Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
The rapid rise of electronic cigarette use over the past decade has created a growing population of surgical patients whose vaping history carries meaningful, if incompletely characterized, perioperative implications. Unlike combustible tobacco, whose perioperative risks are well documented, vape use occupies a more ambiguous space in preoperative risk assessment, and clinicians must now systematically account for it in the evaluation and care of surgical patients (Cutts and O’Donnell, 2021; Feinstein and Katz, 2020).
A thorough preoperative evaluation of the heavy vaper should treat e-cigarette use as clinically distinct from, but related to, combustible smoking. Patients frequently deny “smoking” while continuing regular vaping, so direct and specific questioning about device type, e-liquid composition, nicotine concentration, and frequency of use is essential (Krishna et al., 2020; Cutts and O’Donnell, 2021). Particular attention should be paid to tetrahydrocannabinol (THC)-containing products, which are strongly implicated in e-cigarette or vaping use-associated lung injury (EVALI), largely through the additive vitamin E acetate (Cutts and O’Donnell, 2021). A history of unexplained respiratory symptoms, recent hospitalization for pneumonitis, or eosinophilia should raise suspicion for EVALI or hypersensitivity pneumonitis, as illustrated by a reported adolescent case requiring bronchoscopy, bronchoalveolar lavage, and prolonged corticosteroid therapy following vaping-related lung injury (Krishna et al., 2020).
Respiratory considerations are at the center of discussion around the management of surgical patients with significant vape use, particularly for anesthesiologists. Vaping is associated with increased airway reactivity, bronchoconstriction, impaired mucociliary clearance, and reduced cough reflex due to nicotine’s stimulation of afferent bronchial pathways and diluents and flavoring chemicals in the aerosol (Krishna et al., 2020; Cutts and O’Donnell, 2021). Clinicians should anticipate a higher likelihood of intraoperative bronchospasm and plan accordingly. They should consider deepening anesthesia, employing inhaled beta-agonists or anticholinergics, using volatile agents such as sevoflurane for their bronchodilatory properties, and reserving epinephrine, ketamine, or magnesium for refractory cases (Krishna et al., 2020). Warming and humidifying inspired gases and considering topical or intravenous lidocaine before intubation may further reduce laryngeal and airway hyper-reactivity.
Cardiovascular effects also warrant attention. Nicotine promotes catecholamine release, vasoconstriction, and platelet activation, which together can produce unpredictable hemodynamic swings under anesthesia and a theoretical increase in arrhythmia risk (Cutts and O’Donnell, 2021; Feinstein and Katz, 2020). Because these mechanisms parallel those of traditional smoking, preoperative cardiovascular assessment should be no less rigorous for heavy vapers than for combustible-cigarette smokers, particularly in patients with existing cardiac disease.
The metabolic and wound-healing effects of vaping must also be considered by clinicians. Nicotine affects hepatic cytochrome P-450 pathways and may alter drug metabolism, while volatile organic compounds such as toluene in e-cigarette vapor can produce central nervous system depressant effects that modestly reduce anesthetic requirements (Krishna et al., 2020). Impaired tissue oxygenation and wound infection risk, which are well established with tobacco smoking, appear to extend, to an uncertain degree, to vaping (Cutts and O’Donnell, 2021).
Evidence specific to surgical outcomes in patients with heavy vape use remains limited, and clinicians are largely extrapolating from tobacco literature (Feinstein and Katz, 2020). Given this uncertainty, a cautious approach is warranted: thorough screening, consideration of preoperative cessation counseling, heightened vigilance for airway reactivity and hemodynamic lability, and a low threshold for evaluating unexplained respiratory findings as possible EVALI.
References
- Cutts, T.G., & O’Donnell, A.M. (2021). The implications of vaping for the anaesthetist. BJA Education, 21(7), 243–249. https://doi.org/10.1016/j.bjae.2021.02.001
- Feinstein, M.M., & Katz, D. (2020). Sparking the discussion about vaping and anesthesia. Anesthesiology, XXX(00), 1. https://doi.org/10.1097/ALN.0000000000003093
- Krishna, A., Mathieu, W., Mull, E., & Tobias, J.D. (2020). Perioperative implications of vaping. Journal of Medical Cases, 11(5), 129–134. https://doi.org/10.14740/jmc3451
