At press time, 380 cases of lung illness confirmed or probably related to vaping or e-cigarette use have reported to the Centers for Disease Control and Prevention (CDC). The cases come from 36 states and 1 U.S. territory, and six deaths have been reported in six different states. On Sept. 16, the CDC activated its Emergency Operations Center to help coordinate its response to vaping-associated lung injury.
E-cigarettes produce an aerosol by heating a liquid containing various chemicals, including nicotine, flavorings, and other additives (e.g., propellants, solvents, and oils). Users inhale the aerosol, which can contain harmful or potentially harmful substances, including heavy metals such as lead, volatile organic compounds, ultrafine particles, and cancer-causing chemicals.1 E-cigarettes also can be used to deliver tetrahydrocannabinol (THC) or other drugs, and users could potentially add other substances to the devices.
According to preliminary clinical reports, the onset of respiratory findings, which might include a nonproductive cough, pleuritic chest pain, or shortness of breath, appears to occur over several days to several weeks before hospitalization.2-5 Systemic findings might include tachycardia, fever, chills, or fatigue; reported gastrointestinal findings, which have preceded respiratory findings in some cases, have included nausea, vomiting, abdominal pain, and diarrhea. Most identified patients have been hospitalized with hypoxemia, which, in some cases, has progressed to acute or subacute respiratory failure. Patients have required respiratory support therapies ranging from supplemental oxygen to endotracheal intubation and mechanical ventilation. Many patients initially received a diagnosis of infection and were treated empirically with antibiotics without improvement. Many patients who were treated with corticosteroids improved.2-4 All patients described in these reports to date have had abnormal radiographic findings, including infiltrates on chest radiograph and ground glass opacities on chest computed tomography scan.
All patients have a reported history of e-cigarette product use, and no consistent evidence of an infectious etiology has been discovered. Most have reported using e-cigarette products containing cannabinoids such as THC, some have reported the use of e-cigarette products containing only nicotine, and others have reported using both. No consistent e-cigarette product, substance, or additive has been identified in all cases, nor has any one product or substance been conclusively linked to pulmonary disease in patients.
CDC has created a website to disseminate up-to-date information and a dedicated e-mail address for clinicians and health officials to use to communicate about this public health emergency response. If e-cigarette product use is suspected as a possible etiology for a patient’s pulmonary disease, a detailed history of the substances used, the sources, and the devices used should be obtained.
CDC Recommendations for Clinicians
- Report cases of severe pulmonary disease of unclear etiology and a history of e-cigarette or vaping product use within the past 90 days to your state or local health department.
- Ask all patients who report e-cigarette or vaping product use within the last 90 days about signs and symptoms of pulmonary illness.
- If e-cigarette or vaping product use is suspected as a possible etiology of a patient’s severe pulmonary disease, obtain detailed history regarding:
- Substance(s) used: nicotine, cannabinoids (e.g., marijuana, THC, THC concentrates, CBD, CBD oil, synthetic cannabinoids [e.g., K2 or spice], hash oil, Dank vapes), flavors, or other substances
- Substance source(s): commercially available liquids (i.e., bottles, cartridges, or pods), homemade liquids, and re-use of old cartridges or pods with homemade or commercially bought liquids
- Device(s) used: manufacturer; brand name; product name; model; serial number of the product, device, or e-liquid; if the device can be customized by the user; and any product modifications by the user (e.g., exposure of the atomizer or heating coil)
- Where the product(s) were purchased
- Method of substance use: aerosolization, dabbing, or dripping
- Other potential cases: sharing e-cigarette products (devices, liquids, refill pods, or cartridges) with others
- Determine if any remaining product, including devices and liquids, are available for testing. Testing can be coordinated with the local or state health departments.
- Consider all possible causes of illness in patients reporting respiratory and gastrointestinal symptoms and of e-cigarette product use. Evaluate and treat for other possible causes of illness. Consider consultation with specialists (pulmonary, infectious disease, medical toxicology) as appropriate.
- Clinical improvement of patients with severe pulmonary disease associated with e-cigarette use has been reported with the use of corticosteroids. The decision to use corticosteroids should be made on a case-by-case basis based on risks and benefits and the likelihood of other etiologies.
- Lipoid pneumonia associated with inhalation of lipids in aerosols generated by e-cigarettes has been reported based on the detection of lipid-laden alveolar macrophages obtained by bronchoalveolar lavage (BAL) and lipid staining (e.g., oil red O). The decision about whether to perform a BAL should be based on individual clinical circumstances.
- Lung biopsies have been performed on some patients. If a lung biopsy is obtained, lipid staining may be considered during pathologic examination, and is best performed on fresh tissue. Routine pathology tissue processing (including formalin-fixation and paraffin-embedding) can remove lipids. Conducting routine tissue processing and histopathologic evaluation is still important. Consider consultation with specialists in pulmonary medicine and pathology to help inform any evaluation plan.
- Patients who have received treatment for severe pulmonary disease related to e-cigarette or vaping product use should undergo follow-up evaluation as clinically indicated to monitor pulmonary function.
Sources: CDC website, MMWR Morb Mortal Wkly Rep. 2019;68(36):787-790.
- National Academies of Sciences, Engineering, and Medicine. Public health consequences of e-cigarettes. Washington, DC: The National Academies Press; 2018.
- Layden J, Ghinai I, Pray I, et al. Pulmonary illness related to e-cigarette use in Illinois and Wisconsin—preliminary report. N Engl J Med. Sept. 6, 2019 [epub ahead of print]
- Davidson K, Brancato A, Heetkerks P, et al. Outbreak of e-cigarette-associated acute lipoid pneumonia—North Carolina, July–August 2019. MMWR Morb Mortal Wkly Rep. 2019;68(36):784-786.
- Maddock S, Cirulis M, Callahan S, Wahlen GE. Pulmonary lipid-laden macrophages and vaping. N Engl J Med. 2019. Sept. 6, 2019 [epub ahead of print]
- Henry TS, Kanne JP, Klingerman SJ. Imaging of vaping-associated lung disease. N Engl J Med. Sept. 6, 2019 [epub ahead of print]