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Read the Centers for Disease Control and Prevention (CDC) Interim Guidance for Health Care Providers Evaluating and Caring for Patients with Suspected E-cigarette, or Vaping, Product Use Associated Lung Injury.
Explore This IssueACEP Now: Vol 38 – No 10 – October 2019
More information is available at the Centers for Disease Control and Prevention website and at the Internet Book of Critical Care.
Using electronic cigarettes, or vaping, has become increasingly popular within the past several years. Within the past few months, an outbreak of vaping-associated pulmonary injury (VAPI) has been recognized in locations across the United States. The number of patients involved has rapidly increased to the hundreds, and several deaths have been reported.
This is currently an area of active investigation about which little is known for certain.
Here’s what we do know.
Quick Tips: Diagnosis and Treatment
Available evidence suggests that the predominant form of lung injury is lipoid pneumonia. This may relate largely to the vaping of tetrahydrocannabinol (marijuana-like) products, which are diluted using vitamin E acetate. However, not all patients report a history of vaping with tetrahydrocannabinol, so other products may be involved as well.
The clinical presentation of VAPI usually begins gradually over several days with gastrointestinal and pulmonary symptoms. Early on, patients may appear to have a viral gastroenteritis or mild pneumonia. Eventually hypoxemic respiratory compromise worsens, with the development of bilateral pulmonary infiltrates. Additional symptoms may include fever, chest pain, and weight loss. CT scans typically show bilateral diffuse ground-glass opacification. Steroid administration may be associated with clinical improvement, although this remains unproven and speculative. Severity is variable, with some patients requiring intubation or even extracorporeal membrane oxygenation.
The optimal approach to investigation and treatment of this disorder remains unknown. Evaluation is primarily driven toward exclusion of alternative likely possibilities (especially various types of infectious pneumonia). Whether every patient requires a bronchoscopy is debatable. For critically ill patients at risk of deterioration, the safest approach could be to provide empiric therapy for both pneumonia and VAPI (current approaches are a combination of antibiotics and a steroid).
This is a rapidly evolving topic, and approaches are likely to evolve even as this goes to print. The most important aspect is to be aware that VAPI exists. This awareness should prompt us to take a detailed vaping history among patients with respiratory or gastrointestinal symptoms, especially in otherwise healthy patients not expected to develop acute respiratory illnesses. In suspected cases, specialty consultation may be advisable (most often pulmonology), and local health departments should be notified as they can provide updated clinical guidance and assist in tracking cases.
The Devil We Don’t Know
Vaping’s popularity has been, in part, driven by the medical community, which has viewed the habit as a safer alternative to smoking cigarettes. Unfortunately, the use of vaping as a smoking cessation strategy is scientifically a bit dodgy. Our understanding of the toxicity of cigarettes emerged very slowly. This toxicity wasn’t recognized for decades, until long-term epidemiological evidence implicated smoking in lung cancer. Since vaping hasn’t been around that long, it’s simply impossible to know what its long-term effects will be. Thus, it’s impossible to be sure that the long-term effects of vaping will be less severe than those of smoking. Nonetheless, passion to eliminate smoking has promoted this transition away from the devil we know toward a devil we don’t yet understand.