The CDC recently released clinical guidelines for treating vaping-related illness, recommending hospitalization for suspected cases when patients have oxygen levels below 95 percent.
"The earlier we diagnose vaping-related illness and treat with steroids, the better people do," said Kimberly Bridges, MD, with Pulmonary Associates of the Southeast. "People have a pretty rapid decompensation after about 48 hours, so the CDC is recommending if you have a high suspicion and your patient's oxygen level is low - and their definition of low is 95 percent, which most of us wouldn't bat an eye at - then that patient needs to be observed in the hospital for at least 24 to 48 hours."
Bridges said the first line of defense in the battle against vaping-related lung injury is to talk with patients about vaping and the associated dangers. For pediatricians and family practitioners, that includes talking to parents about what to watch for.
"It's not something patients usually bring up," she said. "In surveys of drug and alcohol use, teenagers were answering no to use of e-cigarettes because they don't call them e-cigarettes. So the surveys often don't ask the questions in the way to get the answers we need to know. We ask every patient if they smoke, if they drink or if they do drugs. We just need to add a fourth question, asking whether or not they vape. I tend to ask, 'do you inhale anything into your lungs besides oxygen?' They may say they don't do drugs, even when they smoke marijuana, because some people don't consider marijuana a drug. As doctors, we need to know how to ask the questions."
Bridges said there have been fewer than 10 cases of vaping-related lung injury in Alabama so far, but she also suspects it is more widespread than most people realize. "The symptoms are very non-specific and until recently most providers didn't know to look for it or what questions to ask, so as is the case nationally, it has likely been under diagnosed," she said. "Based on the available data, patients present with fairly non-specific symptoms like low grade fever, cough, shortness of breath, nausea. Currently it is a diagnosis of exclusion. If you have any suspicion, monitor oxygen levels and check a chest x-ray."
Treatment is primarily supportive care, according to Bridges. Once a patient is admitted to the hospital for observation, they are monitored for progressive respiratory failure. "We provide additional support as needed, including mechanical ventilation if it progresses that far. Reported cases thus far have shown some improvement when treated with corticosteroids. We also consider bronchoscopy for further evaluation, mostly to rule out other causes, as there is currently no diagnostic test for vaping-related lung injury," she said.
Bridges expects the CDE to issue additional guidelines as more becomes known about the illness. "Vaping has been around for years, but no one has known much about the long or short-term consequences," she said. "Now that e-cigarette use has become more popular and vaping-related lung injury is being recognized, we have a little data to create guidelines from. I imagine the guidelines will continue to evolve as we get more information."
CDC Finds Vitamin E Acetate in Fluid Samples
The CDC tested bronchoalveolar lavage (BAL) fluid samples (or samples of fluid collected from the lungs) from 29 patients with vaping-related lung injury and found Vitamin E acetate in every sample. "Vitamin E acetate is used as an additive in the production of e-cigarette, or vaping, products. This is the first time that we have detected a potential chemical of concern in biologic samples from patients with these lung injuries," according to the CDC website.
Kimberly Bridges, MD, with Pulmonary Associates of the Southeast, said a chemical additive such as Vitamin E acetate may turn out to be a cause of vaping-related lung injury, but more research will be necessary. "Those aren't high enough numbers to be conclusive," she said. "Previously a lot of the patients were testing positive for THC in the lungs, and it was thought the problem was from adding THC."
The CDC reports that THC was identified in 82 percent of the samples and nicotine was identified in 62 percent of the samples.
On their website, the CDC added this recommendation: "CDC continues to recommend that people should not use e-cigarette, or vaping, products that contain THC, particularly from informal sources like friends, or family, or in-person or online dealers. We will continue to provide updates as more data become available."
Outbreak Information from the CDC Website
- This complex investigation spans almost all states, involves over 2,000 patients, and a wide variety of brands and substances and e-cigarette, or vaping, products.
- As of November 5, 2019, 2,051* cases of e-cigarette, or vaping, product use associated lung injury (EVALI) have been reported to CDC from 49 states (all except Alaska), the District of Columbia, and one U.S. territory.
- 39 deaths in 24 states and the District of Columbia: Alabama, California (3), Connecticut, Delaware, District of Columbia, Florida, Georgia (3), Illinois (3), Indiana (3), Kansas (2), Massachusetts (2), Michigan, Minnesota (3), Mississippi, Missouri, Montana, Nebraska, New Jersey, New York, Oregon (2), Pennsylvania, Tennessee (2), Texas, Utah, and Virginia.
- The median age of deceased patients was 53 years and ranged from 17 to 75 years
- More deaths are under investigation.
- Among 1,378 patients with data on sex 70 percent are male.
- Among 1,364 patients with data on age:
- The median age of patients is 24 years and ages range from 13 to 75 years.
- 79 percent of patients are under 35 years old.
- By age group category:
- 14 percent of patients are under 18 years old.
- 40 percent of patients are 18 to 24 years old.
- 25 percent of patients are 25 to 34 years old.
- 21 percent of patients are 35 years or older.
- Among 867 patients with information on substances used in e-cigarette, or vaping products in the three months prior to symptom onset:
- About 86 percent reported using THC-containing products; 34 percent reported exclusive use of THC-containing products.
- About 64 percent reported using nicotine-containing products; 11 percent reported exclusive use of nicotine-containing products.