Vaping-related Illness: 7 Things All Physicians Need to Know

The popular trend of vaping has been in the news a lot lately—for all the wrong reasons. The Centers for Disease Control and Prevention (CDC) and other groups have issued warnings about vaping-associated pulmonary illnesses and deaths.

“Health effects of vaping have been happening for years; but it has been difficult to track them, because healthcare professionals have not been asking patients detailed questions about vaping,” said Laura Crotty Alexander, MD, co-author of the American Thoracic Society’s “ATS Health Alert--Vaping Associated Pulmonary Illness,” an associate professor of medicine at the University of California, San Diego, and a staff physician at the VA San Diego Healthcare System.

Rahul Sangani, MD, an assistant professor at the West Virginia University in Morgantown, reported one of the first vaping-associated lung injury cases in 2015. His 31-year-old female patient developed acute lipoid pneumonia and respiratory failure related to e-cigarette use.

The CDC reports more than 1,600 cases and 34 deaths attributed to vaping-related illness, as of October 22, 2019.

“Vaping-related lung injury is horrible, and we need to find out what is causing it and take it off the market,” said Ilona Jaspers, PhD, a toxicologist and professor of pediatrics at the UNC School of Medicine in Chapel Hill, North Carolina. Long term, she added, clinicians need to learn more about vaping habits.

“This is a public health crisis, and a lot of people are working frantically around the clock to find out what the culprit or culprits could be, and what chemicals may be responsible,” said Brandon Larsen, MD, PhD, a surgical pathologist at Mayo Clinic Arizona in a statement.

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7 key factors of vaping use and related illnesses

1. Etiology 

The cause of vaping-related illness remains unknown, although the CDC, the U.S. Food and Drug Administration and others are working on it. Patterns are emerging.

Complicating matters is the many different ways people vape, the different substances they vape and the varying devices, said Keith Naunheim, MD, immediate past president of The Society of Thoracic Surgeons and chief of thoracic surgery at St. Louis University School of Medicine.

Vaping devices and e-cigarettes heat a liquid, creating an aerosol, which users inhale into their lungs. The liquid may contain nicotine, tetrahydrocannabinol (THC), flavorings and other additives.

Ingredients in the vaping fluid, such as propylene glycol or vegetable glycol, a petroleum product, used to generate the smoke, may be responsible for some injuries, Sangani said. But it remains a matter of investigation.

“We will get there,” Sangani said. “There is a lot of interest in the scientific community.”

Researchers at the Mayo Clinic Arizona reviewed lung biopsies from 17 patients suspected of having a vaping-associated lung injury and report that the injuries related to vaping are likely caused by a direct toxicity or tissue damage from noxious chemical fumes.“While we can't discount the potential role of lipids, we have not seen anything to suggest this is a problem caused by lipid accumulation in the lungs,” Larsen said.

2. What is being vaped and by whom? 

Among patients with information about the products they has used in the three months prior to symptom onset, the latest CDC report found 86 percent had used a product with THC, and 11 percent had used exclusively a product containing nicotine.

“There is some question as to whether there may be some chemical adulterating the cartridges with THC,” Naunheim said. “There are cartridges not FDA approved or commercially manufactured. It’s a dangerous landscape if you are vaping.”

The CDC data, as of October 22, 2019, also showed that most of the patients were males (70 percent), and 79 percent were younger than 35 years old. Additionally, about half of the cases, and two deaths, occurred in patients under age 25 years.

About 20 percent of young adults are vaping daily or recreationally, and one in four believe it’s harmless and not addictive, according to the “ASCO 2019 Caner Opinions Survey.” 

Naunheim reported vaping companies came out with ads targeting youngsters with flavors.

3. Screening for vaping use and related illnesses 

“The most important thing for health care providers is to be aware of vaping-associated pulmonary illnesses and to ask specifically about any e-cigarette or vaping device use and pulmonary signs and symptoms in all patients, particularly in any patient who presents with acute lung disease,” said Christine Bojanowski, MD, assistant professor of clinical medicine at Tulane University in New Orleans.

Crotty Alexander recommends physicians use terms patients will understand. Vapers will say they have quit smoking, but the clinician must directly ask about using an electronic device.

“You have to know the terminology, specifically about vaping,” Crotty Alexander said. People vaping, using a JUUL device, will describe the frequency in pods. Jaspers added young people do not consider JUUL a tobacco product.

Naunheim suggested screening begin at age 10.

4. Patient presentations 

Symptoms of vaping-related illness vary. Patients often experience cough, shortness of breath or chest pain. Additionally, some complain about gastrointestinal symptoms or nonspecific constitutional symptoms, including fever, weight loss and fatigue, which are symptoms of other viral syndromes.

“If you are in an ER, it’s hard to pick up that one person in 10 that has something related to vaping,” Naunheim said.

The case definition includes a lung injury with a history of vaping, using e-cigarettes, or dabbing, which is a method of vaping concentrated marijuana, within 90 days of symptom onset; imaging studies showing a lung injury; and the absence of infection or an alternative plausible diagnosis.

“Without having any infection seems to be the key defining aspect of the diagnosis,” Jaspers said.

Sangani suggested that bronchoscopy can determine whether cells contain an oily material. Most cases have been inpatient rather than outpatient.

If vaping is suspected as the cause of the patient’s symptoms, the CDC recommends taking a detailed history about the substances used; the sources, home made or commercially purchased; the device used, including the brand name; whether the device was modified; where the products were purchased; the method used, such as aerosol, dabbing or dripping; and if the patient has shared the device or substance with others. Ask if the patient has any remaining product.

Crotty Alexander cautions that dabbing and dripping may have different health effects. They handle the chemicals differently. The person drops a substance onto a coil.

5. Reporting possible vaping-related illnesses 

“Clinicians should report suspected cases to their state Department of Health as we are still learning about the range of potential effects that e-cigarettes have on the lungs,” Bojanowski said.

The device should be collected, and it and any liquids that remain should be tested.

“To identify what us causing it and to stop it, you need all of the information you can get,” Naunheim said.

6. Treating the patient 

Since patients present with symptoms consistent with a lung infection, physicians often start them on an antibiotic, Jaspers said.

Supportive care, likely with oxygen, intubation, ventilator management or ECMO, may be needed, Sangani said.

“Because the cases that have been well described look like inflammatory lung disease, it is reasonable to treat with steroids,” Crotty Alexander said. “It might help clear the inflammation. You don’t want to hold back on a therapy that might be helpful.”

Ongoing monitoring of pulmonary function should occur during follow up of the initial illness. Patients can fully recover, but it is too early to determine long-term effects if the patient survives and avoids further vaping, Sangani said.

7. Educating patients about vaping

The CDC recommends people stop using vaping or e-cigarette products, especially those containing THC. If people still want to vape, they should not purchase it off the street and not to modify or add substances. Additionally, CDC said youth, young adults, pregnant women and adults not using tobacco products should refrain from vaping.

Jasper recommended physicians assess and treat nicotine addiction, adding that nicotine can be detrimental to the developing brain.

“Pediatricians need to know there is no reason for vaping by a child,” Naunheim said. “E-cigarettes and nicotine is as addictive as regular cigarettes.”

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