By Debra Wood, RN, contributor Oct 29, 2019
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.
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.
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.
reports more than 1,600 cases and 34 deaths attributed to vaping-related
illness, as of October 22, 2019.
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
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7 key factors of vaping
use and related illnesses
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.
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.
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.
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.
will get there,” Sangani said. “There is a lot of interest in the scientific
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
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
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.”
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.
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
reported vaping companies came out with ads targeting youngsters with flavors.
3. Screening for vaping use and related
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.
Alexander recommends physicians use terms patients will understand. Vapers will
say they have quit smoking, but the clinician must directly ask about using an
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.
suggested screening begin at age 10.
4. Patient presentations
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.
are in an ER, it’s hard to pick up that one person in 10 that has something
related to vaping,” Naunheim said.
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.
having any infection seems to be the key defining aspect of the diagnosis,”
suggested that bronchoscopy can determine whether cells contain an oily
material. Most cases have been inpatient rather than outpatient.
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.
Alexander cautions that dabbing and dripping may have different health effects.
They handle the chemicals differently. The person drops a substance onto a
5. Reporting possible
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.
device should be collected, and it and any liquids that remain should be
identify what us causing it and to stop it, you need all of the information you
can get,” Naunheim said.
6. Treating the patient
patients present with symptoms consistent with a lung infection, physicians
often start them on an antibiotic, Jaspers said.
care, likely with oxygen, intubation, ventilator management or ECMO, may be
needed, Sangani said.
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
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
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.
recommended physicians assess and treat nicotine addiction, adding that
nicotine can be detrimental to the developing brain.
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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