*Purpose: E-cigarette, or vaping, product use-associated lung injury (EVALI) is a recently described disease entity prominently reported throughout many sources. Thus far, diagnosis is primarily that of exclusion, requiring high degree of clinical suspicion, with a consistent detailed history. History alone is often a barrier to identification of disease process, and to date, there is no consensus on diagnostic criteria of EVALI, with even less data regarding asymptomatic patients with suspected vape use.

*Methods: In regards to lung transplantation, one case of double lung transplant due to EVALI has been reported, though no reports of donor vape use. Given the relatively recent description of EVALI, of essentially epidemic proportions, more questions remain unanswered than not, with no published data regarding the pathophysiologic findings associated with vaping in an asymptomatic patient. Mucociliary dysfunction due to reduced tracheal mucus velocity has been shown in vitro and in vivo in sheep. Lipid laden macrophages have been described in bronchoalveolar lavage (BAL) from patients with suspected EVALI.Uncertainty raises concern in the field of lung transplantation, especially when evaluating potential high risk donors. We present a case of single lung transplantation from a high risk donor with suspected vape use, not identified on screening. High risk features here include marijuana use, sexual intercourse with IV drug user, and maximum cold ischemic time exceeded.

*Results: Intraoperatively, high peak pressures requiring low tidal volumes were noted on isolated lung ventilation; high ventilatory support requirements persisted postoperatively. First chest x-ray revealed well aerated new lung, consistent with aerated alveoli. Intraoperative donor lung bronchoscopy revealed thick strings of white mucus throughout small airways of new lung. BAL with lipid-laden macrophages.

*Conclusions: Peak pressures normalized within 72 hours and patient was extubated. Within 2 weeks patient ambulating on 5L nasal cannula.

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