with tetrahydrocannabinol (THC) products, frequent use, and is found primarily in young adults. “Dabbing” refers to the process of heating THC containing oils or waxes with butane solvents to vaporize cannabinoids for inhalation. CASE REPORT: An obese 20-year-old college male with a history of prematurity and anxiety presented with cough, dyspnea, nausea, vomiting and diarrhea that began 3 days prior. He reported smoking marijuana, but denied vaping. Multiple PCR tests for SARS-CoV-2 were negative. Initial chest radiograph demonstrated multifocal pneumonia. He was hypoxic on presentation requiring two liters of oxygen via nasal cannula. Broad spectrum antibiotics for pneumonia and steroids were initiated. Oxygen requirements rapidly increased and humidified high flow oxygen was instituted and escalated to 60 liters per minute and 90 % FiO2. He remained hypoxic, prompting intubation 48 hours from presentation. His ventilatory settings were steadily escalated to a positive end expiratory pressure of 15 cm H2O with 100% FiO2. Despite this, the patient had oxygenation saturations as low as 57% requiring transition to venovenous extracorporeal membrane oxygenation (VV-ECMO). Computed tomography angiography ruled out pulmonary embolism but redemonstrated extensive alveolar and interstitial infiltrates bilaterally. Bronchoscopy with alveolar lavage was performed with negative cultures and cytology. Blood cultures were also negative and antibiotic therapy was stopped. Extensive laboratory investigation for autoimmune vasculitis was performed and found to be negative. Discussion with family revealed that the patient regularly inhaled concentrated THC wax with butane as a solvent. Treatment continued with high dose intravenous steroids and supportive care. The patient received a total of 5 days of ventilator support after which he was extubated, and an additional 5 days of VV-ECMO. At discharge, the patient required 2 liters of continuous oxygen at rest and 4 liters with activity. He was otherwise asymptomatic and at his baseline level of function. He was discharged on daily steroids with taper and close outpatient follow up. DISCUSSION: While the majority of hospitalized patients with EVALI require intubation, the necessity of VV-ECMO utilization represents a rare severe presentation. Dabbing remains a rare cause of acute respiratory distress syndrome and EVALI, however, dabbing is emerging as a trend among young adults and represents an under-investigated cause of severe inhalational lung injury.