![What You Need to Know About Vaping-Associated Pulmonary Injury](https://www.acepnow.com/wp-content/uploads/2019/10/ACEP_1019_pg1a.png)
Once commercialized, vaping has rapidly expanded to new markets. Companies have aggressively promoted vaping to adolescents, using advertisement campaigns on Instagram and products of various flavors, including fruit and candy flavors. Consequently, vaping has become common among adolescents, who have been led to believe that vaping is a safer alternative to smoking. Currently, more than a third of high school seniors report some use of vaping.
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ACEP Now: Vol 38 – No 10 – October 2019Trouble Brewing
The gastrointestinal tract has evolved to take in widely heterogeneous material, absorb nutrients, and excrete the remainder. Overall, the gut is astonishingly successful at coping with foreign materials while remaining healthy. In comparison, the lungs are not well-designed to deal with foreign material. Vaping exposes the lungs to a dizzying array of chemicals (some of which are known to cause lung disease). This is a recipe for potential disaster.
About a dozen case reports over the last several years have described various forms of lung disease that may result from vaping. The most fulminant form is acute eosinophilic pneumonia, a form of respiratory failure, which may also be caused by smoking cigarettes. Other forms of lung disease associated with vaping include lipoid pneumonia and cryptogenic organizing pneumonia. These are more gradual but may nonetheless progress to ventilator-dependent respiratory failure. To simplify matters, these various forms of VAPI share similar features—they cause bilateral pulmonary infiltrates, which generally respond to steroids.
Despite some early signals of harm, most practitioners have remained blissfully unaware of vaping risks, so it is not a part of medical culture to think about it. Vaping wasn’t taught to us as something to ask about during a medical history the way other substance use was. It’s possible that some cases of VAPI weren’t diagnosed simply because we didn’t know enough to ask about it.
Public Health Considerations
The current epidemic has cast a harsh light on the lack of regulation of vaping products. Vaping is now a billion-dollar industry in the United States and may already be influenced by substantial political contributions. The U.S. Food and Drug Administration (FDA) was given authority to oversee vaping in 2016. However, companies have been given until 2022 before they must submit products for review. Overall, the industry has remained largely unregulated.
Vaping itself may turn out to be safer than smoking, as it takes oncogenic tobacco and smoke out of the equation. In fact, the current epidemic of VAPI most likely relates to adulterants (eg, vitamin E acetate), which, once discovered and banned from e-cigarettes, will likely render VAPI a rare entity. However, this outbreak is doubtless facilitated by the use of vaping products that are designed to be modifiable. And so one of e-cigarettes’ appeals—the diversity in product it can deliver—may be a setup for other hazards we have yet to discover.
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3 Responses to “What You Need to Know About Vaping-Associated Pulmonary Injury”
October 22, 2019
David KnoxSeveral points in the article need more clarification. It is not the nicotine or THC that is causing VAPI. People have been inhaling those substances for years without this type of pulmonary inflammatory disease. The carrier oils, or other additives, or their heat generated byproducts are the culprits. The statistics show that 84% of cases have vaped THC containing products and 16% Nicotine only products. Cannabis differs from nicotine as it is not water soluble, and extracts are very viscous, therefore requiring a cutting oil to make it flow in the cartridge in order to evenly contact the heating element. Vitamin E acetate only started to be used as a cutting oil in 2018, so it is a prime suspect in this recent epidemic, but unfortunately does not account for all of the cases of VAPI. The other confounder is related to the legal status of cannabis in this country. In many cases, the vape products were purchased off the street, where there is no oversight as to the contents; counterfeit cartridges abound with who knows what in the mix. Alternatively, there is little incentive to purchase nicotine products on the black market.
Politicians have used this epidemic as a reason to ban flavorings from vaping products, not because they are necessarily the causative agent, but because it ties in to the concern of the appeal of vaping to adolescents, it serves as a tool to address that issue. Banning flavorings may not reduce the incidence of VAPI, other than by possibly reducing the overall number of vapers.
A recent study showed that vaping solutions with NO THC or Nicotine, only the common carrier oils, resulted in inflammation in the lungs of otherwise healthy persons who never vaped or smoked previously. Vaping these products, at temperatures below combustion, still generates many byproducts, including formaldehyde, acetaldehyde, acrolein, etc. Also, these oils vaporize with heat but they condense at body temperature, and precipitate in the airways. This is why tissues show macrophages in the lungs with vacuoles full of oil, but it is not clear that this accounts for the severe inflammatory reaction in VAPI. I would be more suspicious of a heat generated byproduct for some of these cases that do not conform to a diagnosis of lipoid pneumonia.
In absolute numbers, there are only a few thousand cases of VAPI amongst millions of vapers, making the cause even harder to find. This could be from a contaminant or additive, or may depend on any individuals inflammatory reaction to a substance that a majority of vapers tolerate.
To be clear, THC and Nicotine are the reasons WHY people are vaping, but they are NOT the cause of VAPI. It is hard to know if a product is adulterated in the current marketplace, but THC products off the street should certainly be suspect. I applaud the quick research being done on this problem, which hopefully will find a real solution soon. In the meantime, I will continue to advise patients that the long term, or even short term, consequences of vaping are unknown (but may be significant if YOU are the statistic), and this risk needs to be considered strongly in what or how they are using these products.
November 16, 2019
Erica RemerProviders need to be aware that VAPI is not the term that CDC has adopted. They are using, “EVALI,” which stands for “electronic cigarette/vaping associated lung illness.” A new ICD-10-CM code will be created to describe the condition, likely to be presented in March (2020). Providers should probably use the acronym, “EVALI,” instead of VAPI to ensure that the condition is captured accurately by the coders (once the code exists). Would also recommend if your EHR supports acronym expansions, build an Enterprise-wide expansion so there is never any ambiguity.
November 26, 2019
FrankIf you think you might have VAPI and go to the doctor.. what type of tests will they do to determine you have an injury?