Episode 171.0 – Vaping Associated Lung Injury

Show Notes

Why this matters

• As of Oct 15, vaping has been associated with acute lung injury in over 1400 people
• 33 deaths have been confirmed in 24 states
• 70+% of those with VALI are young men
• A large number of patients are requiring ICU/ intubation/ ECMO

4 main ingredients in solvent

• +/- Flavor additives
• +/- Nicotine or THC (Tetrahydrocannabinol)
• Propylene Glycol (PG)
• Vegetable Glycerin (VG)

CDC definition of VALI (Vaping Associated Lung Injury)

1. Using an e-cigarette (“vaping”) or dabbing* in 90 days prior to symptom onset AND
2. Pulmonary infiltrate, such as opacities, on plain film chest radiograph or ground-glass opacities on chest CT AND
3. Absence of pulmonary infection on initial work-up. 
4. No evidence in the medical record of alternative plausible diagnoses (e.g., cardiac, rheumatologic, or neoplastic process).

*Dabbing allows the user to ingest a high concentration of THC.  Butane Hash Oil (BHO), an oil or wax-like substance extracted from the marijuana plant, is placed on a “nail” attached to a specialized glass bong called a “rig.” A blow torch is used to heat the wax, which produces a vapor that can then be inhaled to supposedly produce an instantaneous effect.

Pathophysiology

• At present, no single compound or ingredient has emerged as the cause, and there may be more than one cause
• The only common thread among the cases is that ALL patients reported using e-cig or vaping products
• Leading potential toxins:
  • Vaping products containing THC concentrates: most cases are linked to THC concentrates that were either purchased on the street or from other informal sources (meaning not from a dispensary)
  • Vitamin E acetate: nutritional supplement safe when ingested or applied to the skin (but likely not when inhaled) has been found in nearly all product samples of NY state cases of suspected VALI
    • vitamin E acetate is NOT an approved additive at least by NYS Medical Marijuana program
• Other potential toxins:
  • IT CANNOT BE UNDERSTATED that a small percentage of persons w/ VALI have reported exclusive use of nicotine-containing vape products, such as JUUL; as such, we must consider the potential toxicity of standard e-liquid or vape juice
  • Flavor additives, that exists as chemical aldehydes: irritating and potentially damaging to lung tissue
  • PG/VG: shown not only to break down to formaldehyde which is a known carcinogen, but also to produce lipoid pneumonia in rat lungs
  • Some devices are easily manipulated to increase the capacity to produce vapor; increasing these settings may impact heating temperature, metabolic breakdown, and release of microscopic metal particles
  • Lungs are multifunctional, including serving as an immune organ: lungs cleave proteins of all of the bacteria, viruses and other pathogens we are exposed to and inhale daily
    • human studies on those that are chronic e-cig users or vapers have revealed that these products are shifting the balance of proteases and antiproteases in our lungs such that the proteases are destroying native lung tissue similar to how traditional cigarettes cause COPD
• Many potential reactions:
  • NEJM article in references: details four radiographic phenotypes essentially reflecting different pathologic changes

Long-term Effects

• Long term effects are unknown (some pts have required home oxygen on discharge)
• Risk for recurrence or relapse, especially if repeat exposure

Presentation

• 95% of pts have had pulmonary sxs (cough, cp, dyspnea)
• 77% of pts have had GI sxs (abd pain, n/v/d)
• 85% of pts w/ constitutional sxs (f/c, weight loss)
• 57% w/ hypoxia (O2 < 95%)
• Unfortunately auscultation has been unreliable and poorly sensitive

Workup

• There is no specific test or marker for dx, so VALI is still considered a dx of exclusion
  • Labs:
    • CBC
    • ESR/CRP (93% w/ elevated ESR)
    • LFTs (50% w/ transaminitis)
    • ABG: hypoxia
  • Imaging:
    • CXR: typically shows bilateral infiltrates, although not always and there have even been some cases w/ unremarkable chest XR (so high degree of clinical suspicion in any person p/w hypoxia)
    • CT: ground glass opacities, typically bilaterally 

Management

• Dispo:
  • 96% of cases required hospitalization
    • Any pt w/ hypoxia, respiratory distress, or comorbidities
  • Outpatient only if: no hypoxia or respiratory distress, reliable followup within 48h and good social support (keep in mind that some patients w/ mild symptoms of first presentation deteriorated rapidly within 48h)
• Empiric treatments for pneumonia inc abx, antivirals
• Steroids (methylpred 60mg q6h, based on how index cases in Illinois were managed)
  • Case reports have documented improvement
  • Mechanism: blunting of inflammatory response
• Aggressive supportive care

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Special Thanks To:

Dr. Larissa Laskowski, DO

Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, NYC Health + Hospitals/ Bellevue

New York City Poison Control Center

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References:

Outbreak of Lung Injury Associated with E-Cigarette Use, or Vaping.  https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html

Carlos WG, Crotty Alexander LE, Gross JE, Dela Cruz CS, Keller JM, Pasnick SP, Jamil S.  Vaping-associated Pulmonary Illness (VAPI). Public Health Information Series. Am J Respir Crit Care Med Vol. 200, 13-15, 2019.  www.atsjournals.org/doi/pdf/10.1164/rccm.2007P13

Henry TS, Kanne JP, Kilgerman SJ.  Images of Vaping-Associated Lung Disease — Correspondence.  N Engl J Med. 2019 Oct 10; 381;15.  

Layden JE, Ghana I, Pray I, Kimball A, Layer M, Tenforde M, Navon L, Hoots B, Salvatore PP, Elderbrook M, Haupt T, Kanne J, Patel MT, Saathaff-Huber L, King BA, Schier JG, Mikosz CA, Meiman J.  Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report.  N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print].  https://www.ncbi.nlm.nih.gov/pubmed/31491072?dopt=AbstractPlus

Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury — United States, October 2019. MMWR Morb Mortal Wkly Rep 2019;68:919–927. DOI: http://dx.doi.org/10.15585/mmwr.mm6841e3external icon.

https://www.health.ny.gov/press/releases/2019/2019-09-05_vaping.htm