The Vapes of Wrath (ref 1)
Myron Yaster MD
Deborah A Rusy, Anita Honkanen, Mary F Landrigan-Ossar, Debnath Chatterjee, Lawrence I Schwartz, Kirk Lalwani, Jennifer R Dollar, Randall Clark, Christina D Diaz, Nina Deutsch, David O Warner, Sulpicio G Soriano. Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine. Anesth Analg. 2021 Sep 1;133(3):562-568. PMID: 33780391
Sonali Shah, Garret Weber, Naveen Nathan. Beyond the Smoke Screen: Vaping in Adolescents. Anesth Analg. 2021 Sep 1;133(3):561. PMID: 34403383
New York Times September 9, 20221
Richtel M. F.D.A. Delays Decision on Juul’s E-Cigarettes but Orders Others Off the Market. New York Times. https://www.nytimes.com/2021/09/09/health/fda-e-cigarettes-vaping.htm
It’s unusual for a pediatric anesthesia article to get an infographic (see below) and cover art in a major anesthesia journal and have a consensus statement by the ASA, SPA, and AAP, authored by a “who’s who” of pediatric anesthesiology. Despite this, when I first read these articles, I thought maybe I shouldn’t post it in the PAAD…after all, the FDA was going to ban electronic cigarettes this month so what was the point? But NOOOO, yesterday the FDA gutlessly punted. So, I’m afraid some of these products, yet another plague affecting our citizens, will be with us for a while longer.
“This narrative review discusses the spectrum of disease severity related to vaping-associated lung injury. Although respiratory complications are logically predicted, at the extreme end point of the scale, the need for extracorporeal membrane oxygenation may even be required in some cases. The infographic illustrates some of the many concepts discussed in this review (see below). Clinical presentation typically involves constitutional, cardiopulmonary, and gastrointestinal systems. Risk factors for developing e-cigarette or vaping-associated lung injury (EVALI) include the addition of tetrahydrocannabinol (THC) in the inhalant, increased frequency of use, preexisting asthma, and respiratory toxins. There is an expected increase in the incidence of EVALI considering the marketing toward younger demographics”.2
All of you know that that cigarette smoking has been implicated as a risk factor for postoperative complications in many different surgical subspecialties (“Duhh”!). Most of the data comes from adult studies. Adult “patients who smoke or vape and undergo surgery have longer hospital stays, a higher risk of readmission, a higher rate of being admitted to an intensive care unit, poor wound healing, and an increased risk of in-hospital mortality in comparison to nonsmoking patients”.3-6
What many of you may not know is the idea of “the teachable moment”.7-9 Because surgery and general anesthesia are so fraught with fear and anxiety, it is an event that “motivates individuals to spontaneously adopt risk-reducing health behaviors”.7-9 Indeed, some evidence suggests that major surgery for a smoking-related illness can serve as a teachable moment for smoking cessation.7-9 Rusy et al. suggest that “smoking/vaping cessation discussions should be introduced early by patient’s primary care provider; however, it is also imperative that this topic is discussed in both the surgical and anesthesia preoperative screening clinics”. Further, they recommend that screening regarding vaping use be done on all adolescents undergoing preoperative evaluations.
Preoperative workup should include “a thorough history enquiring about smoking history including e-cigarette and vaping use, respiratory symptoms (eg, cough, chest pain, and shortness of breath), gastrointestinal symptoms (eg, abdominal pain, nausea, vomiting, and diarrhea), fever, chills, and weight loss. Physical examination should include vital signs and pulse oximetry, as these patients may present with tachycardia, tachypnea, and O2 saturation <95% at rest on room air. If respiratory symptoms are present, consider chest X-ray or chest CT scan”.3
There is currently no data to guide intra- and post-operative monitoring and management of adolescent patients who vape. Is this a teachable moment? This is a great opportunity for us to study this issue using SPA, along the lines of our other multi-institutional studies such as, difficult airway management, blood loss conservation, etc. Are any of you interested in taking the lead? If you are let John Fiadjoe and me know…with the ASA and SPA coming up we can hopefully set up a meeting.
Myron Yaster MD
1. Shah SI, Javier JR, Brumberg HL: The vapes of wrath: advocating to protect children from electronic nicotine systems in the age of flavored vapes. Pediatr Res 2020; 87: 972-975
2. Shah S, Weber G, Nathan N: Beyond the Smoke Screen: Vaping in Adolescents. Anesth Analg 2021; 133: 561
3. Rusy DA, Honkanen A, Landrigan-Ossar MF, Chatterjee D, Schwartz LI, Lalwani K, Dollar JR, Clark R, Diaz CD, Deutsch N, Warner DO, Soriano SG: Vaping and E-Cigarette Use in Children and Adolescents: Implications on Perioperative Care From the American Society of Anesthesiologists Committee on Pediatric Anesthesia, Society for Pediatric Anesthesia, and American Academy of Pediatrics Section on Anesthesiology and Pain Medicine. Anesth Analg 2021; 133: 562-568
4. Lavernia CJ, Sierra RJ, Gomez-Marin O: Smoking and joint replacement: resource consumption and short-term outcome. Clin Orthop Relat Res 1999: 172-80
5. Delgado-Rodriguez M, Medina-Cuadros M, Martínez-Gallego G, Gómez-Ortega A, Mariscal-Ortiz M, Palma-Pérez S, Sillero-Arenas M: A prospective study of tobacco smoking as a predictor of complications in general surgery. Infect Control Hosp Epidemiol 2003; 24: 37-43
6. Troiano C, Jaleel Z, Spiegel JH: Association of Electronic Cigarette Vaping and Cigarette Smoking With Decreased Random Flap Viability in Rats. JAMA Facial Plast Surg 2019; 21: 5-10
7. Shi Y, Warner David O: Surgery as a Teachable Moment for Smoking Cessation. Anesthesiology 2010; 112: 102-107
8. Shi Y, Warner DO: Pediatric surgery and parental smoking behavior. Anesthesiology 2011; 115: 12-7
9. McBride CM, Emmons KM, Lipkus IM: Understanding the potential of teachable moments: the case of smoking cessation. Health Educ Res 2003; 18: 156-70