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Vaping-associated pulmonary injury

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Vaping-associated pulmonary injury
Other names	Vaping-associated lung injury, e-cigarette, or vaping, product use associated lung injury (EVALI)
CT scan of the chest showing vaping-associated lung injury
Specialty	Pulmonology
Symptoms	Shortness of breath, hypoxic, fever, cough, diarrhea
Causes	Vaping
Diagnostic method	Opacities on chest radiograph
Treatment	High-flow oxygen therapy
Deaths	34 (1,604 cases U.S.)

Vaping-associated pulmonary injury (VAPI) is a lung disease associated with the use of vaping products, also known as electronic nicotine delivery systems (ENDS), which include e-cigarettes, vapes, vape pens, e-hookah

Signs and symptoms[edit]

In September 2019, the Centers for Disease Control and Prevention (CDC) reported an outbreak of severe lung disease linked to vaping. The cases of lung injury date back to at least April 2019. The clinical presentation of VAPI can initially mimic common pulmonary diagnoses like pneumonia, but individuals typically do not respond to antibiotic therapy. High clinical suspicion is necessary to make the diagnosis of VAPI. In some cases, individuals seek care at outpatient clinics in the days prior to hospital presentation and received antibiotics for presumed pneumonia or bronchitis, which did not improve their symptoms. Affected individuals typically present for care within a few days to weeks of symptom onset. At the time of hospital presentation, the affected individual is often hypoxic and meets systemic inflammatory response syndrome (SIRS) criteria, including high fever. In some cases, they have progressive respiratory failure following admission, leading to intubation. Several affected individuals have needed to be placed in the ICU while being hooked up to a ventilator. Time to recovery for hospital discharge has been from days to weeks. Commonly reported symptoms include shortness of breath, cough, fatigue, body aches, fever, vomiting, and diarrhea. Non-specific laboratory abnormalities have been reported, including elevation in white blood cell count, transaminases, procalcitonin, and inflammatory markers. Negative infectious disease testing (influenza, respiratory viral panel, cultures, etc.). Imaging abnormalities are typically bilateral and may be described as: Chest x-ray: pulmonary infiltrates or opacities. Chest CT: ground-glass opacities. Bronchoalveolar lavage specimens may exhibit an increased level of neutrophils and sparse to moderate amounts of lipid-laden alveolar macrophages.

Infection does not appear to be the source of this lung disease and individuals state their symptoms either developed either over a few days or a few weeks .

Mechanism[edit]

Vaping refers to the increasingly popular practice of inhaling aerosol (vapor) from an electronic cigarette device, which works by heating a liquid that can contain nicotine, cannabis, or other drugs. The long-term health impacts of vaping are unknown. Some individuals also use a different type of device to heat and extract cannabinoids for inhalation in a process called "dabbing." Both vaping and dabbing have been associated with VAPI. Most individuals report vaping the cannabis compounds THC and/or CBD, and some also report vaping nicotine products. In agreement with this, investigations being conduced by the U.S. Food and Drug Administration (FDA) have found many cases of this illness are linked to vaping of THC products . A smaller group reported using nicotine alone. On October 4, 2019, the CDC reported that the cause of the lung illnesses is unknown but it might be related to prefilled THC cartridges. The FDA is currently collecting samples of different products and testing them for chemicals including nicotine, THC, pesticides, opioids, poisons, heavy metals and toxins in order to find a cause of the VAPI .

The CDC states that many of the lung injury cases are due to inhaled THC sold by informal sources. The e-liquid used in many of the cartridges of electronic cigarettes or e-cigarettes contains one or more of the following unregulated chemicals: propylene glycol, acetaldehyde, formaldehyde, acrolein, diacetyl, diethylene glycol, nickel, tin, lead, cadmium, benzene, and ultrafine particles. Many of these chemicals are toxic and can lead to breathing problems, lung damage, and cancer.

Diagnosis[edit]

VAPI is a clinical diagnosis of exclusion when infectious, rheumatologic, neoplastic, cardiac, or other processes cannot explain an acute pulmonary illness in a person known to vape cannabinoids and/or nicotine. The diagnosis is commonly suspected when the person does not respond to antibiotic therapy, and testing does not reveal an alternative diagnosis. Common documented hospital diagnoses for these people have included: acute respiratory distress syndrome (ARDS), sepsis, acute hypoxic respiratory failure, pneumonitis, and pneumonia. As of now it is unclear as to what is the exact cause of this illness; the current investigations taking place are looking into if this is more than one disease process causing similar presenting symptoms or if there is actually one common cause .

The current pathophysiology of vaping-related lung injuries is unknown; in order to find potential causes, the CDC has been collecting and studying lab specimens .

Case definition[edit]

A case of VAPI meets the following criteria: Respiratory illness requiring hospital admission; history of vaping or dabbing within 90 days of symptom onset; pulmonary infiltrates or opacities on chest radiograph or chest CT. Presentation is not explained by infectious or other alternate etiology.

Treatment[edit]

Guidelines for treatment of VAPI are not available. Most individuals require supplemental oxygen via nasal cannula, high-flow oxygen, bilevel positive airway pressure (BiPAP), or mechanical ventilation. Anecdotally, treating physicians have trialed the use of steroids with some possible benefit. Information on dosing and duration of steroids is not available. Corticosteroids might be helpful in treating this injury. Several case reports describe improvement with corticosteroids, likely because of a blunting of the inflammatory response. For patients who do not require immediate hospitalization, but are seeking medical care due to respiratory symptoms, prophylactic antivirals should be considered. An important part of treatment for VAPI involves quitting vaping.

Epidemiology[edit]

As of October 22, 2019, the CDC has received complete gender and age data on 1,604 lung injury cases: 70% of cases are male. The median age of cases is 24 years and ranges from 13 to 75 years. 81% of cases are under 35 years old.

On 28 September the first case of vaping-associated pulmonary injury was identified in Canada.

There are now 1,604 reports of lung injury due to use of vaping products in all states excluding Alaska with 34 deaths reported within 24 states .

Current CDC Action Plan

Due to the increased number of injuries and death related to vaping, the CDC has begun to work around the clock to learn more. The CDC has devised a plan to reduce the prevalence. This plan includes activating the Emergency Operations Center (EOC) and partnering with individual state and government agencies, including the Federal Drug Administration and public health partners.

The overall goals of the CDC include determining risk factors, identifying and tracking incidences, and creating guidelines to combat for vaping-relating lung injuries.

In order to keep the nation informed, the CDC's website is updated weekly, in addition to scheduled calls and meetings to ensure all information is conveyed to clinicians and the public.

The CDC along with the FDA are working together to create a system of putting together information in order to obtain the most accurate results efficiently in order to gain a better understanding of this illness and the cause .

The CDC recognizes that individuals are vaping instead of smoking traditional cigarettes. Because of the health problems that are occurring, the CDC recommends that those who quit vaping because of the risks involved should not smoke cigarettes instead. As an alternate, the CDC suggests using an FDA approved nicotine replacement therapy, such as a patch, gum, lozenge, inhaler, or nasal spray.